SEPTAL ABSCESS

SEPTAL ABSCESS
This picture depicts a nose with a swelling of the middle partition or septum due to an abscess. Nasal obstruction is the most common presenting symptom seen with septal abscess. Others include nose pain, general malaise, fever, headache, and tenderness over the nose. The presenting symptoms depend on the cause. A history of trauma can usually be elicited. Staphylococcus aureus is the most common organism. Streptococcus pneumoniae, Streptococcus milleri, Streptococcus viridans, Staphylococcus epidermis, Haemophilus influenzae are found occationally. There are several proposed mechanisms for the development of a septal abscess. (1) direct extension along the tissue planes as seen with sinusitis; (2) infection of a septal hematoma; (3) infections of dental etiology; and (4) venous spread from the orbits or cavernous sinus. Nasal septal abscess usually occurs secondary to a nasal hematoma. There is usually an inciting traumatic event, ranging from major trauma, including child abuse and nasal septoplasty, to less traumatic and forgotten events such as falling off a bicycle or bumping heads during play. The rupture of the small vessels that supply the nasal septum form a hematoma that separates the mucoperichondrium from the septal cartilage. Cartilage destruction follows as a result of ischemic and pressure necrosis. Blood forms a medium for bacterial growth and subsequent abscess formation.The initial treatment usually consists of fine needle aspiration of the hematoma or abscess under topical anesthesia. The aspirate is sent for gram stain, culture and sensitivity. Intra venous antibiotic should be started.The most common pathogen involved is S aureus, thus a semisynthetic penicillin is a reasonable choice. In patients who are allergic to penicillin, vancomycin can be used. After antibiotics have been started, the next step in management is incision and drainage. The hematoma or abscess should be evacuated to relieve the pressure and restore blood flow. Intravenous antibiotics should be continued for 3 to 5 days and if the patient exhibits a favorable response then it is reasonableto switch to oral antibiotics. Oral antibiotics should be continued for 7 to 10 days. The complications of a septal abscess include meningitis, saddle nose deformities, sepsis, bacteremia, and in younger patients maxillary hypoplasia. Meningitis, sepsis, and bacteremia can result from vascular, lymphatic, or direct spread through tissue planes.