An unusual presentation of nasal septal abscess in 13-year-old boy

Santosh Kumar Swain; Sanjeev Gupta; Anwesha Banerjee; Mahesh Chandra Sahu

doi:10.4103/am.am_21_17

CASE REPORT

Year : 2018 | Volume : 15 | Issue : 1 | Page : 41-43

An unusual presentation of nasal septal abscess in 13-year-old boy

Santosh Kumar Swain¹, Sanjeev Gupta², Anwesha Banerjee³, Mahesh Chandra Sahu⁴
¹ Department of Otorhinolaryngology, IMS and Sum Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
² Department of Otorhinolaryngology, Apollo Hospital, Bhubaneswar, Odisha, India
³ Department of Anesthesiology, IMS and Sum Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
⁴ Directorate of Medical Research, IMS and Sum Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Web Publication

2-Apr-2018

Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha "O" Anusandhan University, Bhubaneswar, Odisha
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_21_17

Abstract

Nasal septal abscess is an uncommon clinical entity. There is a collection of the pus in the space between the nasal septum and its overlying mucoperichondrium and/or mucoperiosteum. It usually results from the trauma which leads to nasal septal hematoma and followed by septal abscess formation. If nasal septal abscess is not treated early, this may lead to fatal complications. In the growing child, early treatment along with reconstruction of the damaged septal cartilage is essential for normal development of midfacial area. Here, we are presenting a case of bilateral nasal septal abscess completely obstructing the nostrils in a mentally retarded child without any known history of trauma.

Keywords: Incision and drainage, mentally retarded child, nasal septal abscess

How to cite this article:
Swain SK, Gupta S, Banerjee A, Sahu MC. An unusual presentation of nasal septal abscess in 13-year-old boy. Apollo Med 2018;15:41-3

How to cite this URL:
Swain SK, Gupta S, Banerjee A, Sahu MC. An unusual presentation of nasal septal abscess in 13-year-old boy. Apollo Med [serial online] 2018 [cited 2023 Feb 3];15:41-3. Available from: https://apollomedicine.org/text.asp?2018/15/1/41/229056

Introduction

Nasal septal abscess is collection of pus between nasal septal cartilages or bone and the overlying mucoperichondrium or mucoperiosteum. It usually affects the anterior part of the nasal septal cartilage. Blunt nasal trauma is a major cause for nasal septal abscess. Nasal trauma is commonly encountered in children than adults.^[1] The nasal septal hematoma is frequently encountered among children after nasofacial trauma and often goes undiagnosed till complications arise. In children, there is loose attachment between the mucoperichondrium and mucoperiosteum with septal cartilage and bone, so it easily induces occurrence of septal hematoma and abscess formation.^[2] The etiological factors for nasal septal abscess is classified into three groups: primary where the causative factor is trauma to the nose; secondary where it develops from dental or sinonasal infections; and spontaneous where no underlying cause is find out.^[3] Prompt diagnosis and treatment is needed to prevent the complications of nasal septal abscess. Here, we report an unusual case of nasal septal abscess in a mentally retarded child which looks such as bilateral nasal polyps, confirmed by imaging, and started emergent management.

Case Report

A 13-year-old mentally retarded boy attended outpatient Department of Otolaryngology with complaints of complete nasal obstruction in both nostrils for 5 days. He was presenting with mouth breathing and difficulty in respiration during sleep. He had no history of facial trauma, sinusitis, and any dental infections. On examination, it revealed bilateral nasal mass mimicking with nasal polyps [Figure 1]. He had mild fever and mild tenderness on palpation over the tip of nose which gives suspicion of the nasal septal abscess. There were no dental caries or gum infections and blood count showed increased total leukocyte count of 22,300/mm³ and the white cell differential count revealed 81% neutrophil. Computed tomography (CT scan) of the nose and paranasal sinus showed hypodense area surrounded by a rim of enhancement which is in favor of the diagnosis of the nasal septal abscess [Figure 2]. Then, the patient was underwent urgent bilateral incision and drainage of the nasal septal abscess. After drainage of the abscess, anterior nasal pack was placed for 72 days along with intravenous amoxicillin and clavulanic acid. After pack removal, there was uneventful without showing any recurrent collection of pus. Wound healed smoothly, and the patient was discharged from the hospital after 72 h.

Figure 1: Patient showing bilateral nasal septal abscess

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Figure 2: Computed tomography scan picture of bilateral nasal septal abscess

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Discussion

Nasal septal abscess is an uncommon clinical condition and little described in the medical literature. It is a collection of the pus in the between the nasal septal cartilage/bone and mucoperichondrium and/or mucoperiosteum. The first description of the nasal septal abscess was done in the year 1810 when the abscess was treated with incision and drainage.^[4] The incidence of nasal septal abscess is rare and more common among children with male predominance. The majority of nasal septal abscess develop due to trauma of the nose.^[5] The trauma on the nose cause septal hematoma which separates the mucoperichondrium from the nasal septum, causing ischemia, and necrosis of the septal cartilage. When it is infected, leads to abscess formation. Nasal septal cartilage get its blood supply from the rich vascular network from its overlying mucoperichondrium through a process of diffusion.^[6] Hence, bilateral separation of the mucoperichondrium results in impairment of its blood supply, leading to ischemia and cartilage necrosis. Direct trauma to the nose causes injury and tearing of the blood vessels in the mucoperichondrium of the nasal septum. Then, blood is collected between the septal cartilage and the mucoperichondrium, leading to hematoma formation. The septal hematoma separates the mucoperichondrium from the septal cartilage and leads to deprivation of the blood supply to the septal cartilage. Pressure from the hematoma and ischemia causes necrosis and destruction of the nasal septal cartilage. This gives an ideal environment for bacterial growth and formation of abscess. Due to the destruction of the cartilage, unilateral abscess becomes bilateral rapidly. Nasal septal abscess may occur due to other causes than nasal trauma. Other less common causes for nasal septal abscess are nasal surgery, furuncles at the nasal vestibule, sinusitis, and dental infections. It may be seen spontaneously in case of immunocompromised patients.^[7] In this case, there was no known history of trauma from the patient side. As patient is mentally challenged, it is difficult to assess the exact etiology of nasal septal abscess. The common clinical presentations of nasal septal abscess are unilateral or bilateral nasal obstruction. Bilateral abscess formation on either side of the nasal septum is more common clinical presentation than unilateral one. This bilateral abscess formation is explained by the fact that bilateral septal hematoma is more common than one side. Another cause for bilateral abscess formation could be the extension of the infection from one side to other through the infected cartilage which dissolves it rapidly. Patient may present with breathing difficulty due to bulging of anterior nasal septum. The anterior part of nasal septum looks swollen, erythematous, and tender on palpation. Some patient of nasal septal abscess may show fever, headache, increase heart rate, and leukocytosis. On inspection, smooth and pinkish appearance is noted in one or both sides of the nasal septum. There is protrusion and fluctuant on palpation of the bulging of the nasal septum. Nasal septal abscess may be confused with a gross deviated or thickened nasal septum and hypertrophied turbinate by general practitioners. The common organisms found in the culture of nasal septal abscess are Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, beta-hemolytic group A Streptococcus, Haemophilus influenzae, and anaerobic bacteria.^[8] Delayed diagnosis and treatment of nasal septal abscess leads to compromised blood supply to the cartilaginous part of the nasal septum and leads to saddle nose deformity. Other than saddle nose, serious complications such as sepsis, meningitis, orbital cellulitis, cavernous sinus thrombosis, and brain abscess may occur due to nasal septal abscess. In nasal septal abscess, radiological confirmation is not always required. However, in certain situations, CT scan is advised where the etiology is unclear or in suspicion of Wegener's granulomatosis, tuberculosis, sarcoma, syphilis, or lymphoma or failure of treatment or complications such as cavernous sinus thrombosis or brain abscess.^[9] In these situations, contrast-enhanced CT scan is very useful. CT scan is also useful in case of septal abscess without any history of trauma such as in rhinosinusitis or dental infections. Nose and sinus CT scan is an excellent imaging tool for detection of the early or extensive abscess and possible complications. Needle aspiration from nasal septal abscess confirms the diagnosis, relieve pain due to pressure and provide pus for culture and sensitivity.^[10] Medical treatment with antibiotics is not sufficient alone for nasal septal abscess. Surgical incision and drainage are essential for complete drainage of the abscess along with or without placing drainage tubes. A deep longitudinal incision provides adequate drainage of the abscess. Nasal packing is done for 2–3 days after drainage of the abscess for preventing reaccumulation of the pus in the nasal septum. In pediatric patients, early reconstruction of the lost infected septal cartilage has been advised for preventing the long-term effect on the facial growth.^[11]

Conclusion

Nasal septal abscess is an uncommon and serious clinical entity which needs urgent surgical intervention. Delayed diagnosis and management of nasal septal abscess may lead to saddle nose, meningitis, intracranial abscess, orbital cellulitis, or cavernous sinus thrombosis. The emergency department physician should consider the nasal septal abscess as the differential diagnosis in mass in the anterior nasal cavity and paramount in establishing the diagnosis by using imaging and start immediate treatment with drainage and antibiotics.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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