International Journal of Pediatric Otorhinolaryngology 75 (2011) 737–744

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Review article

Nasal septal abscess in children: From diagnosis to management and prevention

Nada Alshaikh *, Stephen Lo
ENT Department, Tan Tock Seng Hospital, Singapore

A R T I C L E I N F O A B S T R A C T

Article history: Background: Nasal septal abscess (NSA) is an uncommon condition. It is a collection of pus in the space
Received 2 January 2011 between the nasal septum and its overlying mucoperichondrium and/or mucoperiosteum. If left
Received in revised form 9 March 2011 untreated, there are risks of intracranial complications, facial deformity, and delayed facial growth.
Accepted 10 March 2011
There is no universally agreed consensus on the treatment of this condition. This study reviews evidence
Available online 14 April 2011
in the literature to determine its etiology, presentation, investigation, management options, and
outcome.
Keywords:
Method: A structured review of the PubMed, EMBASE and the Cochrane Collaboration databases
Nasal septum
Nasal cartilage
(Cochrane Central Register of Controlled Trials, Cochrane Database of Systemic Reviews) was
Children undertaken, using the MeSH terms: nasal septum, nasal cartilage, trauma, hematoma, abscess,
Nasal trauma reconstructive surgery, rhinoplasty, pediatric, and children.
Septal hematoma Results: A total of 159 citations from 1920 to date were reviewed regarding nasal septal abscess, of which
Abscess 81 articles were identified to be relevant to this review. No randomized controlled trials or systematic
Nasal septum reconstruction reviews were found in the Cochrane Collaboration database, PubMed or EMBASE. NSA is more common
in children and in male. Nasal trauma and untreated septal hematoma are the leading cause.
Staphylococcus aureus is isolated in up 70% of the cases. Clinically, nasal septal swelling, pain and
tenderness, with purulent discharge are mostly evident. The immediate management of NSA is incision
and drainage and antibiotic therapy. Recent studies suggest early septal reconstruction in children in
order to prevent immediate and late facial deformity and nasal dysfunction. Autologous cartilage is the
implant material of choice.
Conclusion: Nasal septal abscess is a serious condition that necessitates urgent surgical management in
order to prevent potential life threatening complications. In the growing child, early reconstruction of
destructed septal cartilage is essential for normal development of the midface (nose and maxilla).
ß 2011 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
3.1. Related anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
3.2. Incidence and distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
3.3. Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
3.4. Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739
3.5. Microbiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739
3.6. Clinical presentation and diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739
3.7. Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 740
3.8. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 740
4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743

* Corresponding author. Tel.: +65 98904549; fax: +65 63577749.

E-mail address: nadaats@yahoo.com (N. Alshaikh).

0165-5876/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2011.03.010
738 N. Alshaikh, S. Lo / International Journal of Pediatric Otorhinolaryngology 75 (2011) 737–744
1. Introduction
Nasal septal abscess (NSA) is a very uncommon condition about
which little has been written in the literature. It is best defined as
collection of pus in the space between the nasal septum and its
overlying mucoperichondrium and/or mucoperiosteum [1]. The
recognition of the nasal septal abscess is traced back to 1810 when
Cloquet and Arnal healed a septal abscess by drainage [2]. Nasal
trauma and associated septal hematoma is believed to be the most
common causative factor of nasal septal abscess formation. High
index of suspicion and vigilant examination of patients presenting
with facial injuries could contribute to early detection of septal
hematoma and consequent prevention of such complication.
Management includes abrupt incision and drainage of the abscess
and antibiotic administration. In children, however, early recon-
struction of the lost infected cartilage has been recommended in
order to prevent the long term effect on growth of facial skeleton
[3]. The first who recommended and successfully implanted
homologous cartilage immediately into the cleaned septal abscess
cavity with long-term follow-up were Huizing [4] and Masing [5].
This article aims to review the literature on published evidence
in support of the diagnosis and management of nasal septal abscess
in children.
2. Materials and methods
A structured review of the PubMed, EMBASE and the Cochrane
Collaboration databases (Cochrane Central Register of Controlled
Trials, Cochrane Database of Systemic Reviews) was undertaken,
using the MeSH terms: nasal septum, nasal cartilage, trauma,
hematoma, abscess, reconstructive surgery, rhinoplasty, pediatric,
and children. In this current review, we are focusing on reviewing
the diagnosis and management of nasal septal abscess in pediatric
population.
3. Results
A total of 159 citations from 1920 to date were reviewed
regarding nasal septal abscess, of which 81 articles were identified
to be relevant to this review on the management of nasal septal
abscess in pediatric population. All articles were either case reports
or case series with few longitudinal cohort studies. No randomized
controlled trials or systematic reviews were found in the Cochrane
Collaboration database, PubMed or EMBASE.
3.1. Related anatomy
One of the earliest descriptions of the blood supply of the nasal
septum was written by Aymard in 1917. He stated that
cartilaginous septum receives its blood supply from a network
of blood vessels arising from the overlying mucous membrane and
penetrate the mucoperichondrium through vascular canals situat-
ed at the chondro-maxillary joint. He made it clear that any
disruption or removal of mucoperichondrium from both sides of
the cartilaginous septum will impair its blood supply and lead to its
destruction and death [6].
The nasal septum is composed of the five bones premaxilla,
maxillary crest, palatine crest, vomer, perpendicular plate, and the
cartilaginous quadrangular cartilage. The blood supply of the nasal
septum is from branches of both internal and external carotid
arteries. Septal cartilage receives its blood supply and nutrition
from the rich vascular network of its overlying mucoperichon-
drium through a process of diffusion [7]. Thus, any bilateral
disruption or separation of the cartilage from its overlying
mucoperichondrium results in impairment of its blood supply,
ischemia, and cartilage necrosis.
3.2. Incidence and distribution
The actual incidence of NSA is unknown. Reported case series
differ significantly in their number depending on the reporting
institution and the period of time over which data was collected.
One of the largest reported series in the literature was of 116
pediatric cases over a period of 6 years from Russia [8]. On the
other hand, 43 cases were reported from Toronto, Canada, over a
period of 8 years [9], and 3 and 16 cases from two different
pediatric institutions in USA over 10 year period [10,11]. Zielnik-
Jurkiewicz retrospectively reviewed 2500 pediatric facial trauma
patients over 7 years time and found 22 cases of NSA secondary to
nasal trauma leading to an incidence of 0.9% of facial trauma
patients [12].
Literature suggests a strong male predominance in hematomas
and abscesses of the septum with nasal trauma as the major causal
factor [13]. It has been proposed that males are more commonly
engaged in aggressive activities, violence, and road traffic
accidents than females which puts them at greater risk for
development of NSA with a ranging male to female ration from 2:1
up to 6:1 [8–12,14].
Nasal trauma is extremely common during childhood and
likewise, NSA is more commonly encountered in children than in
adults [15]. This is most likely because septal hematoma in
children with nasal or facial trauma without evidence of fracture is
more often missed and goes undiagnosed until complications
ensue [16]. Another explanation is that mucoperichondrium and
mucoperiosteum are loosely adhered to the septum in children,
and this facilitates both occurrence and spread of septal hematoma
and abscess formation [17].
3.3. Etiology
In general, Beck classified the etiological factors of NSA into
three groups. Primary in which the causative factor is nasal trauma,
secondary causes in which NSA develops secondary to dental or
sinonasal infections, and spontaneous when no underlying cause
could be elicited [18].
Trauma is by far the most common cause of septal hematoma
which if not diagnosed early and treated adequately may result in
formation of septal abscess. In up to 85% of the cases, NSA develops
secondary to infected traumatic nasal septal hematoma [19]. In fact,
15% of patients who sustain nasal trauma may develop septal
hematoma and thus are at risk of secondary infection and purulence
[13]. It seems that occurrence of traumatic NSA has been variable
along the years and around the world ranging between 0.8 and 1.6%
of the cases of nasal trauma attended in the emergency room by
otorhinolaryngologists [11,17]. Besides the common causes of nasal
trauma like accidents, falls, fights, and nose picking, chronic
irritation and injury of the nasal septum by naso-gastric tube has
been reported as the leading cause for NSA formation [20].
Infections within the nasal cavity and sinuses may also result in
NSA formation. Mechanism of infection is either as direct
extension from the overlying infected mucosa, or via lymphatic
and/or vascular spread [21]. Sinusitis, nasal vestibulitis, and
furunculosis are the leading causative infections. Although
extremely rare, isolated acute sinusitis such as sphenoiditis and
spheno-ethmoiditis has been documented as a direct cause of NSA.
In 1945, the first case of NSA complicating acute ethmoiditis was
reported. Forty years later, isolated acute sphenoiditis was
reported as a potential cause for NSA development [18,22]. Pang
and Sethi described a case of NSA secondary to acute spheno-
ethmoiditis in a 12-year-old boy who presented with nasal
obstruction and unilateral periorbital oedema of 5 days duration.
Computed tomography scan showed bilateral anterior nasal septal
abscess and sinusitis. Drainage was performed and antibiotics
 N. Alshaikh, S. Lo / International Journal of Pediatric Otorhinolaryngology 75 (2011) 737–744
were given. Patient recovered completely with no evidence of
cartilage destruction or deformity after 2 months of follow-up [23].
Similar to the case presented by Collins, it was postulated that the
mechanism of septal involvement was direct subperiosteal
extension from the anterior portion of the sphenoid bone [22,23].
Besides nose and sinus infections, dental infections could result
in NSA formation. Lopes reported the first NSA of dental origin in
1953 [24]. To date, only nine reported cases were found in the
literature, four of which are not in English language [24–31]. In 7
cases, NSA developed secondary to infected teeth, usually the
incisors [7]. Unusual presentations have been reported, one was
secondary to an infected impacted tooth within the nasal septum
and the other was secondary to an infected dentigerous cyst
[28,29].
Iatrogenic causes of NSA could follow any kind of nasal surgeries
including major functional endoscopic sinus surgery, septal
surgeries such as sub-mucosal resection, septoplasty and septorhi-
noplasty, and a variety of turbinate surgeries [32]. The exact
incidence is unknown [33]. Lo and Wang reported a case of 52 year
old man who presented with Klebsiella pneumoniae NSA complicat-
ing potassium-titanium-phosphate 532-nm laser inferior turbinate
surgery which illustrates the potential for serious complications
following minor ambulatory intranasal surgeries [34].
Shah reported non-traumatic, yet non-spontaneous NSA in five
immunocompromised patients (HIV, insulin-dependant diabetes
mellitus, sarcoidosis). The suggested underlying causes for abscess
formation included furunculosis, sinusitis, and cocaine abuse [35].
Five years later, another case of NSA in a 9-year-old patient – with
severe chronic graft-versus-host disease following allogenic bone
marrow transplantation as a treatment for chronic myelogenous
leukemia – was reported. The cause of NSA was repetitive nasal
trauma caused by dryness-induced nose picking [36]. Although
this case and the five cases presented earlier were in immuno-
compromised patients, there was a well-documented eliciting
cause for NSA formation in each one of them, and thus, were not
truly spontaneous in nature [35,36].
Spontaneous occurrence of NSA (without evidence of underly-
ing cause or triggering factor) has been documented in both
immunocompromised as well as immunocompetent patients [37–
40]. To date, only 4 cases of spontaneous NSA in immunocompro-
mised patients have been reported [37,38].
The first reported spontaneous NSA in immunocompromised
patient was in a 64-year-old man with a history of Crohn’s disease
and pulmonary fibrosis treated with immunosuppressive medica-
tion, who gave 2-week history of bilateral nasal obstruction and
discomfort. He was managed with surgical drainage and systemic
antibiotics. Microbiological cultures revealed Aspergillus flavus. The
patient was treated with 6 weeks of outpatient intravenous anti-
fungal therapy. At 18-month follow-up, there was no evidence of
functional or cosmetic sequelae [37]. This case emphasized that
NSA in immunocompromised patients may present without
antecedent trauma or cause, and that it may be caused by atypical
organisms such as fungi.
Three other cases of spontaneous occurrence of NSA in
immunocompromised HIV carriers were described in the litera-
ture. Drainage was performed within 4 days of presentation. Two
recovered completely without any long-term sequelae. One
progressively developed loss of tip support and deviation of the
septum for which total septal reconstruction was performed 7
months after the drainage. In all three cases, no underlying or
predisposing factor could be elicited [38].
Two reports documented NSA in immunocompetent patients
[39,40]. The latest report was of 38 year-old lady, otherwise
healthy, who presented with anterior nasal septal abscess without
history of nasal trauma or evidence of sinusitis, frunculosis, or
dental origin. She was treated successfully with incision and
739
drainage of the abscess and antibiotic with no signs of cartilage
destruction or deformity on follow-up [40].
3.4. Pathophysiology
Force generated by nasal trauma causes separation of the
mucoperichondrium and/or mucoperiosteum from the underlying
septal cartilage and/or bone. This in turn will tear the sub-mucosal
vessels and lead to bleeding into the potential space between the
septum and its overlying mucoperichondrium. The formed
hematoma separates the mucoperichondrium from the septal
cartilage, impedes nasal septal cartilage perfusion, exerts increas-
ing pressure on the cartilaginous septum, and forms an ideal
medium for the colonization and growth of bacteria, leading to the
formation of NSA. Hematoma can get infected within 3 days of its
formation. This in turn can result into septal cartilage ischemia,
avascular necrosis, and septal resorption. Cartilage damage can
ensue within 24 h of hematoma formation. Frequently, the process
of necrosis and liquefaction is intensified by collagenases that are
produced by the insulting bacteria such as Staphylococcus aureus,
Haemophilus influenzae, and Streptococcus species strains [41].
Studies have also shown that activities of Cathepsin D enzyme, a
proteolytic autolytic collagen degrading intracellular acidic
enzyme naturally present and equally distributed in the chon-
drocytes the human nasal septal cartilage; increase during
infection because of the acidic medium and thus may enhance
cartilage degradation. This finding may help to explain the rapidity
of cartilaginous destruction within hours in many cases of NSA
[42,43].
Delay in treatment may result into serious septic complications,
deviation of the nasal septum, septal perforation, and/or saddle
nasal deformity formation [44].
In sinusitis and dental infections, septal abscess could result
from direct spread of inflammation and infection along tissue
planes and/or under the periostium or perichondrium, through
bone fissures or congenital bone malformations, or through
hematogenous venous spread ‘‘thrombophlebitis’’ [44,45].
Bilateral abscess formation on either side of the septum is the
usual clinical presentation. This can be explained by the fact that
bilateral septal hematoma is far more common than unilateral one.
Another reason could be the extension of infection from one side to
the other through the infected cartilage that tends to dissolve
rapidly.
3.5. Microbiology
Bacterial infection is the most common cause of NSA, in
particularly aerobic bacteria. Reports showed that S. aureus
contributes to 70% of the microbiology of NSA. Other bacteria
frequently involved are H. influenzae and group A b-Hemolytic
Streptococcus, Streptococcus pneumoniae, and other Streptococcus
species [14,46]. Less frequently, K. pneumoniae, Enterobacteriaceae,
Streptococcus milleri, and anaerobic bacteria are cultured from NSA
[20,34,47,48].
Rarely, Methicillin Resistant S. aureus has been isolated from
immune-suppressed and immunocompetent patients with NSA
[38,49].
Mycotic NSA secondary to fungal infection is rare, and has only
been reported in 3 cases of immunocompromised patients. The
isolated fungi were A. flavus in 2 cases and Fusarium verticillioides in
the third [36,37,50].
3.6. Clinical presentation and diagnosis
History is of paramount value in raising the suspicion of NSA.
Patients often present to the emergency department complaining
740 N. Alshaikh, S. Lo / International Journal of Pediatric Otorhinolaryngology 75 (2011) 737–744
of progressive bilateral nasal obstruction over a short period of
time that is usually less than one-week duration [13]. While 50–
100% of patients report a localized worsening pain over the nasal
dorsum or inside the nose, only a quarter of them will complain of
associated fever and/or purulent nasal discharge [14]. Generalized
symptoms such as headache and malaise may also be experienced
by some patients, especially adults. In children, however, reduction
in normal activity may be noticed by parents [13]. Less frequently,
patients may present with epistaxis and external nasal swelling
[17]. Rarely, if there has been a delay in seeking medical advice
and/or a history of immune-suppression, the patient may present
with symptoms and signs of serious life threatening complications
such as meningitis and cavernous sinus thrombosis [51].
Once such symptoms is reported, NSA should be considered in
the differential diagnoses and as such, eliciting a history of
preceding nasal trauma is frequently diagnostic. As stated before,
up to 85% of NSA is caused by infected septal hematoma secondary
to nasal trauma [14]. The time interval between the nasal injury
and NSA presenting symptoms is usually 5–7 days [13]. Clinically,
it can be difficult to distinguish between hematoma and septal
abscess. Generally, NSA is larger, more painful; the overlying
mucosa may be inflamed and covered with exudates, and
frequently accompanied by fever and leukocytosis [52].
In cases with no history of nasal injury, inquiry about preceding
upper respiratory tract infection, dental symptoms, and recent
nose, sinus, or dental procedures is important in detecting the
underlying etiology.
Examination should include vital signs, nasal and central
nervous system examination. Nasal examination should include
inspection, palpation, anterior rhinoscopy, and nasal endoscopy.
The most common findings are a swollen, edematous, and tender
external nose with bilateral purple/dusky looking nasal septal
swelling obstructing the airway with or without purulent nasal
discharge [13,14]. Although NSA usually involves the anterior
cartilaginous nasal septum, there are few reports of isolated
posterior involvement of the nasal septum, and hence nasal
endoscopy is essential when anterior rhinoscopy appears normal
or inconclusive [53,21].
Radiological confirmation of NSA is not indicated, since pus can
be easily aspirated. There are, however, certain situations in which
computed tomography scanning (CT scan) is highly advised in the
author’s opinion. These include situations in which underlying
etiology is unclear, suspicion of Wegener’s granulomatosis, TB,
syphilis, sarcoma, or lymphoma particularly in spontaneous cases
of immunocompromised patients, and in the presence of
complications or lack of response to medical and surgical
treatment [47]. A contrast-enhanced CT scan taken in the axial
and coronal planes is the radiological modality of choice. In cases of
NSA, it will usually show a widened anterior nasal septum that
contained fluid collection (bilaterally and crossing the midline)
with a thickened, mildly enhancing rim.
In addition, CT scan is useful in identifying the leading cause of
NSA in the absence of trauma such as sinusitis or dental abscess,
and in suspected complications such as cavernous sinus thrombo-
sis, brain abscess, and orbital complications.
3.7. Complications
NSA is a serious condition that necessitates urgent medical
attention and management. Delayed or inadequate treatment can
result in life threatening complications such as cavernous sinus
thrombosis. Anatomically, the nose is located within the danger-
ous area of the face which is a triangular zone that extends from the
corners of the mouth to the nasal root (Glabella) and also includes
the medial part of the maxilla. The veins in this region (anterior and
posterior ethmoidal veins which drain to ophthalmic vein,
sphenopalatine and greater palatine veins which drain to
pterygoid veins, and angular, lateral nasal and superior labial
veins which drain to facial vein) are valveless and all ultimately
drain into the cavernous sinus, making any infection in this
dangerous area a potential cause of cavernous sinus thrombosis
[54]. Thus careful ophthalmologic, neurological, and cranial nerves
examination is essential in all patients presenting with NSA.
Besides hematogenous spread, complications can also result
from either lymphatic drainage or direct spread through tissue
planes. The lymphatic of the superior meatus of the nose drain into
the subarachnoid space via the vertical plate of ethmoid and the
cribiform plate, thus infection can spread via this route [11].
Complications of NSA can be categorized according to the onset
into early (during the acute onset of the NSA) and late (within one
month of the infection) [55]. They can also be classified according
to the site of involvement into local (at the area of the nose and
paranasal sinuses), cranial, orbital, and systemic (Fig. 1)
[9,10,17,43,55–57].
An intact nasal septum is necessary for the normal mid facial
development. The normal nasal septum has 2 major growing
centers, which are thicker (3 mm) than the surrounding cartilage
(0.75 mm). These include the sphenodorsal zone, which regulates
the length and height of the nose, and the sphenospinal zone
(basal), which stimulates the development of the anterior nasal
spine and the maxilla [58].
Thus, destruction of the cartilaginous nasal septum during
childhood can result in delayed development of the mid face
including the nose and the maxilla which in turn could result in
major aesthetic and functional problems [59–62]. Such sequelae
include underdevelopment of the nose and maxilla, tip over-
rotation, saddle nose deformity, grossly deviated nasal septum,
retracted columella, maxillary hypoplasia, and midface retro-
position [3,55]. It has been shown by long-term follow-up that the
growth inhibition of the mid face is more pronounced the earlier
the nasal injury has occurred [1].
Smaller defects in the thinner anterior central part of the
cartilaginous septum, located between the major growing centers,
do not seem to interfere with maxillary–nasal growth [58].
Nevertheless, reconstruction of such small defects should be
considered to avoid the development of septal perforation [3].
Less frequently, NSA can result into nasal septal perforation
which could either be a sequence of the tissue loss by the infection
or iatrogenic in nature due to incision and drainage of the abscess
from both sides of the septum at opposing sites [47].
Rarely, nasal–oral fistula may develop especially if the source of
NSA is dental or vestibular in origin [11].
3.8. Treatment
Detection of the presence of septal hematoma is the first and
most important step in prevention of NSA development by means
of incision and drainage of the sub-perichondrial blood collection.
Once NSA develops, treatment should be directed towards
drainage of the abscess in order to release the pressure and re-
establish blood supply of the septum while ensuring debridement
of the infected cartilage and continuous evacuation of the
purulent discharge. Awareness of the potential serious complica-
tions is warranted, thus avoidance of delay in surgical interven-
tion and adequate medical management should be taken to
prevent such complications from occurring. An equally important
yet frequently unrecognized aim in the management of NSA
should be directed towards the prevention of the long term
sequelae secondary to the loss of septal cartilage in childhood
which is a serious condition that requires adequate reconstructive
surgical therapy to prevent functional and aesthetic problems in
the future [59].
[()TD$FIG] N. Alshaikh, S. Lo / International Journal of Pediatric Otorhinolaryngology 75 (2011) 737–744
Fig. 1. Complications of nasal septal abscess according to site of involvement.
There is a general international consensus about the initial
management of NSA. Patients should be admitted to the hospital
for adequate treatment and observation for potential life
threatening complications. Incision and drainage of the abscess
can be done under local anesthesia in the majority of cases. In
children, however, this might be challenging and may result
inefficient and inadequate drainage not to mention the unpleasant
painful experience to the child. Thus, drainage of NSA in children is
ideally performed under general anesthesia. Incision is made at the
septum on the side of the abscess. In bilateral cases which is the
usual, one side incision could be adequate to drain both sides if
septal cartilage is found necrotic. Yet, bilateral non opposing
incisions are recommended for cases where cartilage is intact and
collection in the other side could not be drained completely with a
single one side incision.
Various incisions have been described in the literature
including Killian’s transverse one, and L-shape. Once the incision
has been made, sample of pus should be sent for microbiological
assessment. After complete drainage of the purulent discharge,
debridement of the necrotic cartilage, and gentle repeated
irrigation of the cavity, it is recommended by many authors to
keep either a light cavity pack or a small Penrose drain in order to
prevent early wound closure and re-accumulation of pus. Most
surgeons will keep the nose packed for 48–72 h again with the aim
to prevent reaccumulation [41].
Empirical systemic parentral antibiotic should be started
immediately. It is strongly advised to start with a broad-spectrum
antibiotic that covers the most common pathogens recovered from
NSA. The most commonly and successfully used empirical
antibiotics are Augmentin, Penicillin, Cloxacillin, and Cefuroxime.
Culture based antibiotic is recommended only if patients show no
improvement or deterioration over time. Some clinicians advised
the addition of Gentamycin to cover gram-negative bacteria, while
others recommended Metronidazole when the infection is dental
in origin and anaerobic bacteria is expected [17,63]. Clindamycin is
recommended when S. milleri has been isolated [64].
741
After nasal pack removal, the patient can be discharged from
hospital with close observation for recollection during outpatient
follow-up visits. The antibiotic therapy is usually continued orally
for 7–10 days following discharge.
Early (saddle nose deformity, deviated nasal septum, and
columellar retraction) and late (midface underdevelopment,
maxillary hypoplasia, grossly deviated nasal septum, septal
perforation) sequelae of NSA must be addressed during manage-
ment of such patients. To date, there is no consensus among
clinicians with regard to early versus late surgical management of
such sequelae. Proponents of early reconstruction of the lost septal
cartilage – either at the time of incision and drainage or soon after
the infection subsides – believe that it corrects early deformity,
restores function, and prevents long term effect on the growth of
midfacial skeleton.
Opponents, on the other hand, advocate delaying reconstruc-
tion to adulthood as it corrects ‘‘eventual’’ functional and cosmetic
consequences without the risk of graft infection and failure. Among
the cited articles, the largest reported series of NSA were managed
simply with incision-drainage and antibiotic therapy without
further early reconstruction. There is no single study in the medical
literature comparing the outcome between these two approaches.
This is due to the rarity of the condition and the fact that it is
commonly dealt as an emergency handled by otorhinolaryngol-
ogists who may not have the necessary experience of septal
reconstruction.
Some authors suggested that destroyed and infected septal
cartilage could yet regenerate after resolution of infection [65].
Close and Guinness followed up three patients (2 adults and 1
child) for 3 months after resolution of NSA where the cartilage was
found to be extensively destroyed during surgery. They noticed
complete regeneration of the septal cartilage in 2 of the 3 patients.
However, their conclusion was based on a small sample, very early
follow-up, and without histological evidence. Indeed, cartilage
regeneration was well documented four years after early
homologous cartilage reconstruction of a totally lost nasal septum
742 N. Alshaikh, S. Lo / International Journal of Pediatric Otorhinolaryngology 75 (2011) 737–744
secondary to NSA. In this report, the author documented clinical
and histological presence of regenerated autogenous cartilage
among some remaining islands of the implanted cartilage. Such
observations lead to the assumption that slow regeneration of
septal cartilage can take place from the surviving healthy
mucoperichondrium [1]. Such findings were further explored
and confirmed in animal models. In a recent study, Kaiser and
colleagues performed submucosal resection of the septal cartilage
for 17 rabbits followed by histological examination of the septum 7
months later. They found a newly formed cartilage – between the
perichondrial flaps of every animal – which consisted of
chondrocytes within chondrons and was comparable in shape
and structure to the native septal cartilage. They concluded that
the septal cartilage with a healthy overlying mucoperichondrium
possesses the ability to regenerate after resection [66].
Probably, the best way to examine the effect of early
reconstruction of nasal septum on nasal and facial growth is to
compare results with a control, such as an identical twin. In one
observation, Grymer and Bosch reported distorted midfacial
growth (saddle nose deformity, upward displacement of the
anterior part of the maxilla, diminished vertical development of
the nasal cavity, and a retrognathically positioned maxilla due to
decreased anteroposterior maxillary growth) of the twin who had
homologous cartilage reconstruction of the nasal septum at the
time of abscess drainage 10 years later when compared to his
identical normal twin who had normal midfacial growth [67]. In
fact, similar observations were noted around three decades earlier
when one of identical twins developed hypoplastic premaxilla and
inhibited growth of nasal tip when compared to his identical
normal twin four years after immediate septal drainage and
homologous cartilage reconstruction [68]. This case reports
suggest that cartilaginous nasal septum is an important factor
influencing vertical and sagittal growth of the maxilla and the nose
and that use of homograft material despite early reconstruction
may not prevent late nasal and midfacial deformity probably due
to resorption. Question remains whether this sequelae is the result
of the initial injury or the septal abscess pathology.
There is debate on which material to be used for reconstruction
of the nasal septum. Autologous cartilage graft is believed to be the
material of choice for reconstruction because of less risk of
infection, resorption, and rejection. It can be used either by re-
implantation of nasal septum (use of autologous septal bone and
cartilage between the septal flaps), or by harvested conchal, tragal,
or costal cartilage for reconstruction [3,69–71]. Homograft
material is suggested when septal cartilage is not available or
there is fear of graft failure secondary to persistent infection within
Table 1
Summary of reported cases of early nasal septal reconstruction in the management of nasal septal abscess.
Author/s year No. of patients Reconstruction material
Mills [76] One Homologous cartilage
Masing [5] 5 Homologous cartilage
Masing and Hellmich [68] One of two Homologous cartilage
monozygotic twins
Vase and Johannessen [72] 5 Homologous cartilage
Huizing [4] 2 Homologous cartilage
Grymer and Bosch [67] One of two Homologous cartilage
monozygotic twins
Dispenza et al. [77] 7 3 homologous cartilage/4
autologous septal cartilage
Menger et al. [3] 6 Autologous conchal/costal
cartilage
the remaining cartilage [72]. Synthetic materials such as polyeth-
ylene graft have also been used for acute phase septal reconstruc-
tion [73].
For early septal reconstruction, Hellmich described three
surgical options. (1) Reconstruction with the posterior cartilage
residue or bony septum to adjust deformities in the anterior
septum ‘‘Exchange technique’’. (2) Reconstruction with small
fragments of residual cartilage fixed together with fibrin glue
‘‘Mosaicoplasty’’. (3) Reconstruction with a preserved rib cartilage
allograft when the septal material is not available ‘‘Homograft’’
[74].
The current available data that describes the surgical techni-
ques and results of early reconstruction of the nasal septum either
during or shortly after the initial incision and drainage of NSA is
extracted from some sporadic case reports and a few case series, of
which the largest series will be highlighted in this review.
The majority of pediatric otorhinolaryngologic surgeons
recommend early reconstruction whenever feasible in order to
restore and maintain both contour and function, prevent nose and
mid facial growth retardation, not to mention the prevention of
potential risk for long term psychological problems secondary to
disturbed self-image and self-esteem because of the gross nasal
deformity [75].
Most surgeons prefer the open approach for reconstruction
surgery as it allows direct access to the nasal base and all areas of
the nasal septum, precise estimation of the cartilage loss and thus
how much reconstruction is needed [3,4,75–77].
Early septal reconstruction goes back to 1951 when Mills
reported the use of homograft to reconstruct septal cartilage
during initial incision and drainage surgery of NSA [76]. Shortly
after, Cottle et al. proposed the implantation of nasal septum
recommending the treatment within 8–12 weeks from abscess
drainage when resolution of the infection could assure a successful
implantation [69]. Vase and Johannessen reported their results 33
months following the treatment of 5 children with early septal
reconstruction using homograft cartilage implantation at time of
abscess drainage. They stated that cosmetic and functional results
were satisfactory with no evidence of cartilage rejection nor
resorption, saddle deformity, retracted columella, or deviated
septum. Their series, however, was small with a relatively short
follow-up period and was mainly based on observational evalua-
tion [72].
Few other encouraging results for early septal reconstruction
(at the time of incision and drainage of the abscess) have been
reported with the longest follow up period of 19 years [4]. The two
largest cohorts included 7 and 6 children, respectively. In the first
F/U period Sequelae
– –
4 years No functional complications.
No saddle deformity.
4 years Underdevelopment of nasal tip and premaxilla.
No saddle deformity.
33 months Satisfactory with no saddle deformity, retracted columella,
or deviated septum.
17–19 years Normal nasal growth and function is with minimal saddle.
10 years Saddle deformity, upward displacement of anterior part of
the maxilla, diminished vertical development of the nasal
cavity, retrognathically positioned maxilla.
10 years Normal development of face and nasal pyramid
with normal function.
Four mild non-obstructing deviation of the nasal septum.
38 months Normal nasal development.
One mild collumellar retraction.
Three mild over-rotation of the nasolabial angle.
 N. Alshaikh, S. Lo / International Journal of Pediatric Otorhinolaryngology 75 (2011) 737–744
series, all 7 children who received immediate surgical reconstruc-
tion with homologous L-shape cartilage graft (3 children) or
mosaicoplasty where residual septal cartilage was fixed by fibrin
glue (4 children) showed normal development and function of the
nose after a period of 10 years [77]. In the second series of 6
children, all were reconstructed immediately with an autologous
cartilage graft (auricular or costal) that was stabilized and fixed on
polydioxanone plate, positioned between the vomer, the upper
lateral cartilages, and perpendicular plate or remnants of the
cartilaginous septum and sutured by mattress through an open
approach. With a mean follow-up period of 38 months, all children
showed normal development of the nose (length of nose and
amount of nasal tip projection) in comparison to the standardized
growth curves for central Europe [3]. Reports of early septal
reconstruction are summarized in Table 1 [3–5,67,68,72,76,77].
Although such results are promising, the small number of cases
makes it difficult to draw a significant conclusion. Further, in most
series, children were still in the growing phase, and there was no
control group for comparison.
4. Conclusion
Nasal septal abscess is a serious condition that necessitates
urgent surgical management. In the growing child, reconstruction
of partially or completely destructed septal cartilage as a
complication of abscess formation is essential for normal
development of the midface (nose and maxilla). To achieve
successful long-term functional and aesthetic results in children
with NSA, early reconstruction of the lost cartilage is recom-
mended based on available literature despite the lack of strong
supporting evidence. At present, autologous cartilage is widely
believed to be the implant material of choice.
Conflict of interest
Authors have no personal, academic, or financial conflict of
interests.
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