Honorary Assistant Plastic Surgeon, Royal Melbourne Hospital; Honorary Research Fellow, Department of Surgery, University of Melbourne

Transcription

1 THE PTHOLOGY ND TRETMENT OF H~MTOM OF THE NSL SEPTUM By HUNTER J. H. FRY, M.S., F.R.C.S., F.R..C.S. Honorary ssistant Plastic Surgeon, Royal Melbourne Hospital; Honorary Research Fellow, Department of Surgery, University of Melbourne SEPTL h~ematoma following nasal trauma is probably more common than generally acknowledged and requires early treatment to avoid undesirable sequelae. Though the literature abounds with fleeting references to the condition and its various complications, FIG. i FIG. 2 Fig, i.--classical case of nasal septal hmmatoma following a nasal injury. The patient had been given antibiotics immediately upon diagnosis and is shown here two weeks later. Immediate drainage was carried out when she was referred. The collection was straw-coloured fluid and the only trace of cartilage was a small piece at the anterior nasal spine and a little at the articulations with the lateral cartilages. Fig girl aged 4 years with a septal hmmatoma five weeks after injury. ntibiotics were started after one week and continued for a month. The collection had not changed in size, there was clear discharge from the right nostril and the child was snorting. Drainage was carried out two days after referral. The cartilage was thinned out and curved convexly into the right nasal cavity. The collection was predominantly right-sided. the rationale of treatment has still to be clearly stated. The purpose of this paper is to discuss the relative merits of conservative and active treatment and to show why active treatment is to be preferred. Pathology.--When the nasal septum is damaged by a buckling stress, blood vessels may be torn. If the mucosa remains intact blood collects in the soft tissues and between the mucoperichondrium and the cartilage. Should bleeding continue, a discrete h~ematoma develops and the lining is almost always stripped from the cartilage. If there is a fracture of the cartilage (or bone), blood may track through to the other side and a bilateral hmmatoma is formed. Since cartilage gains its nutrition from the perichondrium, variable interference with the nutrition of the cartilage may result. vascular cartilage will stay alive for about three days at body temperature but eventually metabolic necessity imposes its time limit and the chondrocytes die ; this would be expected to lead to slow absorption

2 332 BRITISH JOURNL OF PLSTIC SURGERY C B D FIG. 3 ~ This man attended hospital four days after a nasal injury. B, There was already lack of septal support. C, The septal hmmatoma blocked both airways. D, t operation the same day, the collection was found to be diluted blood ; all that remained of the cartilage was a few detached globules of soft material. The most solid of these is shown delivered into the wound by the sucker tip. The collection was sterile.

3 H/~MTOM OF THE NSL SEPTUM 333 of the cartilage. t the same time the septal cartilage may become absorbed very quickly within a ha:matoma even in the absence of infection (Fig. I). The mechanism of this is not clear but will be referred to below. The h~ematoma may behave in one of two ways. Partial or perhaps even complete resorption may occur although there is usually some permanent thickening of the septal partition, or infection may supervene with the added complication of ascending spread and intracranial complications. Infective destruction of cartilage and lining may occur. Treatment.--Two forms of treatment have their adherents, conservative treatment with antibiotics and active treatment, i.e. drainage of the h~ematoma. Conservative Treatment.--Essentially this consists of antibiotic therapy to prevent the hmmatoma becoming infected, or to prevent spread of any infection which has already occurred. So long as the appropriate antibiotic is selected, this limited but quite inadequate aim may be achieved. Such hmmatomas may remain fluctuant for weeks (Fig. 2) and cause nasal obstruction while organisation causes permanent thickening. Though the patient is protected from infection, the septal cartilage dies and may become absorbed remarkably quickly (Fig. 3). In a child, normal growth of the central part of the nose may thus be lost ; in an adult, a " saddle" deformity usually results. The writer has seen two instances where the h~ematoma has been predominantly unilateral and the underlying cartilage has been thinned out presumably by partial surface absorption. This is bound to change the growth patternin a child (Fig. 4) or the shape in an adult (Fig. 5) as the mechanical characteristics of the cartilage are likely to be altered (Fry, 1967). In both unilateral

4 334 BRITISH JOURNL OF PLSTIC SURGERY B C D FIG. 5 to D, Late results seen in adult patients with septal h~ematomata treated conservatively. The blame should be shared between the injury and the treatment.

5 H/~,MTOM OF THE NSL SEPTUM 335 cases with erosion, abnormal curvature of the affected area in the cartilage had already occurred. Perforation of the septum is probably prevented by conservative treatment in most instances. From these theoretical and practical considerations it is apparent that too many undesirable and irreversible consequences may occur after conservative treatment. Furthermore, long-continued antibiotic therapy is probably not desirable on general grounds if there is a reasonable alternative. ctive Treatment.--By active treatment is meant adequate surgical drainage of the h~ematoma as soon as it is diagnosed. There are no theoretical objections to this form of treatment although it will not prevent damage to the cartilage which has already occurred from the injury itself and the effects of the hmmatoma ; however, further damage should be prevented. The collection should be drained at the most dependent point by an adequately long surgical incision. Bilateral drainage is necessary if the hmmatoma is bilateral and there is still cartilage between the two layers. ll too frequently, however, the cartilage has disappeared, leaving a common cavity requiring only one incision. The mucoperichondrium should be replaced against the cartilage after drainage and supported there by intranasal packing. Should the haematoma already be infected, and this can occur within 48 hours of injury, the indication for drainage is urgent. dequate drainage removes the possibility of complications from the hmmatoma itself as well as allowing the nutrition of the cartilage to be re-established. DISCUSSION The very rapid absorption of cartilage in a sterile ha~matoma (Fig. 3) is mysterious. When seen in the actual stage of absorption, the cartilage appears like semi-liquid cheese and is reminiscent of the texture and appearance of septal cartilage incubated with collagenase (Fry, 1968). It is possible that such an enzyme is responsible for the rapid disappearance of the cartilage in the absence of infection since tissue collagenases have been identified in many tissues (Gross and Lampiere, 1963 ; Evanson, Jeffrey and Krane, 1967 ; Riley and Peacock, 1967). CONCLUSION Nasal septal h~ematomata should be drained surgically as soon as the diagnosis is made. ntibiotic treatment alone is inadequate. I am indebted to Mr Thomas Gibson for stimulating my interest in nasal septal hcematoma and to Mr John Hueston for encouraging that interest. REFERENCES EVNSON, J. M., JEFFREY, J. J. and KRNE, S. M. (I967). Science, N.Y. I58, 499. FRY, H. J. H. (I967). Br. ]. plast. Surg. zo, I (I968). Plastic reconstr. Surg. 4o, 426. GROSS, J. and L~aPIERE, C. M. (I963). " Mechanisms of Hard Tissue Destruction ", ed. Sogannaes, R. F., p S. Washington~ D.C. RILEY, W. B. and PECOCK, E. E. (I967). Proc. Soc. exp. Biol. Med. x24, 207.