Management and Complications of Nasal Septal Collections

Olusola Ayodele Sogebi, Emmanuel Abayomi Oyewole

ENT Unit, Department of Surgery, Faculty of Clinical Sciences, OACHS, Olabisi Onabanjo University, Sagamu, Nigeria 

Correspondences to: Dr Olusola A Sogebi, E-mail: ayosogebs@gmail.com

Received: 29 May 2020; Revised: 24 July 2020; Accepted: 11 August 2020; Available online: 1 September 2020

Abstract

Background: Nasal septum collections (hematoma and abscess) can lead to structural and functional abnormalities. Our objective was to assess the clinical characteristics, management and complications of nasal septal collections, and document factors associated with their complications. Methods: This was a retrospective study of patients managed for nasal septal collections. Socio-demographic and clinical information was recorded, and the main investigations and results noted. Follow-up and complications of septal collections were documented and the clinical factors associated with the complications explored. Results: Twenty-four patients records were studied: male: female ratio=2:1, mean age 40.1±13.1years,62.5% presented with complaints of nasal obstruction, 66.7% had antecedent nasal trauma, presentation was from 2 to 13 days,25%had co-morbid disease(s). All patients had incision and drainage of the septal collection within 1–7 h; 41.2% of the aspirated collections cultured microorganisms, 20.8% developed complications. Increased age above 45 years, co-morbidity, delayed presentation, culture-positive aspirate was all significantly associated with development of complications. Conclusion: Nasal septal collections were more common in adult males with antecedent nasal trauma;20% developed complications associated with the presence of culture-positive abscesses, increased age, and duration of septal collection.

 

Keywords: Nasal trauma, Septal hematoma, Septal abscess, Complications
Ann Afr Surg. 2021; 18(2): 79–84
DOI: http://dx.doi.org/10.4314/aas.v18i2.4
Conflicts of Interest: None
Funding: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License. 

Introduction 

Nasal septal collection is an accumulation of fluid between the cartilage or the bony septum and the overlying mucoperichondrium or mucoperiosteum (1). The fluid is either blood (hematoma) or pus (abscess). Septal collections are generally not common; the prevalence of nasal septal hematoma and abscess in children has been reported as 0.9% (2). Many publications on septal collections have been on hematomas while studies that combined septal collections reported comparatively more hematomas than abscess (3,4). Oftentimes an abscess results from a secondary infection of hematoma (5), thus it is rarer. Most reports of septal abscess involve adults who had experienced nasal trauma (1).The main etiology of septal collections is different types of trauma to the nose. The mechanism that induces a septal hematoma is a buckling stress that tears the submucosal blood vessels. If the mucosa remains intact, the blood will accumulate between the mucoperichondrium and the septal cartilage, which relies on the mucoperichondrium for its blood supply. The stagnant blood is an excellent medium for bacteria to proliferate and it eventually results in the formation of a localized abscess (6). Common types of trauma include explosive forces, leading to fracture of nasal bones in road traffic accidents, blows from punches, and sports injuries to the nose (7). Sometimes infections in contiguous areas of the face such as paranasal sinuses, oral cavity, or orbits (6,8) lead to septal collection. Spontaneous septal abscess has been associated with immunocompromised disease conditions (5,9).Appropriate management of a nasal septal collection requires prompt diagnosis, adequate surgical drainage, and parenteral administration of antibiotics (1). However, complications may arise when the accumulation has remained for a relatively long period or an abscess has developed. Thus, optimal time is required in the treatment to have a good outcome and prevent complications (10). The dreaded complications include severe functional and cosmetic sequelae with deformity of the nasal bridge, forming a saddle nose (11). The goals of management will include relief of nasal obstruction, maintenance of the nasal bridge architecture, and prevention of intracranial complications.The medical literature on septal collections has been mostly case reports about strange or unusual causes of septal collections, whereas the characteristics and profile of septal collections has been less reported. Factors associated with complications have rarely been sought or reported. This study aimed to assess the characteristics, management and complications of nasal septal collections, and to also explore clinical factors that may be associated with the complications. This will suggest the factors to explore in cases of septal collections to accomplish the best outcome possible.

Methods

This was a retrospective cross-sectional study of patients who were admitted and managed at the Ear, Nose and Throat Department of a teaching hospital, in south-western Nigeria. The patients were managed within an 8-year period, from January 2012 to December 2019. The study protocol was approved by the Institutional Health Research Ethics Committee, approval number 341/2020AP. Eligible patients had nasal septal collection (either hematoma or abscess) and were managed within the study period. The patients excluded were those who had associated intracranial injury or infection and those referred to other medical centers for primary management. Records that had missing important information of patients were also excluded.
The case note records of the patients were retrieved from the clinic, emergency center, and ward admission registers to obtain clinical information. Information extracted included socio-demographic parameters such as age and sex, clinical information for the main presenting symptom(s), duration of symptom(s) before presentation at the hospital, predisposing factors, presence of co-morbid disease or otherwise. The main investigations were noted and the results of microscopy culture and the sensitivity of the aspirate of the septal collection were recorded.
The protocol employed was the standard procedure for surgically draining nasal septal hematoma and abscess described by Kass and Ferguson (12). Topical administration of a mixture of 2% lidocaine for local anesthesia and oxymetazoline solution (to constrict the nasal turbinates) were used to obtain a clearer view. A J-shaped incision was made on the mucosa of the bulgy side of the septal collection and deepened into the cavity. Fluid was directly aspirated with a syringe to collect a sample for microbiological analyses. Suction drainage with a machine completed evacuation of the cavity. Both nasal cavities were packed firmly with lubricated antibiotic-laden gauze to prevent or reduce the tendency of the fluid to re-accumulate. We routinely administered parenteral antibiotics during and continued for a minimum of 24 h after the drainage procedure. The antibiotics regimen was reviewed based on the microscopy, culture, and sensitivity results of the aspirate. Nasal packs were usually removed after 72 h. A few modifications such as irrigating the septal cavity with 0.9% saline in septal abscess or use of a tampon for nasal packing were made as the situation demanded.
The follow-up duration (based on the last record) was calculated, and the outcome and complications of the septal collections were noted.
Data generated were presented in a general descriptive format while comparative analyses of clinical factors associated with development of complications used SPSS version 21.0 (Chicago, IL, USA). Categorical variables were compared using the chi-square test. Normality of continuous variables was explored using the Shapiro–Wilk test, and comparative analyses used Student’s t-test. The results were presented in tabular format with p<0.05 considered statistically significant.

 

Results

Thirty-one patients were managed for nasal septal collection during the study period, and 24 case records with complete information were retrieved. There were 16 male and 8female patients, male: female ratio = 2:1. The ages ranged from 13 to 62 years, and the highest proportion of patients were in the 21–40 years age group. Age group distribution according to sex of the patients revealed no females in the <20 years age group, male preponderance was observed in other age groups (21–40 and 41–60 years), up to the 61 years and above group that had one male and one female. The mean age was 40.1±13.1 years. Patients presented with varying complaints: 62.5% presented with the main complaint of nasal obstruction or blockage, and 29.2% with nasal swelling. Two-thirds (66.7%) of the patients had a history of nasal trauma before developing the collections while there was no obvious etiology in five (20.8%) patients. All patients presented between 2 and 13 days from the onset of symptoms/predisposing factors, with a median of 4 days. Three-quarters of the patients had no co-morbid disease with the nasal septal collections, while three (12.5%) had uncontrolled diabetes.
All patients had the septal collections incised and drained. The waiting time of the patients before the procedure ranged from 1 to 7 h (median 4). All patients had aspirates of the collection sent for microscopy, culture, and sensitivity. Seventeen (70.8%) patients had documented aspirate microbiological results, with seven (41.2%) reporting the growth of microorganisms. The organisms cultured were Staphylococcus aureus in five patients and Klebsiella pneumonia and Streptococcus pneumonia in one patient each.
The final diagnosis of the patients was septal hematoma in 15 (62.5%) and abscess in 9(37.5%). Follow-up was for a minimum of 6 months; the range was 6–15 (median 9) months. Five patients (20.8%) developed complications including nasal deformity in three patients, facio-orbital cellulitis in one patient, and intracranial infection in one patient.
Clinical parameters were compared between patients who did not have and those who had complications, to explore the factors associated with the complications (Table 1). In the comparative analyses, any clinical factor wi