Volume 4, Issue 4 , Pages 150-154, December 2009
Septal abscess in a 14-month-old child: Diagnosis, management, and discussion of reconstructive options
Article Outline
Summary
Objectives: Highlight the importance of early diagnosis and treatment of septonasal abscesses to prevent life threatening consequences. Explain the aesthetic implications as well as the complications affecting nasal function in toddlers and preschool age children. Suggest reconstructive options and approaches to the pediatric nasoseptum after the deleterious effects of acute inflammation. Methods: Case presentation from a tertiary referral center. Literature review of contemporary and historic treatment of pediatric nasoseptal abscesses. Results: An open approach to nasal reconstruction is recommended with exposure of the caudal septum leaving the dorsal cartilage untouched in order to reduce the risk of nasal and/or midface growth retardation. Costal cartilage is the material of choice to reconstruct the nose because of its proportional growth with the native tissue. Conclusions: The foremost consideration in treatment of nasoseptal hematoma or abscess includes acute drainage and culture-directed antimicrobial medical management to avoid systemic complications. Affected children may require nasal reconstruction, preferably after the 4th year of life. Conscientious surgeons must have an awareness of nasal function, nasofacial development, potential graft donor sites, and subsequent psychological impact of delayed treatment. Our preference is the open approach with the use of autologous costal cartilage for structural reconstruction.
Keywords: Nasal deformity, Acquired, Nasal obstruction, Streptococcus pneumoniae, Rhinoplasty, Abscess
Case report
Despite the fact that minor facial trauma in children is relatively common, the occurrence of nasal septal hematoma and abscess formation is surprisingly rare. In toddlers and preschool children in particular, the diagnosis and treatment of nasoseptal abscess is often delayed because of a low index of suspicion and non-specific symptoms, including low-grade fever, poor feeding, generalized malaise, and nasal obstruction [1]. Timely management of nasoseptal abscesses in children is critical in order to reduce acute complications such as meningitis, brain abscess, subarachnoid empyema, and cavernous sinus thrombosis [1]. The long-term consequences of nasoseptal abscess formation can be severe, including cartilage destruction, saddle nose deformity, internal and external nasal valve collapse, and retraction of the columella. Long-term deleterious effects on the growth of the nose and midface are also possible [2]. These findings highlight the aesthetic implications as well as the complications affecting nasal function. We present the case of a young child with a nasoseptal abscess, review of his diagnostic work-up and care, as well as discuss reconstructive options specific to the pediatric population.
A 14-month-old, full-term, healthy male was referred to the Geisinger Medical Center Department of Otolaryngology with a 5-day history of mid-face edema, widening of the nasal dorsum, nasal obstruction, poor feeding, and fever to 102.4°F. The child's history was significant for a recent bout of viral gastroenteritis with emesis and a fall against a coffee table 1-week prior. Per his parents’ history, the fall resulted in a forehead abrasion without obvious nasal trauma or suspected nasal injury. He was evaluated by his pediatrician on the day prior to presentation, who diagnosed a unilateral otitis media, as well as bilateral nasal obstruction, and sent him to an outside otolaryngologist for further evaluation. Upon finding a widened nasal septum suspicious for hematoma, the child was immediately transferred to our institution.
On physical examination the child appeared healthy, interactive and developmentally appropriate for age. There was a widened caudal nasal septum with complete bilateral obstruction (Fig. 1). The nasal dorsum was tender to palpation, but no perinasal ecchymosis or other evidence of trauma was present. A clinical diagnosis of a septal hematoma was made. He was afebrile, neurologically intact, and without symptoms of sepsis. A right suppurative otitis media was noted.
Figure 1.
Base view of widened caudal nasal septum with complete bilateral obstruction seen on initial presentation.
The child was admitted to our service and taken to the operating room within hours of presentation. A sedated CT scan with contrast of the maxillofacial anatomy was performed immediately prior to surgery and revealed an organized, rim-enhancing fluid collection of the caudal nasal septum, measuring 2.2
cm×2.4cm×1.1cm (Fig. 2). There was no extension into the surrounding facial structures or intracranial cavity. Intraoperatively, bilateral Killian septal incisions were made, and purulence was drained and sent to microbiology for Gram-stain, culture, and sensitivity testing. The nose and septal area were irrigated with sterile saline. There appeared to be loss of the caudal nasal septum on palpation and examination using a zero degree pediatric nasal endoscope. A drain was not placed due to concern for aspiration. Instead, Gelfoam® splints coated with mupirocin ointment 2% were inserted into bilateral nasal cavities to reapproximate the mucosal flaps.
Figure 2.
Preoperative CT scan demonstrating a 2.2
cm×2.4cm×1.1cm organized, rim-enhancing fluid collection of the caudal nasal septum with resultant bilateral nasal airway obstruction.
Post-operatively, the child was hospitalized for close monitoring and intravenous (IV) antibiotics. The septal flaps remained flat without evidence of recurrent abscess or hematoma. The culture results revealed colonies of Streptococcus pneumoniae, beta-lactamase negative Haemophilus influenzae, and Corynbacterium species, each sensitive to the chosen antibiotic (ampicillin and sulbactam sodium). The child did well, remained afebrile, playful, and tolerated the antibiotics. On post-operative day 5, he was discharged home to complete a 14-day course of IV antibiotics via PICC line.
At follow-up, the child had a nasodorsal depression in the region of the anterior septal angle and persistent, mild edema along the nasal sidewalls (Fig. 3). The bony dorsum was intact, and septal cartilage was palpable despite our initial intraoperative concerns. Throughout the hospitalization and again in the post-operative clinic examinations, we discussed with his parents the possibility of long-term side-effects, including loss of septal support and residual nasal deformity, necessitating nasoseptal reconstruction in the future.
Figure 3.
Seven month follow-up. Note the persistent nasodorsal depression at the anterior septal angle.
Discussion
The incidence of nasoseptal abscess formation within the pediatric population remains a relatively rare diagnosis but one with significant aesthetic and potentially life-threatening implications. Injury to the nasal septum can result in a submucoperichondrial hematoma and, if left untreated, abscess. Prolonged septal hematoma or abscess may lead to destruction of the septal cartilage due to both necrosis secondary to impaired blood supply as well as autolysis due to leukocytosis and the Cathepsin D enzyme located within septal cartilage [2].
The consequences of nasoseptal hematoma or abscess can be seen both acutely and in the long-term. As discussed previously, acute complications can include intracranial extension. Over time, the effects of septal cartilage destruction may result in columellar retraction, saddling, internal nasal valve obstruction, and, possibly, midface growth disruption [2].
Prelingual, ambulatory children pose a particular risk of missed or late diagnosis of nasoseptal hematoma or abscess. Therefore, the index of suspicion for this diagnosis should remain high in any child who presents with a history of minor facial trauma and fever of unknown origin. This case highlights the often confusing clinical picture of a child presenting with fever and malaise with a confounding history of recent illness.
Early imaging with a CT contrast study can be invaluable in order to assess the extent of suppuration and potential for intracranial involvement. Imaging may also be helpful to assess the state of septal structural subunits and guide operative planning for drainage. Other indications for CT scanning in pediatric patients with nasoseptal abscess include extensive facial cellulitis, meningism, altered consciousness, focal neurological signs, severe headache, failure to improve following drainage of a nasal septal abscess, extensive delay to presentation, and isolation of a virulent organism [3]. Intraoperative cultures with sensitivities should be collected to direct post-operative antimicrobial therapy, and PICC line placement for IV antibiotics should be considered.
Surgical management of a nasoseptal abscess in the published literature reveals a consensus on immediately drainage, but there is considerable controversy surrounding the timing of reconstruction in a young child. This stems from the knowledge that the nose and septum continue to grow during childhood until the mid-teens. Many reconstructive surgeons recognize the possibility that nasal septal growth may affect midface skeleton and growth. Animal studies have demonstrated that keeping intact the mucoperichondrial flap of the nasal septum may also be necessary in order to maintain normal facial and nasal growth [4].
Reconstruction of the nose after septal hematoma or abscess requires attention to both structure and aesthetics. Historically, Cottle recommended that reconstruction be performed 8–12 weeks from the time of abscess treatment and resolution of infection. In the 1960s, immediate reconstruction at the time of acute drainage was proposed and illustrated some success based on early follow up. In the late 1980s the use of costal cartilage was championed to avoid the risk of disrupting growth centers within the remaining dorsal septum [5].
The open approach to nasal reconstruction allows the surgeon direct access for nasal base stabilization and rebuilding of the saddled nasal dorsum. Extensive soft tissue scarring and contracture of the remaining septum can be a consequence of septal hematoma or abscess, so we prefer to access only the caudal-most aspect of the septum during repair. This approach is especially useful in children in order to limit removal of any remaining septal cartilage which may result in nasal and/or midface growth retardation.
Costal cartilage is our preferred material in the reconstruction of the nose after nasoseptal abscess or hematoma (Fig. 4). Long-term follow-up in microtia and cleft lip nasal deformity repair reveals that cartilage grafts can grow commensurate with nasal growth [6]. Cadaveric costal cartilage may be used, however the surgeon must be aware of the increased risk of resorption. We do not recommend the use of alloplast grafts due to the potential risk of immediate or delayed infection [7]. As discussed previously, the use of the remaining septal cartilage to reconstruct the caudal septum in children is contraindicated because of the potential for destroying the growing portions of the dorsal septum [2].
Figure 4.
Example of a costal cartilage extended columellar strut graft used in the reconstruction of nasal saddle deformity after nasoseptal abscess.
The psychosocial implications of aberrant nasal and facial growth in children after septal hematoma or abscess must be considered. At the age of five, the child becomes self-aware, with formation of self-esteem and self-image [6]. As illustrated in microtia surgery, reconstructing the nose before 5 years of age could help to reduce the risk of long-term psychological problems for the child. The surgeon must also heed the potential for problematic facial and nasal growth after early reconstruction in young child. In morphometric studies of over 1500 children, there appears to be a rapid growth phase in the nose between the ages of 1 and 4 years [8]. Farkas et al. recommend that the surgeon delays whenever possible surgical intervention during these times of rapid nasal growth. Therefore, our preference for nasal reconstruction in a young child is just after the 4th year of life when feasible.
Conclusion
The first priority in management of a child with a suspected nasoseptal hematoma or abscess is immediate drainage, culture-directed antibiotic therapy, and prevention (or treatment) of immediate complications. A high index of suspicion should be aroused when presented with a child who has a widened nasal dorsum, nasal obstruction, and fever. Imaging should be considered to elucidate the degree of nasal involvement as well as to assess for intracranial involvement. Unfortunately, many of these children will have destruction of some or all of the nasal septal cartilage as a result of the nasoseptal hematoma or abscess. Therefore, parents should be counseled that the child may require nasal reconstruction in the future. In determining the timing of such reconstruction, the surgeon must take into consideration the effect nasal septal destruction has on nasal function, nasofacial development, potential graft donor sites, and subsequent psychological impact in children older than 5 years if reconstruction is delayed.
Conflict of interest statement
No financial, personal relationships with other people or organizations, employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding has biased this work. No sources of funding contributed to the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; or decision to submit the manuscript for publication. No study sponsors were involvement in the intellectual concept or execution of the document.
References
- . Hematoma and abscess of the nasal septum in children. Arch. Otolaryngol. Head Neck Surg. 1996;122(December (12)):1373–1376
- Management of nasal septal abscess in childhood: our experience. Int. J. Pediatr. Otorhinolaryngol. 2004;68(November (11)):1417–1421
- . Extradural frontal abscess complicating nasal septal abscess in a child. Int. J. Pediatr. Otorhinolaryngol. 1998;45(October (2)):183–186
- Nasal growth after external septoplasty in children. Arch. Otolaryngol. Head Neck Surg. 1996;122(August (8)):816–821
- . Reconstruction of the destroyed septal infrastructure. Otolaryngol. Head Neck Surg. 1989;100(February (2)):92–94
- . Nasal reconstruction with a forehead flap in children younger than 10 years of age. Plast. Reconstr. Surg. 2004;114(August (2)):316–325(discussion 326–8)
- . Management of posttraumatic nasal deformities: the crooked nose and the saddle nose. Facial Plast. Surg. Clin. North Am. 2004;12(February (1)):111–132
- Growth patterns of the nasolabial region: a morphometric study. Cleft Palate-Craniofac. J. 1992;29(July (4)):318–324
PII: S1871-4048(08)00074-9
doi:10.1016/j.pedex.2008.11.003
© 2008 Elsevier Ireland Ltd. All rights reserved.
Volume 4, Issue 4 , Pages 150-154, December 2009
