Nasal Septal Abscess

April 15, 2007

A 63-year-old man with myelodysplasia presented with oral thrush, intranasal dryness, and congestion that developed 2 months earlier. Intranasal saline rinse and sleeping with the head elevated temporarily relieved the nasal symptoms.

 

A 63-year-old man with myelodysplasia presented with oral thrush, intranasal dryness, and congestion that developed 2 months earlier. Intranasal saline rinse and sleeping with the head elevated temporarily relieved the nasal symptoms.

Direct examination revealed a deviated nasal septum, with dry, red mucosa and hypertrophied inferior turbinates. He was initially treated with fluconazole. Ten days later, the oral thrush had resolved but the postnasal drainage continued, the nasal swelling had worsened, and the nasal septum had enlarged and had become exquisitely tender. Treatment with levofloxacin was started.

A contrast-enhanced CT scan taken in the axial and coronal planes showed a widened nasal septum that contained a fluid collection (a) with a thickened, mildly enhancing rim (A). The fluid (a) spanned the entire cephalad to caudad extent of the cartilaginous nasal septum (B). These findings are diagnostic of a nasal septal abscess. A CT scan of the patient obtained 5 years earlier is shown for comparison: note the mild deviation to the right in an otherwise normal nasal septum (C).

The nasal septal abscess was surgically drained. Culture of the aspirated material grew Staphylococcus aureus that was resistant to levo- floxacin (and other antibiotics, but sensitive to rifampin). The patient's symptoms completely resolved after surgery and a 2-week course of oral antibiotic therapy.

Although uncommon, nasal septal abscesses are usually a complication of nasal trauma or a nasal furuncle. Sinusitis, influenza, and dental infection have also been implicated. An abscess as a complication of inferior turbinate laser surgery has been reported. The most commonly isolated organisms are S aureus, Haemophilus influenzae, and Streptococcus pneumoniae.

Enlargement or destruction of the nasal septum can also occur in patients with Wegener granulomatosis, lymphoma (formerly lethal midline granuloma), sarcoidosis, or beryllium exposure. Consider these conditions in the radiographic differential diagnosis. In addition to the cosmetic defects (ie, saddle nose deformity) that result from destruction of the nasal septum, severe complications have been associated with nasal septal abscess, including meningitis, intracranial abscess, orbital cellulitis, cavernous sinus thrombosis, and nasal oral fistula.