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.
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.
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 (
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 (
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.
Nasal septal abscess is a collection of pus between the nasal septal cartilage or bony septum and the mucoperichondrium or mucoperostium [
reported in 1810 by Arnal who assisted Cloquet to drain a nasal septal abscess in a patient suffering from “coryza” [
The most common presenting symptom of nasal septal abscess is nasal obstruction and pain [
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 [
Prompt recognition with surgical drainage of nasal septal abscess and antibiotic administration is thus required. The commonest aetiological agent is Staphylococcus aureus [
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.