Pediatrics and Neonatology (2012) 53, 213e215

Available online at www.sciencedirect.com

journal homepage: http://www.pediatr-neonatol.com

CASE REPORT

Nasal Septal Abscess in an Immunocompetent Child

Yi-Chuan Huang a, Pi-Lien Hung a, Hsin-Ching Lin b,*

a
Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine,
Kaohsiung, Taiwan
b
Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine,
Kaohsiung, Taiwan

Received Apr 8, 2011; received in revised form Jul 4, 2011; accepted Aug 3, 2011

Key Words Nasal septal abscess is defined as a collection of pus between the cartilage or the bony septum
child; and the overlying mucoperichondrium or mucoperiostium. Appropriate management of a nasal
immunocompetence; septal abscess requires prompt diagnosis, adequate surgical drainage, and parenteral admin-
nasal septal abscess istration of antibiotics. This can prevent the potentially dangerous spread of infection and
development of severe functional and cosmetic sequelae. Incidence of nasal septal abscess
is rare, and most reports involve adults who had experienced nasal trauma. Herein, we report
a case of nasal septal abscess caused by methicillin-resistant Staphylococcus aureus in
a healthy immunocompetent child.
Copyright 2012, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights
reserved.

1. Introduction which NSA develops secondary to dental or sinonasal

Nasal septal abscess (NSA) occurs rarely. Usual causes of
NSA are linked to nasal trauma which can lead to hematoma
and, subsequently, abscess formation.1 Other less common
causes of NSA include nasal surgery, furunculosis, dental
infection, and sinusitis.2e4 Beck classified the etiological
factors of NSA into three general groups: primary, in which
the causative factor is nasal trauma; secondary causes, in
infections; and spontaneous, when no underlying cause
could be detected.5 Studies show that non-traumatic nasal
septal abscess occurs mainly in immunocompromized indi-
viduals.6 Only two reports of non-traumatic nasal septal
abscess in immunocompetent adults have been pub-
lished.7,8 This paper reports a case study of non-traumatic
nasal septal abscess in a healthy child who showed no
evidence of sinusitis or other local infections.

* Corresponding author. Department of Otolaryngology, Chang

2. Case Report
Gung Memorial Hospital, Number 123, Ta-Pei Road, Niao-Sung
Township, Kaohsiung 833, Taiwan. An 11-year-old healthy girl with a two-day history of high
E-mail address: enthclin@aol.com (H.-C. Lin). fever, painful swelling in the nose, and progressive nasal

1875-9572/$36 Copyright 2012, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
doi:10.1016/j.pedneo.2012.04.011

Downloaded for mardiah tahir (mardiahtahir@yahoo.com) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 13, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
214 Y.-C. Huang et al

obstruction with difficulty in breathing was admitted to

the emergency department. She had no history of sinus-
itis, facial trauma, or dental infections. Physical exami-
nation revealed a remarkable inflammation of the nasal
mucosa. The nasal septum was swollen, fluctuant, and it
obstructed both the nasal cavities (Figure 1). There was no
nasal and septal wound or crust. No dental caries or signs
of gum infection were found. A complete blood cell count
revealed an increased total white cell count of 23,200/
mm3, and the white cell differential count revealed
a neutrophil count of 78%. In addition, an elevated C-
reactive protein level (149.3 mg/L) was noted. Emergency
computed tomography (CT) of the paranasal sinuses
revealed swelling of the soft tissue and a collection of low-
density pus in the anterior nasal cavity; these findings
indicated abscess formation (Figure 2). The paranasal
sinuses were almost clearly observed on the CT scan.
Treatment of the patient was commenced with intrave-
nous administration of Unasyn (ampicillin sodium/sulbac-
tam sodium, 1.5 g) four times per day. Trans-septal
endoscopic incision and drainage were performed under
general anesthesia on the second day of hospitalization.
Approximately 15 mL of thick purulent mucopus was
drained, and four-fifths of the necrotic nasal septal Figure 2 The computed tomography scan of the paranasal
cartilage was excised. Nasal packs were then inserted into sinuses shows the swelling of the soft tissue and a collection of
both the nasal cavities, and a Penrose drain was sutured low-density pus (arrow) in the anterior nasal cavity.
on the left side of the nasal septum for 72 hours. Culture
of the pus revealed the presence of methicillin-resistant furunculosis of the nasal vestibule, dental disease, influ-
Staphylococcus aureus (MRSA). After these results were enza, and acute sinusitis.1e4 Non-traumatic spontaneous
obtained, Unasyn was substituted with teicoplanin for the nasal septal abscess has been reported mainly in immuno-
next 5 days. Within 72 hours after the surgery, swelling, compromized patients.6 There have been only two reports
erythema, and congestion in the nasal cavity improved of non-traumatic spontaneous nasal septal abscess in
gradually. The nasal packs and drain were then removed. immunocompetent adults.7,8 In this study, the patient was
The patients symptoms were totally resolved and patient a healthy child who had not undergone nasal trauma and
was discharged 5 days postoperatively. Oral linezolid was had no dental caries. She denied past history of sinonasal
administered for 5 days after discharge. Subsequently the infection and had no present symptoms or signs of sinusitis,
nasal mucosa had healed well; only a very mild saddle though a little opacification of the right maxillary sinus was
nose deformity was noted 2 years later. noted on the CT scan.
The causes of nasal obstruction are multifactorial. The
differential diagnosis involves analyses of the physiological
3. Discussion and anatomic pathology and includes a wide range of
conditions, including rhinitis, nasal polyposis, choanal
Studies indicate that nearly 75% of all nasal septal atresia, adenoid hypertrophy, septal perforation, presence
abscesses are secondary to nasal trauma.1 In rare instances, of nasal foreign bodies, and nasal vestibulitis.9 Nasal septal
nasal septal abscess can occur after nasal surgery, abscess can also present itself as unilateral or bilateral

Figure 1 The nasal septum is swollen and fluctuant, and totally obstructed both the nasal cavities: (A) right nasal cavity; (B) left
nasal cavity.

Downloaded for mardiah tahir (mardiahtahir@yahoo.com) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 13, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
Pediatric nasal septal abscess
nasal obstruction. Difficult breathing occurs because of the
diffused bulge of the anterior nasal septum. When this
occurs, the surface of the nose is often swollen, tender, and
erythematous. Some patients can also develop fever,
a faster heart rate, headache, and leukocytosis.1 In this
study, the patient exhibited high fever and a painful,
swollen, erythematous, and stuffy nose with progressively
difficult breathing.
Studies show that the most common organisms detected
in the culture of nasal septal abscess are Staphylococcus
aureus, Staphylococcus epidermidis, Streptococcus pneu-
moniae, beta-hemolytic group A Streptococcus, Haemo-
philus influenzae, and anaerobic bacteria.1,2,8,10 In this
case, the culture of the nasal septal abscess revealed
presence of MRSA. Incidence of MRSA infections has been
increasing worldwide. In Taiwan, MRSA infections account
for 25e75% of all community-acquired Staphylococcus
aureus infections in children.11 It is advised that MRSA
infections be treated with glycopeptide antibiotics if the
clinical response is not good or if it is delayed even after
adequate incision and drainage. This is because late diag-
nosis and treatment of nasal septal abscess is linked with
serious complications such as cavernous sinus thrombosis,
meningitis, brain abscess, subarachnoid empyema, orbital
cellulitis, and orbital abscess.1,2,8,12 As the septal cartilage
is avascular and derives its nourishment from the overlying
mucoperichondrium, the stripping of the mucoperichon-
drium that occurs during abscess formation can cause
ischemic necrosis and subsequent septal perforation, which
can result in an obvious saddle nose deformity and abnor-
malities of nasal and facial growth.1,7,9,13e15
Prompt diagnosis and treatment of nasal septal abscess
is important. Emergency incision and drainage of the
abscess as well as broad-spectrum intravenous antibiotic
treatment is advised. Nasal deformity can be corrected by
reconstruction using an autologous tragal cartilage graft.15
In our patient emergency incision and drainage of the
septal abscess and removal of the necrotic nasal septal
cartilage were performed on the second day of her admis-
sion. The prognosis was good, and only slightly depressed
nasal dorsum was noted 2 years after the treatment. To
date, no additional cartilage implantation has been per-
formed, because in the opinion of the patients parents,
there were no cosmetic changes.
Downloaded for mardiah tahir (mardiahtahir@yahoo.com) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 13, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
215
This paper reports a healthy child with nasal septal
abscess caused by community-acquired MRSA but no nasal
trauma or surgical history. The possible presence of nasal
septal abscess in a pediatric patient with progressive nasal
obstruction should be considered. Prompt diagnosis and
adequate treatment for preventing the potentially
dangerous spread of infection and the development of
severe functional and cosmetic sequelae are important.
References
1. Ambrus PS, Eavey RD, Baker AS, Wilson WR, Kelly JH. Manage-
ment of nasal septal abscess. Laryngoscope 1981;91:575e82.
2. Matsuba HM, Thawley SE. Nasal septal abscess: unusual causes,
complications, treatment, and sequelae. Ann Plast Surg 1986;
16:161e6.
3. Da Silva M, Helman J, Elicher I, Joachims H. Nasal septal
abscess of dental origin. Arch Otolaryngol 1982;108:380e1.
4. Collins MP. Abscess of the nasal septum complicating isolated
acute sphenoiditis. J Laryngol Otol 1985;99:715e9.
5. Beck AL. Abscess of the nasal septum complicating acute
ethmoiditis. Arch Otolaryngol 1945;42:275e9.
6. Shah SB, Murr AH, Lee KC. Nontraumatic nasal septal abscesses
in the immunocompromised: etiology, recognition, treatment,
and sequelae. Am J Rhinol 2000;14:39e43.
7. Bennett JD, Rapado F. Nasal septal abscess in a healthy, non-
immunocompromised patient. Hospital Med 1998;59:78.
8. Salam B, Camilleri A. Non-traumatic nasal septal abscess in an
immunocompetent patient. Rhinol 2009;47:476e7.
9. Chandra RK, Patadia MO, Raviv J. Diagnosis of nasal airway
obstruction. Otolaryngol Clin N Am 2009;42:207e25.
10. Cantey PA, Berkowitz RG. Hematoma and abscess of the nasal
septum in children. Arch Otolaryngol Head Neck Surg 1996;
122:1373e6.
11. Chen CJ, Huang YC. Community-acquired methicillin-resistant
Staphylococcus aureus in Taiwan. J Microbiol Immunol Infect
2005;38:376e82.
12. Eavey RD, Malekzakeh M, Wright Jr HT. Bacterial meningitis
secondary to abscess of the nasal septum. Pediatrics 1977;60:
102e4.
13. Olsen KD, Carpenter III RI, Kern EB. Nasal septal injury in
children. Arch Otolaryngol 1980;106:317e20.
14. Close DM, Guinnes MDG. Abscess of the nasal septum after
trauma. Med J Aust 1985;142:472e4.
15. Menger DJ, Tabink I, Nolst Trenite GJ. Treatment of septal
hematomas and abscesses in children. Facial Plast Surg 2007;
23:239e43.