A nasal septal hematoma is a collection of blood between the cartilage or bone of the nasal septum and its overlying mucosal lining. To understand why this is so dangerous, it is essential to first understand the anatomy of the septum.

The nasal septum is the wall that runs down the middle of your nose, separating it into a left and right nasal passage. The back part of the septum is made of thin bone, but the front two-thirds are made of cartilage. This cartilage gives the front of your nose its shape and support.

Crucially, cartilage does not have its own blood supply. It relies entirely on a thin, tightly adherent layer of tissue called the perichondrium to deliver its oxygen and nutrients. The perichondrium is rich with blood vessels and acts as the cartilage’s lifeline.

A helpful analogy is to think of the septal cartilage as a delicate plant and the perichondrium as the thin layer of nutrient-rich soil it is planted in. In a nasal septal hematoma, trauma causes the blood vessels in the perichondrium to rupture. Blood then pools in the space between the “soil” (the perichondrium) and the “plant” (the cartilage), lifting the cartilage away from its only source of nutrients.

This creates two immediate and serious problems:

1. Cartilage Death (Necrosis): Starved of its blood supply, the septal cartilage can begin to die within just a few days.
2. Risk of Infection: The stagnant pool of blood is a perfect breeding ground for bacteria, which can lead to the formation of a dangerous septal abscess.

In practice, I’ve found that patients often think they just have a “swollen nose” after injury. But if both nostrils look unusually blocked or the septum feels soft and boggy, I always suspect a septal hematoma, it’s one of those things we can’t afford to miss.

Nasal septal hematoma is caused by the rupture of blood vessels that supply the perichondrium of the nasal septum. When these vessels break, blood dissects and separates the perichondrium from the underlying cartilage, creating the fluid-filled pocket. This process is almost always initiated by some form of trauma that delivers a significant force to the nose.

In my experience, kids are more vulnerable. Even a minor bump during play can lead to a septal hematoma. It’s crucial not to overlook nasal symptoms in children following even minor trauma.

You develop a nasal septal hematoma when a forceful impact or surgical manipulation causes blood vessels in the septum to rupture, but the overlying mucosa remains intact.

Nasal Trauma: The Overwhelming Cause

 In nearly all cases, a nasal septal hematoma is a direct result of significant trauma to the nose. This is why it is considered a critical complication of a “broken nose.” Common causes of nasal trauma include:

• Falls: Especially common in young children who are learning to walk or are unsteady on their feet.
• Sports Injuries: A direct blow from a ball, an elbow, or a collision with another player in sports like basketball, soccer, rugby, or martial arts.
• Assault or Physical Altercation: A punch to the nose.
• Motor Vehicle Accidents.

It is particularly common in children because their septal cartilage is thicker and more flexible than in adults, making it more prone to buckle and tear the overlying blood vessels without necessarily fracturing.

Nasal Surgery

Less commonly, a septal hematoma can be a complication following a surgical procedure on the nose, such as a septoplasty (to correct a deviated septum) or a rhinoplasty (“nose job”).

Spontaneous Hematoma (Very Rare)

In extremely rare instances, a septal hematoma can occur spontaneously, without any trauma. This is usually only seen in individuals with severe bleeding or clotting disorders (coagulopathies) or in those taking high doses of anticoagulant (blood-thinning) medications.

I’ve seen cases missed in ERs when the focus was on external injuries. Unless we look inside the nose, especially after trauma, a hidden septal hematoma can quietly progress to infection or deformity.

The symptoms of a septal hematoma can develop in the hours to days following a nasal injury. Unlike a simple nosebleed that flows out of the nostrils, a septal hematoma involves blood being trapped inside the septum.

The single most important and characteristic symptom of a nasal septal hematoma is progressive, severe, bilateral nasal obstruction. After an injury, it is normal to have some difficulty breathing through the nose due to swelling. However, a person with a septal hematoma will often describe a feeling of complete blockage on both sides, as if their nose is plugged with cotton, that gets worse over time.

Other key signs and symptoms include:

• Nasal pain and tenderness that may seem out of proportion to the initial injury.
• A feeling of pressure inside the nose.
• External swelling of the nose.
• A clear, watery nasal discharge (rhinorrhea) may also be present.
• A nosebleed may have occurred at the time of the injury, but it may have stopped, which can give a false sense of reassurance.

If a patient complains of nasal blockage after trauma, I always do an anterior rhinoscopy. A key sign is when the septum looks bulky and symmetrical, rather than deviated, classic clue for hematoma.

When to Seek Urgent Medical Care

Any individual, especially a child, who experiences significant trauma to the nose followed by the development of severe nasal obstruction and pain should be evaluated by a medical professional urgently. This is not an injury to “wait and see” if it gets better at home.

The Diagnostic Process

Diagnosis is mostly clinical, based on symptoms and physical examination.

• Medical History: The doctor will ask detailed questions about how and when the injury occurred.
• Physical Examination: This is the definitive step. The doctor will use a light source and often a tool called a nasal speculum to gently open the nostril and look directly at the septum.
  • A septal hematoma appears as a soft, wide, bluish or reddish, grape-like swelling on one or, more commonly, both sides of the nasal septum.
  • To differentiate it from the firm swelling of a deviated septum, the doctor may gently palpate the swelling with a cotton-tipped applicator. A hematoma will be soft, boggy, and fluctuant (feeling like it is filled with fluid).

Imaging tests like a CT scan are generally not needed to diagnose the hematoma itself but may be ordered if the doctor is concerned about other facial fractures or a more extensive injury.

A flashlight and nasal speculum are usually all we need. If a patient can’t breathe through the nose and there’s bilateral swelling with no obvious cause like congestion, it’s time to act.

The management of a diagnosed nasal septal hematoma is straightforward and urgent: it must be drained immediately.

Incision and Drainage (I&D)

The definitive treatment is a surgical procedure called incision and drainage, which is typically performed by an otolaryngologist (ENT doctor) or an emergency physician.

• The Procedure: The inside of the nose is numbed with a local anesthetic. The doctor then uses a scalpel to make a small incision in the lining of the hematoma to allow the trapped blood and blood clots to be completely suctioned out.
• Packing: After drainage, nasal packing is almost always placed. This involves placing gauze or other material into both nostrils to apply firm pressure. This pressure pushes the perichondrium back into contact with the cartilage, preventing the hematoma from refilling with blood. The packing is usually left in place for 2 to 5 days.
• Antibiotics: Patients are always prescribed a course of oral antibiotics to prevent the now-drained hematoma from becoming infected and forming a dangerous abscess.

Complications of an Untreated Hematoma

 If a septal hematoma is not drained promptly (within about 24-72 hours), the consequences can be severe and permanent.

• Septal Abscess: The stagnant pool of blood is highly susceptible to infection, which can lead to the formation of a pus-filled abscess. A septal abscess is a more serious infection that can spread to surrounding areas and can more rapidly destroy the cartilage.
• Septal Perforation: As the cartilage is starved of its blood supply, it dies (a process called aseptic necrosis). The dead cartilage is then reabsorbed by the body, leaving a permanent hole, or perforation, in the nasal septum. A septal perforation can cause chronic nasal crusting, whistling when breathing, and nosebleeds.
• Saddle Nose Deformity: This is the most feared cosmetic complication. If much septal cartilage is destroyed, the nose bridge loses its primary structural support. This causes the bridge to collapse and sink downward, resulting in a flattened, saddle-shaped appearance to the nose. This deformity is permanent and requires complex reconstructive surgery (rhinoplasty) with cartilage grafting to repair.

I always stress urgency with septal hematomas. The longer it sits, the higher the risk of irreversible cartilage damage. Quick drainage can save a patient from lifelong nasal deformity.

A nasal septal hematoma is a serious and time-sensitive complication of nasal trauma that must be distinguished from a simple nose bleed or routine swelling. It represents a collection of blood that is actively separating the septal cartilage from its life-sustaining blood supply. While the initial injury may seem minor, the hallmark symptom of progressive, severe bilateral nasal obstruction should be considered a major red flag demanding immediate medical attention. What I always tell patients is this: a swollen nose after trauma isn’t always “just a bruise.” If breathing feels off or swelling is persistent, it’s worth getting checked, early action can prevent long-term damage.

American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS). (n.d.). Nosebleeds. Retrieved from https://www.enthealth.org/conditions/nosebleeds/ (Note: While not a direct source for septal hematoma, it is a related patient resource).

Merck Manual Professional Version. (2023). Nasal Septal Hematoma. Retrieved from https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/approach-to-the-patient-with-nasal-and-pharyngeal-symptoms/nasal-septal-hematoma

Patel, N. A., & Ferguson, B. J. (2023). Nasal Fracture. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470247/