Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes Salim hussain Ibrahim Department of surgrry

A b s t r a c t Objective: To evaluate the clinical features, and surgical treatment of haematoma and abscess of the nasal septum (HANS). Patients& methods: Retrospective study. In the Ear nose and throat department at Tikrit Teaching Hospital.Iraq.Thirty-eight patients with HAND were admitted during eight years, 22 patients(57.8%) with septal abscess and 16 patients(42.2%) with septal haematoma.All treated by urgent drainage under GA,and to prevent recollection, a corrugated drain and packing were used in 17 patients(44.7%)(Group A), and a unilateral incision along septal floor, with septal splint and packing in 21 patients (55.3%)(Group B). Four patients from this group with septal abscess dorsal and columellar strut were done using available septal cartilage and bones(Group C).All receive antibiotics. Follow up of the patients for functional and cosmetic results for minimum six months. Results: The HANS were common in children 27 patients (71.1%) were in age between (3mon.-10 year). History of trauma was in (92.1%). The mean time of diagnosis following trauma in septal haematoma was(1.9day) ,and for septal abscess was(5.7days).Bilateral nasal obstruction was the commonest symptoms in(94.7%),then rhinorrhea (57.267%) , pain and tenderness (55.26%).Toxemia (pyrexia and rapid pulse) found only in patients with septal abscess in (86.4%). The complications were more in septal abscess, especially external nasal deformities was (86.4%) in septal abscess, and (6.25%) in septal haematoma. The use of unilateral septal incision and splint found effective in reducing recollection of blood or pus, thick septum, nasal obstruction, and septal perforation. But little significant on preventing external nasal deformities. Three patients(75%) with immediate septal reconstruction not have saddle nose deformity. No septic intracranial complications occurs. Conclusion: The HAND are uncommon condition, but should be considered in any patient with history of nasal trauma, especially in children, presented with acute nasal obstruction, The toxemia with pain suggestive formation of septal abscess which have a dangerous complications. The immediate septal reconstruction in septal abscess, and unilateral septal incision and septal splint are effective to minimize the functional and cosmetic complications.

Key word: Nasal Septal Haematoma; Nasal septal Abscess; Nasal -Injuries; Saddle nose deformity; Nasal septum-Diseases-Complications.

Introduction Nasal septal haematoma is collection of blood beneath mucoperichndrium or mucoperi-osteum of the septum (1). It follows trauma to the septum (2)(3), when sub- mucosal blood vessels torn with intact mucosa, rare in blood dyscresia.Thehaematoma interfere with the vitality of the cartilage which depends on the perichondrium for nutrition ,by diffusion (4). Avascular cartilage can probably remain for three days, then the chondrocytes die and absorption of the cartilage follows, which easily infected leads to septal abscess formation(5)(6), which may follows measles, scarlet fever ,nasal furnuclosis (1), immuno-

compromized patients, and sphenoidal sinusitis(7). The septal abscess leading to nasal deformities (saddle nose)and sever impairment of nasal patency and growth(8), so late recognition and the improper management of septal haematoma may have a disastrous outcome(3), like septal abscess and intracranial complications(9)(10), even death in (6.52%) of cases due to brain abscess(11).

Patients and Methods This a retrospective study was carried

out on patients with haematoma or abscess of the nasal septum, admitted in the E.N.T

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes

department at Tikrit Teaching Hospital. Iraq. During the period from Jan.1997-Dec. 2004. They were 38 patients,22 patients (57.8%) with septal abscess and 16 patients (42.2%) with septal haematoma. They were evaluated by history taken about nasal trauma (type&duration), recent external nasal deformities, nasal obstruction, nasal discharge, nasal pain and headache. General appearance of the patients, pulse rate, temperature. Full E.N.T examination was done stressing mainly on the nose, inspection for swelling, deformity, palpation for tenderness, elevation tip of the nose by the thumb for septal swelling mostly occlude the lumen of both nostrils, cystic in probing and anterior rhinoscopy for localized septal haematoma or abscess. The diagnosis was confirmed by needle aspiration of blood or pus. All patients underwent general anesthesia,oro-trachial intubation, pharyngeal pack was inserted, Via hemitransfixation incision, subperichondrial dissection and evacuation of the blood, pus and all necrotic cartilage removed, the pus send for culture and sensitivity test. To prevent recollection before 2001 Insertion of small corrugated drain in the floor of the septum with anterior nasal packing for three days (Group A). After 2001 a longitudinal incision was made along the inferior border of the septum on one side, septal splint and anterior nasal pack for three days, the stent removed after seven days (Group B). (Group C). Includes patients with septal abscess were immediate reconstruction of destroyed necrotic nasal septal cartilage using available cartilage and part of vomer bone for dorsal and columellar strut, because there is no cartilage bank available in our city. (The insertion of the dorsal graft in a pocket via unilateral intercartilagenous incision),to prevent recollection as in (group B). Simple close reduction was done for patients with fracture nasal bones. All patients receive parentral antibiotics Ampiclox or cephalothin initially till the results of culture and sensitivity results appears. Follow up of the patients for functional and cosmetic outcomes were done for at least six months.

Results There were thirty-eight patients with

nasal septal haematoma and abscess, 21

(55.3%) were male and 17 (44.7%) were female, underwent surgical drainage at Tikrit Teaching Hospital during the period of eight years by same author.22 patients (57.8%) with septal abscess, and 16 patients (42.2%) with septal haematoma. Commonest age group affected was (3 months-5 years) were21 patients(55.3%),then age Group (6-10 years) were 6 patients (15.8%), then (11-15 year), and(>20 year) both were4 patients (10.5%), lastly the age group(16-20 year)was 3 patient (7.9%).The septal abscess was common than septal haematoma in the age groups (3 months-5 year) and (6-10 year), while septal haematoma was common in the older age groups (Table 1). Nasal trauma was the causes for all cases of septal haematoma, but in septal abscess 3 patients (13.62%) were spontaneous (unknown) causes. Personal accidents were the commonest type of trauma 17 patients (44.75%), personal assaults were 11 patients (28.93%), animal attacks were 3 patients (7.9%), lastly post surgical (iatrogenic)two cases (5.26%) of septal haematoma following septoplasty, and sporting also two patients (5.26%) ( Table 2). The mean time of presentation following trauma, for septal haematoma was 1.9 day (8 hours-4 days),and for septal abscess was 5.7 days (3-14 days). Common presentation was bilateral nasal obstruction 36 patients (94.7%), all 22 patients (100%) with septal abscess and 14 patients (87.5%) with septal haematoma,two patients with localized septal haematoma. Rhinorrhea were 22patients (57.26%) more with septal abscess 16 patients (72.7%),while in septal haematoma were 6 patients (37.5%).Pain and tenderness over nasal tip were 21 patients (55.26%),18 patents(81.8%)with septal abscess, and 3 patients (18.75%) with septal haematoma due to fracture nasal bones. Toxemia (pyrexia and rapid pulse) were found in 19 patients (86.4%) with septal abscess only. External nasal swelling or deformities were 16 patients(42.1%).Five with fracture nasal bones{three with septal haematoma,and two with septal abscess},the others reddening of the nasal bridge and swelling with septal abscess (Table 3). The 16 patients with septal haematoma, to prevent recollection, Group(A) were(7) patients (43.75%), and Group (B) were (9)

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes

patients (56.25%). Recollection occurs only in Group A, were two patients (28.6%), one patient converted to septal abscess gets external nasal deformities(supra tip depression). Four patients (25%) gets thick septum {3 patients Group A(42.85%) ,and one patient (11.1%) group B}. Five patients (31.2%) gets nasal obstruction{3 patients (42.85%) Group A, and 2 patients (22.2%) Group B} (Table 4). The 22 patients with septal abscess. Group A were 10 patients (45.45%), Group B were 8 patients (36.37%), and Group C were 4 patients (18.18%) aged 15, 17, 20, 27 year. External nasal deformity(form simple supratip depression to obvious saddle Nose) occurs in

18 patients (81.81%) {10 patient (100%) in Group A, 7 patients (87.5%) in Group B, and one patient (25%) in Group C}. Recollection of pus occurs in 3 patients (13.6%), all patients from Group A (30%). Thick septum occurs in 5 patients (22.7%) {4 patients (40%) were Group A, and one patient (12.5%) Group B}.Nasal obstruction occurs in 10 patients 45.45%){6 patients (60%) In Group A, 3 patients (37.5%) in Group B, and one patient (25%)in Group C}. Septal perforation occurs in one patient (4.5%) in patient with recollection following drainage using corrugated drain in both operations (Table 5). No cases of intracranial septic complications were occurred (Table 5).

Table (1):Age distribution of HANS.

Age group Septal haematoma. Septal abscess. Total % (3mon-5 year ) 7 (43.75%) 14 (63.6%) 21 (55.3%) (6-10 year) 2 (12.5%) 4 (18.2%) 6 (15.8%) (11-15year) 2 (12.5%) 2 (9.1%) 4 (10.5%) (16-20year) 2 (12.5%) 1 (4.55%) 3 (7.9%) ( >20 year) 3 (6.25%) 1 (4.55%) 4 (10.5%) Total 16 (42.2%) 22 (57.8%) 38 (100%) Table 2 : Causes of septal haematoma and abscess

Causes Septal haematoma NO. (%)

Septal Abscess No. (%)

Total No. (%)

Personal accidents 5 (31.25%) 12 (54.54%) 17 (44.75%) Personal assaults 6 (37.50%) 5 (22.72%) 11 (28.93%) Animal attacks 1 (6.25%) 2 (9.1%) 3 (7.9%) Post operative(Iatrogenic) 2 (12.5%) 0 2 (5.26%) Sporting 2 (12.5%) 0 2 (5.26%) Spontaneous(Unknown) o 3 (13.64%) 3 (7.9%) Total 16 (100%) 22 (100%) 38 (100%) Table 3: Clinical features of nasal septal haematoma and abscess.

Septal haematoma Septal abscess Total Mean time of presentation 1.9 day (8hr-4 days) 5.7days(3-14 days) Bilateral nasal obstruction 14 (87.5%) 22 (100%) 36 (94.7%) Rhinorrhea 6 (37 %) 16 (72.7%) 22 (57.26%) Pain and tenderness 3* (18.75%) 18 (81.8%) 21 (55.26%) Toxemia(pyrexia, rapid pulse) 0 19 (86.4%) 19 (50%) External deformities 3 * (18.75%) 13 **(59.1%) 16 (42.1%) * Three patients were having fracture nasal bones. **Two patients were having fracture nasal bones, others due to redness and swelling.

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes

Table 4 : The results of septal haematoma.

S u r g i c a l p r o c e d u r e Complications

Group (A)*[No.7] Group (B)** [No.9]

Total

Recollection 2***(28.6%) 0 2 (12.5%) External nasal deformities

1**** (14.3%) 0 1 (6.25%)

Thick septum 3 (42.85%) 1 (11.1%) 4 (25%) Nasal obstruction 3 (42.85%) 2 (22.2%) 5 (31.25%) *Insertion of small corrugated drain in the floor of the septum with anterior nasal pack. **A unilateral longitudinal incision was made along the inferior border of the septum with septal splint, and anterior nasal pack. ***one case Converted to septal abscess. ****Developed supratip depression. Table 5 : The out comes of septal abscess.

S u r g i c a l p r o c e d u r e Complications

Group (A)* [No.10]

G r o u p(B) **[No.8]

Group(C)*** .[No.4]

Total

Recollection. 3( 30%) 0 0 3(13.6%) External nasal deformities.

10(100%) 7(87.5%) 1(25%) 18(81.81%)

Thick septum. 4 (40%) 1 (12.5%) 0 5 (22.7%) Nasal obstruction. 5(50%) 3 (37.5%) 1(25%) 9 (40.9%) Septal perforation. 1 (10%) 0 0 1 (4.5%) Septic complications.

0 0 0 0

*Insertion of small corrugated drain in the floor of the septum with anterior nasal pack. **Aunilateral longitudinal incision was made along the inferior border of the septum with splint, and anterior nasal pack.

*** Patients with immediate septal reconstruction, and septal incision and splint were used.

Discussion Nasal septal haematoma and abscess are uncommon conditions (13), were 38 patients during eight years, study in Mexico found 16 patients during five years (12), other found 52 patients during 10 years (14), in nigeria46 patients with septal haematoma during five year represent 0.2% of total attendances to the ENT clinic over the period (11). Jalaludin in Singapore report 14 septal abscess during 10 years (13). Septal haematoma is common in children because the muco-perichodrium is not closely bound down to the cartilage in this age group compared with adults (2) .so easily collection of blood subperichondrially when torn of submucosal blood vessels(12). In this study 27 patients (71.1%) with HANS were between (3 mon.-10 year). which mostly as result of nasal trauma, and the haematoma usually followed by septal abscess, in delay recognition or improper management of the septal haematoma (6) (9) (12) (15). It is necessary to be aware of possibility of septal haematoma and abscess of the nasal septum in nasal trauma (6) (10) (15), especially in children, when presented with bilateral nasal obstruction

which the commonest presentation, then rhinorrhea. The toxemia(pyrexia and rapid pulse) with pain and localized nasal tenderness suggestive septal abscess formation (1) (3) (5). The higher incidence of septal abscess(57.8%)in this study, because late presentation of the patients following trauma, or miss diagnosed of septal haematoma as turbinate swelling as most cases were children examined firstly by non-otolaryngologist (13) [pediatricians or general practitioner].so the mean time of presentation for septal abscess were (5.9 days) following trauma due to delay diagnosis of septal haematoma , while (1.9day) in haematoma. Study in Nigeria was found that the majority of septal haematoma (65.5%) were unknown (spontaneous) causes, while ( 30.4%) were due to trauma .Most studies found that nasal trauma was the commonest causes (2) (3), Canty

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes

et al all the patients had a history of trauma (3), Jalaludin (85.7%) of septal abscess due to trauma(13). Alvarez H (56.2%) due to trauma

(12). There is conflicting evidence regarding the benefit of using a drain to prevent recollection of the blood or the pus after drainage (3), author using nasal packing for five days to allow healing to begin adequately (16), other maintain drainage by inserting drainage tube in the buttom of the cavity and the mucosa replaced and maintained in this position by nasal packing (5), other maintain drainage by excising small square of the mucoperichondrium on one side with nasal packing (1). Another treatment option is immediate drainage and Placement of Penrose drain (18), or using soft rubber drain with packing (2). In this study to prevent recollection, using corrugated drain and anterior nasal packing for early cases, and make a longitudinal incision along the floor of the nose on one side and sialastic septal stent inserted and packing in other cases. Cosmetically both methods have no significant effect on preventing saddle nose in septal abscess. The use of the septal stent found to be effective for reducing the incidence of recollection of septal haematoma or the abscess by preventing oozing by made both mucoperichondrium in contact closer than presence of the corrugated drain which located in between, as well the longitudinal incision along the inferior border of the septum which made continuous drainage, added by persistent pressure of septal stent, while in cases using a corrugated drain recurrence and revision surgery were indicated in (two patients (28.6%) in septal haematoma, and three patients (30%) in septal abscess), and functionally septal splent gives better results, less incidence of nasal obstruction because of less incidence of thick nasal septum. Nasal obstruction due to thick(widened) septum which reduce airway(2) due to incomplete evacuation of blood, or continue oozing. The blood clots will organized and fibrosis causes thick septum. As well collapse of the cartilaginous nasal septum in saddle nose which commonly following septal abscess. So the external nasal deformities, and nasal obstruction were common in septal abscess than septal haematoma. Saddle nose deformity results from necrosis of septal

cartilage. The cartilage replaced with fibrous tissue which can retract leaving the lower two-third of the nose unsupported (17).The saddle nose is inevitable in septal abscess, characterized by loss of nasal dorsal height which represent wide range of severity (10) (11), related to the severity of cartilage necrosis ,from simple supratip depression to obvious dorsal depression with loss of nasal tip support and definition (10). But a study on two patients with extensively destroyed cartilage were examined a few months and the septal cartilage appeared to have completely regenerated (15), synichia which also affect nasal patency occurs in three patients all not use septal stent. One case of septal perforation that usually occurs over the area of cartilaginous necrosis. was found in one patient with septal abscess using a drain. The drainage and immediate reconstruction of the destroyed nasal septum in acute phase are the golden standard in the treatment of septum infected haematoma in children, to prevent short and long- term effect on nasal and mid face growth (7)(19), Using materials taken from the nose (20), if this material can't be obtained, implantation of homologous bank cartilage or mosaic plastic using small pieces of residual septal cartilage assembled with fibrin glue(7), or using preserved rib cartilage allo graft(21) The homograft cartilage can be harversed from patient who have undergone submucosal resection and conveniently stored in 0.1% sodium mercurothiosalicylate (5). In our study four patients with septal abscess, dorsal and columellar strut were done using available healthy septal cartilage and vomer bone, with success in three cases (75%). This may prevent saddle nose deformity and reduce the indication for augmentation rhinoplasty later. Cartilage graft can be used even if the abscess formation has occurred (22) ( 23) (24), have all shown that these grafts takes well and effectively in prevent the saddling deformities which other wise inevitably occur (5). In conclusion, the HAND should be considered in any patient with history of nasal trauma, especially in childrens, presented with acute nasal obstruction, The toxemia with pain suggestive formation of septal abscess which have a dangerous complications. This point l recommended that the pediatricin and general practitioner should aware about for early detection of septal haematoma befor converted to abscess. The immediate septal

Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes

reconstruction in septal abscess, and unilateral septal incision and septal splint are effective to minimize the functional and cosmetic complications.

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Haematoma and Abscess of Nasal Septum, Clinical Features and Surgical Treatment Outcomes