Hematome n Nasal Septal Abscess

7/27/2019 Hematome n Nasal Septal Abscess

1/4

Hematoma and Abscess of the Nasal Septumin ChildrenPaul A. Canty, MBBS; Robert G. Berkowitz, FRACS

Objective: To evaluate the clinical characteristics andtreatment outcome of hematoma and abscess of the na-sal septum (HANS) in children.

Design: Retrospective case series.

Setting: Pediatric tertiary care facility.

Patients: Consecutive series of 20 children (age, 2months to 15 years; mean age, 7 years) who were admit-ted to the hospital for treatment of HANS after nasaltrauma during an 18-year period.

Interventions: In addition to receiving antibiotics, allpatients underwent general anesthetic for incision andevacuation of the collection of blood and pus togetherwith nasal packing.

Results: All patients had a history of nasal trauma. TheHANS was a consequence of child abuse (2 patientsyounger than 2 years), minor nasal trauma (14 patientsaged 1 to 10 years), and sports injury (4 patients olderthan 10 years). The diagnosis was made 1 to 14 days

(mean, 5.9 days) after the episode of trauma. Nasal ob-struction was the most common symptom found and was

present in all but 1 patient. Pain, rhinorrhea, and feveroccurred in 50%, 35%, and 25% of patients, respec-tively. Nasal fracture was present in 3 children. Abscesswas found at surgery in 12 patients and was universallyassociated with septal cartilage destruction. Hematomawas present in 8 patients and associated with cartilagedestruction in 2 patients. Organisms cultured were Staphy-lococcus aureus, Streptococcus pneumoniae, and group A\g=b\-hemolyticstreptococcus and were obtained from all12 patients with septal abscess and from 1 patient withseptal hematoma. Corrective nasal surgery has been per-formed in 5 patients, 4 of whom had a history of septalabscess.

Conclusion: The diagnosis of HANS must be consid-

ered in all children who haveacute onset

of nasal ob-struction and a history of recent nasal trauma to mini-mize the risk of nasal deformity and prevent thedevelopment of septic complications.

Arch Otolaryngol Head Neck Surg. 1996;122:1373-1376

MINORNASAL trauma in

children is common,but it is only rarely associated with the de

velopmentof hema

toma and abscess of the nasal septum(HANS). As a consequence, the diagnosis of HANS may be overlooked and leadto late diagnosis, which may be associated with the development of complications. In particular, septal cartilage destruction and cosmetic nasal deformitymay result.1"3 More severe complications,however, such as meningitis,14 cerebral abscess,56 subarachnoid empyema,6 and cavernous sinus thrombosis5 also have been

reported.Hematoma and abscess of the nasal

septum is defined as a collection of bloodor pus between the cartilaginous or bonynasal septum and its normally applied

mucoperichondrium or mucoperios-teum.7 Only a few references to HANSexist in the medical literature, and this isespecially true in the pediatrie population

(TobleI).89

Early diagnosis and treatment are essential to prevent the development of complications. However, it may be difficult todetermine the group at risk of experiencing HANS among the many children whosustain minor nasal trauma. We reviewed our experience of 20 cases of HANSin children who were seen during an 18-year period at the Royal Children's Hospital, Melbourne, Australia.

See Patients and Methodson next page

From the Department ofOtolaryngology, RoyalChildren's Hospital,Melbourne, Australia.

on April 9, 2012www.archoto.comDownloaded from
http://www.archoto.com/http://www.archoto.com/http://www.archoto.com/http://www.archoto.com/


2/4

PATIENTS AND METHODS

A retrospective study was carried out from July 1,1977, to July 30, 1995, of all children admitted tothe Royal Children's Hospital with a condition diagnosed as HANS. Children with septal collectionsoccurring after nasal surgery were excluded. Allchildren were admitted and underwent urgentdrainage under general anesthetic, together withnasal packing (bismuth iodoform in paraffin paste)with or without insertion of a Penrose drain. Swabsof the fluid drained were sent for microscopicexamination and culture. Antibiotics were administered to all patients.

RESULTS

The study group included 18 boys and 2 girls rangingin age from 2 months to 15 years, with a mean age of 7

years. A history of nasal trauma was obtained in allpatients. Patient characteristics, cause of injury, andtime elapsed before treatment following trauma aregiven in Table 2.

The 2 youngest children were cases of suspectedchild abuse. Both had severe facial and neck bruisingand nasal trauma. In 1 child, skeletal survey showedmultiple old rib fractures. Both children had histories ofinjury requiring a visit to the hospital emergencydepartment, but child abuse was not recognized at the

time. The 2-month-old infant had beenseen

3 weekspreviously following a head injury and was found tohave a parietal skull fracture. The mechanism of injurywas unobtainable at the time due to the inconsistent

history given by the parents. The 22-month-old childhad been seen previously with an atypical pattern ofinjury that raised the possibility of child abuse, butinadequate evidence was found at the time to confirmthe diagnosis.

Minor nasal trauma was the major causal factor inchildren between 2 and 10 years of age. This included

simple falls, collisions with stationary objects, falls froma

bicycle,and minor altercations with

siblings (Table 2).In older children, septal injury was sustained while playing sports, including a fall during a cycling race, a blow

by a tennis racquet, and a punch in the face while playing hockey.

The mean time elapsed before being seen for hematoma and abscess following nasal trauma was 5 and 6.5days, respectively, with an overall mean of 5.9 days andrange of 1 to 14 days. In 5 patients (25%), the diagnosiswas missed on the first visit, and, in 1 patient, diagnosiswas made on the third visit. In these children, treatmentwas

delayedan average of 4.6

days (range,3-7

days).Af

ter eventual diagnosis, a septal abscess was found in 4 ofthese 5 patients, with all 5 having evidence of septal cartilage destruction.

Details of the initial signs and symptoms are givenin Table 3. Nasal obstruction was the most common

symptom (95% of patients). Patients with easily visiblesigns of injury such as nasal fracture, epistaxis, or cel-lulitis were seen earlier than those without. Three children were assessed clinically to have nasal bone fractureand all underwent closed reduction at the time of drainage of the septal collection. Radiologicalconfirmation wasobtained in only 1 patient; no other children had radio

logical examination.Nasal packs were left in situ from 1 to 7 days,with an average of 2.7 days. Penrose drains were usedin only 4 patients. Three patients (15%) requiredreturn to the operating room for repeat drainage following re-collection, which occurred between 1 and 3days after nasal pack removal. All 3 patients had aninitial diagnosis of septal abscess and had nasal packsin situ for 3 days. Two of the 3 patients also had Pen-rose drains inserted at the time of the initial drainageprocedure.

Surgical findings, microbiologie examination re

sults, antibiotics used, and length of stayare

given inTable 4. Septal abscess was found in 12 patients and allwere associated with cartilage destruction and positiveculture results. Septal hematoma was found in 8 patients, but cartilage destruction was present in only 2 ofthese patients. An organism was cultured in only 1 caseof septal hematoma and was associated with the presence of cartilage destruction. Staphylococcus aureus wasthe most common organism grown. The other organisms cultured were Streptococcus pneumoniae and groupA -hemolytic streptococcus.

Seventeen patients (85%) were available for

follow-up duringa

period rangingfrom 1 week to 12

months, but only 6 patients were observed beyond 6 weeksfollowing surgery. Five of these 6 patients required subse-

Table 1. Recently Reported Series of Hematoma and Abscess of the Nasal Septum

No. of Cases

Source, y Time Period, y-

Hematoma Abscess Total

Eavey et al,41977Fearon et al,1 1961Jalaludin,101993

Ambrus et al,71981Larchenko,81961Chukuezi,51992Kryger and Dommerby,91987

108

10

1065

10

Pediatrie

Pediatrie

Pediatrie and adult

Pediatrie and adultPediatrie and adultAdult

Adult

013

0

0113827

343

14

16105

812

35614

16116

4639



3/4

quent corrective nasal surgery, 4 of whom had a historyof septal abscess with cartilage destruction and 1 who hada history of septal hematoma and cartilage dislocation butnot destruction.

Table 2. Age, Sex, Cause, and Time Elapsed BeforeTreatment After Injury to Nasal Septum

Patient No./Sex/Age Cause at Injury Time ElapsedBefore Treatment, d

1/M/2 mo Child abuse Unknown2/IW22 mo Child abuse 1

3/M/2 y Fall off chair 4

4/M/2 y* Collision with stationary object 75/M/2 y Simple fall 76/M/4 yt Simple fall 47/M/7 y Punch by sibling 48/M/7y* Fall off bicycle 109/M/9y Simple fall 7

10/M/8y Kick by sibling 711/M/8y Fall off bicycle 112/F/7 yt Fall during epileptic seizure 3

13/M/8y Collision with stationary object 1114/M/8 y*t Clash of heads 515/IW9y* Punch by sibling 1416/M/9y Simple fall 1017/M/10y Clash of heads 118/M/12 y* Hit by tennis racquet 619/M/12 y Fall from bicycle during race 520/F/15 y Sporting Injury; punch 5

* Indicates diagnosis missed on first visit.tReturned to operating room for second drainage procedure.

COMMENT

Cosmetic nasal deformity and other complications ofHANS are preventable by early diagnosis and treatment.Acute suppurative complications of HANS are rare andin general occur when a diagnosis is notably delayed.Chukuezi3 described 4 patients with brain abscess and 1with cavernous sinus thrombosis secondary to HANS inwhich the

averagetime before

beingseen was 3 to 4 weeks.

It is therefore important to identify which children areat risk of experiencing HANS among the larger group ofchildren who sustain minor nasal trauma. The literature suggests a strong male predominance,5'710 and minor nasal trauma is the major causal factor,710 as was foundin our study, but other causes also have been reported,

Table 3. Signs and Symptoms at First Visit

Signs and SymptomsNo. (%)of Cases

Mean TimeElapsed BeforeTreatment, d

Mean Ageof Patient, y

Nasal obstructionPainRhinorrhea

Fever

Nasal fracture

BleedingCellulitis

HeadachePoor feeding

19(95)10(50)5(25)5(25)3(15)2(10)1(5)1(5)1(5)

5.67.25.8

6.0

4.3

5.5

3.010.0

Unknown

7.2

8.05.8

6.68.38.07.0

9.02.0

Table 4. Surgical and Microbiological Findings

Culture Results

PatientNo.

Surgical Cartilage Staphylococcus Streptococcus Group AFindings Necrosis aureus pneumoniae Streptococcus Antibiotics"

Length ofStay, d

1

23

4t5

6t-78t9

1011

12*

13

14tt15f16

1718t

19

20

AbscessHematomaAbscessAbscessAbscess

AbscessHematomaAbscessHematoma

HematomaHematomaAbscess

Abscess

AbscessHematomaAbscess

HematomaAbscess

Abscess

Hematoma

Total

Nil

PartialTotalPartialTotal

PartialPartial

NilNilNil

Total

Total

TotalPartial

Partial

Total

Partial

Nil

IV floxacillin and penicillin G sodiumIV floxacillin/oral amoxicillinIV floxacillin/oral floxacillinIV floxacillinOral trimethoprim and sulfamethoxazoleIV floxacillin and penicillinOral amoxicillinIV floxacillin

Oral amoxicillinOral amoxicillin

Oral amoxicillinIV floxacillin and chloramphenicol

sodium succinateIV floxacillin and peniciilin/oral floxacillin

and penicillinOral amoxicillin and clavulanic acidIV floxacillin/oral floxacillinIV floxacillin and chloramphenicol/

oral floxacillinOral amoxicillinIV floxacillin/oral trimethoprim and

sulfamethoxazoleIV floxacillin and penicillin/oral amoxicillin

and clavulanic acid

Oral floxacillin

1210

33

37

3232

1

9

*IV indicates intravenous.

t Diagnosis missed on first visit.^.Returned to operating room for second drainage procedure.



4/4

including ethmoiditis,11 sphenoiditis,1213 dental abscess,14 and nasal furuncles.710 Nasal obstruction is themost common initial symptom,4710 and HANS usuallyis not associated with nasal bone fracture,57 which alsois supported by our findings. The diagnosis of HANSshould therefore be considered in all children with acuteonset of nasal obstruction preceded by recent nasaltrauma.

Whena

boggynasal

swellingis

observed andHANS

is suspected, recognition of a septal collection may be enhanced by application of topical anesthetic and decon-gestant followed by palpation of the swelling with a waxcurette or similar blunt instrument. If the diagnosis is stillunclear, needle aspiration will confirm the diagnosis, relieve pressure, and provide a specimen for microbiologie examination before definitive drainage and nasalpacking. Routine preoperative needle aspiration has beensuggested by Ambrus et al.7

Hematoma and abscess of the nasal septum in youngchildren warrants special consideration because the in

jury may have occurred as a consequence of child abuse.The 2 patients described in this series had other cranio-facial injuries besides septal injury, and a background ofprevious hospital visits. In a young child, HANS shouldsuggest the possibility of child abuse and lead to a moredetailed search for other injuries or evidence of previous trauma.

The proposed mechanism of HANS formation isrupture of the small blood vessels supplying the nasal septum as a result of minor nasal trauma. Hematoma forms,which separates the mucoperichondrium from septalcartilage. Cartilage destruction follows as a result of ischemia and pressure necrosis. This provides an ideal en

vironment for bacterial colonization and subsequent abscess formation.2 7 From an analysis of data in Tables 2and 4, the average time before the patients with cartilagedestruction were seen was 6.9 days, compared with 3.6days for those with intact septal cartilage. This underscores the significance of early diagnosis and treatment.

Management of HANS is universally accepted to beurgent surgical drainage of the collection with nasal packing and antibiotic cover.124715 Drainage in children is bestachieved under general anesthetic, by surgical incisionover the collection followed by nasal packing. Two to 3days seems to be an appropriate time for nasal packing,

but close observationis

necessaryto

detectre

collection, which occurred in 3 of our patients, all within3 days of nasal pack removal. No causal factor was identified to explain why fluid re-collected in the 3 patients,but all had septal abscess. Insertion of a Penrose drainwas not found to be beneficial. Although a drain was usedin only 4 patients, a re-collection occurred in 2 of thesepatients. In view of re-collection occurring in 3 patients, the technique of using a dissolvable quilting suture to appose mucoperichondrium and cartilage and

thereby eliminate dead space is recommended, although this was not used in our study.

The only organisms recovered in our study wereS aureus, S pneumoniae, and group A -hemolytic streptococcus, which suggests that floxacillin alone would provide appropriate antibiotic cover. In other studies, however, Haemophilus influenzae also has been isolated.46716

Despite the limited numbers available for follow-

up,it seems

thatthe children with

septal abscess, cartilage destruction, and positive bacterial culture are morelikely to experience nasal deformity, so this group merits long-term follow-up.

The incidence of severe complications is directly related to delay in treatment. Diagnosis of HANS shouldbe considered in all children with acute onset of nasalobstruction and a history of recent nasal trauma to minimize the risk of nasal deformity and prevent the development of septic complications.

Accepted for publication July 30, 1996.Presented at the Annual

Meeting ofthe American So

ciety of Pediatrie Otolaryngology, Orlando, Fla, May 9,1996.

Corresponding author: Robert G. Berkowitz, FRACS,Department of Otolaryngology, Royal Children's Hospital, Flemington Road Parkville, Victoria, Australia 3052.

REFERENCES

1. Fearon B, McKendry JB, Parker J. Abscess of the nasal septum in children.Arch Otolaryngol. 1961;74:408-412.

2. Fry HJH. The pathology and treatment of hematoma of the nasal septum. Br JPlast Surg. 1969;22:331-335.

3. Olsen KD, Carpenter RJ III, Kern EB. Nasal septal injury in children. Arch Oto-laryngol. 1980;106:317-320.4. Eavey RD, Malekzakeh M, Wright HT. Bacterial meningitis secondary to ab-

scess of the nasal septum. Pediatrics. 1977;60:102-104.5. Chukuezi AB. Nasal septal hematoma in Nigeria. J Laryngol Otol. 1992;106:

396-398.

6. McCaskey CH. Rhinogenic brain abscess. Laryngoscope. 1951;61:460-467.7. Ambrus PS, Eavey RD, Sullivan Baker A, Wilson WR, Kelly JH. Management

of nasal septal abscess. Laryngoscope. 1981;91:575-582.8. Larchenko RM. On abscesses of the nasal septum in children. Vestn Otorino-

laringol. 1961;23:46-49.9. Kryger H, Dommerby H. Hematoma and abscess of the nasal septum. Clin

Otolaryngol. 1987;12:125-129.10. Jalaludin MAB. Nasal septal abscess: retrospective analysis of 14 cases from

university hospital, Kuala Lumpur. Singapore Med J. 1993;34:435-437.11. Beck AL. Abscess

of the nasal septum complicating acute ethmoiditis. ArchOtolaryngol. 1945;42:275-279.12. Collins MP. Abscess of the nasal septum complicating isolated acute sphe-

noiditis. J Laryngol Otol. 1985;99:715-719.13. Matsuba H. Nasal septal abscess: unusual causes, complications, treatment

and sequelae. Ann Plast Surg. 1986;16:161-166.14. da Silva M, Helman J, Eliachar I, Joachims H. Nasal septal abscess of dental

origin. Arch Otolaryngol. 1982;108:380-381.15. Close DM, Guinness MDG. Abscess of the nasal septum after trauma. Med J

Aust. 1985;142:472-474.16. Chundu KR, Naqvi SH. Nasal septal abscess caused by Haemophilus influen-

zae type B. Pediatr Infect Dis. 1986;5:276.


Documents

Hematome n Nasal Septal Abscess