Case presentation

A previously healthy three-year-old female was running when she tripped and hit her nose directly on the edge of a hard chair. There was no loss of consciousness or emesis post-injury. In the first hospital, she was given xylometazoline to treat epistaxis, paracetamol for analgesia, and ice packs to minimize swelling. Thereafter, she presented to the Emergency Department of our tertiary care pediatric hospital with post-traumatic epistaxis and nasal congestion.

The otolaryngology team was consulted. Examination revealed visible swelling and bruising on the bridge of the nose. Additionally, there was a small hematoma on the lateral side of the left nasal cavity at the caudal end corresponding to the location of the ala. The edematous lateral nostril mucosa was red to purple in color, covered with blood crust, and had minimal oozing of blood. No bony deformity was noted. Anterior rhinoscopy of the left septum was not possible because of the obstructive internal left alar swelling and tenderness with manipulation. The right side of the septum only had scant blood with no apparent hematoma and normal right nasal alar tissue. An X-ray had been completed and did not reveal any nasal fracture. Blood tests showed a normal blood count and coagulation profile.

The patient was taken to the operating theatre for incision and drainage of the alar hematoma within 24 hours of the injury. Using a zero-degree nasal endoscope, bilateral nasal passageways were examined to the level of the choana. A lateral bulge suggestive of a hematoma covered with a crust was observed anteriorly at the level of the left alar cartilage (Figure 1). An incision was made using an 11-blade along the most convex portion of the lesion, releasing blood and consequently reducing the swelling significantly. To prevent recurrence of the hematoma, a Merocel pack coated with fucidic acid antimicrobial ointment was inserted in the patient's left nasal cavity, ensuring appropriate anterior coverage by the ala. Systemic antibiotics were prescribed. Postoperatively, the patient was monitored overnight and showed no signs of recurrence, fever, bleeding, swelling, or shortness of breath. Following the observation, she was discharged on oral antibiotics for a total of a two-week course. During both her one-week and two-week follow-up appointments, there were no symptoms of nasal bleeding, congestion, or obstruction, and anterior rhinoscopy did not reveal any evidence of infection or recollection.

Figure 1: Left alar hematoma