Airway and ENT emergencies

Septal haematoma

Overview and approach

A septal haematoma is blood trapped beneath septal perichondrium after trauma, threatening cartilage viability.

  • Blood separates the perichondrium from septal cartilage, cutting off its blood supply; untreated collections can cause cartilage necrosis, septal perforation and saddle nose1,2,3.
  • Why children are at risk: their mucoperichondrium is only loosely stuck to the cartilage, so even mild nasal trauma can lift it and let blood collect4.
  • It can also complicate septal surgery, which is why surgeons suture the flaps together afterwards4.
  • Why the nose collapses: the front of the septum holds up the cartilaginous nose. If that cartilage dies, the bridge sinks into a saddle deformity4,5.
Assessment and clinical features

Inspect both sides of the septum for boggy swelling and obstruction, especially after nasal injury.

  • Bilateral nasal obstruction after trauma, a red or purple, soft, bulging midline swelling that does not shrink with decongestant; may be painful1,3. Children can present after minor trauma.
  • Looking from below, the septum is thickened and swollen on both sides, narrowing both nasal passages; there may be an associated septal fracture4,5.
  • Marked tenderness is not a feature of a simple haematoma; significant tenderness, pain or fever suggests it has become infected4.
  • Check for a compound nasal fracture and head injury at the same time5.
Differentials and investigations

Clinical examination is key; do not let reassuring plain imaging replace inspection.

  • Differentials: deviated septum, turbinate swelling, simple mucosal oedema, septal abscess (fever, pain, tenderness).
  • Palpate with a probe or cotton bud if in doubt. Imaging is not needed to diagnose; look for associated nasal or facial fractures if clinically indicated.
  • Nasal X-rays add little; use imaging only to look for other facial skeletal injuries5.
Management and follow-up

Urgent same-day ENT assessment for drainage and prevention/treatment of infection.

  • Urgent drainage, ideally within hours: aspirate small collections, incise and drain larger ones, then pack, quilt or drain to prevent reaccumulation; prophylactic antibiotics. If abscess: drain, culture pus and give broad-spectrum antibiotics1,2,3.
  • Review for reaccumulation and nasal shape.
Red flags and clinical pearls

Delay may cause septal abscess and saddle-nose deformity.

  • Septal abscess can spread intracranially (cavernous sinus thrombosis, meningitis): fever, severe pain and swelling need urgent admission.
  • Any nasal trauma with obstruction = look inside the nose.
  • Once an abscess forms, cartilage necrosis and later saddle deformity are almost certain4.
  • Infection can spread through the facial veins to the orbit or cavernous sinus and can be fatal, particularly in children4,5. Cavernous sinus thrombosis presents with headache, rigors, bilateral proptosis and ophthalmoplegia4.
References
  1. ENT UK: Nasal septal haematoma
  2. ENT UK: Nasal septal abscess
  3. ENT and Skull Base Hub: Septal haematoma
  4. Dhillon RS, East CA. Ear, Nose and Throat and Head and Neck Surgery: An Illustrated Colour Text. 4th ed. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 2, Nose and paranasal sinuses.
  5. Murtagh J. John Murtagh's General Practice. 5th ed. Sydney: McGraw-Hill Australia; 2011. Chapter 60, Nasal disorders.

Last updated from Sen’s notes on 22 October 2026.