Nasal septal abscess in children: from diagnosis to management and prevention

Nasal Obstruction: Overview of Pathophysiology and Presentation of a Clinically Relevant Preoperative Plan for Rhino(Septo)plasty

Impairment of nasal breathing is a highly prevalent and bothersome symptom that affects daily functioning and/or sleep quality. Those surgeons dealing with patients seeking rhinoplasty need to carefully analyze the preoperative nasal breathing capacity and predict the positive or even negative impact of rhino(septo)plasty on nasal breathing. Given the lack of correlation between the subjective feeling of suboptimal nasal breathing and the objective measurements of nasal flow and nasal resistance, a critical and mainly clinical evaluation of all anatomical, mucosal, and sensory mechanisms involved in nasal obstruction is mandatory. Indeed, thermo-, mechano-, and chemosensory receptors on the nasal mucosa, airflow, and respiratory dynamics might all contribute to the overall perception of nasal breathing capacity. In this review, we provide an overview of the factors determining suboptimal nasal breathing including different diagnostic and experimental tests that can be performed to evaluate nasal flow and nasal resistance and current limitations in our understanding of the problem of nasal breathing in an individual patient. An algorithm for the preoperative or diagnostic workup for nasal obstruction is included that might be useful as a guide for clinicians dealing with patients seeking nose surgery.

Idiopathic pediatric nasal septal and epidural abscess: A case report and review of the literature

Nasal septal abscess is an uncommon otolaryngologic condition with little reported in the literature. Most commonly arising secondary to hematoma, idiopathic abscess formation is rare. A previously healthy 13-year-old male with no preceding nasal hematoma or trauma presented with rhinorrhea, nasal pain, and obstruction. Initial incision and drainage were not curative; the patient returned to care with complaints of new-onset headache. Neuroimaging revealed abscess recurrence alongside pansinusitis and epidural empyema. The patient was transferred to a tertiary care center for joint otolaryngologic and neurosurgical care. The patient's postoperative course was uncomplicated. Nasal septal abscesses have become increasingly uncommon, but they still occur. Prompt treatment is warranted to mitigate the potential risk of further intracranial spread and facial deformity, as seen in this case.

Management of Traumatic Nasal Avulsion Injuries

Soft tissue injuries to the midface (and nose) are common causes for seeking trauma care. As trauma patients, observing advanced trauma life support protocols is warranted given the risk of concomitant injuries. Here, options for optimizing tissue preservation, microvascular replantation, non-microvascular tissue replacement, and wound stabilization are discussed. Included in this discussion are data-driven predictors for successful replantation as well as technique descriptions with anatomic references to guide surgeons in choosing optimal donor vessels. In both partial and complete avulsion injuries, venous congestion is common. Several postoperative wound care protocols to maximize tissue perfusion and long-term viability are discussed.

Point-of-Care Ultrasound of a Nasal Septal Abscess

ABSTRACT

Although nasal septal abscesses (NSA) are rare, complications can be significant and devastating. Thus, timely diagnosis of NSA is critical. In this case report, we describe the use of point-of-care ultrasound in diagnosing NSA in a healthy boy presenting with viral upper respiratory infection symptoms and fever. Point-of-care ultrasound findings resulted in expediting this patient's treatment and transfer to a quaternary care center for definitive treatment.

Spontaneous abscess of the nasal septum in children: a 10-year series

BACKGROUND

This paper reports a 10-year series of spontaneous nasal septal abscesses in immune-competent children, with suggestions for optimal management.

METHODS

A retrospective case note review was conducted of children undergoing an operation for incision and drainage of nasal septal abscesses between 2013 and 2023.

RESULTS

Six children were identified via electronic hospital records during the 10-year review period, five with a spontaneous abscess. The children were aged 10-14 years. All were immunocompetent and none had active sinus infection. The most common presenting features were nasal swelling, facial swelling, headache, nasal congestion and fever. The most common bacterial isolate was Staphylococcus aureus. All children received prompt surgical drainage and intravenous antibiotic therapy. Complications were seen in three children, with one child developing significant intracranial complications.

CONCLUSION

To our knowledge, this is the first series of spontaneous nasal septal abscesses in immunocompetent children. The high prevalence of Staphylococcus aureus suggests spread from the nasal mucosa or vestibule. Early recognition, computed tomography scanning, surgical drainage and antibiotic therapy are the mainstays of treatment, to prevent potentially life-threatening complications.

Nasal septal abscess in adult patients - A single center study

PURPOSES

The purpose of this study was to present and analyze the etiologic factors, clinical manifestations, bacteriology, and treatment outcomes of nasal septal abscess in a large cohort of adult patients.

MATERIAL AND METHODS

Retrospective analysis.

RESULTS

36 adult patients, age from 19 to 85 (mean age, 51.83), with nasal septal abscesses were treated at Ear Nose Throat Hospital of Ho Chi Minh City from January 2020 to August 2022. The most common symptoms were nasal obstruction (75 %), headache/facial pain (58.33 %). Etiologic factors were found in 83.33 % of cases with the most common were diabetes mellitus (47.22 %), nose-picking (44.44 %). 75 % of cases had positive bacterial culture, of which 70.37 % were Staphylococcus aureus. Septal abscess was successfully treated in all cases using our treatment protocol, which involved an extended modified Killian's incision, irrigation with 1 % poviodine, placement of gauze in the abscess pocket, and nasal packing with Merocels.

CONCLUSIONS

Diabetes and nose-picking were the most common etiologic factors; Staphylococcus aureus was the most common organism of nasal septal abscess in our study. Our treatment protocol is safe and effective.

Nasal Septal Hematoma and Abscess in Children: An Uncommon Otorhinolaryngology Emergency Revisited

OBJECTIVE

To evaluate the demographic factors, trauma type, treatment, and long-term results in patients with nasal septal hematoma (NSH) and nasal septal abscess (NSA) in pediatric age group.

METHODS

Between the years 2006 and 2019, patients who received a diagnosis of NSA and NSH were included for the study. Demographic data, the surgical findings, and long-term follow-up results were recorded.

RESULTS

A total of 68 patients were identified. Forty-five patients were diagnosed as NSA and 23 patients were diagnosed with NSA. Mean age of the patients was 7.00 ± 3.33 years. Patients did not differ in terms of age, gender, and etiology. Mean duration of the symptoms was significantly high in NSA group (4.11 ± 4.00 days for NSH and 7.61 ± 7.71 days for NSA, P = 0.011). Associated nasal fracture was significantly high in NSH group. Previous nasal examination was significantly high in NSA group. Epistaxis was present significantly high in NSH group (P = 0.013). Fever and purulent nasal discharge was observed significantly high in NSA group. Forty-seven (n = 47) patients can be reevaluated for long-term deformity (NSH, n = 34 [72.34%] and NSA, n = 13 [27.65%]). Mean follow-up period of the patients was 8.7 years. In total, 61.7% of the patients experienced minor or major sequelae. Both NSA and NSH groups did not differ in terms of minor sequelae and major sequelae. No sequleae was significantly high in NSH group (for NSH n = 17/34-(50,0%); for NSA n = 1/13- (7,7%), p = 0.008). Both NSA and NSH groups did not differ in terms of no sequelae and minor sequelae.

CONCLUSION

The NSH and NSA are uncommon conditions that needed prompt diagnosis and intervention.

Nasal septal hematoma in children: Time to diagnosis and resulting complications

OBJECTIVES

To determine the time from initial injury to diagnosis of nasal septal hematoma (NSH). Additional objectives included determining number of medical evaluations prior to diagnosis and long-term complications.

METHODS

A retrospective chart review was performed on all patients diagnosed with NSH at a tertiary pediatric hospital between January 1, 2003 and April 1, 2019 were identified. Time to diagnosis was defined as time between initial trauma to date of diagnosis. Number of evaluations was defined as all medical evaluations prior to diagnosis.

RESULTS

Of 2762 charts that were reviewed, 13 patients with NSH were identified. Of those, 92% were male and trauma was the cause in 85% of patients. Median time to diagnosis was 7 days (0-21 days), with an average of 2.2 evaluations (1-4 evaluations). Settings where diagnosis were missed included EDs (N = 9, 82%), primary care (N = 6, 55%), urgent care (N = 1, 9%) and otolaryngology clinic (N = 2, 18%). Four patients (31%) were evaluated by an otolaryngologist in the ED. The median time to otolaryngology outpatient visit was 7.5 days. In five patients (46%), septal hematomas were missed in multiple clinical settings. Seven patients (54%) experienced complications, including saddle nose deformity (N = 3, 23%).

CONCLUSIONS

NSH is a rare but serious emergency. To avoid multiple visits and delay in diagnosis, additional education and awareness is needed for providers who evaluate these patients. Early diagnosis will reduce the risk of abscess formation and saddle nose deformity.

Nasal septal abscess with a dental origin: a case report and a review of the literature

Since the first report of a nasal septal abscess (NSA) from a dental origin (1920), six articles have been published in the English literature to date. The most common cause of NSA is an infection of the nasal septal hematoma after trauma. This is a report of an uncommon cause of NSA with a dental origin. A PubMed search performed regardless of year and country using the terms (“nasal septal abscess”) OR (“nasal septum abscess”) initially yielded 229 articles. After screening, seven articles (eight patients) were selected. Addition of two related articles produced a total of nine articles (10 patients) to be included. The age of the included patients ranged from 7 to 69 years (mean, 32.82 years; standard deviation, ±23.86 years). The sex composition was as followed: males (n=7; 63.6%), females (n=4; 36.4%). Dental histories were various: periapical lesions, caries, extraction, endodontic therapy, and cystic lesions. The maxillary incisor dominated as the tooth of origin. Early diagnosis and treatment of NSAs are important to avoid not only facial deformity, but also severe complications (e.g., intracranial infection). If NSA is suspected in patients without facial trauma, the possibility of a dental origin, especially from the maxillary incisor area, should be considered.

Non-accidental trauma presenting with nasal septal hematoma or abscess

OBJECTIVES

Failure to diagnose non-accidental trauma (NAT) leaves the victim at risk of further injury or even death. It is incumbent upon physicians and other health care personnel to identify trauma patterns that have a high likelihood of being caused by NAT. The objective of this study is to discuss the presentation of nasal septal hematoma (NSH) or nasal septal abscess (NSA) as a sign of NAT.

METHODS

This is a retrospective case series of patients presenting with nasal septal hematoma or abscess between 2010 and 2019. The primary endpoint was the etiology of the injury. Secondary endpoints included demographics, concomitant injuries and treatments rendered.

RESULTS

There were 28 patients who presented with septal hematoma or abscess. The etiologies included 20 (71.4%) due to accidental trauma, four (13.8%) with NAT, one infectious, and three unknown. All four NAT patients were male and infants with an average age of 5.4 months (SD 4.6) significantly (p = 0.0069) younger than 10.3 years (SD 5.1) in the accidental trauma group. There was a delayed time to presentation for the NAT patients compared to other etiologies. Two of four NAT patients were initially thought to have a congenital midline nasal dermoid, yet surgical intervention revealed a hematoma. Further NAT evaluation noted concomitant injuries including rib fractures and intracranial injuries in 75% of the NAT patients.

CONCLUSIONS

Presentation of a child with NSH/NSA prior to the onset of ambulation or with a delayed time to presentation should prompt suspicion and further workup for NAT.

An Unusual Case of a Pediatric Nasal Septal Abscess with Life-Threatening Complications in COVID-19 Pandemic

In this modern era, when access to healthcare services is improved, and awareness among the general population is enhanced, the presentation of mere septal abscess of the nose as a fatal complication is less common. Due to various lockdown restrictions in the COVID-19 scenario and fear to contract an infection, patients are presenting late to the health care setting for proper management. We treated an 11-year old child of complicated nasal septal abscess who responded well to aspiration of pus and medical treatment. Our patient is a rare case report who progressed from vestibulitis to septal abscess and further leading to sinusitis, orbital, and intracranial complications.

Nasal Septal Abscess Developed After Radiofrequency Cauterization for Epistaxis

Nasal septal abscesses are commonly caused by nasal trauma, infection, and nasal surgery. As delayed treatment of nasal septal abscesses can cause various complications, including saddle nose, a prompt diagnosis with the relevant intervention is important. However, the diagnosis of nasal septal abscesses is difficult when nasal pain occurs after cauterization because there have been no formal reports of nasal septal abscesses owing to cauterization for epistaxis. Here, the authors report the first case of a nasal septal abscess that developed after cauterization. A 48-year-old woman underwent radiofrequency cauterization as a treatment for epistaxis. She developed nasal pain 10 days following cauterization, and a computed tomography scan revealed a nasal septal abscess. Careful observation should be undertaken in patients who undergo cauterization of the nasal septum, especially in patients complaining of nasal pain.

Pediatric nasal tip abscesses

Nasal tip abscesses in children are uncommon. We report on 7 children/teenagers who presented with an advanced nasal tip abscess that required intravenous antibiotics and surgical drainage, despite adequate pre-admission antibiotic therapy with amoxicillin/clavulanic acid or cephalosporins. Cultures were positive for Staphylococcus aureus, that was clindamycin-resistant but TMP/SMX sensitive.

Nasal septal abscess: a 10-year retrospective study

OBJECTIVE

Nasal septal abscess is an uncommon condition but it can cause potentially life-threatening intracranial complications and cosmetic nasal deformity.

METHODS

We analyzed ten years of cases to determine the optimal diagnostic and therapeutic modalities. A retrospective review of case notes from Tri-Service General Hospital archives was performed. Records of six patients diagnosed with nasal septal abscess, who were treated from September 2007 to August 2017 were retrospectively reviewed. Patients' clinical symptoms, etiology, diagnostic methods, bacteriology, antibiotic and surgical treatment were recorded and analyzed.

RESULTS

Out of six patients diagnosed with nasal septal abscess, three were male and three were female. Ages ranged from 19 to 75 years (mean 51 years). The most common symptoms at presentation were nasal pain and nasal obstruction. Typical etiologies were trauma or acute sinusitis, but uncontrolled diabetes mellitus was also an important etiology. In the series of six patients, four of them had positive findings of abscess and in drainage, had the following bacterial cultures: Staphylococcus aureus (two cases), methicillin-resistant S. aureus (one case), and Klebsiella pneumoniae (one case). In addition to antibiotic treatment, all patients underwent surgical drainage and had complete resolution of disease without intracranial complications during at least 1 year of follow-up. However, two out of the six patients developed saddle nose deformity.

CONCLUSIONS

This study highlights that: 1. In view of the rapidly increasing number of diabetes mellitus cases, uncontrolled diabetes mellitus is an important etiology of nasal septal abscess. 2. Although S. aureus is the most common pathogen, we must pay attention to methicillin-resistant S. aureus (MRSA) to prevent severe complications and patients who are at increased risk for MRSA colonization should be administrated antibiotics against MRSA initially. 3. Nasal septal abscess should be managed with parenteral broad spectrum antibiotics, appropriate drainage and immediate reconstruction of the destructed septal cartilage with autologous cartilage graft, to prevent serious intracranial complications and cosmetic nasal deformity.

Nasal septal abscess caused by anaerobic bacteria of oral flora

Although nasal septal abscess (NSA) was formerly common, it has become rare since the development of antibiotics. NSA, if left untreated, can lead to intracranial complications such as meningitis and eventually result in saddle-nose deformity. NSA often occurs after injury, and indigenous skin bacteria such as Staphylococcus aureus are frequently detected. We treated a patient who had injured the upper alveolus in a fall on the stairs and developed NSA two weeks later. Anaerobic bacteria, including Veillonella parvula and Peptostreptococcus sp., were detected. Symptoms were relieved by needle and incisional drainage. Our patient represents a very rare case of NSA in terms of the cause of onset and the detected bacteria. Early drainage can result in good outcomes.

The Route by Which Intranasally Delivered Stem Cells Enter the Central Nervous System

Intranasal administration is a promising route of delivery of stem cells to the central nervous system (CNS). Reports on this mode of stem cell delivery have not yet focused on the route across the cribriform plate by which cells move from the nasal cavity into the CNS. In the current experiments, human mesenchymal stem cells (MSCs) were isolated from Wharton’s jelly of umbilical cords and were labeled with extremely bright quantum dots (QDs) in order to track the cells efficiently. At 2 h after intranasal delivery in immunodeficient mice, the labeled cells were found under the olfactory epithelium, crossing the cribriform plate adjacent to the fila olfactoria, and associated with the meninges of the olfactory bulb. At all times, the cells were separate from actual nerve tracts; this location is consistent with them being in the subarachnoid space (SAS) and its extensions through the cribriform plate into the nasal mucosa. In their location under the olfactory epithelium, they appear to be within an expansion of a potential space adjacent to the turbinate bone periosteum. Therefore, intranasally administered stem cells appear to cross the olfactory epithelium, enter a space adjacent to the periosteum of the turbinate bones, and then enter the SAS via its extensions adjacent to the fila olfactoria as they cross the cribriform plate. These observations should enhance understanding of the mode by which stem cells can reach the CNS from the nasal cavity and may guide future experiments on making intranasal delivery of stem cells efficient and reproducible.

Management of Pediatric Nasal Surgery (Rhinoplasty)

Nasal surgery in children, most often performed after trauma, can be performed safely in selected patients with articulate, deliberate, and conscientious operative plan. All nasal surgery in children seeks to avoid disruption of the growth centers, preserving and optimizing nasal growth while improving the form and function of the nose. A solid appreciation of long-term outcomes and effects on growth remain elusive.

Spontaneous Nasal Septal Abscess Presenting as a Soft Tissue Mass in a Child

BACKGROUND

Nasal septal abscess (NSA) is a rare condition most commonly seen as a complication of nasal trauma. The diagnosis of NSA requires emergent treatment, because delayed management can result in significant morbidity. Typically, NSA presents as a purulent collection that can be managed with drainage, either surgically or at bedside.

CASE REPORT

We report an unusual presentation of a spontaneous NSA in a 7-year-old boy as a solid nasal mass eroding the nasal septum. The solid, tumor-like nature of the mass necessitated intervention beyond drainage and was ultimately excised. Imaging initiated in the emergency department revealed a partially cystic mass and erosion of the septum, which was key to the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the ease with which a diagnosis of NSA may be missed and the need for urgent management upon diagnosis of a NSA, we aim to highlight the clinical, radiologic, and histopathologic aspects that aid in diagnosis of NSA. Imaging, obtaining culture results, and initiation of antibiotics are paramount in management. In addition, NSAs may also necessitate bedside drainage given their emergent nature.

Nasal septal abscess in association with pediatric acute rhinosinusitis

INTRODUCTION

Nasal septal abscess (NSA) in the pediatric population is rare and can result in devastating complications. Objective of this study is to review a case series of pediatric patients presenting with NSA in association with acute rhinosinusitis (ARS) for possible risk factors and predisposing conditions.

METHOD

This is a retrospective review of pediatric patients that presented to a tertiary care hospital with nasal septal abscess associated with ARS. Patient demographics, presence of ARS, sinuses involved, and other potential risk factors were recorded. In addition, a literature review was conducted to evaluate other reported cases of NSA in association with ARS. Cases of NSA associated with trauma or other causes were excluded from analysis.

RESULTS

Five patients with NSA were treated by the pediatric otolaryngology department of a tertiary care center from 2003 to 2014. Three of these cases were associated with ARS. Of these cases, the average age at diagnosis was 9.7 years. Two were male and one was female. In these cases, the bilateral frontal, maxillary and ethmoid sinuses were involved. Sphenoid involvement occurred in two patients. One case was associated with ipsilateral middle turbinate concha bullosa. The cartilaginous septum was compromised in all three cases. All patients were treated with incision and drainage.

CONCLUSION

This is the largest case series of NSA described in the pediatric population. NSA is exceedingly rare but may be associated with ARS. While the etiology of NSA is not always clear, identifying and treating nasal septal abscesses early is imperative to reduce potentially devastating complications.

Pediatric septoplasy: a review of the literature

OBJECTIVES

Controversy has surrounded the procedure of pediatric septoplasty since the 1950s due to concerns over an adverse effect on nasal and facial growth. However, more recent evidence has demonstrated that septoplasty can be safely performed without affecting nasal and facial development in the appropriately selected pediatric patient. The purpose of this article is to establish the impact of pediatric septoplasty on nasal and facial growth and review the clinical indications and evidence for timing of surgery according to the most recent literature.

METHODS

A structured review of the PubMed, Ovid Medline and Cochrane Collaboration databases (Cochrane Central Register of Controlled Trials, Cochrane Database of Systemic Reviews) was undertaken, using the terms: pediatric, childhood, septoplasty, nasal septum, indications, nasal growth and facial growth.

RESULTS

Three long term follow up studies using anthropometric measurements were identified which concluded that pediatric septoplasty does not interfere with normal nasal or facial development. A further similar study concluded that external septoplasty does not affect most aspects of nasal and facial growth, but may negatively influence growth of the nasal dorsum. Furthermore, one study demonstrated that a group of children with symptomatic uncorrected deviated nasal septum had a statistically significant increased occurrence of facial and dental anomalies compared with age and sex matched controls, therefore supporting a role for septoplasty.

CONCLUSIONS

Evidence exists to support that pediatric septoplasty can be performed without affecting most aspects of nasal and facial growth. Furthermore, not performing or delaying septoplasty when indicated may adversely affect nasal and facial growth with compounding adverse effects in terms of deformity and asymmetry. Despite the majority advocating the timing of septal surgery to be 6 years and older, more clinical studies are required that may provide further evidence for correction of septal deviations in younger children, perhaps even at birth.