Alar Cartilage Hematoma: Case Report and Literature Review

Abstract

Nasal hematomas can occur after nasal trauma. It can involve the septal, alar, or all levels, with the septum being the most commonly affected site. We present a case of alar hematoma in a five-year-old boy after nasal trauma. The patient came to the emergency room complaining of nasal pain, epistaxis, and nasal deformity. A complete ear, nose, and throat examination was performed, and X-ray and computed tomography imaging of the facial bone were done to confirm the presence of a nasal alar hematoma. The alar hematoma was successfully treated via surgical evacuation. Alar cartilage hematoma is a rare entity that can lead to undesirable complications when missed.

Background

Blunt trauma to the midface frequently causes nose injuries [1]. Nasal fractures are more frequently accompanied by nasal trauma, accounting for 48–50% of all facial fractures [1]. Nasal fractures among pediatric patients are caused by bicyclists or pedestrians, sports injuries, intended injuries such as weightlifting, and home injuries [2]. Nasal fractures are complicated by hematomas and infections, which can eventually lead to abscess formation and necrosis of the nasal cartilages [3]. The nasal septum is frequently involved in the development of nasal hematomas [4]. However, few cases have documented the involvement of other locations, such as the alar cartilage [5, 6]. Nasal hematomas occur when blood vessels within the perichondrium are torn. The collection of blood between the cartilage and the overlying intact perichondrium gives rise to a sub-perichondrial hematoma [7], which may lead to nasal cartilage necrosis and perforation. In this case, we describe an alar cartilage hematoma in a five-year-old patient after blunt nasal trauma.

Case Presentation

A five-year-old boy with unremarkable medical and surgical history presented to the emergency department of the Security Force Hospital after falling from his bed while sleeping on his face. He complained of nasal pain, epistaxis, and nasal deformity with no associated loss of consciousness, focal neurological deficit, eye complaints, or shortness of breath. On general examination, the patient was in pain, and oriented to time, place, and person. The patient had stable vital signs with a heart rate of 78 bpm, respiratory rate of 18 breaths/min, blood pressure of 100/70 mmHg, and body temperature of 37.1 °C. Nasal examination showed nasal edema and deformity (Fig. 1a). Anterior rhinoscopy examination showed significant nasal edema and a hematoma in the nasal floor below the alar cartilage of the right nostril (Fig. 1b). This was confirmed by aspiration. There was no active bleeding or septal hematoma, and the rest of the ear, nose, and throat examination was unremarkable. X-ray imaging of the nasal bone and computed tomography (CT) imaging of the facial bone were performed to rule out complications. The X-ray film showed a nasal fracture (Fig. 2), and the CT scan showed a right nasal bony fracture (Fig. 3a) with soft tissue swelling and minimal collection (Fig. 3b). The patient was admitted for alar cartilage hematoma evacuation. The preoperative and anesthesia assessments were done. The laboratory tests included CBC, coagulation profile, and renal and bone profile. The patient consented to the surgery. Surgery was performed under general anesthesia, and alar hematoma evacuation was successfully performed. A non-absorbable nasal packing was applied and then removed on the following day to prevent recollection. The patient was followed up at the clinic one and two weeks postoperatively, and there were no signs of nasal deformity or recollection.

Fig. 1.

a A five-year-old boy is admitted with alar cartilage hematoma. Nasal examination shows nasal edema and deformity, b Right nostril anterior rhinoscopy shows hematoma in the nasal floor below alar cartilage

Fig. 2.

X-ray film of the nasal bone shows a nasal bone fracture

Fig. 3.

a An axial computed tomography scan shows a right nasal bony fracture, b with soft tissue swelling fat stranding and minimal collection

Discussion

Nasal hematomas can occur in the nasal septum. However, it can also occur at the alar level. Nasal alar hematoma is uncommon and was first described in 1994 (Meehan et al., 1994). Alar hematoma refers to the collection of blood between the alar cartilage and overlying intact perichondrium. Only seven cases have been documented in previous literature [5, 6, 8, 9]. Like other nasal hematomas, alar hematomas can develop into abscesses [10]. Moreover, it can cause serious complications, such as a brain abscess, subarachnoid empyema, meningitis, cavernous sinus thrombosis, lateral sinus thrombosis, and naso-oral fistula [10–17]. Alar hematomas can be diagnosed using anterior rhinoscopy [18]. However, this can be missed and rarely requires CT or magnetic resonance imaging for proper diagnosis [19]. A case of alar hematoma was missed and referred to otolaryngology as a case of a nasal fracture two weeks after facial trauma for reassessment. This could have been prevented through a direct otolaryngology consultation at the emergency room. This resulted in persistent alar cartilage injury [6]. However, the guidelines on managing nasal fractures are limited and unspecific [19]. Furthermore, correct assessment and management of nasal fractures are crucial to prevent complications and achieve good aesthetic outcomes [20]. Nasal cartilage hematomas are mainly treated by evacuation to prevent complications [21].

Conclusion

Alar cartilage hematomas after nasal injury are uncommon. However, proper evaluation of the facial and nasal injuries leads to correct diagnosis and management, and prevents undesirable complications.

Funding

No funding was received to assist with the preparation of this manuscript.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

Consent form was taken from patient parents.