A STRAWBERRY IN THE NOSE

Abstract

Dear Editor, A 4-year-old girl presented to Accident and Emergency with a history of an accidental fall approximately 7 days prior. Her mother was particularly concerned by what she described as the ‘meaty’ appearance of the inner aspect of her daughters nose. The child had symptoms of nasal obstruction and mild swelling of the nasal dorsum. Evacuation of the nose confirmed a large septal haematoma (Fig. 1). Subsequent evacuation of the haematoma was performed under general anaesthesia. The integrity of the caudal and dorsal cartilaginous septum appeared intact. A Yates drain was placed in situ to prevent re-accumulation of the haematoma, and the nose was packed with Merocel sponges bilaterally. The drain and packs were removed the next day, and the patient was discharged from the hospital with an uneventful recovery. The parents were informed that subsequent aesthetic changes could evolve secondary to ischaemic chondral necrosis, as a result of the injury and the prolonged duration of the haematoma. Septal haematoma of the nose giving the appearance of a ‘strawberry’ in the nose. Nasal trauma is common in children with most injuries being sustained through accidental or sports injuries.1 Any suspicion of injury sustained through non-accidental injury should be discussed and acted upon in accordance with the guidelines of that particular hospital. Septal haematoma is an important diagnosis that requires prompt recognition by the attending physician.2 Management by evacuation is necessary to prevent destruction of the nasal septum as the haematoma can compromise the blood supply to this fragile cartilaginous septum.3 If not managed quickly, the probability of the formation of a septal abscess is high, and with it, necrosis of the septal cartilage is almost definite. Subsequently, there is the possibility of the child developing a ‘saddle nose’ deformity in the future. This may require correction by means of a septorhinoplasty when the child becomes an adult. Nasal trauma is frequent in children; however, nasal septal haematoma in this age group appears to be relatively rare. Perhaps, this is due to the predominantly cartilaginous structure of the nasal dorsum that provides flexibility and resistance to significant traumatic injury to the septal vasculature. In this case, the child did not present until a week after the fall, and, therefore, we can not be clear how long the haematoma had indeed been present. It is important to stress that early diagnosis is essential. Septal haematoma must be managed promptly and cannot be managed conservatively. This is to prevent irreversible aesthetic changes that in a developing face could bare severe consequences requiring major surgery such as a septorhinoplasty in later life.