Case Presentation Saad Alsaleh, MBBS

History 23 year old single Saudi lady, medically free Referred from a private hospital & presented to ER C/O: Nasal Obstruction for 10 days ▫Gradual in onset, constant & progressive in severity. ▫Bilateral ▫Ass. with nasal & facial pain, undocumented fever (No chills or rigors). ▫Reported presence of a small swelling in the Rt. nostril before her symptoms began.

History No Hx of nasal discharge, epistaxis, allergic Sx, postnasal drip, ear or throat Sx, ocular pain or vision disturbance. No Hx of trauma, nasal surgery, dental disease, bleeding tendency, immunodeficiency or diabetes. Drug Hx: -ve Past Medical & surgical Hx: Unremarkable. Family & Social Hx: Unremarkable.

Physical Exam Looks well. V/S: ▫Temp. 36 O C ▫Pulse 91 bpm ▫Bp 118/78 mmHg External nasal exam: ▫No visible deformities. ▫No ecchymosis.

Physical Exam

No facial tenderness. No periorbital swelling, ocular mobility & vision are intact. Ear bil. & throat: Normal No cervical LAP. Cranial Nerves are intact.

Investigations CBC: ▫WBC 7.0 ▫Hb 12.7 ▫PLT 509 Coagulation Profile ▫PT 13 ▫PTT 34.3 U/E ▫Urea 2.4 ▫Creatinine 51 ▫Na ▫K 4.83

Summary 23 year old female presented to ER C/O: Bil. Nasal Obstruction for 10 days. Ass. with nasal & facial pain. No Hx of trauma or surgeries. O/E: ▫V/S stable, Afebrile ▫Bil. reddish soft anterior septal swelling. ▫Other aspects were normal.

Differential Diagnosis of Nasal Obstruction Congenital: ▫Neurogenic Tumors ▫Cysts ▫Teratoma ▫Choanal atresia ▫Septal deformities Infectious: ▫Rhinitis ▫Chronic sinusitis ▫Adenoid hypertrophy ▫Septal abscess Tumour: ▫Chondromas ▫Papillomas ▫Nasal Polyps ▫Haemangioma ▫Pyogenic granulomas ▫Angiofibroma ▫Malignancies Neurologic: ▫Vasomotor rhinitis Trauma: ▫Nasal & septal fractures ▫Septal hematoma ▫Synechia ▫Foreign Body Drugs & toxins: ▫Rhinitis medicamentosa ▫Tobacco ▫Anti HTN, Anti thyroid Rx ▫Aspirin ▫Cocaine & Marijuana Systemic: ▫Diabetes ▫Hypothyroidism ▫Pregnancy ▫Granulomatous disease ▫Vasculitis ▫Allergy ▫Cystic Fibrosis

Hospital Course Admitted to the ward. Started on: ▫Clindamycin 600 mg IV Q8h ▫Ceftriaxone 1 g IV Q12h Shifted to OR: ▫Under GA an incision was made in the most anterior and inferior part of the swelling in the Rt. nostril. ▫Pus was drained and sent for culture and sensitivity. ▫Necrotized septal cartilage in the anterior inferior part was removed. ▫A Penrose drain was inserted, secured by nylon. ▫Merocel packs were inserted bil.

Hospital Course 2 nd day post op: ▫Pain ▫Packs removed bil. 3 rd day post op: ▫Drain removed. ▫C/S result: Staph. aureus sensitive to clindamycin. 5 th day post op: ▫D/C IV Abx ▫Discharged in good condition on cefuroxime 500 mg po bid with 1/52 F/U.

Septal Abscess

Is a collection of pus between the cartilaginous or bony nasal septum and its normally applied mucoperichondrium or mucoperiostium. Its recognition traces back to 1810 when Cloquet (a French Physician) healed an abscess by drainage. Its a rare entity.

Etiology Infection of a septal hematoma (most common). furuncle of the nasal vestibule (McKenzie D, 2007). Sinusitis (Santiago, 1999). Infections of dental origin (Da Silva, 1982). Immunodeficiency (Shah SB, 2000). Venous spread from the orbits or cavernous sinus.

Pathogens Staphylococcus aureus (most common). Streptococcus pneumonia. Streptococcus milleri, Streptococcus viridans, Staphylococcus epidermidis, Hemophilus influenza. Rarely, anaerobic bacteria* *Brook, Recovery of anaerobic bacteria from a post-traumatic nasal septal abscess. A report of two cases, Ann. Otol. Rhinol. Laryngol. 107 (1998) 959—960.

Symptoms Nasal obstruction (most common). throbbing nose pain. general malaise and fever. Headache.

Signs Tender, erythematous, and swollen nasal bridge. Bilateral swelling of the anterior septum that can range in color from gray to reddish purple. The size of the swelling depends on the stage at which the patient is examined. Check also facial tenderness, ocular changes and cranial nerves.

(Santiago R, 1999)

Investigations CBC: Leukocytosis. APRs ↑ CT of the paranasal sinuses

Management fine needle aspiration of the abscess under topical anesthesia, sending it for gram stain, culture and sensitivity. Parenteral antibiotics should be started and given for at least for 3 to 5 days then changed to oral for 7 to 10 days. Mucoperichondrial incision, removal of necrotic cartilage and Penrose drain insertion under local or general anesthesia + Packing.

Management Reconstruction: ▫Immediate vs. Late ▫Controversial ▫Management of nasal septal abscess in childhood: our experience. International Journal of Pediatric Otorhinolaryngology, Volume 68, Issue 11, Pages C. Dispenza, et al (2004)

Complications Meningitis. Cavernous sinus thrombosis. intracranial abscess. Orbital cellulitis. Sepsis. Saddle nose deformities or septal perforation.

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