A 22-year-old man comes to the urgent care clinic after being hit in the face with a basketball. He had bleeding from both sides of his nose for about 10 minutes that stopped with pressure. He is currently unable to breathe through his nose. Medical history is significant for allergic rhinitis treated with oral antihistamines. Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respiratory rate is 14/min. Oxygen saturation is 99% on room air. On examination, there is bruising across the nose and under the eyes. Anterior rhinoscopy reveals no bleeding. There is soft, fluctuant swelling of the septum bilaterally. There is no blood in the oropharynx. Which of the following is the best next step in management of this patient?

Question

A 22-year-old man comes to the urgent care clinic after being hit in the face with a basketball.  He had bleeding from both sides of his nose for about 10 minutes that stopped with pressure.  He is currently unable to breathe through his nose.  Medical history is significant for allergic rhinitis treated with oral antihistamines.  Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respiratory rate is 14/min.  Oxygen saturation is 99% on room air.  On examination, there is bruising across the nose and under the eyes.  Anterior rhinoscopy reveals no bleeding.  There is soft, fluctuant swelling of the septum bilaterally.  There is no blood in the oropharynx.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d8bf_5f8b_bc81_2d3131041110_MD0003_00 This patient who sustained nasal trauma and now has nasal obstruction and fluctuant swelling of the nasal septum has a septal hematoma, which is an accumulation of blood between the perichondrium and the septal cartilage. Although the incidence is rare, the complications of an untreated septal hematoma are significant. Infection can develop rapidly (2-3 days) and lead to a septal abscess. In addition, because the septal cartilage has no direct blood supply and receives all nutrients via diffusion from the perichondrium, a septal hematoma can cause avascular necrosis of the septal cartilage. Destruction of the nasal septal cartilage can result in septal perforations, external nasal deformities (eg, saddle nose), or internal nasal valve collapse (ie, nasal obstruction). Therefore, all patients who sustain nasal trauma undergo examination of the nasal septum. Palpation can differentiate between a deviated nasal septum (firm) and a septal hematoma (soft, fluctuant). Patients with a septal hematoma require prompt incision and drainage. After incision and drainage, anterior nasal packing should be placed to compress the perichondrium to the nasal septum; ice packs and NSAIDs can reduce edema due to inflammation (Choices A and D). Patients are treated with antibiotics and require otolaryngology evaluation after a few days for packing removal and assessment. (Choice B) Embolization of the sphenopalatine artery is one method to control posterior epistaxis. This patient does not currently have epistaxis because blood has already accumulated in the nasal septum. (Choice E) A complete blood count is ordered in cases of severe epistaxis that may require transfusion, but it is not needed in this patient who has had no further bleeding. Coagulation studies are ordered in patients who are anticoagulated or have recurrent, spontaneous epistaxis. This patient is healthy and has an obvious cause of epistaxis (trauma). Educational objective: A septal hematoma presents after nasal trauma as fluctuant swelling of the nasal septum. It should be recognized and promptly drained to avoid complications of infection, septal perforation, and nasal deformities. References: Traumatic injuries of the ear, nose and throat. (http://www.ncbi.nlm.nih.gov/pubmed/30454776) Critical ENT skills and procedures in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/23200328) Videos in clinical medicine. Treatment of hematoma of the nasal septum. (http://www.ncbi.nlm.nih.gov/pubmed/26017844)

A 22-Year-Old Man Comes to the Urgent Care Clinic After