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Nasal septal abscess.

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An 8-year-old boy complaining of worsening nasal congestion presented to the emergency room with a diagnosis of sinusitis 1 week after experiencing unspecified nasal trauma in an accident. Obvious broad dorsal nasal swelling and tenderness were present on examination (figure 1), along with low-grade fever. Endonasal examination revealed a bilateral swelling in the nasal septum completely obstructing the nasal cavity (figure 2). A diagnosis of nasal septal hematoma and abscess was made, and the patient was taken urgently to the operating room for surgery.

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Intraoperatively, incision and drainage of the nasal septum released copious pus from the septal abscess, and a small piece of necrotic cartilage flowed out from the incision site. After drainage, examination of the nasal septum showed complete loss of all septal cartilage support, resulting in a severe saddle-nose deformity (figure 3). The patient was treated with intravenous antibiotics for 7 days followed by oral antibiotics for another week. Secondary reconstruction of the nasal septal deformity with auricular cartilage was planned, but unfortunately the child was lost to follow-up.

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Nasal trauma is the most common facial injury, particularly in the pediatric population. Even minor trauma may injure the nasal septum, which can lead to the development of a nasal septal hematoma or nasal septal abscess, defined as a collection of pus between the cartilaginous or bony nasal septum and its normally coapted mucoperichondrium or mucoperiosteum. (1) Although the occurrence of nasal septal abscess is uncommon, serious complications may result, necessitating prompt diagnosis and management.

The formation of a nasal septal abscess typically begins when nasal trauma causes tearing of the vasculature in the mucoperichondrium. Hemorrhage from these vessels creates a hematoma between the mucoperichondrium and the septal cartilage, depriving the avascular cartilage of its blood supply. The resulting ischemia combined with pressure generated by the enlarging hematoma produces necrosis of the septal cartilage, creating an ideal environment for bacterial proliferation and abscess formation. (1-3) A unilateral nasal septal abscess has the potential to become bilateral via spread through fractured or dissolved septal cartilage.

While most nasal septal abscesses result from trauma, cases have been reported after nasal surgery, nasal vestibule furuncle, sinusitis, and dental infection. (1-4) Abscess culture most frequently isolates Staphylococcus aureus, but other organisms, including Staphylococcus epidermidis, Streptococcus spp, Haemophilus influenzae, and anaerobes have also been reported. (1-4)

Patients with nasal septal abscess most commonly present with symptoms of nasal obstruction or congestion. Other common symptoms include nasal pain, swelling, erythema of the overlying skin, perinasal tenderness, headache, fever, and malaise. (1-3) The physical exam typically reveals unilateral or bilateral "cherry-like" swelling of the nasal septum that narrows the nasal cavity, and palpation of the involved portion of the septum may reveal tenderness and fluctuance. Destruction of septal cartilage may lead to septal perforation or saddle-nose deformity caused by the loss of cartilaginous support to the distal portion of the nose. Spread of untreated infection from the abscess can lead to a number of dangerous complications, including orbital cellulitis, meningitis, subarachnoid empyema, intracranial abscess, cavernous sinus thrombosis, and sepsis. (1-4)

Needle aspiration of the abscess allows diagnostic confirmation and provides a sample for Gram stain and culture. (1) Definitive management should include incision and drainage followed by bilateral nasal packing. Nasal splints and intranasal packing applied at the time of incision and drainage will help to coapt the mucoperichondrial flaps and reduce the risk of reaccumulation of the abscess. IV antibiotics directed at the most common pathogens should be administered for 3 to 5 days, followed by oral antibiotics based on culture and sensitivity results for another 7 to 10 days. (1)

Cartilaginous deformities of the nasal septum may be reconstructed secondarily using an autologous cartilage graft. (4) Close follow-up is essential to monitor for abscess reaccumulation and the need for further intervention.

References

(1.) Ambrus PS, Eavey RD, Baker AS, et al. Management of nasal septal abscess. Laryngoscope 1981;91(4):575-82.

(2.) Canty PA, Berkowitz RG. Hematoma and abscess of the nasal septum in children. Arch Otolaryngol Head Neck Surg 1996; 122(12): 1373-6.

(3.) Alvarez H, Osorio J, De Diego JI, et al. Sequelae after nasal septum injuries in children. Auris Nasus Larynx 2000;27(4):339-42.

(4.) Menger DJ, Tabink IC, Trenite GJ. Nasal septal abscess in children: Reconstruction with autologous cartilage grafts on polydioxanone plate. Arch Otolaryngol Head Neck Surg 2008;134(8):842-7.

Jordan Cain, MD; Soham Roy, MD, FACS, FAAP
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Title Annotation:PEDIATRIC OTOLARYNGOLOGY CLINIC
Author:Cain, Jordan; Roy, Soham
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:1USA
Date:Apr 1, 2011
Words:741
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