Case report

NASAL SEPTAL
ABSCESS IN CHILDREN

By
Putu Vira Rikakaya
Scientific Advisor
dr. Luh Made Ratnawati, Sp.THT-KL

2014

INTRODUCTION

Introduction

Nasal Septal Abscess (NSA) defined as a collection

of pus between the cartilaginous or bony nasal
septum and its overlying mucoperichondrium or
mucoperiosteum
Predisposing factors : nasal trauma (75% of cases)
by accident, fall, fighting, nose picking ; nasal
surgery, sinusitis, furuncle of nasal vestibule, dental
infection, foreign body and immune deficiency
One of the rhinology emergency septal
perforation destruction of the cartilaginous
saddle nose but also intracranial infections
prompt diagnosis and treatment is very important

Introduction

Nasal septal abscess is a rare entity, it

is not frequently and has been
documented rarely in the literature.
Based on data at ENT Policlinic
Sanglah Denpasar General Hospital
from 2010-2013 was only 3 cases
A case of nasal septal abscess on a
child, male 9 years old, that treated
with incision and drainage, systemic
antibiotics with a good results has
been reported in Sanglah hospital

Incidence and Distribution

Uncommon condition
Major medical centers < 10 cases per year
116 pediatric cases over a period of 6 years in
Russia ; 43 cases from Toronto, Canada 8 years ;
16 cases in USA 10 years
Male > female = 2 : 1
Nasal trauma most common during childhood
More common in children than in adults
16-35 years old 43% ; < 15 y.o and > 35 y.o
28,5%

Anatomy

Anatomy

Predisposing factors and Etiology

Nasal
trauma

Accident, falls, fights, nose picking,

injury by NGT
Most common up to 75% of cases

Dental or
sinonasal
infections

Ethmoiditis, sphenoiditis,
furunculosis
Infected impacted incisors teeth

Spontaneous

Immunocompromised or
immunocompetent patients

Pathophysiology
Nasal
trauma

NSA
formation
bilateral or
unilateral

Tear the sub

mucosal
vessels

Bleeding between
septum and
mucoperichondrium

Cartilage perfusion ,
cartilage pressure ,
ideal medium for
growth of bacteria

Cartilage ischemia
and avascular
necrosis

Cartilage
damage

Hematoma

Pathophysiology
Necrosis intensified by collagenases that are
produced by the insulting bacteria S.aureus,
H.influenzae, Streptococcus strain
Activities of Cathepsin D enzyme degrading
intracellular acidic enzyme naturally and distributed
in the chondrocytes cartilage enhance cartilage
degradation
Bilateral is more common than unilateral
In sinusitis/dental infections direct spread
under periosteum/through bone
fissures/hematogenous venous (thrombophlebitis)

Microbiology
Most common bacteria aerobic
Staphylococcus aureus 70 %
Streptococcus pneumoniae, Streptococcus mileri,
Streptococcus viridans, Staphylococcus
epidermidis, Haemophilus influenzae,
Streptococcus -hemolyticus group A, Klebsiella
pneumoniae, Enterobacteriaceae and anaerobic
bacteria
Fungal infection rare

Diagnosis
History of
nasal trauma
Nasal
obstruction,
pain,
headache,
malaise,
fever

Anamnesis

Physical
examination
Cherry like
swelling of
nasal septum
Tenderness
and
fluctuation

Needle
aspiration pus
Culture and
sensitivity test
Laboratorium
leukocytosis

Additional
examination

Diagnosis
Clinically difficult to distinguish
between hematoma and NSA
NSA larger, more painful, the
mucosa may be inflamed, covered with
exudates, accompanied by fever and
leukocytosis
NSA can be unilateral or bilateral
bilateral is more common
NSA usually involves the anterior
cartilaginous nasal septum, but it can
be at posterior of the nasal septum

Treatment

Incision and
drainage

Bilateral non
opposing incision
if cartilage is
intact and pus
couldnt be drained

Various incision :
Killians transverse one
or L shape
fluctuation or near with
nasal floor

Empirical systemic
broad spectrum
antibiotics

Treatment
Systemic antibiotics directed at the most common
pathogens 3-5 days
Some clinicians advised the addition Gentamycin
to cover gram(-) bacteria
Metronidazole recommended when the infection
is dental in origin and anaerobic bacteria is
expected
After culture is finished antibiotics based on
culture and sensitivity
The antibiotics continued orally for 7-10 days
following discharge

Complications
NSA
complication

Local

-deviated nasal
septum
-saddle nose
-nasal valve
collapse
-sinusitis
-facial celullitis/
abscess
-nasal vestibulitis

Systemic

-bacteremia
-sepsis

Orbital

Cranial

-orbital cellulitis

-cavernous sinus

-sub periosteal
abscess
-orbital abscess

thrombosis
-epidural abscess
-meningitis
-intracranial abscess

Case report
Patient AS, male, children with 9 years old, class 3
of elementary school, from Banyuwangi came to
ENT clinic on April 16 2013 with main complaint
mass on both nasal cavity that just noticed 5 days
before
Initially the size was as small as pimple that
enlarge gradually
Tenderness and nasal obstruction
History of nose picking (+), cough and runny nose (-)
Fever (+), trauma or accident (-), dental infection (-)
No history of treatment

Case report
ENT examination :
Ear and throat : within
normal
Nose :both of nasal cavity
were narrow
Bilateral nasal septal
swelling, round, erythema
(+), soft, tenderness and
fluctuation
Aspirate pus 2 cc
culture and sensitivity test

Case report
Diagnosis : nasal septal
abscess
Incision and drainage with local
anesthesia
Vertical incision on the left side
pus + blood
Evaluation on the right nasal
cavity has defleted
Drain and nose packed
Patient then admitted for
hospitalization Ampicillin
4x500 mg (iv), metronidazole
3x250 mg (iv), paracetamol
forte syrup 3xcth1

Case report

April 16
2013

WBC 15,2 g/dl ; Hb 11,3 g/dl

Plt 506,5 g/dl ; GDS 101 mg/dl

April 18
2013

Nose pack removed

Mucosa hyperemi, swelling (+), drainage
pus (+)
Drain and nose pack was reinserted

April 20
2013

Nose pack removed

Mucosa is minimal hyperemi and swelling,
fluctuation (-), drainage pus (-)

Case report
April 21
2013

Minimal hyperemi, swelling (-), septal perforation

sign (-), the incision has closed
Culture Staphylococcus aureus 1st
generation of cephalosporin
Patient was discharge Cefadroxil forte syrup
2xcth1 and paracetamol forte syrup 3xcth1

April 23
2013

Patient controlled pain (-), nasal cavity

was wide, hyperemi (-), septal perforation (-)
Antibiotics continued for 7 days

April 30
2013

Patient controlled no complaint

Case report

DISCUSSION
Literature
NSA is uncommon condition

Case
Male , 9 years old

16-35 years old ; < 15 years old ; > 35 years

old
Male > female

Diagnosis : anamnesis, physical and

additional examination
Anamnesis : history of nasal trauma, nose
picking, obstruction, pain, headache and fever
Physical examination : cherry like swelling,
hyperemi, soft, fluctuation, tenderness

Same

Discussion
Literature

Case

Usually involves the anterior septum

and more common bilateral

Same

Additional examination : aspiration

pus culture and sensitivity test

Same

Laboratorium : leukocytosis

Same, leukocyte 15,2 g/dl

Treatment should be directed

incision and drainage abscess local
or general anesthesia

Same with local anesthesia

Incision : Killians transverse one or L

shape or near the nasal floor

Vertical incision

Incision is made at the one side

drain and nose packed

Same

Discussion
Literature

Case

Empirical systemic antibiotics advised

Ampicillin and
to start with broad spectrum that covers metronidazole
the most pathogens Staphylococcus
aureus Penicillin
Antibiotics treatment based on culture
result

Staphylococcus aureus
1st generation of
cephalosporin Cefadroxil

Most common complications nasal

septal perforation and saddle nose

Adequate medical
management prevent
such complications

CONCLUSSION
A case of nasal septal abscess on a child, male 9
years old, that treated with incision and drainage,
systemic antibiotics with a good results has been
reported
NSA is uncommon condition
With symptom nasal septal swelling, hyperemi,
fluctuation and tenderness
NSA rhinology emergency prompt diagnosis
incision and drainage directed adequate
systemic antibiotic prevent complications

Thank you