spontaneus nasal septal abscess

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Yuan-Heng Tsao, et al.J Med Sci 2005;25(5):251-254http://jms.ndmctsgh.edu.tw/2505251.pdfCopyright 2005 JMS

Received: August 31, 2004; Revised: December 15, 2004;

Accepted: January 20, 2005.*Corresponding author: Hsing-Won Wang, Department of

Otolaryngology-Head and Neck Surgery, Tri-Service Gen-

eral Hospital, 325, Cheng-Gong Road Section 2, Taipei 114,

Taiwan, Republic of China. Tel: +886-2-8792-7192; Fax: +

886-2-8792-7193; E-mail: [email protected]

Spontaneous Nasal Septal Abscess

Yuan-Heng Tsao, Chao-Jung Lin, and Hsing-Won Wang*

Department of Otolaryngology-Head and Neck Surgery,

Tri-Service General Hospital, National Defense Medical Center,

Taipei, Taiwan, Republic of China

In the absence of early diagnosis and proper management, a nasal septal abscess, an uncommon entity, may lead to lethal

complications. It is most frequently seen in cases of traumatic septal hematoma with subsequent infection but also occurs in

cases of furunculosis of the nasal vestibule, sinusitis, influenza, and dental infection. To our knowledge, this is the first case

report of a nasal septal abscess developing spontaneously in an immunocompromised and coagulopathic patient. We report

this case to reinforce the need for scrupulous evaluation in immunocompromised and coagulopathic patients presenting with

nasal obstruction without a history of trauma.

Key words: nasal septum, spontaneous nasal septal abscess

INTRODUCTION

Nasal septal abscess (NSA) is defined as a collection of

pus between the cartilaginous or bony nasal septum and the

mucoperichondrium or mucoperiosteum1. NSA is uncom-

mon and usually occurs subsequent to traumatic nasal

hematoma with infection. NSA is also less frequently

associated with nasal vestibular furunculosis, sinusitis,

influenza, and dental infection1-4. In cases presenting with

nasal obstruction but no history of preceding events suchas those mentioned above, the possibility of an NSA might

be ignored and the condition treated as for rhinitis with

septal deviation or thickened nasal septum5. The complica-

tions of an NSA, such as meningitis, brain abscess, sub-

arachnoid empyema, and cavernous sinus thrombosis,

could be lethal. Other complications include saddle nose

deformity, septal perforation, and permanent nasal

obstruction1,2,6. Early diagnosis and proper management

are necessary to prevent the potentially dangerous spread

of infection and the development of severe functional and

cosmetic sequelae2.

We present an uncommon case of spontaneous NSA inan immunocompromised patient with coagulopathy, to

alert physicians to be more vigilant when this disease

presents. The etiology, pathogenesis, bacteriology, and

management of septal abscess are discussed.

CASE REPORT

A 63-year-old male presented to our emergency depart-

ment with symptoms of frontal headache, nasal pain, and

nasal obstruction, which he had experienced for the previ-

ous month. He had received medical treatment at anotherclinic for rhinitis with nasal septal deviation and thickened

nasal mucosa. He denied a prior history of nasal trauma,

sinusitis, epistaxis, or dental procedures, but had a history

of allergic rhinitis. The patients medical history included

type 2 diabetes mellitus, uremia with maintained hemo-

dialysis, hepatitis B virus-related liver cirrhosis with

splenomegaly, anemia, thrombocytopenia, esophageal

varices, and hypertensive cardiovascular disease. On arrival,

the patients body temperature was 36.3oC without chills

and his blood pressure was 227/95 mm Hg. Physical

examination revealed erythematous skin of the nasal dor-

sum with saddle deformity. Bilateral dull purple swellingof the nasal septum was noted. This swelling resulted in

total obliteration of the nasal airway (Fig. 1A). The nasal

septal swelling did not change in size when topical

oxymetazoline nasal spray was applied, and it fluctuated

when probed.

Other otolaryngological examinations were unre-

markable. A complete blood cell count showed a raised

total white blood cell count of 11.10103/L with a raised

differential count of 88.2% neutrophils, and a diminished

platelet count of 86103/L. The partial thromboplastin


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time and prothrombin time were within normal range.

However, bleeding time exceeded 15 minutes. A post-

contrast axial and coronal computed tomography (CT) ofthe paranasal sinuses showed a swollen anterior nasal

septum with central low-density fluid collection (Fig. 1B).

In view of the clinical symptoms and radiological

findings, the clinical impression was that of a nasal septal

abscess. Parenteral administration of antibiotic was initi-

ated with 1.0 g intravenous cefazolin, which was followed

by 1.0 g intravenous cefazolin every 24 hours. The patient

underwent surgical drainage under general anesthesia after

the impaired hemostatic status had been corrected by

transfusion of 20 units of cryoprecipitate and intravenous

administration of desmopressin (16g). A vertical 8 mm

incision was made through the dependent portion of theright anterior nasal septum and 8 mL of pus was drained

from underside of the mucoperichondrium. The segmented

and necrotic septal cartilage was removed. The nose was

packed with Vaseline- and tetracycline-impregnated gauze,

and the incision wound was kept open with a wet dressing.

The patients headache subsided on the day following

the operation. We changed the wet dressing twice daily and

the nasal packing every 3 days. On day 6 of hospitalization,

conscious disturbance developed and infection with cra-

nial spread was suspected. Cerebrospinal fluid analysis

and magnetic resonance imaging of the brain were nega-

tive for intracranial infection. The antibiotic regimen was

changed to 1 dose of 1.0 g intravenous vancomycin and 1.0 g

ceftazidime every 12 hours for 3 days. Three days later, the

patient regained normal consciousness. The antibiotic regi-

men was then changed to 250 mg oral ciprofloxacin twicedaily because bacterial culture revealed the presence of

Pseudomonas aeruginosa, which is sensitive to cipro-

floxacin. A follow-up examination 3 weeks after the opera-

tion showed that the septal abscess had subsided and the

wound had healed. The nasal airway was patent but saddle

nose deformity persisted (Figs. 2A,B).

DISCUSSION

An NSA is an uncommon entity. The incidence rate

does not appear to have been accurately documented. To

the best of our knowledge, major centers managed fewerthan 10 cases annually1,7. NSA most frequently results from

an infected nasal hematoma following nasal trauma1,8 and

is usually seen in younger patients1. Less frequently, NSA

is associated with a preceding event such as furunculosis of

the nasal vestibule, sinusitis, influenza, dental infection,

and nasal surgery1-4.

A spontaneous NSA is far less common than that asso-

ciated with preceding events and may be missed as a

common cold or thickening of the mucoperichondrium, as

illustrated by our case. The uremic patient has bleeding

Fig. 1 (A) Bilateral dull purple bulging of the nasal septum

resulting in total obliteration of the nasal airway. (B)

Axial computed tomography image with contrast show-

ing swelling of the nasal septum with hypodense fluid

collection.

Fig. 2 (A) Persistent saddle nose deformity. (B) Patency of the

patients nasal airway after treatment.


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Yuan-Heng Tsao, et al.

diathesis, which aggravates the tendency for mucocutane-

ous bleeding because it affects serosal and mucosal

surfaces9. Ecchymoses and epistaxis are the major bleed-

ing manifestations10. Thus, the etiology in our patient is

that the coagulopathy and immunocompromised status

predisposed him to spontaneous nasal septal hematoma

with subsequent opportunistic infection.

The most common presentation of the NSA is nasal

obstruction. Other signs and symptoms include nasal pain,

headache, fever, saddle nose, and swelling of the nasal

septum1. The nasal septum may be swollen and fluctuant

on palpation. Fine-needle aspiration together with CT

scanning with contrast enhancement may be helpful for

accurate diagnosis and identification of the area involved.

Physicians should be aware of the life-threatening com-

plications of NSA, which include osteomyelitis, orbitalcellulitis, orbital abscess, intracranial abscess, meningitis,

and cavernous sinus thrombosis. Life-threatening compli-

cations in the immunocompromised patient may progress

rapidly if the NSA remains unchecked and untreated5. The

infection can spread via several routes. Orbital or perior-

bital complications are associated with the contiguous

invasion of the infection8. Further intracranial extension is

linked to the venous communication between the nasal

septum and facial angular and ophthalmic veins, which are

valveless and lead back to the cavernous sinus1. Moreover,

lymphatics of the superior meatus drain via the cribriform

plate and the vertical plate of the ethmoid bone into thesubarachnoid space. Perineural sheaths of the olfactory

nerve, transmitting through the cribriform plate, represent

avenues for intracranial invasion1. Additionally, func-

tional and cosmetic sequelae may be secondary to ischemic

necrosis and bacterial destruction of the nasal septal carti-

laginous or bony supports.

In general, adequate management of NSA consists of

prompt drainage and simultaneous intravenous adminis-

tration of broad-spectrum antibiotics that can cross the

blood-brain barrier. Aggressive control and treatment of

underlying medical problems are also mandatory to pre-

vent the infection from spreading rapidly. As illustrated inthis case, control of uremic bleeding diathesis is necessary

to prevent excessive intra-operative bleeding and accumu-

lation of the hematoma. Control of blood sugar level is help-

ful in improving immune status.

A thorough understanding of the bacteriology of NSA is

helpful. The most common pathogen is Staphylococcus

aureus. Less frequently, Streptococcus pneumoniae, group

A beta hemolytic Streptococcus, anaerobes,Hemophilus

influenzae, and coliforms have been reported1. In this case,

the culture revealedPseudomonas aeruginosa, which is an

opportunistic pathogen commonly seen in immunocom-

promised populations.

In conclusion, the possible existence of an NSA would

occur to physicians examining patients presenting with

nasal obstruction accompanied by preceding events. In our

case, there was no evidence of preceding trauma or other

sources of infection. In view of the patients underlying

medical problems, coagulopathy and immunocompromised

status predisposed the patient to progressive spontaneous

nasal hematoma and subsequent infection resulting in

abscess formation. We would like to emphasize that NSA

in patients with underlying impaired hemostatic and im-

mune systems could develop silently. In cases of suspected

NSA, it is important that a thorough rhinologic examina-

tion is made and a detailed history obtained. In addition, it

is important to prevent disease progression by aggressivetreatment and control of underlying diseases.

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10. Remuzzi G, Schieppati A, Minetti L. Hematologic

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