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46
5 Injuries oftheEyelids, Canaliculi, andCanthi
Fig. 5.8 (a) Partial-
thickness laceration of
the left lower eyelid. (b,
c) Postoperative aspect
of the same patient
6months after the injury
a
b
c
of the laceration in relation to the muscle bers
of the m. orbicularis oculi. Lacerations parallel
to the muscle bers do not tend to gape even in
cases of laceration of the underlying diaphragms. When the wound forms an angle or is
vertical to the muscle bers, it tends to gape
and in cases of injury of the underlying diaphragms, fat herniation is possible (Mustardé
1991). Small, partial-thickness lacerations par-
allel to the muscle bers may not need suturing,
especially in children. Wound approximation
and xation with steristrips usually sufce.
Larger wounds are sutured using either inter-
rupted (Prolene 6.0 or Nylon 6.0) (Fig.5.9) or a
continuous suture (Prolene 5.0 or 4.0). Partialthickness lacerations at an angle or vertical to
and involvement of the muscle bers are best
closed in two layers. The muscle bers are
sutured with interrupted Vicryl 5.0 or 6.0
sutures and the skin as described above.
Meticulous adaptation of the muscle at the
upper eyelid fold is mandatory in order to
restore its form. Multiple lacerations are treated
with the same principles as mentioned for single lacerations. Sutures are usually removed on
the fth postoperative day.
5.2 Eyelid andCanalicular Lacerations
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47
Fig. 5.9 (a, b) Male
patient with left upper
and lower eyelid
lacerations, which were
sutured with interrupted
6.0 nylon sutures
Fig. 5.10 Male patient with full-thickness laceration of
the left upper and lower eyelids
ab
Presence of multiple scraping lacerations
(abrasions) requires careful cleaning with an
antiseptic solution (e.g., Cetavlon 1%) and thorough removal of all foreign bodies and dirt in
order to avoid permanent skin tattooing. Special
care is taken during debridement not to remove
tissue which may be viable. Eyelids have a rich
vascular supply, and even “dodgy” tissue may
nally survive. Extensive debridement may lead
to extensive scarring with resulting deformation.
Deeper abrasions may need suturing, and supercial ones are treated with local antibiotics (3×
daily) or are dressed with a non-adherent dressing (e.g., Jelonet) which promotes epithelialization. Change of dressing is required daily.
Full-thickness lacerations involve all three
layers of the eyelids (Figs.5.10 and 5.11). They
are usually oblique, and not vertical, due to the
protection of the supraorbital margin, the nose,
and the cheeks. Occasionally, they extend to the
underlying cornea; therefore, thorough preoperative eye examination is of great importance. Aim
of closure in the marginal lacerations is the exact
adaptation of the wound edges to avoid excessive
scar formation and notching.
When full-thickness lacerations are sutured, it
is advisable to use a cornea shield in order to
avoid iatrogenic cornea abrasions. When approximating the wound surfaces, a guiding suture is
rst placed at the gray line. Several techniques
exist to close the full-thickness lacerations. All
aim at suturing three layers: tarsus/conjunctiva,
orbicularis oculi muscle, and skin. Care is taken
to place the knots of the rst layer facing the tarsus to avoid cornea damage. Interrupted sutures
are used by the author, whereas other surgeons
prefer continuous sutures for this purpose
(Mustardé 1991). Finally, two last sutures are
placed on each side of the gray line, which
achieves a stable reapproximation of the free
margin. The ends are left long and attached to the
skin. If the wound is extended beyond the eyelid,
the remainder is closed in layers. Steristrips cover
the sutures, and ophthalmic ointment is used for
the conjunctiva. Additional incisions or Z-plasties
48
5 Injuries oftheEyelids, Canaliculi, andCanthi
a
b c
de
Fig. 5.11 (a, b) Female patient with serious left perior-
bital injury. There is a full-thickness laceration of the
upper eyelid, a small laceration of the lower eyelid, and
extensive hyposphagma. (c) CT scan of the same patient
showing extensive bony injury of the left side of the
orbital face. (d) Postoperative illustration 2weeks after
repair of the injury. (e) Postoperative illustration 1 year
later. A left enophthalmos was surgically corrected in the
meantime
are avoided during primary closure. If both eyelids are injured, the same principles are applied
for the lower as well as the upper eyelid.
Traumatic eyelid avulsion (Fig. 5.12) is
reported infrequently. Surgical reimplantation is
possible even 10h after injury, especially if the
avulsed part has been handled properly. Goldberg
et al. (1992) conducted an experimental study,
after successful reimplantation of an avulsed
upper eyelid (>75% of total eyelid surface) and
suggested that eyelid tissues should not be
immersed in saline and should be stored at 4°C,
and if reimplantation time is <6 h, storage in a
cold, moist environment is adequate. In cases of a
total eyelid avulsion, meticulous microsurgical
techniques are necessary for reanastomosis of the
arterial supply to the avulsed eyelid. Fortunately,
these cases are rare and often result after animal
bites (Soueid etal. 2006).
Close attention must be paid to avoid vertical
tension on the wound site or surrounding tissues
of a repaired lower eyelid during closure because
this increases lid retraction and the possibility of
postoperative ectropion or lagophthalmos.
Postoperative care includes liberal application
of topical antibiotic ointment to the wound,
avoiding sun and water exposure, and limiting
makeup application for 2–3 weeks (Chang and
Rubin 2002).
Canalicular involvement has been reported to
occur in 36% of eyelid injuries (Naik etal. 2008).
The lower canaliculus is more frequently injured
(54.1%) than the upper (33.3%). Injury of both
canaliculi is less frequent (12.5%) as was reported
in a study of 66 cases with eyelid injuries (Naik
etal. 2008) (Fig.5.13).
Direct, indirect, or diffuse forces may injure
canaliculi. Avulsive blunt injuries (due to indirect
or diffuse trauma) accounted for 45.7% of the
lacerations, whereas direct penetrating injuries
were more frequent and accounted for 55.2% of
the canalicular lacerations in a study of 236
patients from the University of Ottawa Eye
Institute, Ottawa, Canada (Jordan et al. 2008).
Lacerations involving other parts of the eyelids,
periocular area, and face made up the greatest
number of associated injuries and occurred with
equal frequency in the direct penetrating group
5.2 Eyelid andCanalicular Lacerations
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49
a
bc
de
Fig. 5.12 (a, b) Male patient with a complex left perior-
bital injury. There is a partial avulsion of the upper eyelid
and a full-thickness laceration of the lower eyelid. (c)
Preoperative picture clearly showing the partially avulsed
upper eyelid. (d) Immediate postoperative picture. (e) The
same patient 1year after initial repair
interest in oculoplastic surgery across the United
Kingdom were sent questionnaires to determine
caseload, intraoperative techniques (magnication, suture, and stents), and postoperative management (antibiotic use, stent placement and
replacement, and secondary lacrimal surgery) of
patients with canalicular injury. Eighty-nine
(74%) questionnaires were returned and analyzed.
Most of the respondents (63%) treated between
one and ve canalicular injuries over the previous
year. Thirty-eight (43%) of them would repair a
Fig. 5.13 Patient with naso-orbital injury extending to
the right canalicular system
monocanalicular injury only if the lower canaliculus was involved, and 36 (40%) would always
repair a monocanalicular injury. Eighty-two
and the indirect/diffuse group. More serious
associated injuries including orbital fractures,
globe rupture, other body injuries, and head
trauma were more commonly seen when diffuse
trauma was involved (Jordan etal. 2008).
The management of lacrimal canalicular injury
is controversial. There is disagreement among
surgeons regarding technique (use of magnication, sutures, catheters–stents) and postoperative
management. Data provided by the study by Ho
and Lee (2006) are indicative of the existing controversy. One hundred and twenty National Health
Service-based consultant ophthalmologists with
(92%) respondents used magnication during surgery. Fifty-one would never consider using the
pigtail probe. Eighty-ve (96%) would use the
bubble test and/or uorescein dye to locate the
severed medial canalicular end. Vicryl or Dexon
was the suture of choice for 76 (85%) and 63
(71%) respondents for repairing pericanalicular
and canalicular tissues, respectively. Thirteen
respondents did not stent their canalicular repairs.
Forty-seven (53%) routinely used prophylactic
antibiotics. Finally, 76% of the respondents would
wait between 3 and 12months before undertaking
further lacrimal surgery (Ho and Lee 2006).
50
5 Injuries oftheEyelids, Canaliculi, andCanthi
A review of the literature conrmed the existing controversy regarding the treatment of canalicular injuries. Surgical repair of monocanalicular
injuries ranges from urgent primary microsurgical repair (Struck 2009) to simple closure of the
supercial m. orbicularis oculi and skin without
canalicular reconstruction (Smit and Mourits
2000). The latter, simple way of treatment
resulted in a totally blocked canaliculus in all
patients. In spite of this, however, none of the
patients experienced epiphora either indoors or
outdoors. At a follow-up 3–33 months posttrauma (mean 13.7months), tear drainage of the
ipsilateral unharmed canaliculus was functioning
normally in such a way that epiphora was prevented (Smit and Mourits 2000).
A recent literature search concluded that
monocanalicular stents seem to be efcacious
and well tolerated, although extrusion rates vary
from 0% to 29% (Wladis etal. 2019). Additionally,
canalicular laceration repair with Mini Monoka
stent in children younger than 10years showed
good outcomes both anatomical and functional
irrespective of time lag since injury (Agarval
etal. 2021).
The author of this study was trained to always
repair the lower canaliculus using magnication
and stents and not repair the upper canaliculus,
merely suturing the supercial injured layers.
Potential complications of monocanalicular
stent repair include extrusion (most commonly),
tube displacement, granuloma, ectropion, slit
punctum, stula, and infection (Wladis et al.
2019).
Postoperative follow-up reveals the presence,
or not, of epiphora or dacryocystitis, in which
case secondary lacrimal surgery is indicated.
Waiting time is usually 6 months after primary
repair. It should be noted that success rate of primary repair is roughly 70–82% (Struck et al.
2004). Tint etal. (2011) reported a minimal, mild,
and moderate epiphora of 18%, 12.5%, and 2.5%,
respectively, after bicanalicular surgical repair
and stenting (bicanalicular Crawford stent).
Dacryocystorhinostomy (DCR), the removal of
bone lying between the lacrimal sac and the nose
and creation of an anastomosis between median
wall of the sac and nasal mucosa, has a success
rate of 87.5% (Struck etal. 2004). In cases without
prior DCR, endoscopic dacryocystorhinostomy
has a similar success rate (83.3%—Kim et al.
2013). However, only 57.1% of the revision cases
reported resolution of epiphora after endoscopic
DCR (Kim etal. 2013). External dacryocystorhinostomy with silicon intubation remains one of the
most effective procedures for patients with traumatic lacrimal blockage (Sodhi etal. 2003).
5.3 Medial andLateral Canthus
Lacerations
The medial canthal tendon is a strong structure
with an average breaking strength of 36 Newtons
and an elongation of 6.25 mm (Dagum et al.
1995). In addition to its functional importance in
relation to the lacrimal pump mechanism, the
medial canthus denes the intercanthal distance
and the size and shape of the palpebral ssure.
During trauma, partial or total disruption of its
bony insertion occurs. Failure to reattach it results
in medial canthal dystopia with rounding of the
palpebral angle and alteration of the size and
inclination of the palpebral ssure (traumatic
telecanthus, Fig.5.14). Correction of this deformity, in cases of full rupture, requires dissection
Fig. 5.14 Patient with
traumatic telecanthus.
(a) Preoperatively. (b)
Immediately after
canthal repair
(canthopexy) and
reduction of the
intercanthal distance
ab
5.3 Medial andLateral Canthus Lacerations
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51
Fig. 5.15 (a, b)
Anterior and lateral
X-ray showing the
transnasal wire and
securing plates after a
direct canthopexy
a b
and adequate mobilization of the medial canthal
tendon, subperiosteal exposure of the medial
orbit, precise identication of the correct anatomical location for tendon placement, and secure
xation of the tendon (Antonyshyn etal. 1996).
Whether as a primary or a secondary procedure,
the divided ends of the severed medial canthus
ought to be sought and resutured. If the medial
stump cannot be identied, the canthal tendon
may be xed to the periosteum of the orbital margin with a 5.0 Prolene (nonabsorbable) suture. If
suturing of the medial canthus to the periosteum
does not adequately correct the deformity, the
canthal tendon is held in place by a 0.3mm soft
stainless transnasal wire, passed by means of a
curved awl across the nasal cavity through a hole
drilled in the opposite nasal bone and twisted/
secured over a small plate or button lying on the
lateral side of the contralateral nasal bone (direct
canthopexy) (Freihofer 1980; Mustardé 1991)
(Fig. 5.15). The technique of transnasal wiring
has been widely used. The overall results after
treatment of 14 canthopexies in recent trauma
cases were reported as acceptable (Freihofer
1980) (Fig.5.16). Other surgeons have preferred
the ipsilateral techniques that include the nylon
anchor suture, stainless steel screw, and cantilevered mini plates. Antonyshyn et al. (1996)
described the Mitek Mini GII Anchor, which features a titanium body with a hole for suture placement. A drill hole is made at the precise location
of tendon attachment, and the anchor is tted in
the drill hole. Pulling back locks the arcs of the
anchor against the bone and thus provides secure
bone xation. The medial canthus is dissected,
mobilized, and secured through a suture to the
bone at the anchor. Goldenberg et al. (2008)
described the titanium micro-anchor device and
reported stable improvement of the distance from
the medial canthus to the midline 1year postoperatively. For all patients though, nal values
were lower than those initially obtained.
When the canthal ligament is still attached to
a bony fragment, the latter ought to be reduced
and xed by means of wire or mini plate osteosynthesis to adjacent bone, thus indirectly repairing the canthal dislocation (indirect
canthopexy).
A recent anatomical study showed that the
anterior limb of the medial canthal ligament is
the most developed and rmly adherent part.
According to the authors, reattachment of that
part seems to be adequate for repair of a traumatically detached medial canthus (Gulses et al.
2012).
It should not be forgotten that if the fullthickness injury lies medial to the punctum, the
canaliculus will have been severed, and in the
lower eyelid the previously described steps (see
canalicular injury, same chapter) must be taken to
repair this structure.
The lateral canthal ligament is attached to the
orbital tubercle a few millimeters inside the lateral orbital margin. Because of this, the ligament
pulls the lids round the globe and not simply out
towards the lateral wall. Any repair of the ligament must try to achieve the same direction of
pull of the canthus (Mustardé 1991).
Traumatic dislocation of the lateral canthus
may result from injury to this structure. Suturing
52
5 Injuries oftheEyelids, Canaliculi, andCanthi
ab
Fig. 5.16 (a, b) Postoperative picture of a male patient a few weeks after direct canthopexy. The intercanthal distance
is within normal limits
of the divided ligament, or the exposed cut edges
of the tarsal plate with 5.0 Prolene to the stump of
the ligament (inside of the orbital margin) or to
the periosteum round the orbital tubercle, will
repair the injury. If the injury is severe and the
displacement considerable, a more secure canthopexy may be achieved by drilling a hole in the
lateral orbital wall and securing the canthus to
bone.
References
Agarval R, Patidar N, Mohan A, etal. Pattern of presen-
tation and surgical outcomes of canalicular laceration
repair in a pediatric population. J Pediatr Ophthalmol
Strabismus. 2021;58:42–7.
Anson BJ, McVay CB. Special senses. In: Anson BJ,
McVay CB, editors. Surgical anatomy. Philadelphia,
PA: Saunders; 1971. p.61.
Antonyshyn OM, Weinberg MJ, Dagum AB.Use of a new
anchoring device for tendon reinsertion in medial canthopexy. Plast Reconstr Surg. 1996;98:520–3.
Chang EL, Rubin PA.Management of complex eyelid lac-
erations. Int Ophthalmol Clin. 2002;42:187–201.
Dagum AB, Antonyshyn O, Heam T.Medial canthopexy:
an experimental and biomechanical study. Ann Plast
Surg. 1995;35:262–5.
Freihofer HPM.Experience with transnasal canthopexy. J
Maxillofac Surg. 1980;8:119–24.
Goldberg SH, Bullock JD, Connelly PJ. Eyelid avul-
sion: a clinical and experimental study. Ophthal Plast
Reconstr Surg. 1992;8:256–61.
Goldenberg DC, Bastos EO, Alonso N, etal. The role of
micro-anchor devices in medial canthopexy. Ann Plast
Surg. 2008;61:47–51.
Gulses A, Varol A, Gayretli O, et al. Anthropometry
of the medial canthal ligament related to nasoorbitoethmoidal fractures. J Craniofac Surg.
2012;23:1151–3.
Ho T, Lee V.National survey on the management of lac-
rimal canalicular injury in the United Kingdom. Clin
Exp Ophthalmol. 2006;34:39–43.
Jordan DR, Ziai S, Gilberg SM, et al. Pathogenesis of
canalicular lacerations. Ophthal Plast Reconstr Surg.
2008;24:394–8.
Kim C, Kacker A, Pearlman AN, et al. Results of com-
bined multispecialty endoscopic dacryocystorhinos-
tomy. Orbit. 2013;32:156–60.
Mustardé JC. Repair and reconstruction in the orbital
region. Edinburgh: Churchill Livingstone; 1991.
Naik MN, Kelapure A, Rath S, etal. Management of cana-
licular lacerations: epidemiological aspects and expe-
rience with Mini-Monoka monocanalicular stent. Am
J Ophthalmol. 2008;145:375–80.
Romanes GJ. The skin and the sensory organs. In:
Romanes GJ, editor. Cunningham’s textbook of
anatomy. London: Oxford University Press; 1972.
p.812–4.
Smit AJ, Mourits MP. [Absence of epiphora in patients
with a monocanalicular injury without surgical recon-
struction]. Ned Tijdschr Geneeskd. 2000;144:1584–7.
Sodhi PK, Pandey RM, Malik KP.Experience with bican-
alicular intubation of the lacrimal drainage apparatus
combined with conventional external dacryocystorhi-
nostomy. J Craniomaxillofac Surg. 2003;31:187–90.
Soueid NE, Khoobehi K, Lee MR.Microsurgical replan-
tation of total upper eyelid avulsion. Ann Plast Surg.
2006;56:99–102.
Struck HG. [Lacrimal system lacerations and their surgi-
cal repair]. Ophthalmologe. 2009;106:223–8.
Struck HG, Horix D, Ehrich D. [Lacrimal system injuries-
primary and secondary surgical care]. Klin Monatsbl
Augenheilkd. 2004;221:609–14.
Tint NL, Alexander P, Cook AE, etal. Eyelid avulsion
repair with bi-canalicular silicone stenting without
medial canthal tendon reconstruction. Br J Ophthalmol
2011;95:1389–92.
Wladis EJ, Aakalu VK, Tao JP, et al. Monocanalicular
stents in eyelid lacerations: a report by the American
Academy of Ophthalmology. Ophthalmology.
2019;126:1324–9.
Injuries oftheNose
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6
6.1 Anatomy oftheNose
The nose is a pyramidal structure situated in the
middle of the face. It is composed of a bony and
a cartilaginous skeleton (Fig.6.1). The free anterior margin (bridge) runs to its root at the forehead and terminates below at the apex or lobule
of the nose. The lateral walls of the pyramid
expand into the mobile alae (wings) of the nose.
The base presents two apertures or nares separated by a median column or septum (Fig.6.2).
The overlying skin is thin and mobile over the
root of the nose, but it is thick and adherent over
the apex.
The nasal bones, the cartilage of the septum,
and the three pairs of cartilages (lateral, greater,
and lesser alar) make up the skeletal framework
of the external nose. At the cranial end, at the root
of the nose, the nasal bones articulate with the
frontal bone, the perpendicular plate of the ethmoid, and the frontal process of the maxillae. At
their caudal end, they are broad and thin, much
exposed to trauma, whereas at the cranial end,
they are narrow, thick, and well protected from
injury.
The lower part of the nose has a framework of
cartilages and small muscles responsible for
movements of the nostrils. The lateral cartilages
are situated immediately below the nasal bones.
Their anterior borders are continuous with each
other and with the anterior margin of the septal
cartilage, while inferiorly they are connected
with the greater alar cartilages. Each greater alar
cartilage is situated below the corresponding lateral cartilage. The lateral crus (its main body) lies
in the ala, and the medial crus lies against the
lower edge of the septal cartilage, which separates it from its contralateral fellow. Three or four
lesser alar cartilages intervene between the lateral crus and the maxilla.
The septal cartilage forms the greater part of
the nasal septum. It is situated slightly to one or
other side of the midline, most frequently to the
left (Wyburn 1972). Its anterosuperior border is
attached to the back of the internasal suture and
the anterior margins of the lateral nasal cartilages. The anteroinferior border lies between the
medial crura of the greater alar cartilages. The
posterosuperior border is joined to the perpendicular plate of the ethmoid, and the posteroinferior border is attached to the vomer and the
anterior nasal spine.
The external nose has an abundant vascular
supply, and therefore post-injury ischemic aps
have a great possibility to survive. The arteries
are branches of the facial artery and the ophthalmic artery. The veins drain to the facial vein and
also communicate with the ophthalmic veins.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
C. A. Ioannidis, Soft Tissue Injuries of the Head and Neck,
https://doi.org/10.1007/978-3-031-14915-3_6
53
54
e
Septal cartilage
Fig. 6.1 Schematic
representation of the
bony and cartilaginous
skeleton of the nose
6 Injuries oftheNose
Lateral n. cartilage
Greater alar cartilag
Lesser alar cartilage
Fig. 6.2 Schematic representation of the nasal septum
6.2 Diagnosis ofNasal Trauma
Once life-threatening injuries, when present, are
stabilized, a careful history and physical examination should be completed and treatment individualized. The ultimate objective of treatment is
to achieve both a functional and a cosmetic restoration with timely diagnosis and repair. The history of a patient with nasal trauma is important
for the management. The mechanism of injury,
time of injury, patient age, and presence of preexisting nasal deformities are essential factors.
Fig. 6.3 Nasal laceration of the right side and nasal
deformity. The strong clinical suspicion of a nasal fracture
needs to be conrmed radiologically
The type and extent of injury depend on the
mechanism, the vector, and the magnitude of
force. The time of injury in relation to the time of
initial examination and treatment is a further factor to consider. Within the rst few hours postinjury, before substantial swelling, more accurate
evaluation is possible and surgical treatment is
easier. The age of the patient (child, adult) is
important, among others, for the type of anesthesia to be used for treatment (local, sedation). It is
also important to obtain a medical history regarding previous nasal trauma and deformities.
External physical examination assesses the
location and extent of soft-tissue injury as well as
the possible loss of soft tissue. If there is suspicion
of a nasal fracture (Fig.6.3), radiographic imaging
6.3 Septal Hematoma
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55
is indicated. Internal physical examination is facilitated by a headlight, nasal speculum, suction, and,
occasionally, a exed endoscope. Cleaning of the
nasal cavity (careful removal of blood clots, suctioning out any blood) allows better inspection.
Occasionally, a local anesthetic with vasoconstrictive effects (e.g., 2% xylocaine with adrenalin
1:200,000) should be used to control the bleeding
and facilitate examination. Special attention is
paid to the nasal septum and the possible presence
of a hematoma. Mucosal tears and their extent are
noted. The nasal endoscope better visualizes the
posterior part of the septum and nasal cavity.
After completion of the examination, an individualized treatment plan is set up. Immediate
repair is ideal and, when medically possible,
should be carried out in order to decrease longterm sequelae.
6.3 Septal Hematoma
A nasal septal hematoma (Fig.6.4) may occur in
1% of nasal trauma cases (Leopard etal. 2012).
This blood collection in the potential space
between the nasal septal cartilage and its overlying mucoperichondrium occurs as a consequence
of shearing forces and small-vessel rupture. The
nasal cartilage depends on its surrounding perichondrium and supporting tissue for its metabolic needs. An untreated septal hematoma
physically separates the cartilage from its perichondrium and thus deprives the former from its
nutrients. This results in rapid destruction of the
septal cartilage, often within 24 h, which may
further result in septal perforation and/or an
unsightly saddle nose deformity (Canty and
Berkowitz 1996; Zielnik-Jurkiewicz etal. 2008).
Furthermore, infection of the hematoma usually results in an abscess, which may either
spread or cause local cartilage destruction. Other
complications of a nasal septal abscess are rare.
They include meningitis, orbital cellulitis, cavernous sinus infection, and thrombosis and osteomyelitis of the cranial bones (Wallenborn and
Fitz-Hugh 1963).
Nasal obstruction is the most common symptom. Pain, rhinorrhea, and fever (in cases of an
infection) occur in half of the patients (Canty and
Berkowitz 1996).
Successful management of hematoma (or
abscess) depends on immediate incision and
drainage, as well as appropriate antibiotic therapy. Unfortunately, quite often, patients, especially children, present several days after the
episode of trauma (Kryger and Dommerby 1987;
Canty and Berkowitz 1996).
The hematoma should be drained at its most
dependent point by a horizontal incision across
the swollen area, as low as possible in the septum, so that subsequent loculation of pus is prevented (Shapiro 1978). Bilateral drainage is
occasionally necessary, if the hematoma has not
resulted in cartilage destruction. Any loose pieces
of cartilage should be removed. A drain is placed
followed by intranasal packing, which replaces
the mucoperichondrium against the cartilage.
Broad-spectrum antibiotics, covering among others staphylococci, should be started parenterally,
and the regimen is adjusted according to the culture results. Kryger and Dommerby (1987)
reviewed 27 patients (of a total of 52 surgically
treated patients) with a septal hematoma and 12
patients with a septal abscess, all resulting after
trauma. The average delay of treatment was 48h
for patients with a hematoma and 11 days for
patients with abscesses. Incision, drainage, and
nasal packing under general anesthesia were performed in all patients. Eight patients (20%)
showed cartilage resorption. Further follow-up
showed that seven patients (17%) had received
further surgical treatment during the observation
period (mean 44months).Fig. 6.4 A nasal septal hematoma of the right side
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