Abses Septum

International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 79-81
http://dx.doi.org/10.4236/ijohns.2013.23019 Published Online May 2013 (http://www.scirp.org/journal/ijohns)
Spontaneous Nasal Septal Abscess Presenting as Complete

Nasal Obstruction
Joseph Chun-Kit Chung*, Athena Ting-Ka Wong, Wai-Kuen Ho
Division of Otorhinolaryngology, Head & Neck Surgery, Department of Surgery, The University of Hong Kong,
Queen Mary Hospital, Hong Kong, China
Email: *jckchung@graduate.hku.hk
Received March 23, 2013; revised April 3, 2013; accepted May 3, 2013
Copyright 2013 Joseph Chun-kit Chung et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Nasal septal abscess is an uncommon condition, yet presents as a rhinological emergency. Its symptoms resemble upper
respiratory tract infection and the diagnosis may be missed leading to intracranial complication and cosmetic deformity.
We present a healthy patient with idiopathic nasal septal abscess who complained of acute complete nasal obstruction,
fever and nasal pain. Common aetiologies, causative agents, complications and management of nasal septal abscess are
discussed.
Keywords: Nasal Septum; Abscess; Emergencies
1. Introduction
Nasal septal abscess is an uncommon condition. High
index of suspicion and prompt drainage is required to
prevent intracranial infection and future nasal deformity.
However the clinical manifestations may be subtle and
mimic upper respiratory tract infection. It usually happens after surgery or trauma. Here we present a case of
spontaneous nasal septal abscess and discuss the management plan.
2. Case Report
A 41-year-old gentleman who enjoyed good past health
was referred to our ENT clinic by his family physician
with four days history of complete nasal obstruction,
fever and nasal pain. He also had prior history of myalgia
and headache for 1 week. There was no prior history of
nasal surgery, trauma. On physical examination, his nasal
dorsum was swollen and tender. Anterior rhinoscopy
revealed bilateral cherry red septal bulge (Figure 1).
Other than running a fever of 38.8C, there was no associated neurological deficit or neck stiffness. The rest of
the examination including nasoendoscopy was unremarkable. The diagnosis of nasal septal abscess was confirmed by needle aspiration of pus. The sample was sent
for culture and sensitivity testing. His white blood cell
count was elevated to 2.1 1010/l with neutrophil pre*
Corresponding author.
Copyright 2013 SciRes.
dominance. Blood glucose was normal. Urgent CT scan

revealed a 3 cm 1.2 cm 1.6 cm ill-defined rim enchancing hypodense collection at the anterior nasal septum (Figures 2(a) and (b)). The rest of the paranasal
sinuses were clear. Dental assessment later could not
identify any infection of dental origin.
Emergency transnasal drainage of the abscess under
general anaesthesia was subsequently performed. Intraoperatively, the central portion of cartilaginous nasal septum was necrotic and destroyed by infection. The superior and caudal septal cartilage struts were still intact, but
soften and thinned as a result of inflammation (Figure 3).
A drain was anchored in the abscess cavity and both nasal cavities were packed with merocele.
Figure 1. Nasal septal abscess resembling hypertrophic turbinates.

IJOHNS
J. C.-K. CHUNG
80
ET AL.
Figure 3. Central cartilage destruction by inflammation,

superior and caudal strut (S) still preserved.
(a)
(b)
Figure 2. Computer tomographic scan: (a) Axial cut showing abscess involving anterior cartilaginous nasal septum;
(b) Coronal cut showing showing no intra-cranial extension.
Bacteriological culture yielded methicillin-sensitive

Staphylococcus aureus that was sensitive to Augmentin.
Patient was treated accordingly for 2 weeks. Follow up
nasoendoscopy at 2 weeks showed intact nasal septum
and complete resolution of the abscess. At 6 months later,
he noted a mild depression over his nasal dorsum. Augmentation rhinoplasty has been suggested, but he refused.
3. Discussion
Nasal septal abscess is a collection of pus between the
nasal septal cartilage or bony septum and the mucoperichondrium or mucoperostium [1]. This entity was first
reported in 1810 by Arnal who assisted Cloquet to drain

a nasal septal abscess in a patient suffering from coryza
[2]. The commonest aetiology is nasal trauma leading to
haematoma formation and subsequent infection [2,3].
Nearly 75% are secondary to nasal injury [1]; less frequently following septal surgery. Other causes include
localized nasal sinusitis, vestibulitis [3-5]; nearby dental
abscess, infected dentigerous cyst [6]; an immunocompromised state in patients who suffered from diabetes
mellitus, HIV infection or receiving chemotherapy [2,7].
In the literature, there are only two idiopathic nasal septal
abscesses reported previously [8], similar to the present
case. Most of the abscess cavity situated at the anterior
cartilaginous nasal septum. Posterior septal abscess may
be missed if only anterior rhinoscopy is performed [4].
The most common presenting symptom of nasal septal
abscess is nasal obstruction and pain [2], in distinction
with uncomplicated septal haematoma which usually
presents as painless nasal obstruction after injury. Other
symptoms include fever, malaise, headache and epistaxis.
On rhinoscopy, this uncommon pathology is often mistaken as inferior turbinate hypertrophy, deviated nasal
septum or simple mucosal oedema [2,4] by less experience physicians and causal examination. This may be
avoided by cautious inspection and palpation, confirming
a fluctuant swelling arises from nasal septum.
The accumulation of pus between the cartilage and
perichondrium will lead to ischaemia and pressure necrosis of the cartilage. Together with the digestive process
of leukocytes and Cathepsin D, an enzyme responsible
for reshaping the quadrangular cartilage, this may result
in septal cartilage destruction, saddle nose deformity and
lead to both functional and cosmetic problems [9]. In a
growing child in particular, there may be additional disturbance of the normal development of the nose and
maxilla [9,10]. Delayed diagnosis and management may
also lead to life-threatening intracranial infective comIJOHNS
J. C.-K. CHUNG
plications such as brain abscess, meningitis and cavernous sinus thrombosis, especially in immunocompromised
patients [2-8].
Prompt recognition with surgical drainage of nasal
septal abscess and antibiotic administration is thus required. The commonest aetiological agent is Staphylococcus aureus [3], others include Haemophilus influenzae, Streptococcus pneumonia and group A beta-haemolytic streptococcus [5]. In immunocompromised patients, the abscess may be caused by anaerobes or polymicrobial infections. Opportunistic fungal agents, for
instance Candida, Cryptococcus and Aspergillus have
been reported in HIV or poorly controlled DM patients
resulting in a high mortality [2,7]. With this knowledge
of microbiology, together with the general condition of
the patient, empirical antibiotic treatment can be started
immediately once diagnosis is made before the organism
is isolated and its sensitivity is identified.
In case of nasal deformity after complete or near complete septal destruction, reconstruction of the nasal septum may be performed to address both functional and
cosmetic problems. It may be carried out immediately
after drainage of the abscess as a primary treatment, or
secondary treatment after resolution of the infection [6,9].
Reconstruction of the destroyed septal infrastructure may
be made use of residual septal cartilage by mosaicplasty
or exchange technique; or autologous cartilage grafts
from tragus, auricle or rib [9,10].
In conclusion, non-traumatic nasal septal abscess is a
rarely seen rhinological emergency. High index of suspicion and careful examination is essential because of its
non specific flu-like symptoms. Early drainage would
prevent nasal deformity and intra-cranial complications.
REFERENCES
[1]
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and J. H. Kelly, Management of Nasal Septal Abscess,
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Nasal Septal Abscesses in the Immunocompromised: Aetiology, Recognition, Treatment and Sequelae, American
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Kuala Lumpur, Singapore Medical Journal, Vol. 34, No.
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Posterior Nasal Septal Abscess in a Healthy Adult Patient, Journal of Laryngology & Otology, Vol. 122, No.
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Lee, Nasal Septal Abscess: An Unusual Presentation of
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International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 79-81

http://dx.doi.org/10.4236/ijohns.2013.23019 Published Online May 2013 (http://www.scirp.org/journal/ijohns)

Spontaneous Nasal Septal Abscess Presenting as Complete

Copyright 2013 SciRes.

dominance. Blood glucose was normal. Urgent CT scan

Figure 1. Nasal septal abscess resembling hypertrophic turbinates.

Figure 3. Central cartilage destruction by inflammation,

Bacteriological culture yielded methicillin-sensitive

reported in 1810 by Arnal who assisted Cloquet to drain

P. S. Ambrus, R. D. Eavey, A. S. Baker, W. R. Wilson

Copyright 2013 SciRes.

S. B. Shah, A. H. Murr and K. C. Lee, Nontraumatic

M. A. B. Jalaludin, Nasal Septal AbscessRetrospective Analysis of 14 Cases from University Hospital,

A. George, W. K. Smith, S. Kumar and A. G. Pfleiderer,

P. H. Huang, Y. C. Chiang, T. H. Yang, P. Z. Chao and F.

J. G. Cho, H. W. Lim, P. Zodpe, H. J. Kang and H. M.

B. Salam and A. Camilleri, Non-Traumatic Nasal Septal

C. Dispenza, C. Saraniti, F. Dispenza, C. Caramanna and

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