1. DEFINITION

• Septal haematoma = collection of blood between septal cartilage/bone and its mucoperichondrium/mucoperiosteum.

• Occurs when trauma causes separation of mucoperichondrium from underlying cartilage.

• Surgical emergency, because:

  • Cartilage is avascular

  • Nutrient supply comes only from mucoperichondrium

  • Blood collects → cuts off nutrition → cartilage necrosis within hours

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2. WHY IT IS AN ENT EMERGENCY

• Septal cartilage survives solely on diffusion from perichondrium.

• Haematoma lifts mucoperichondrium → ischemia, resulting in:

  • Septal cartilage necrosis

  • Septal abscess

  • Saddle nose deformity

  • Severe DNS

  • Intracranial spread → cavernous sinus thrombosis (rare but fatal)

Key rule:
Any nasal trauma must always be assessed for septal haematoma — never miss it.

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3. EPIDEMIOLOGY

• Seen in all ages, especially children, because:

  • Loose mucoperichondrial attachment

  • Even minor trauma can form haematoma

• Common after:

  • Road traffic accidents

  • Sports injury

  • Fall on nose

  • Fist blow injuries

  • Iatrogenic (after nasal surgery)

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4. APPLIED ANATOMY

4.1 Septal Composition

• Anterior portion: quadrilateral cartilage

• Posterior portion: bone

• Both covered by mucoperichondrium/periosteum

4.2 Blood Supply

• Septum gets blood from:

  • Kiesselbach plexus

  • Septal branch of sphenopalatine

  • Anterior ethmoidal artery

  • Superior labial artery

4.3 Why Cartilage Is Vulnerable

• Cartilage has no direct blood supply.

• Even small haematoma can cause:

  • Chondritis

  • Necrosis

  • Collapse of dorsal support → saddle nose

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5. ETIOLOGY

5.1 Traumatic Causes (Most Common)

• Direct blow to nose

• Sports injuries (cricket ball, football, boxing)

• Road traffic accidents

• Falls

• Altercations

• Iatrogenic (septal surgery, nasal intubation)

5.2 Non-traumatic Causes (Rare)

• Bleeding disorders

• Hemophilia

• Leukemia

• Anticoagulant therapy

• Spontaneous haematomas in infants during birth trauma

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6. PATHOGENESIS

Step 1: Trauma

• Impact causes rupture of submucosal vessels.

Step 2: Mucoperichondrium separates

• Blood accumulates between:

  • Cartilage and mucoperichondrium

  • Or bone and mucoperiosteum

Step 3: Pressure increases

• Separation is sustained as blood pressure expands hematoma.

Step 4: Cartilage ischemia

• No nutrients → cell death within 24–48 hours.

Step 5: Superinfection

• Stagnant blood accumulates → bacterial growth → septal abscess

Step 6: Cartilage necrosis

• Loss of structural support → saddle nose deformity

This is why urgent drainage is mandatory.

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7. CLINICAL FEATURES

7.1 Symptoms

• Nasal obstruction on both sides (bilateral haematoma)

• Feeling of nasal blockage after trauma

• Dull pain in nasal bridge

• Headache

• Change in nasal shape (collapse if delayed)

• Fever if abscess develops

• Difficulty breathing, snoring in children

Important:
Obstruction is disproportionately severe for the degree of trauma.

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7.2 Signs (Very Important for Exams)

A. Anterior Rhinoscopy Shows:

• Smooth, round, fluctuant, bluish-red swelling on one or both sides

• Located anteriorly, displacing septum

• Swelling is tender, fluctuant, and does NOT shrink with decongestant

B. Bilateral Haematoma

• Septum appears widened

• Nasal airway nearly blocked

C. Differentiating from Deviated Nasal Septum

D. Septal Abscess Indicators

• High fever

• Severe throbbing pain

• Pus seen under mucosa

• Overlying mucosa erythematous

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8. DIAGNOSIS

8.1 Clinical Diagnosis

• Mainstay; no advanced tests required

• Visual inspection + palpation with probe

8.2 Nasal Endoscopy

• Used if:

  • Trauma severe

  • Hidden posterior extension

  • Suspicion of abscess

8.3 Imaging

Not routine.
Used when:

• Fractures suspected

• Complex trauma

• CT scan reveals:

  • Septal deviation

  • Fractures

  • Associated sinus issues

Always treat first → do CT later if needed.

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Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

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9. MANAGEMENT (ENT PURE)

Septal haematoma → URGENT SURGICAL DRAINAGE.

9.1 Immediate Steps

• Admit patient

• Analgesia

• Antibiotic coverage

• Prepare for drainage

9.2 Drainage Procedure (Step-by-Step)

1. Anesthesia

• Local anesthesia with lignocaine + adrenaline

• Children need general anesthesia

2. Incision

• Horizontal incision over most prominent part

• Made on mucosal surface

• Blood evacuated

3. Suction & Irrigation

• Remove all clots

• Irrigate with saline

• If abscess: drain pus + send for culture

4. Bilateral cases

• Drain both sides separately

5. Quilting Sutures

• Prevent reaccumulation

• Compress perichondrium back onto cartilage

6. Packing

• Anterior nasal pack for 24–48 hours

7. Antibiotics

• Broad-spectrum (e.g., co-amoxiclav)

• Continue 5–7 days

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10. MANAGEMENT OF SEPTAL ABSCESS

If haematoma becomes infected:

Features

• Fever

• Increased pain

• Red mucosa

• Pus under mucosa

• Toxic appearance in children

Management

• URGENT I&D

• Broad-spectrum IV antibiotics

• Culture and sensitivity

• Monitor for complications (e.g., meningitis)

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11. COMPLICATIONS (IF UNTREATED)

EXTREMELY IMPORTANT EXAM QUESTION

Local Complications

• Cartilage necrosis

• Saddle nose deformity (classic sign)

• Septal perforation

• Severe DNS

• Cosmetic deformity

Infective Complications

• Septal abscess

• Cellulitis

• Cavernous sinus thrombosis

• Meningitis

Functional Complications

• Permanent nasal obstruction

• Snoring

• Chronic sinusitis

In Children

• Disturbed nasal growth

• Midface deformity

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12. PROGNOSIS

• Excellent if drained early

• Poor if diagnosis delayed:

  • Irreversible cartilage loss

  • Cosmetic deformity requiring reconstructive surgery

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13. SPECIAL NOTES FOR VIVA

• Most important complication: saddle nose deformity

• Most important sign: fluctuant swelling that does not shrink with decongestant

• Most common cause: trauma

• Treatment of choice: immediate incision & drainage

• Septal abscess must be treated within hours

• Always examine for septal haematoma after ANY nasal trauma

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14. HIGH-YIELD ENT VIVA QUESTIONS

• Define septal haematoma.

• Why is it an ENT emergency?

• How do you differentiate DNS from septal haematoma?

• Steps of drainage procedure.

• Why is saddle nose formed?

• What is the blood supply of septal cartilage?

• What complications occur if not treated?

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15. CLINICAL CASE (EXAM STYLE)

A 9-year-old child presents after a fall. He has nasal obstruction and soft, red swelling on anterior septum. Decongestant spray produces no change.

Diagnosis:

Septal haematoma.

Management:

Immediate bilateral drainage + packing + antibiotics.

Risk if delayed:

Saddle nose deformity.

16. HISTOPATHOLOGY & MICROSCOPIC DETAILS

16.1 Early Phase (First 24 Hours)

• Blood accumulates in the potential space between cartilage and mucoperichondrium.

• Microscopy shows:

  • Fresh RBC collections

  • Few neutrophils

  • Intact cartilage matrix but early signs of ischemia

• Perichondrium appears:

  • Edematous

  • Expanded

  • Beginning to separate from cartilage surface

16.2 Intermediate Phase (24–48 Hours)

• Cartilage begins to lose viability.

• Microscopy shows:

  • Chondrocyte death

  • Loss of nuclear staining (pyknosis → karyolysis)

  • Perichondrial inflammatory infiltrate

• Bacteria may begin colonization → transition into abscess formation.

16.3 Late Phase (48–72 Hours)

• Cartilage becomes necrotic.

• Mucoperichondrium:

  • Thickened

  • Filled with polymorphs

  • May show tissue breakdown

• Pus formation replaces blood → septal abscess.

• Necrotic cartilage loses structural integrity → increases risk of saddle nose deformity.

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17. PEDIATRIC SEPTAL HAEMATOMA (VERY IMPORTANT FOR EXAMS)

17.1 Why Children Are at Higher Risk

• Loose mucoperichondrial attachments

• Thicker mucosa → swelling less visually obvious

• Greater cartilage dependence for nasal growth

• Even minor trauma (light hit during play) can cause haematoma

17.2 Why Pediatric Septal Haematoma Must Never Be Missed

• Growth disturbances of:

  • Dorsal nasal support

  • Maxillary development

  • Mid-face symmetry

• Potential for long-term cosmetic and functional deformity

17.3 Pediatric Presentation

• Irritability

• Mouth breathing

• Nasal blockage

• Feeding difficulty in infants (because they are obligate nasal breathers)

• Delayed diagnosis common because:

  • Children may not report trauma

  • Parents overlook initial symptoms

17.4 Pediatric Management Differences

• General anesthesia preferred

• Wider incision margins

• Longer antibiotic course

• Closer follow-up to detect:

  • Synechiae

  • Re-accumulation

  • Nasal growth disturbances

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18. SEPTAL ABSCESS (ADVANCED EXPANSION)

18.1 Definition

• Pus collection between septal cartilage and mucoperichondrium.

• Usually arises from untreated septal haematoma.

18.2 Etiology

• Infected haematoma

• Nasal furunculosis spread

• Dental infections (rare)

• Immunocompromised states:

  • Diabetes mellitus

  • Steroid use

  • HIV

18.3 Microbiology

• Common organisms:

  • Staphylococcus aureus (most common)

  • Streptococcus species

  • Hemophilus influenzae in children

• Rare but severe:

  • Anaerobes

  • MRSA

18.4 Clinical Features

• Severe pain

• Fever

• Erythematous mucosa

• Fluctuant bilateral swelling

• Systemic toxicity in children

18.5 Complications

• Cavernous sinus thrombosis

• Orbital cellulitis

• Meningitis

• Intracranial abscess

• Toxic shock (rare)

18.6 Management

• Urgent I&D

• IV antibiotics

• Culture and sensitivity testing

• Nasal packing

• Evaluate for intracranial extension if severe

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19. POST-DRAINAGE MONITORING

19.1 Monitoring Timeline

• First 24 hours:

  • Bleeding

  • Pain

  • Re-accumulation

• 48–72 hours:

  • Remove packing

  • Inspect incision

  • Look for synechiae

• 1–2 weeks:

  • Healing mucosa

  • Airway patency

• 1–3 months:

  • Assess cosmetic appearance

  • Detect subtle collapse

  • Evaluate sinus function

19.2 Warning Signs for Complications

• Persistent fever → abscess

• Increasing obstruction → reaccumulation

• Saddle deformity onset → cartilage loss

• Foul smell → infection or foreign body residue

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20. SURGICAL RECONSTRUCTION FOR DEFORMITIES

(Broadened because your free material will rank higher with deep surgical notes)

20.1 Saddle Nose Deformity

• Occurs due to:

  • Loss of dorsal septal cartilage

  • Destruction of cartilage after abscess

  • Collapse of internal nasal valve

Reconstructive Options

• Autologous cartilage grafts:

  • Septal cartilage (if residual exists)

  • Conchal cartilage

  • Costal cartilage (for major collapse)

• Dorsal augmentation with:

  • Cartilage batten graft

  • Fascia

  • Irradiated bone (rare)

• External rhinoplasty approach often required

20.2 Persistent DNS After Haematoma

• Endoscopic septoplasty is preferred because:

  • Less mucosal trauma

  • Better visualization

  • More precise correction

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21. RADIOLOGICAL DETAILS FOR DNS + HAEMATOMA COMPLEX

Though septal haematoma is primarily clinical, you will outrank competitors by including radiologic detail.

21.1 Non-contrast CT PNS

Possible findings:

• Soft tissue density along septum

• Bulging mucoperichondrium

• Depressed or fractured cartilage

• Sinus opacification if associated

• Air-fluid levels in abscess formation

21.2 MRI (Rarely Used)

Used when:

• Suspicion of intracranial extension

• Differentiation from tumors

MRI shows:

• T1 hyperintense blood

• T2 signal variation based on clot age

• Rim enhancement in abscess

• Edema of adjacent cartilage

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22. IMPORTANT DIFFERENTIAL DIAGNOSES

22.1 Traumatic Swelling vs Haematoma

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22.2 Septal Abscess vs Haematoma

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23. DETAILED COMPLICATION MECHANISMS (OPTION-3 LEVEL)

23.1 Saddle Nose

Mechanism:

• Cartilage necrosis → dorsal support loss → collapse

• More severe in:

  • Children (growth center involvement)

  • Bilateral haematomas

  • Delay > 48 hours

23.2 Septal Perforation

Mechanism:

• Bilateral mucoperichondrial necrosis

• Opposing surfaces die → hole formation

• Results in:

  • Whistling sound

  • Crusts

  • Recurrent infections

23.3 External Nasal Valve Collapse

Mechanism:

• Loss of caudal septal support → alar collapse during inspiration

• Leads to:

  • Paradoxical obstruction

  • Snoring

  • Mouth breathing

23.4 Chronic Sinusitis

Mechanism:

• DNS → OMC obstruction → retained secretions

• Superadded infections become chronic

23.5 Midface Hypoplasia (Children)

Mechanism:

• Septum = growth center for nose and maxilla

• Damage results in:

  • Saddle nose

  • Retruded upper jaw

  • Flattened midface

  • Dental malocclusion

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Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

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24. ADVANCED MANAGEMENT PEARLS (FOR HIGH RANKING SEO + PRO LEVEL NOTES)

• Never delay drainage even if imaging is pending.

• Always check both sides; unilateral trauma often creates bilateral haematoma.

• Use quilting sutures in all cases to prevent reaccumulation.

• Broad-spectrum antibiotics are mandatory (cover staph + strep).

• In children, always counsel parents about possible long-term deformity.

• Reconstructive surgery must wait 3–6 months after infection resolution.

• Septal abscess drainage should include collection for culture & sensitivity.

• Always perform follow-up endoscopy at 1 week, 1 month, and 3 months.

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25. ADVANCED ENT MCQs SECTION (SEO + exam-focused)

Q1. Septal haematoma most commonly presents with:

A. Firm septal swelling
B. Bluish, fluctuant swelling on septum
C. Bilateral nasal polyps
D. Deviated nasal septum

Correct answer: B
Reason: Haematoma is soft, smooth, and fluctuant.

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Q2. Primary blood supply of septal cartilage is from:

A. Sphenopalatine artery
B. Mucoperichondrium
C. Intrinsic cartilage vessels
D. Superior labial artery

Correct answer: B
Cartilage has no intrinsic supply.

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Q3. Most common complication of untreated septal haematoma:

A. Septal perforation
B. Saddle nose deformity
C. CSF leak
D. Encephalocele

Correct answer: B

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Q4. Treatment of choice:

A. Observation
B. Oral antibiotics
C. Immediate incision & drainage
D. Topical decongestants

Correct answer: C

26. EXTENDED ANATOMICAL CORRELATIONS

26.1 Why the Anterior Septum Is A Vulnerable Zone

• The anterior septum is the thickest and most exposed portion.

• Trauma commonly displaces mucoperichondrium from:

  • Quadrilateral cartilage

  • Maxillary crest

• This region lacks fibrous attachments → blood easily dissects into potential space.

26.2 Relationship With Nasal Valves

• Septal haematoma enlarges and narrows the internal nasal valve, the key area of airway resistance.

• Even a small haematoma can cause significant dyspnea, especially in infants.

26.3 Why Posterior Haematomas Are Rare

• Posterior septum is attached firmly to:

  • Perpendicular plate (ethmoid)

  • Vomer

  • Palatine bone

• These areas do not separate easily.

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27. DETAILED STEPWISE DIFFERENTIATION FROM OTHER SEPTAL PATHOLOGIES

27.1 Septal Haematoma vs Septal Abscess

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27.2 Septal Haematoma vs Septal Deviation

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27.3 Septal Haematoma vs Turbinate Hypertrophy

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28. SEVERE AND RARE COMPLICATIONS — DETAILED EXPLANATION

28.1 Cavernous Sinus Thrombosis

Mechanism:

• Septal abscess → spread via angular and ophthalmic veins → cavernous sinus.

• Symptoms:

  • High fever

  • Ophthalmoplegia (CN III, IV, VI)

  • Proptosis

  • Severe headache

• Management:

  • IV antibiotics

  • ICU care

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28.2 Orbital Cellulitis

Mechanism:

• Infection spreads from:

  • Ethmoid sinus

  • Septal vasculature

• Symptoms:

  • Periorbital swelling

  • Painful eye movements

  • Vision impairment

• ENT emergency requiring imaging + IV therapy.

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28.3 Meningitis

Mechanism:

• Hematogenous spread

• Symptoms:

  • Fever

  • Neck rigidity

  • Photophobia

• Occurs especially in:

  • Children

  • Diabetics

  • Immunocompromised patients

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28.4 Midface Growth Disturbance (Children)

• Septal cartilage = structural growth center for:

  • Nasal dorsum

  • Maxilla

  • Midface

• Injury → reduced anterior-posterior growth → facial flattening.

• Once affected, only reconstructive surgery can correct it.

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29. SPECIAL CLINICAL SCENARIOS

29.1 Septal Haematoma in an Unconscious Patient

• Must inspect nose in all head injury patients.

• Bilateral haematoma may hide behind edema.

• Missed diagnosis → permanent deformity despite survival of trauma.

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29.2 Septal Haematoma in Infants

• Infants are obligate nasal breathers → obstruction causes:

  • Feeding difficulty

  • Cyanosis

  • Failure to thrive

• Even a small swelling becomes life-threatening.

• Drain under GA + ensure airway support.

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29.3 Recurrent Haematoma

Occurs if:

• Inadequate incision

• No quilting sutures

• Premature pack removal

• Underlying coagulopathy

Management:

• Re-drain

• Investigate hematologic disorders

• Use longer-term splints

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30. OPERATIVE TECHNIQUE — EXTENDED SURGICAL DETAIL

30.1 Instrument List

• Killian nasal speculum

• Freer’s elevator

• Blades (No. 15)

• Suction tip

• Irrigation syringe

• Quilting suture needle

• Merocel or ribbon gauze pack

• Headlight or endoscope

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30.2 Operative Steps (Expanded)

A. Exposure

• Clean nasal cavity with antiseptic.

• Insert nasal speculum carefully (avoid mucosal tears).

B. Incision Placement

• Horizontal incision:

  • Along mucosa

  • Near the most prominent part

  • Avoid cartilage damage

• Depth: just enough to reach haematoma cavity.

C. Aspiration Check

• Needle aspiration before incision confirms diagnosis.

• Syringe with dark red blood = confirmation.

D. Evacuation

• Allow blood to drain by gravity + suction.

• Large clots require gentle curettage.

E. Irrigation

• Copious saline irrigation until cavity is clean.

• If abscess: irrigate with saline + antibiotic solution.

F. Packing / Quilting

• Bilateral packing provides pressure to oppose flaps.

• Quilting sutures reduce need for prolonged packing.

G. Hemostasis

• Gentle pressure

• Packing soaked with antibiotic ointment

• Avoid tight packing → may cause necrosis.

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31. POSTOPERATIVE FOLLOW-UP — ADVANCED LEVEL

Day 1–2

• Check for bleeding

• Ensure pack remains moist

• Monitor for reaccumulation

Day 3–5

• Remove packing

• Inspect incisions

• Clean crusts

Week 1–4

• Saline irrigation

• Avoid nose blowing

• Topical antibiotics

• Look for:

  • Synechiae

  • Septal perforation

  • Persistent deviation

Months 1–6

• Track cosmetic development

• Evaluate nasal airflow

• Address persistent deformity early

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32. TIMING OF RECONSTRUCTIVE SURGERY

If deformity develops:

Children:

• Delay reconstruction until:

  • 16–18 years (after growth)

• Exception: severe disfigurement → early correction with cartilage grafts.

Adults:

• Reconstruction after:

  • Infection resolution

  • 3–6 months of stabilization

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33. EXTENDED VIVA BANK (HIGH-YIELD)

• Why is septal haematoma missed frequently?

• What is the first nutritional source of septal cartilage?

• What is the earliest sign of septal abscess?

• Why must bilateral cavities be drained separately?

• Describe saddle nose mechanism in one line.

• Why is general anesthesia preferred in children?

• Name three complications of quiltless drainage.

• Why does decongestant spray not shrink septal haematoma?

• Why are infants more symptomatic with haematoma than adults?

• Name organisms commonly isolated from septal abscess.

• What structure prevents cartilage necrosis during early drainage?

• Why is the dorsal nasal support lost after septic necrosis?

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34. CASE SCENARIOS (ADVANCED)

Case 1 — Missed Haematoma

A 25-year-old male presents 1 week after a nasal injury with nasal obstruction and external depression.

Findings:

• Mild pain

• Saddle nose deformity

• Foul-smelling discharge

• DNS

Diagnosis:

• Missed septal haematoma → septal abscess → cartilage necrosis

Management:

• Drain abscess

• IV antibiotics

• Plan reconstructive surgery after 6 months

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Case 2 — Pediatric Emergency

A 3-year-old child with nasal obstruction after fall, refusing feeds.

Findings:

• Bilateral bluish swelling

• Crying, irritability

• No fever (early stage)

Management:

• Drain urgently under GA

• Pack lightly

• Admit for observation

• Strong parental counselling regarding nose-molding habits

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Case 3 — Immunocompromised Patient

A diabetic man with septal swelling progressing rapidly to abscess.

Risk:

• Fungal infection

• Meningitis

• Orbital spread

Management:

• Wide drainage

• IV broad-spectrum + anti-pseudomonal antibiotics

• Control glucose

• Repeat endoscopy daily

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Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

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35. MCQs — EXTENDED SET

1. Most important early clinical sign of septal haematoma:

A. Severe fever
B. Fluctuant swelling on septum
C. Saddle nose
D. Purulent discharge
Answer: B

2. Septal cartilage receives nutrition from:

A. Its own vessels
B. Internal maxillary artery
C. Mucoperichondrium
D. Kiesselbach’s plexus only
Answer: C

3. Haematoma does NOT shrink with decongestant because:

A. It is avascular
B. It is deep to mucosa
C. It contains clotted blood
D. All of the above
Answer: D

4. Most serious complication:

A. DNS
B. Nasal crusting
C. Saddle nose deformity
D. Turbinate hypertrophy
Answer: C

5. Best diagnostic method:

A. X-ray
B. CT scan
C. Anterior rhinoscopy
D. MRI
Answer: C