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Review article
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 2 January 2011
Received in revised form 9 March 2011
Accepted 10 March 2011
Available online 14 April 2011
Background: Nasal septal abscess (NSA) is an uncommon condition. It is a collection of pus in the space
between the nasal septum and its overlying mucoperichondrium and/or mucoperiosteum. If left
untreated, there are risks of intracranial complications, facial deformity, and delayed facial growth.
There is no universally agreed consensus on the treatment of this condition. This study reviews evidence
in the literature to determine its etiology, presentation, investigation, management options, and
outcome.
Method: A structured review of the PubMed, EMBASE and the Cochrane Collaboration databases
(Cochrane Central Register of Controlled Trials, Cochrane Database of Systemic Reviews) was
undertaken, using the MeSH terms: nasal septum, nasal cartilage, trauma, hematoma, abscess,
reconstructive surgery, rhinoplasty, pediatric, and children.
Results: A total of 159 citations from 1920 to date were reviewed regarding nasal septal abscess, of which
81 articles were identified to be relevant to this review. No randomized controlled trials or systematic
reviews were found in the Cochrane Collaboration database, PubMed or EMBASE. NSA is more common
in children and in male. Nasal trauma and untreated septal hematoma are the leading cause.
Staphylococcus aureus is isolated in up 70% of the cases. Clinically, nasal septal swelling, pain and
tenderness, with purulent discharge are mostly evident. The immediate management of NSA is incision
and drainage and antibiotic therapy. Recent studies suggest early septal reconstruction in children in
order to prevent immediate and late facial deformity and nasal dysfunction. Autologous cartilage is the
implant material of choice.
Conclusion: Nasal septal abscess is a serious condition that necessitates urgent surgical management in
order to prevent potential life threatening complications. In the growing child, early reconstruction of
destructed septal cartilage is essential for normal development of the midface (nose and maxilla).
! 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords:
Nasal septum
Nasal cartilage
Children
Nasal trauma
Septal hematoma
Abscess
Nasal septum reconstruction
Contents
1.
2.
3.
4.
Introduction . . . . . . . . . . . . . . . . . . . . . . . .
Materials and methods . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.
Related anatomy . . . . . . . . . . . . . . .
3.2.
Incidence and distribution . . . . . . .
3.3.
Etiology . . . . . . . . . . . . . . . . . . . . . .
3.4.
Pathophysiology . . . . . . . . . . . . . . .
3.5.
Microbiology . . . . . . . . . . . . . . . . . .
3.6.
Clinical presentation and diagnosis
3.7.
Complications . . . . . . . . . . . . . . . . .
3.8.
Treatment . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction
3.3. Etiology
In general, Beck classified the etiological factors of NSA into
three groups. Primary in which the causative factor is nasal trauma,
secondary causes in which NSA develops secondary to dental or
sinonasal infections, and spontaneous when no underlying cause
could be elicited [18].
Trauma is by far the most common cause of septal hematoma
which if not diagnosed early and treated adequately may result in
formation of septal abscess. In up to 85% of the cases, NSA develops
secondary to infected traumatic nasal septal hematoma [19]. In fact,
15% of patients who sustain nasal trauma may develop septal
hematoma and thus are at risk of secondary infection and purulence
[13]. It seems that occurrence of traumatic NSA has been variable
along the years and around the world ranging between 0.8 and 1.6%
of the cases of nasal trauma attended in the emergency room by
otorhinolaryngologists [11,17]. Besides the common causes of nasal
trauma like accidents, falls, fights, and nose picking, chronic
irritation and injury of the nasal septum by naso-gastric tube has
been reported as the leading cause for NSA formation [20].
Infections within the nasal cavity and sinuses may also result in
NSA formation. Mechanism of infection is either as direct
extension from the overlying infected mucosa, or via lymphatic
and/or vascular spread [21]. Sinusitis, nasal vestibulitis, and
furunculosis are the leading causative infections. Although
extremely rare, isolated acute sinusitis such as sphenoiditis and
spheno-ethmoiditis has been documented as a direct cause of NSA.
In 1945, the first case of NSA complicating acute ethmoiditis was
reported. Forty years later, isolated acute sphenoiditis was
reported as a potential cause for NSA development [18,22]. Pang
and Sethi described a case of NSA secondary to acute sphenoethmoiditis in a 12-year-old boy who presented with nasal
obstruction and unilateral periorbital oedema of 5 days duration.
Computed tomography scan showed bilateral anterior nasal septal
abscess and sinusitis. Drainage was performed and antibiotics
739
740
[()TD$FIG]
741
742
the remaining cartilage [72]. Synthetic materials such as polyethylene graft have also been used for acute phase septal reconstruction [73].
For early septal reconstruction, Hellmich described three
surgical options. (1) Reconstruction with the posterior cartilage
residue or bony septum to adjust deformities in the anterior
septum Exchange technique. (2) Reconstruction with small
fragments of residual cartilage fixed together with fibrin glue
Mosaicoplasty. (3) Reconstruction with a preserved rib cartilage
allograft when the septal material is not available Homograft
[74].
The current available data that describes the surgical techniques and results of early reconstruction of the nasal septum either
during or shortly after the initial incision and drainage of NSA is
extracted from some sporadic case reports and a few case series, of
which the largest series will be highlighted in this review.
The majority of pediatric otorhinolaryngologic surgeons
recommend early reconstruction whenever feasible in order to
restore and maintain both contour and function, prevent nose and
mid facial growth retardation, not to mention the prevention of
potential risk for long term psychological problems secondary to
disturbed self-image and self-esteem because of the gross nasal
deformity [75].
Most surgeons prefer the open approach for reconstruction
surgery as it allows direct access to the nasal base and all areas of
the nasal septum, precise estimation of the cartilage loss and thus
how much reconstruction is needed [3,4,7577].
Early septal reconstruction goes back to 1951 when Mills
reported the use of homograft to reconstruct septal cartilage
during initial incision and drainage surgery of NSA [76]. Shortly
after, Cottle et al. proposed the implantation of nasal septum
recommending the treatment within 812 weeks from abscess
drainage when resolution of the infection could assure a successful
implantation [69]. Vase and Johannessen reported their results 33
months following the treatment of 5 children with early septal
reconstruction using homograft cartilage implantation at time of
abscess drainage. They stated that cosmetic and functional results
were satisfactory with no evidence of cartilage rejection nor
resorption, saddle deformity, retracted columella, or deviated
septum. Their series, however, was small with a relatively short
follow-up period and was mainly based on observational evaluation [72].
Few other encouraging results for early septal reconstruction
(at the time of incision and drainage of the abscess) have been
reported with the longest follow up period of 19 years [4]. The two
largest cohorts included 7 and 6 children, respectively. In the first
Table 1
Summary of reported cases of early nasal septal reconstruction in the management of nasal septal abscess.
Author/s year
No. of patients
Reconstruction material
Mills [76]
Masing [5]
One
5
Homologous cartilage
Homologous cartilage
4 years
One of two
monozygotic twins
5
Homologous cartilage
4 years
Homologous cartilage
33 months
Huizing [4]
Grymer and Bosch [67]
2
One of two
monozygotic twins
Homologous cartilage
Homologous cartilage
3 homologous cartilage/4
autologous septal cartilage
10 years
Autologous conchal/costal
cartilage
38 months
F/U period
1719 years
10 years
Sequelae
No functional complications.
No saddle deformity.
Underdevelopment of nasal tip and premaxilla.
No saddle deformity.
Satisfactory with no saddle deformity, retracted columella,
or deviated septum.
Normal nasal growth and function is with minimal saddle.
Saddle deformity, upward displacement of anterior part of
the maxilla, diminished vertical development of the nasal
cavity, retrognathically positioned maxilla.
Normal development of face and nasal pyramid
with normal function.
Four mild non-obstructing deviation of the nasal septum.
Normal nasal development.
One mild collumellar retraction.
Three mild over-rotation of the nasolabial angle.
series, all 7 children who received immediate surgical reconstruction with homologous L-shape cartilage graft (3 children) or
mosaicoplasty where residual septal cartilage was fixed by fibrin
glue (4 children) showed normal development and function of the
nose after a period of 10 years [77]. In the second series of 6
children, all were reconstructed immediately with an autologous
cartilage graft (auricular or costal) that was stabilized and fixed on
polydioxanone plate, positioned between the vomer, the upper
lateral cartilages, and perpendicular plate or remnants of the
cartilaginous septum and sutured by mattress through an open
approach. With a mean follow-up period of 38 months, all children
showed normal development of the nose (length of nose and
amount of nasal tip projection) in comparison to the standardized
growth curves for central Europe [3]. Reports of early septal
reconstruction are summarized in Table 1 [35,67,68,72,76,77].
Although such results are promising, the small number of cases
makes it difficult to draw a significant conclusion. Further, in most
series, children were still in the growing phase, and there was no
control group for comparison.
4. Conclusion
Nasal septal abscess is a serious condition that necessitates
urgent surgical management. In the growing child, reconstruction
of partially or completely destructed septal cartilage as a
complication of abscess formation is essential for normal
development of the midface (nose and maxilla). To achieve
successful long-term functional and aesthetic results in children
with NSA, early reconstruction of the lost cartilage is recommended based on available literature despite the lack of strong
supporting evidence. At present, autologous cartilage is widely
believed to be the implant material of choice.
Conflict of interest
Authors have no personal, academic, or financial conflict of
interests.
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