01OverviewDefinition, clinical context and the essential points that orientate the chapter.
A septal haematoma is blood collecting beneath the lining of the nasal septum, commonly after trauma and sometimes after surgery. It differs from an ordinary nosebleed: pressure and clot remain trapped beside the cartilage rather than escaping from a superficial bleeding point. Even a modest injury can produce a significant collection. Delay matters because the septal cartilage depends on the adjacent mucoperichondrium for nutrition.
A septal abscess is a collection of pus in the same tissue plane, often developing when a haematoma becomes infected, although sinonasal infection and other local insults can also contribute. Increasing obstruction and pain, fever or a red swollen nose should raise suspicion. Both conditions need prompt specialist treatment; antibiotics alone do not relieve the pressure or reliably clear a walled-off collection. The emergency drainage pathway is separate from decisions about later reduction of a nasal fracture or correction of cosmetic deformity.
Key points
- Inspect the septum in every relevant nasal injury; an external examination alone can miss a dangerous internal collection.
- A haematoma may obstruct one or both sides and can be confused with a pre-existing septal deviation.
- Fluctuance rather than a firm structural bend supports a collection, assessed gently by an appropriately trained clinician.
- Separating the septal lining from cartilage disrupts its nutrition and can cause necrosis and deformity.
- Urgent incision and drainage is usually preferred to simple needle aspiration because organised blood may not aspirate completely.
- A septal abscess needs drainage, culture and systemic antibiotics, often intravenously in hospital.
- Re-examine after treatment, with ENT UK trauma guidance specifying review within forty-eight hours to detect recollection.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Traumatic or postoperative bleeding
Blunt nasal injury and septal surgery can disrupt vessels beneath the septal lining. Blood then accumulates in a confined tissue plane, sometimes despite little external bleeding.
Secondary infection
A haematoma can become infected and form an abscess. Less commonly, local sinonasal infection or instrumentation contributes without a clearly remembered traumatic event.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Separation of supporting tissue
Accumulating blood or pus lifts the mucoperichondrium away from septal cartilage. This interrupts the close tissue relationship through which the cartilage receives nutrients and oxygen.
- 2Cartilage injury and collapse
Sustained separation and pressure can cause cartilage necrosis and resorption. Loss of structural support may later produce a saddle-shaped deformity or persistent nasal obstruction.
- 3Infective extension
An untreated abscess can spread into adjacent facial tissues, the orbit or intracranial structures. Fever with escalating facial or neurological symptoms signals a broader threat than local obstruction.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Ask about recent blows to the nose, falls, sports, surgery and instrumentation. Record when obstruction and pain began and whether they are worsening. A patient who originally appeared well can develop a collection after the initial assessment.
Look with good light for a reddish-purple bulge arising from the septum, sometimes on both sides. A trained examiner may assess gentle fluctuance; do not repeatedly manipulate a painful swelling or mistake the lateral turbinate for the septum.
Fever, increasing tenderness, erythema, purulent material or systemic malaise favour abscess. Severe frontal or facial pain, orbital findings or neurological symptoms raise concern for extension beyond the septum.
Assess the eye, facial bones, neurological state and possible cerebrospinal fluid leak after significant trauma. Children, patients unable to describe symptoms and immunocompromised patients require particular care because a delayed diagnosis may have major consequences.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Immediate nasal examinationFirst step - Why
- Identify a collection that changes the urgency of management.
- Interpretation and limitations
- The diagnosis is primarily clinical and urgent referral should follow a convincing septal swelling. A normal external nose or absence of a displaced fracture does not exclude a haematoma.
- 02
ENT assessment of the collection - Why
- Confirm extent and plan definitive drainage in a safe setting.
- Interpretation and limitations
- Needle aspiration may help selected diagnostic decisions, but incomplete aspiration of organised blood must not be mistaken for absence of a collection. Incision and drainage often provides more reliable evacuation.
- 03
Culture of drained pus - Why
- Identify organisms and guide subsequent antimicrobial refinement.
- Interpretation and limitations
- Obtain a specimen during abscess drainage and tailor treatment to results. Sampling should accompany source control, not delay urgent antibiotics in a patient with significant infection or sepsis.
- 04
Selective blood tests and imaging - Why
- Assess systemic infection or suspected spread and associated injuries.
- Interpretation and limitations
- Blood count, inflammatory markers, renal function and cultures are selected according to illness severity. CT or other imaging may be needed for complications or additional trauma, but is not a prerequisite for draining an obvious uncomplicated collection.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Pre-existing septal deviation
A longstanding firm septal bend may narrow one nostril but lacks the fluctuant collection of a haematoma. Recent worsening after trauma should prompt careful reassessment rather than attribution to an old deformity.
Turbinate swelling
Inflamed turbinates arise from the lateral nasal wall and can obstruct airflow. Recognising their anatomical position helps avoid confusing ordinary mucosal swelling with a septal collection.
Other postoperative swelling
Oedema and packing can cause expected early obstruction after surgery. Progressive pain, redness, fever or a visible septal bulge require evaluation for a haematoma or abscess instead.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Suspected haematomaArrange drainage without delayFirst stepRecent nasal trauma or surgery is followed by a fluctuant septal swelling.+
- 1Contact ENT immediately and explain the suspected collection, obstruction and time course.
- 2Assess and treat concurrent trauma or airway problems while arranging prompt specialist care.
- 3Avoid postponing referral for a routine fracture review or waiting for external swelling to subside.
- 4Ensure the receiving team plans evacuation and measures to prevent blood collecting again.
02Suspected abscessCombine source control and infection treatmentA septal swelling is accompanied by increasing pain, fever or spreading inflammation.+
- 1Arrange urgent admission or hospital assessment with ENT and evaluate for sepsis or extension.
- 2Begin appropriate systemic antimicrobial treatment through the local ENT and microbiology pathway, using intravenous therapy when clinically indicated.
- 3Drain the collection and send pus for culture, with removal of nonviable tissue if required by the surgeon.
- 4Investigate eye or neurological findings urgently with the relevant specialist teams and imaging pathway.
03After drainagePrevent recurrence and assess tissue survivalA haematoma or abscess has been evacuated by the treating team.+
- 1Use the surgeon's selected approach to oppose tissue planes, such as quilting sutures, a drain, packing or splints.
- 2Arrange early re-examination to detect recollection; the ENT UK trauma resource specifies review within forty-eight hours.
- 3Review pain, fever, nasal patency and any culture result, refining antibiotics when appropriate.
- 4Plan further follow-up for cartilage loss, perforation or developing deformity, particularly in children.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Septal perforation and deformity
Cartilage destruction can result in a hole in the septum or loss of nasal support. These changes can cause bleeding, crusting, whistling and altered appearance or breathing.
Orbital or intracranial spread
Abscess complications include orbital infection, meningitis, brain abscess and cavernous sinus involvement. New visual or neurological symptoms require immediate multidisciplinary hospital assessment.
Recollection and impaired development
Blood or pus can recur if the tissue planes remain separated. In a child, significant cartilage damage may also affect later nasal development and require prolonged specialist follow-up.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- A fall in pain or obstruction after drainage is reassuring, but recurrent blockage or swelling requires prompt re-examination for recollection.
- Monitor fever, haemodynamic status and inflammatory trajectory in abscess, using the patient's clinical state to guide escalation rather than a single laboratory value.
- Review culture results and antimicrobial response with the responsible team; duration and route depend on source control, extent of infection and complications.
- Give explicit advice to return immediately for worsening pain, fever, eye symptoms, headache, confusion or recurrent obstruction.
- Assess the healed septum for perforation, persistent deformity and airway function, arranging specialist reconstruction discussion when needed.
- In children, ensure longer-term follow-up is considered because septal injury can affect the developing nasal framework.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
A fracture is not required
Septal bleeding can occur without a dramatic external deformity or obvious displaced fracture. The presence or absence of a fracture on imaging therefore does not answer the clinically urgent question of whether a collection is present.
Aspiration has a limitation
Organised clot can be difficult to remove through a needle. ENT UK's trauma guidance favours incision and drainage over aspiration for reliable evacuation; a small or absent aspirate should not justify discharge when the examination remains concerning.
Antibiotic choice is contextual
An abscess can require intravenous antibiotics alongside drainage, but the selected regimen depends on allergy, local resistance, renal function, severity and whether orbital or intracranial infection is suspected. A generic community sinusitis course is not an adequate substitute for that inpatient decision.
Global resources and UK referral
The ENT UK global trauma and abscess resources explain the anatomy and drainage principles across care settings. In UK practice, the GGC pathway supports same-day assessment of suspected septal haematoma; procedural responsibility and antimicrobial selection follow the receiving hospital's arrangements.
11Common pitfallsFrequent interpretation and management errors.
- 01
Examining only the outside of an injured nose and missing a septal bulge inside the nasal cavity.
- 02
Waiting several days for fracture-clinic assessment when the immediate problem is a collection threatening cartilage.
- 03
Treating an abscess with oral antibiotics alone without obtaining specialist source control.
- 04
Using failure to aspirate organised clot as evidence that no septal haematoma is present.
- 05
Failing to arrange an early check for recollection after apparently successful drainage.