S. Yusuf, DO

 

Case

A 28-year-old woman with history of bipolar disorder and methamphetamine abuse presented to the ED complaining of nasal swelling and pain. She was unable to provide any medical history regarding the onset of her symptoms or other details, which the ED team attributed to her underlying psychiatric disorder. She denied nasal trauma, insufflation, or insertion of foreign bodies into the nasal cavity. When the patient’s mother was contacted, she stated her daughter’s symptoms, which she believed were secondary to a domestic-violence-related injury, had been present and evolving over the past 2 weeks. She also related that the patient had been treated at another ED 4 days earlier and discharged with oral antibiotics.

On physical examination, the bilateral nares were entirely occluded by soft-tissue swelling, with fluctuance on palpation. The area was erythematous, and there were pustules scattered throughout the local region (Figure 1). There was no evidence of spreading cellulitis. During the examination, the patient had a labile level of alertness that fluctuated between somnolence and agitation; however, she was arousable and had satisfactory airway guarding. Patient’s vital signs remained stable throughout evaluation and treatment in the ED. On physical examination, her pupils were equal bilaterally, extraocular movements were intact, and no neurological deficits were detected. A complete blood cell count showed leukocytosis, with a white blood cell count of 18,240/uL and a predominance (88.2%) of neutrophils. All other laboratory values were within normal limits.

Computed tomography (CT) of the face revealed prominent soft-tissue swelling involving the inferior portion of the nose (Figure 2). In addition to swelling and obstruction of the bilateral nares, heterogeneity was also noted within the affected tissues and thought to represent a fluid component.

To facilitate the examination, the patient received intravenous (IV) clindamycin and intramuscular geodon. A surgeon from oral and maxillofacial surgery services (OMFS) was brought in for consultation and recommended bedside incision and drainage of the presumed abscess under procedural sedation with ketamine. In preparation for the procedure, the patient received approximately 7 cc of 2% lidocaine with 1:100,000 epinephrine via nasal-block technique. A #15 blade was used to incise the septal mucosa on both the left and right sides. Significant purulent drainage (approximately 20 cc of fluid consisting of blood and clots) was obtained during the incision. Exploration of the nasal cavity revealed complete destruction and absence of the septum as a result of the infection. Aerobic and anaerobic cultures were taken, after which the left and right septal mucosae were sutured together with 3-0 chromic gut. The nares were packed to stabilize the tissues out of the airway and to prevent the potential space from reaccumulation of fluid. The patient tolerated the procedure well and recovered mental status to preprocedure baseline. Figure 3 shows the external nose postprocedure.

After the procedure, the patient was admitted to the hospital for observation on the medical psychiatric unit where she received additional IV antibiotic therapy as well as a psychiatric consultation. After a 24-hour observation period, she was discharged on a one-week regimen of oral clindamycin and instructions for outpatient follow-up with OMFS for septal repair. Cultures taken during exploration were positive for pan-sensitive Staphylococcus aureus. The working diagnosis at discharge was bilateral septal abscess from untreated bilateral septal hematoma due to an unreported facial trauma.

 

Discussion

Nasal septal abscess, a rare complication of a nasal septal hematoma, is defined as a collection of pus between the cartilaginous or bony nasal septum and its normally applied mucoperichondrium or mucoperiosteum. Patients most commonly present with fluctuant, tender, bilateral, or unilateral nasal obstruction as a result of anterior nasal septum swelling. Other symptoms include localized pain, swelling, fever, headache, or perinasal tenderness.¹ The external portion of the nose is swollen, erythematous, and tender, and the anterior nasal cavities are occluded by a smooth, round, deep red or grey swelling.² In a review of pediatric patients with nasal septal abscess, the most common complaint was nasal congestion (95%). Other significant complaints were nasal pain (50%), fever (50%), and headache (5%).^3,4

Nasal septal abscess is most commonly caused by a hematoma. Although trauma is typically associated with this condition, it is not the sole cause. Other etiology includes nasal surgery, a furuncle of the nasal vestibule, sinusitis, or, in rare cases, infection from a dental extraction.³

Staphylococcus aureus is the most common pathogen. Streptococcus and other anaerobes are less common, and pediatric patients are more susceptible to Haemophilus influenza than adults. Although rare, Psuedomonas and Klebsiella have also been reported.³

When nasal septal abscess is suspected, prior to drainage, the diagnosis should be confirmed by CT of the face and include the paranasal sinuses. Computed tomography is an excellent imaging tool for abscess detection and is the community standard for evaluation. Magnetic resonance imaging is not usually utilized (especially in the acute or ED setting) as it is unlikely to affect or alter initial management. In radiographs, nasal septal abscess typically appears as fluid collection with thin rim enhancement in the cartilaginous nasal septum5 (Figure 2). These findings can be missed on brain CT alone.⁵

 

In patients presenting several days from a related trauma, distinguishing uncomplicated septal hematoma from nasal septal abscess can be very difficult—though nasal septal abscesses tend to be larger and more painful. In addition, there may be inflammation of the overlying mucosa, occasionally with exudates. In untreated cases, infection can extend into the cavernous sinus causing intracranial infections or cavernous sinus thrombosis. The most common complication of septal abscess is cartilage necrosis that can result in nasal structural collapse and “saddle-nose” deformity. Complications, including meningitis, can develop quickly (ie, within 3 to 4 days).⁶

The structural complications associated with septal abscess result from the avascular nature of the septal cartilage, which receives blood from the adherent mucoperichondrium. Hematoma and abscess can expand and obstruct the blood vessels that supply the nasal cartilage. Pressure of the hematoma on the septum causes progressive avascular necrosis.⁶

Patients with confirmed nasal septal abscess should obtain otolaryngology or OMFS consultation in the ED. Due to the high risk of complications and need for follow up, immediate drainage should also be directed by otolaryngology or OMFS. All patients should be discharged on oral broad-spectrum antibiotics, with a referral to an otolaryngologist or OMFS within 24 hours for evaluation and possible removal of nasal packs.⁷

Dr Yusuf is an academic chief resident, John Peter Smith Emergency Medicine Residency Program, Fort Worth, Texas. Dr Kirk is associate residency director and ultrasound director, department of emergency medicine, John Peter Smith Health System, Fort Worth, Texas.

 

Case

A 28-year-old woman with history of bipolar disorder and methamphetamine abuse presented to the ED complaining of nasal swelling and pain. She was unable to provide any medical history regarding the onset of her symptoms or other details, which the ED team attributed to her underlying psychiatric disorder. She denied nasal trauma, insufflation, or insertion of foreign bodies into the nasal cavity. When the patient’s mother was contacted, she stated her daughter’s symptoms, which she believed were secondary to a domestic-violence-related injury, had been present and evolving over the past 2 weeks. She also related that the patient had been treated at another ED 4 days earlier and discharged with oral antibiotics.

On physical examination, the bilateral nares were entirely occluded by soft-tissue swelling, with fluctuance on palpation. The area was erythematous, and there were pustules scattered throughout the local region (Figure 1). There was no evidence of spreading cellulitis. During the examination, the patient had a labile level of alertness that fluctuated between somnolence and agitation; however, she was arousable and had satisfactory airway guarding. Patient’s vital signs remained stable throughout evaluation and treatment in the ED. On physical examination, her pupils were equal bilaterally, extraocular movements were intact, and no neurological deficits were detected. A complete blood cell count showed leukocytosis, with a white blood cell count of 18,240/uL and a predominance (88.2%) of neutrophils. All other laboratory values were within normal limits.

Computed tomography (CT) of the face revealed prominent soft-tissue swelling involving the inferior portion of the nose (Figure 2). In addition to swelling and obstruction of the bilateral nares, heterogeneity was also noted within the affected tissues and thought to represent a fluid component.

To facilitate the examination, the patient received intravenous (IV) clindamycin and intramuscular geodon. A surgeon from oral and maxillofacial surgery services (OMFS) was brought in for consultation and recommended bedside incision and drainage of the presumed abscess under procedural sedation with ketamine. In preparation for the procedure, the patient received approximately 7 cc of 2% lidocaine with 1:100,000 epinephrine via nasal-block technique. A #15 blade was used to incise the septal mucosa on both the left and right sides. Significant purulent drainage (approximately 20 cc of fluid consisting of blood and clots) was obtained during the incision. Exploration of the nasal cavity revealed complete destruction and absence of the septum as a result of the infection. Aerobic and anaerobic cultures were taken, after which the left and right septal mucosae were sutured together with 3-0 chromic gut. The nares were packed to stabilize the tissues out of the airway and to prevent the potential space from reaccumulation of fluid. The patient tolerated the procedure well and recovered mental status to preprocedure baseline. Figure 3 shows the external nose postprocedure.

After the procedure, the patient was admitted to the hospital for observation on the medical psychiatric unit where she received additional IV antibiotic therapy as well as a psychiatric consultation. After a 24-hour observation period, she was discharged on a one-week regimen of oral clindamycin and instructions for outpatient follow-up with OMFS for septal repair. Cultures taken during exploration were positive for pan-sensitive Staphylococcus aureus. The working diagnosis at discharge was bilateral septal abscess from untreated bilateral septal hematoma due to an unreported facial trauma.

 

Discussion

Nasal septal abscess, a rare complication of a nasal septal hematoma, is defined as a collection of pus between the cartilaginous or bony nasal septum and its normally applied mucoperichondrium or mucoperiosteum. Patients most commonly present with fluctuant, tender, bilateral, or unilateral nasal obstruction as a result of anterior nasal septum swelling. Other symptoms include localized pain, swelling, fever, headache, or perinasal tenderness.¹ The external portion of the nose is swollen, erythematous, and tender, and the anterior nasal cavities are occluded by a smooth, round, deep red or grey swelling.² In a review of pediatric patients with nasal septal abscess, the most common complaint was nasal congestion (95%). Other significant complaints were nasal pain (50%), fever (50%), and headache (5%).^3,4

Nasal septal abscess is most commonly caused by a hematoma. Although trauma is typically associated with this condition, it is not the sole cause. Other etiology includes nasal surgery, a furuncle of the nasal vestibule, sinusitis, or, in rare cases, infection from a dental extraction.³

Staphylococcus aureus is the most common pathogen. Streptococcus and other anaerobes are less common, and pediatric patients are more susceptible to Haemophilus influenza than adults. Although rare, Psuedomonas and Klebsiella have also been reported.³

When nasal septal abscess is suspected, prior to drainage, the diagnosis should be confirmed by CT of the face and include the paranasal sinuses. Computed tomography is an excellent imaging tool for abscess detection and is the community standard for evaluation. Magnetic resonance imaging is not usually utilized (especially in the acute or ED setting) as it is unlikely to affect or alter initial management. In radiographs, nasal septal abscess typically appears as fluid collection with thin rim enhancement in the cartilaginous nasal septum5 (Figure 2). These findings can be missed on brain CT alone.⁵

 

In patients presenting several days from a related trauma, distinguishing uncomplicated septal hematoma from nasal septal abscess can be very difficult—though nasal septal abscesses tend to be larger and more painful. In addition, there may be inflammation of the overlying mucosa, occasionally with exudates. In untreated cases, infection can extend into the cavernous sinus causing intracranial infections or cavernous sinus thrombosis. The most common complication of septal abscess is cartilage necrosis that can result in nasal structural collapse and “saddle-nose” deformity. Complications, including meningitis, can develop quickly (ie, within 3 to 4 days).⁶

The structural complications associated with septal abscess result from the avascular nature of the septal cartilage, which receives blood from the adherent mucoperichondrium. Hematoma and abscess can expand and obstruct the blood vessels that supply the nasal cartilage. Pressure of the hematoma on the septum causes progressive avascular necrosis.⁶

Patients with confirmed nasal septal abscess should obtain otolaryngology or OMFS consultation in the ED. Due to the high risk of complications and need for follow up, immediate drainage should also be directed by otolaryngology or OMFS. All patients should be discharged on oral broad-spectrum antibiotics, with a referral to an otolaryngologist or OMFS within 24 hours for evaluation and possible removal of nasal packs.⁷

Dr Yusuf is an academic chief resident, John Peter Smith Emergency Medicine Residency Program, Fort Worth, Texas. Dr Kirk is associate residency director and ultrasound director, department of emergency medicine, John Peter Smith Health System, Fort Worth, Texas.

 

Case

A 28-year-old woman with history of bipolar disorder and methamphetamine abuse presented to the ED complaining of nasal swelling and pain. She was unable to provide any medical history regarding the onset of her symptoms or other details, which the ED team attributed to her underlying psychiatric disorder. She denied nasal trauma, insufflation, or insertion of foreign bodies into the nasal cavity. When the patient’s mother was contacted, she stated her daughter’s symptoms, which she believed were secondary to a domestic-violence-related injury, had been present and evolving over the past 2 weeks. She also related that the patient had been treated at another ED 4 days earlier and discharged with oral antibiotics.

On physical examination, the bilateral nares were entirely occluded by soft-tissue swelling, with fluctuance on palpation. The area was erythematous, and there were pustules scattered throughout the local region (Figure 1). There was no evidence of spreading cellulitis. During the examination, the patient had a labile level of alertness that fluctuated between somnolence and agitation; however, she was arousable and had satisfactory airway guarding. Patient’s vital signs remained stable throughout evaluation and treatment in the ED. On physical examination, her pupils were equal bilaterally, extraocular movements were intact, and no neurological deficits were detected. A complete blood cell count showed leukocytosis, with a white blood cell count of 18,240/uL and a predominance (88.2%) of neutrophils. All other laboratory values were within normal limits.

Computed tomography (CT) of the face revealed prominent soft-tissue swelling involving the inferior portion of the nose (Figure 2). In addition to swelling and obstruction of the bilateral nares, heterogeneity was also noted within the affected tissues and thought to represent a fluid component.

To facilitate the examination, the patient received intravenous (IV) clindamycin and intramuscular geodon. A surgeon from oral and maxillofacial surgery services (OMFS) was brought in for consultation and recommended bedside incision and drainage of the presumed abscess under procedural sedation with ketamine. In preparation for the procedure, the patient received approximately 7 cc of 2% lidocaine with 1:100,000 epinephrine via nasal-block technique. A #15 blade was used to incise the septal mucosa on both the left and right sides. Significant purulent drainage (approximately 20 cc of fluid consisting of blood and clots) was obtained during the incision. Exploration of the nasal cavity revealed complete destruction and absence of the septum as a result of the infection. Aerobic and anaerobic cultures were taken, after which the left and right septal mucosae were sutured together with 3-0 chromic gut. The nares were packed to stabilize the tissues out of the airway and to prevent the potential space from reaccumulation of fluid. The patient tolerated the procedure well and recovered mental status to preprocedure baseline. Figure 3 shows the external nose postprocedure.

After the procedure, the patient was admitted to the hospital for observation on the medical psychiatric unit where she received additional IV antibiotic therapy as well as a psychiatric consultation. After a 24-hour observation period, she was discharged on a one-week regimen of oral clindamycin and instructions for outpatient follow-up with OMFS for septal repair. Cultures taken during exploration were positive for pan-sensitive Staphylococcus aureus. The working diagnosis at discharge was bilateral septal abscess from untreated bilateral septal hematoma due to an unreported facial trauma.

 

Discussion

Nasal septal abscess, a rare complication of a nasal septal hematoma, is defined as a collection of pus between the cartilaginous or bony nasal septum and its normally applied mucoperichondrium or mucoperiosteum. Patients most commonly present with fluctuant, tender, bilateral, or unilateral nasal obstruction as a result of anterior nasal septum swelling. Other symptoms include localized pain, swelling, fever, headache, or perinasal tenderness.¹ The external portion of the nose is swollen, erythematous, and tender, and the anterior nasal cavities are occluded by a smooth, round, deep red or grey swelling.² In a review of pediatric patients with nasal septal abscess, the most common complaint was nasal congestion (95%). Other significant complaints were nasal pain (50%), fever (50%), and headache (5%).^3,4

Nasal septal abscess is most commonly caused by a hematoma. Although trauma is typically associated with this condition, it is not the sole cause. Other etiology includes nasal surgery, a furuncle of the nasal vestibule, sinusitis, or, in rare cases, infection from a dental extraction.³

Staphylococcus aureus is the most common pathogen. Streptococcus and other anaerobes are less common, and pediatric patients are more susceptible to Haemophilus influenza than adults. Although rare, Psuedomonas and Klebsiella have also been reported.³

When nasal septal abscess is suspected, prior to drainage, the diagnosis should be confirmed by CT of the face and include the paranasal sinuses. Computed tomography is an excellent imaging tool for abscess detection and is the community standard for evaluation. Magnetic resonance imaging is not usually utilized (especially in the acute or ED setting) as it is unlikely to affect or alter initial management. In radiographs, nasal septal abscess typically appears as fluid collection with thin rim enhancement in the cartilaginous nasal septum5 (Figure 2). These findings can be missed on brain CT alone.⁵

 

In patients presenting several days from a related trauma, distinguishing uncomplicated septal hematoma from nasal septal abscess can be very difficult—though nasal septal abscesses tend to be larger and more painful. In addition, there may be inflammation of the overlying mucosa, occasionally with exudates. In untreated cases, infection can extend into the cavernous sinus causing intracranial infections or cavernous sinus thrombosis. The most common complication of septal abscess is cartilage necrosis that can result in nasal structural collapse and “saddle-nose” deformity. Complications, including meningitis, can develop quickly (ie, within 3 to 4 days).⁶

The structural complications associated with septal abscess result from the avascular nature of the septal cartilage, which receives blood from the adherent mucoperichondrium. Hematoma and abscess can expand and obstruct the blood vessels that supply the nasal cartilage. Pressure of the hematoma on the septum causes progressive avascular necrosis.⁶

Patients with confirmed nasal septal abscess should obtain otolaryngology or OMFS consultation in the ED. Due to the high risk of complications and need for follow up, immediate drainage should also be directed by otolaryngology or OMFS. All patients should be discharged on oral broad-spectrum antibiotics, with a referral to an otolaryngologist or OMFS within 24 hours for evaluation and possible removal of nasal packs.⁷

Dr Yusuf is an academic chief resident, John Peter Smith Emergency Medicine Residency Program, Fort Worth, Texas. Dr Kirk is associate residency director and ultrasound director, department of emergency medicine, John Peter Smith Health System, Fort Worth, Texas.