Injury Extra (2004) 35, 1—2 CASE REPORT Nasal septal haematoma with abscess: an unusual complication of nasal injury Menachem Gross*, Ron Eliashar Department of Otolaryngology/Head & Neck Surgery, Hadassah University Hospital, Jerusalem 91120, Israel Accepted 10 November 2003 Case history Conclusion A 32-year-old woman appeared at the Ear, Nose, and Throat Out-Patient Clinic with a 5-day history of nasal swelling, bluish discoloration of the skin on the nasal bridge, and increasing nasal pain, since she struck her nose after an episode of syncope. She also complained of bilateral nasal congestion and obstruction. Initially, at the time of injury, the patient was evaluated at the Emergency Department and was discharged. On physical examination, her nose was swollen and tender with haematoma on the skin of the nasal bridge. Anterior rhinoscopy revealed bilateral dull purple swelling and tenderness of the nasal septum, that bulged into the nasal cavity and narrowed both nasal cavities. The clinical impression was nasal septal abscess. Computer tomography (CT) of the nose showed a displaced fracture of the nasal bone (Fig. 1) and a swollen nasal septum with hypodensic area surrounded by a rim enhancement that is compatible with haematoma and abscess (Fig. 2). The patient underwent bilateral incision, drainage and suction of blood and pus from the nasal septal abscess. Anterior nasal packing was inserted for 72 h and intravenous amoxicillin and clavulanic acid was initiated. Follow-up at hospitalisation did not reveal recurrent collection. Minor and major traumas to the nose are frequent injuries that may cause injury to the nasal septum. Nasal septal abscess resulting from nasal trauma is an uncommon complication of nasal trauma.1 Nasal septal abscess results from a collection of purulent material between the cartilaginous or bony nasal septum and its normally applied mucoperichondrium or mucoperiosteum. Nasal septal abscess resulting from trauma usually develops in a pre-existing septal haematoma. Direct injury to *Corresponding author. Tel.: þ972-2-6776469; fax: þ972-2-6468800. E-mail address: drgrossm@hotmail.com (M. Gross). Figure 1 Axial CT scan of the nose showing displaced fracture of the nasal bone (arrow). 1572–3461/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.11.007 2 M. Gross, R. Eliashar Figure 2 Axial (a) and coronal (b) CT scan of the nose demonstrating nasal septum haematoma and abscess (arrows). the nose causes tearing of blood vessels in the mucoperichondrium. Blood then collects between the mucoperichondrium and the septal cartilage, forming septal haematoma. The haematomas separating the mucoperichondrium from the septal cartilage deprive the cartilage of its blood supply. Ischaemia and pressure from the haematoma lead to necrosis and cartilage destruction. This provides an ideal environment for bacterial colonisation and subsequent abscess formation. A unilateral abscess often becomes bilateral as the cartilage dissolves rapidly. The most common organism cultured from nasal sepal abscess is Staphylococcus aureus.3 Other organisms such as Streptococcus species, Hemophilus infulenza, anaerobes, and coliforms are less frequently isolated.1,3 Nasal septal abscess arises after nasal trauma. Other rare causes for such condition are nasal surgery, furuncles of nasal vestibule, sinusitis, dental infection. It may also occur spontaneously mainly in an immunocompromised patient.2,3 The time interval between the nasal injury and the presenting symptoms is 5—7 days. The most common symptoms of nasal septal haematoma and abscess are nasal obstruction and nasal congestion. Other complaints are nasal pain, swelling, erythema over the nasal skin, headache, fever, and malaise. Physical examination reveals a tender, erythematous, and swollen nasal bridge. Anterior rhinoscopy typically demonstrates tenderness and fluctuation by palpation of unilateral or bilateral swelling of the nasal septum that narrows the nasal cavity. Aspiration by puncture of the swollen nasal septum will reveal purulent material. A patient with septal haematoma and abscess should be referred immediately to otorhinolaryngologist for surgical treatment. Incision and complete drainage of the collection with bilateral nasal packing is the initial treatment. Systemic antibiotics based on culture and sensitivity results are continued for about 2 weeks. The nasal packing is recommended for 48—72 h to prevent re-accumulation. After removal of the nasal packing, close observation is needed to detect recollection which usually occurs within 3 days after nasal packing removal. Delayed diagnosis and management of nasal septal abscess results in a compromised vascular supply to the cartilaginous nasal septum and suddle nose deformity as a final cosmetic complication. Other serious complications are sepsis, meningitis, orbital cellulitis, cavernous sinus thrombosis, and intracranial abscess.1 References 1. Erlich A. Nasal septal abscess: an unusual complication of nasal trauma. Am J Emerg Med 1993;11:149—50. 2. Henry K, Sullivan C, Crossley K. Nasal septal abscess due to Staphylococcus aureus in a patient with AIDS. Rev Infect Dis 1988;10:428—30. 3. Matsuba HM, Thawley SE. Nasal septal abscess: unusual causes, complications, treatment and sequelae. Ann Plast Surg 1986; 16:161—6.