Bilateral spontaneous abscess of the nasal septum: case report

¹Otorhinolaryngology Department of the Military Training Hospital Mohamed V of Rabat, Rabat, Morocco

^&Corresponding author
Marouane Balouki, Otorhinolaryngology Department of the Military Training Hospital Mohamed V of Rabat, Rabat, Morocco

Introduction    

Nasal septal abscess is a rare complication of acute sinusitis, exceptionally the abscess can be spontaneous. Very few cases of spontaneous septal abscess have been described in the literature [1]. We report a case of a girl who presented with a spontaneous abscess of the nasal septum without any triggering factor after several paraclinical examinations.

Patient and observation     

A 29-year old woman, follow-up for type 1 diabetes on insulin with no history of dental care or sinusitis, who was presented to the ENT emergency with an acute onset nasal pain for 3 days without traumatic factor. The pain was associated with acute bilateral nasal obstruction. On admission: the patient was not febrile, she had a swelling of the root of the nasal pyramid, rhinoscopy was sufficient to show a relapsing water-like mass in both nasal cavities at the point of septal origin. The palpation of the septal collection was very painful (Figure 1).

Diagnostic assessment: nasosinus computed tomography (CT) showed a hypodense image of the nasal septum suggestive of an abscess, without filling of the maxillary and ethmoidal sinuses (Figure 2). Biology found hyperleukocytosis at 13,000 elements per mm and C-reactive protein (CRP) at 45.

Diagnosis: at the end of the clinical, biological and radiological investigation, we were able to retain the diagnosis of a spontaneous bilateral abscess of the nasal septum in a young diabetic patient without any otorhinolaryngological infectious focus.

Therapeutic intervention: surgical drainage of the abscess was performed urgently by two interseptocolumellar incisions, on either side of the nasal septum allowing the evacuation of compartments of pus. The septal cartilage was intact. Betadinated wicks were left in place for 24 hours to avoid rapid recollection, then the nasal cavity was wicked with two merocels for 48 hours. The patient was put on bi-antibiotic therapy: Ciprofloxacin and Metronidazole parenterally for eight days with balanced glycemic control, and nasal cavity washings.

Follow-up and outcomes: the evolution after 2 months was favorable, the cartilage was intact, straight, with good nasal permeability.

Informed consent: informed consent was obtained from the patient.

Discussion     

An abscess of the nasal septum is a rare condition [1]. Little cases have been listed in the literature. This condition is of interest to all ages with a predilection for children and males [2]. The etiology of the abscess is dominated by the superinfection of a post traumatic hematoma of the septum, the spread of the infection to the septum from an infectious sinus site, mainly ethmoidal or sphenoidal, or of dental or iatrogenic origin [2]. Our patient very probably arises from a spontaneous mechanism because the examination did not find any obvious sinus, nasal or dental infectious site, neither clinical nor radiological.

The clinical symptomatology is dominated by bilateral nasal obstruction and nasal pain. Purulent rhinorrhea, headache or general fever-like signs are less common. The clinical examination is the key to the diagnosis. Anterior rhinoscopy coupled with nasal endoscopy shows a fluctuating bulging of the septal mucosa which is inflammatory, reddish or purplish. This bulge is generally bilateral, and sits at the anterior part of the septum [3]. Nasosinus CT is the test of choice to confirm diagnosis, look for the cause and neurological or ophthalmological complications.

Treatment of the abscess begins, after a puncture and bacteriological sample, with probabilistic antibiotic therapy which will be modified according to the results of the antibiogram. This antibiotic therapy is initially parenteral for three to five days, then orally with a minimum duration of seven to ten days. The most used molecules are Amoxicilin associated with clavulanic acid or quinolones + metronidazole to cover the most damaged germ, which is staphylococcus and anaerobes, especially if the origin of the abscess is dental [4].

Surgical drainage of the abscess is the mainstay of treatment, usually under local anesthesia in adults. It begins immediately after the puncture. The incision of the abscess is done in full collection allowing the evacuation of pus, necrosis tissue and superinfected blood clots. This may be done with wide unilateral incision at the point of maximal fluctuance, or bilateral non-opposing incisions if the cartilage is intact and the fluctuance is bilateral. The intervention ends with a bilateral wicking of the pits nasal passages for two to three days. After stripping, it an endoscopic examination should be carried out in order to detect possible recollection. Some authors recommend a drainage of the abscess by small Panrose probes [4], others recommend the realization after demising of transseptal sutures absorbable. In the case of secondary abscess, it is imperative to identify and treat the primary focus of infection concomitantly to avoid recurrence and sequelae [5].

Conclusion     

Spontaneous abscess of the nasal septum is a rare but severe condition, which can have serious functional and aesthetic consequences on the septal cartilage, or even be life-threatening and lead to sepsis. The diagnosis is essentially clinical. The treatment is medico-surgical, and must be implemented as soon as the abscess is diagnosed to prevent the onset of complications.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

MB wrote the article. SI have reviewed the literature. SO and FB are responsible for the corrections. All authors have read and approved the final manuscript.

Figures     

Figure 1: bilateral swelling of the nasal septum

Figure 2: nasosinus CT scan, axial section showing abscess of the anterior part of the nasal septum (yellow arrow) (A), absence of sinus filling (yellow arrow) (B)

References