Infected Septal Hematoma

Abstract

A 3-year-old girl presented to the emergency department for evaluation of 1 week of fevers, nasal congestion, and rhinorrhea following a minor fall with nasal impact at school. She was uncomfortable with a challenging intranasal examination due to pain, which made it difficult to clearly visualize the medially based swelling of the septum obstructing the nasal passages (Figure, A ). The history and examination were suggestive of septal hematoma with progression to abscess, although septal deformity, neoplasm, and polyps also were considered. The initial evaluation in her pediatrician's office 2 days previously was notable for a nasal tip abrasion, limited intranasal examination, and a persistent fever thought to be viral in nature. Laboratory diagnostics were notable for white blood cell count 20.9. Due to the inconclusive examination, otolaryngology recommended contrast-enhanced computed tomography of the face, which demonstrated a 2.2-cm anterior nasal septal collection (Figure, B). In the operating room, incision and drainage of the septal collection revealed purulence and subtotal loss of septal quadrangular cartilage. Septal mucoperichondrial flaps were suture-reapproximated to prevent recollection. Culture-driven antibiotics were initiated. Fevers resolved, and there was no recollection at follow-up with otolaryngology. The parents were counseled regarding the risk of saddle nose deformity with potential need for future rhinoplasty. Septal hematoma results from traumatic separation of the septal cartilage from the overlying mucoperichondrium, which perfuses the cartilage. Within a few days, cartilage destruction and superinfection with abscess formation can occur.1Alshaikh N. Lo S. Nasal septal abscess in children: from diagnosis to management and prevention.Int J Pediatr Otorhinolaryngol. 2011; 75: 737-744Crossref PubMed Scopus (36) Google Scholar Aerobic bacteria, particularly Staphylococcus aureus, are most commonly isolated.1Alshaikh N. Lo S. Nasal septal abscess in children: from diagnosis to management and prevention.Int J Pediatr Otorhinolaryngol. 2011; 75: 737-744Crossref PubMed Scopus (36) Google Scholar The diagnosis of septal hematoma is often delayed—a median of 7 days in one series.2Ali H.M. Zavala H. Chinnadurai S. Roby B. Nasal septal hematoma in children: time to diagnosis and resulting complications.Int J Pediatr Otorhinolaryngol. 2021; 145: 110734Crossref PubMed Scopus (4) Google Scholar Complications include sepsis, locoregional infectious spread to the orbit or cavernous sinus with resultant thrombosis, and development of saddle nose deformity.1Alshaikh N. Lo S. Nasal septal abscess in children: from diagnosis to management and prevention.Int J Pediatr Otorhinolaryngol. 2011; 75: 737-744Crossref PubMed Scopus (36) Google Scholar, 2Ali H.M. Zavala H. Chinnadurai S. Roby B. Nasal septal hematoma in children: time to diagnosis and resulting complications.Int J Pediatr Otorhinolaryngol. 2021; 145: 110734Crossref PubMed Scopus (4) Google Scholar, 3Sayin I. Yazici Z.M. Abakay M.A. Saygan G.B. Gunes S. Nasal septal hematoma and abscess in children: an uncommon otorhinolaryngology emergency revisited.J Craniofac Surg. 2021; 32: e125-e128Crossref PubMed Scopus (2) Google Scholar Septal hematoma should be considered for children presenting with nasal pain and progressive nasal obstruction preceded by nasal trauma. Progression to abscess formation may be associated with fevers and purulent discharge. Examination should include vital signs, neurologic examination, and anterior rhinoscopy with nasal speculum. Unilateral or bilateral septal swelling suggests the diagnosis, which can be confirmed by needle aspiration of blood or purulence. The swelling is medially based, thus not to be mistaken for the laterally based inferior turbinates. If the diagnosis is indeterminate, contrasted-enhanced computed tomography of the face can evaluate for iso- or hypoattenuating collections in the nasal septum. Following diagnosis, otolaryngology should be involved for nasal endoscopy, incision and drainage, and outpatient monitoring. Antibiotic treatment should be empirically targeted toward common causative agents—with amoxicillin–clavulanate or equivalent being commonly and successfully used choices.1Alshaikh N. Lo S. Nasal septal abscess in children: from diagnosis to management and prevention.Int J Pediatr Otorhinolaryngol. 2011; 75: 737-744Crossref PubMed Scopus (36) Google Scholar