NASAL SEPTAL ABSCESS IN CHILDREN

By

Putu Vira Rikakaya

Scientific Advisor

dr. Luh Made Ratnawati, Sp.THT-KL

2014

Case report

INTRODUCTION

Introduction

Nasal Septal Abscess (NSA) defined as a collection of pus between the cartilaginous or bony nasal septum and its overlying mucoperichondrium or mucoperiosteum

Predisposing factors : nasal trauma (75% of cases) by accident, fall, fighting, nose picking ; nasal surgery, sinusitis, furuncle of nasal vestibule, dental infection, foreign body and immune deficiency

One of the rhinology emergency septalperforation destruction of the cartilaginous saddle nose but also intracranial infections prompt diagnosis and treatment is very important

Introduction

Nasal septal abscess is a rare entity, it is not frequently and has been documented rarely in the literature. Based on data at ENT Policlinic Sanglah Denpasar General Hospital from 2010-2013 was only 3 cases

A case of nasal septal abscess on a child, male 9 years old, that treated with incision and drainage, systemic antibiotics with a good results has been reported in Sanglah hospital

Incidence and Distribution

Uncommon condition

Major medical centers < 10 cases per year

116 pediatric cases over a period of 6 years in Russia ; 43 cases from Toronto, Canada 8 years ; 16 cases in USA 10 years

Male > female = 2 : 1

Nasal trauma most common during childhood

More common in children than in adults

16-35 years old 43% ; < 15 y.o and > 35 y.o 28,5%

Anatomy

Anatomy

Predisposing factors and Etiology

Accident, falls, fights, nose picking, injury by NGT

Most common up to 75% of cases

Nasal trauma

Ethmoiditis, sphenoiditis, furunculosis

Infected impacted incisors teeth

Dental or sinonasalinfections

Immunocompromised or immunocompetent patients

Spontaneous

Pathophysiology

Nasal trauma

Tear the sub mucosal vessels

Bleeding between septum and

mucoperichondrium

Hematoma

Cartilage perfusion , cartilage pressure ,

ideal medium for growth of bacteria

NSA formation bilateral or unilateral

Cartilage ischemia and avascular

necrosis

Cartilage damage

Pathophysiology

Necrosis intensified by collagenases that are produced by the insulting bacteria S.aureus, H.influenzae, Streptococcus strain

Activities of Cathepsin D enzyme degrading intracellular acidic enzyme naturally and distributed in the chondrocytes cartilage enhance cartilage degradation

Bilateral is more common than unilateral

In sinusitis/dental infections direct spread under periosteum/through bone fissures/hematogenous venous (thrombophlebitis)

Microbiology

Most common bacteria aerobic Staphylococcus aureus 70 %

Streptococcus pneumoniae, Streptococcus mileri, Streptococcus viridans, Staphylococcus epidermidis, Haemophilus influenzae, Streptococcus -hemolyticus group A, Klebsiellapneumoniae, Enterobacteriaceae and anaerobic bacteria

Fungal infection rare

Diagnosis

History of nasal trauma

Nasal obstruction, pain, headache, malaise, fever

Anamnesis

Cherry like swelling of nasal septum

Tenderness and fluctuation

Physical examination

Needle aspiration pus

Culture and sensitivity test

Laboratorium leukocytosis

Additional examination

Diagnosis

Clinically difficult to distinguish between hematoma and NSA

NSA larger, more painful, the mucosa may be inflamed, covered with exudates, accompanied by fever and leukocytosis

NSA can be unilateral or bilateral bilateral is more common

NSA usually involves the anterior cartilaginous nasal septum, but it can be at posterior of the nasal septum

Treatment

Incision and drainage

Various incision : Killians transverse one

or L shape fluctuation or near with

nasal floor

Bilateral non opposing incision if cartilage is intact and pus

couldnt be drained

Empirical systemic broad spectrum

antibiotics

Treatment

Systemic antibiotics directed at the most common pathogens 3-5 days

Some clinicians advised the addition Gentamycin to cover gram(-) bacteria

Metronidazole recommended when the infection is dental in origin and anaerobic bacteria is expected

After culture is finished antibiotics based on culture and sensitivity

The antibiotics continued orally for 7-10 days following discharge

Complications

NSA complication

Local

-deviated nasalseptum

-saddle nose-nasal valve

collapse-sinusitis

-facial celullitis/abscess

-nasal vestibulitis

Systemic

-bacteremia-sepsis

Orbital

-orbital cellulitis-sub periosteal

abscess-orbital abscess

Cranial-cavernous sinus

thrombosis-epidural abscess

-meningitis-intracranial abscess

Case report

Patient AS, male, children with 9 years old, class 3 of elementary school, from Banyuwangi came to ENT clinic on April 16 2013 with main complaint mass on both nasal cavity that just noticed 5 days before

Initially the size was as small as pimple that enlarge gradually

Tenderness and nasal obstruction

History of nose picking (+), cough and runny nose (-)

Fever (+), trauma or accident (-), dental infection (-)

No history of treatment

Case report

ENT examination :

Ear and throat : within normal

Nose :both of nasal cavity were narrow

Bilateral nasal septalswelling, round, erythema (+), soft, tenderness and fluctuation

Aspirate pus 2 cc culture and sensitivity test

Case report

Diagnosis : nasal septalabscess

Incision and drainage with local anesthesia

Vertical incision on the left side pus + blood

Evaluation on the right nasal cavity has defleted

Drain and nose packed

Patient then admitted for hospitalization Ampicillin 4x500 mg (iv), metronidazole 3x250 mg (iv), paracetamolforte syrup 3xcth1

Case report

WBC 15,2 g/dl ; Hb 11,3 g/dl Plt 506,5 g/dl ; GDS 101 mg/dl

April 16 2013

Nose pack removed Mucosa hyperemi, swelling (+), drainage pus (+)

Drain and nose pack was reinserted

April 18 2013

Nose pack removed Mucosa is minimal hyperemi and swelling,

fluctuation (-), drainage pus (-)

April 20 2013

Case report

Minimal hyperemi, swelling (-), septal perforation sign (-), the incision has closed

Culture Staphylococcus aureus 1st

generation of cephalosporin Patient was discharge Cefadroxil forte syrup

2xcth1 and paracetamol forte syrup 3xcth1

April 21 2013

Patient controlled pain (-), nasal cavity was wide, hyperemi (-), septal perforation (-)

Antibiotics continued for 7 days

April 23 2013

Patient controlled no complaintApril 30

2013

Case report

DISCUSSION

Literature CaseNSA is uncommon condition Male , 9 years old

16-35 years old ; < 15 years old ; > 35 yearsold

Male > female

Diagnosis : anamnesis, physical and additional examination

Same

Anamnesis : history of nasal trauma, nose picking, obstruction, pain, headache and fever

Physical examination : cherry like swelling,hyperemi, soft, fluctuation, tenderness

Discussion

Literature CaseUsually involves the anterior septum and more common bilateral

Same

Additional examination : aspiration pus culture and sensitivity test

Same

Laboratorium : leukocytosis Same, leukocyte 15,2 g/dl

Treatment should be directed incision and drainage abscess local or general anesthesia

Same with local anesthesia

Incision : Killians transverse one or L shape or near the nasal floor

Vertical incision

Incision is made at the one side drain and nose packed

Same

Discussion

Literature CaseEmpirical systemic antibiotics advised to start with broad spectrum that covers the most pathogens Staphylococcus aureus Penicillin

Ampicillin and metronidazole

Antibiotics treatment based on culture result

Staphylococcus aureus 1st generation of cephalosporin Cefadroxil

Most common complications nasal septal perforation and saddle nose

Adequate medical management prevent such complications

CONCLUSSION

A case of nasal septal abscess on a child, male 9 years old, that treated with incision and drainage, systemic antibiotics with a good results has been reported

NSA is uncommon condition

With symptom nasal septal swelling, hyperemi, fluctuation and tenderness

NSA rhinology emergency prompt diagnosis incision and drainage directed adequate systemic antibiotic prevent complications

Thank you