Management and Complications of Nasal Septal Collections
Olusola Ayodele Sogebi, Emmanuel Abayomi Oyewole
ENT Unit, Department of Surgery, Faculty of Clinical Sciences, OACHS, Sagamu, Nigeria.
Correspondences to: Dr Olusola A Sogebi, E-mail:
Background: Nasal septum collections (hematoma and abscess) can lead to structural and functional abnormalities. Objectives: To assess the clinical characteristics, management and complications of nasal septal collections, and document factors associated with its complications. Material and Methods: Retrospective study of patients managed for nasal septal collections. Socio-demographic and clinical information were recorded. Main investigations and results were noted. Follow-up and complications of septal collections were documented. Clinical factors associated with the complications were explored. Results: Twenty-four patients records were studied; M: F=2:1, mean age 40.1 ± 13.1years. A sum total of 62.5% presented with complaints of nasal obstruction, 66.7% had antecedent nasal trauma while presentation was from 2 to 13 days. Twenty-five percent of the patients had co-morbid disease(s). All the patients had incision and drainage of the septal collection within 1-7 hours. A total of 41.2% of the aspirated collections cultured microorganisms, 20.8% of patients 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. One-fifth developed complications. Complications were associated with presence of culture positive abscess, increased age and duration of septal collection.
Keywords: Nasal trauma, septal hematoma, septal abscess, complications
Ann Afr Surg. ****; **(*):***
Conflicts of Interest: None
© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.
Nasal septal collection is an accumulation of fluid between the cartilage or the bony septum and the overlying mucoperichondrium or mucoperiostium (1). The fluid is either blood (hematoma) or pus (abscess). Septal collections are generally not common; prevalence of nasal septal hematoma and abscess in children was reported as 0.9% (2). Many publications on septal collections had been on hematoma while studies that combined septal collections had reported comparatively more of hematoma than abscess (3, 4). Oftentimes an abscess results from a secondarily infected 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 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 like the paranasal sinuses, oral cavity or the 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 abscess requires prompt diagnosis, adequate surgical drainage, and parenteral administration of antibiotics (1). However, complications may arise when the accumulation had 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 also include relief of nasal obstruction, maintenance of the nasal bridge architecture and prevention of intracranial complication.
Medical literature on septal collections had been more of case reports about strange, or unusual causes of septal collections. The characteristics and profile of septal collections had been less reported. Factors associated with complications had rarely been sought or reported. This study aims to assess the characteristics, management and complications of nasal septal collections, and also explore clinical factors that may be associated with the complications. This will suggest the factors to explore in cases of septal collections in order to accomplish the best outcome possible.
Materials and Methods
This is 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 eight years 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. Patients excluded were those who had associated intracranial injury or infection and referred to other medical centers for primary management. Data of patients that had missing important information were also excluded.
Case note records of the patients were retrieved from the clinic, emergency center and ward admission registers to obtain clinical information. Information extracted included the socio-demographic parameters like 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 results of microscopy culture and sensitivity of the aspirate of the septal collection was recorded.
The protocol employed was the standard procedure for surgical drainage of nasal septal hematoma and abscess described by Kass and Ferguson (12). Topical administration of a mixture of 2% Lidocaine for topical anesthesia and Oxymetazoline solution (for constriction of the nasal turbinates) for clearer vision. A J-shaped incision was made on the mucosa of bulgy side of the septal collection and deepened it into the cavity. Direct aspiration of the fluid with a syringe was done collect the sample for microbiological analyses. Suction drainage with a machine was thereafter applied for complete evacuation of the cavity. Both nasal cavities were packed firmly with lubricated antibiotic-laden gauze to prevent or reduce the tendency of re-accumulation of the fluid. We routinely administered parenteral antibiotics during, and continued for a minimum of 24 hours 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 hours. Few modifications like irrigation of the septal cavity with 0.9% Saline in septal abscess or use of tampon for nasal packing were made as the situation demanded.
The follow-up duration (based on the last record) was calculated, the outcome and complications of the septal collections were noted.
Data generated was presented in general descriptive format while comparative analyses of clinical factors associated with development of complications were performed using the statistical package SPSS version 21.0 (Chicago, IL, USA). Categorical variables were compared with the Chi-square test. Normality of continuous variables was explored using Shapiro-Wilk test, and comparative analyses performed with Student’s t-test. The results were presented in tabular format with the p value <0.05 considered as statistically significant.
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 males and 8 female patients, M: F=2:1. The age ranged from 13 to 62 years, while the age group of 21-40 years had the highest proportion. The age group distribution according to Sex of the patients revealed no female in the group <20 years in age, male preponderance was observed in other age groups (21-40, and 41-60 years), until the group 61 years and above, where there was one male and one female. The mean age was 40.1 ± 13.1years. Presenting complaints of the patients varied, however 62.5% presented with main complaints of nasal obstruction or blockage, and 29.2% presented with nasal swelling. Two thirds (66.7%) of the patients had history of nasal trauma prior to development of the collections while there was no obvious etiology in 5 (20.8%) patients. All the patients presented between 2 and 13 days from the onset of symptoms/ predisposing factors, with median of 4 days. Three quarter of the patients (75.0%) had no co-morbid disease with the nasal septal collections, while 3(12.5%) had uncontrolled diabetes.
All the patients had incision and drainage of the septal collections. The waiting time of the patients before the procedure ranged from 1-7 (median 4) hours. All patients had aspiration of the collection sent from microscopy, culture and sensitivity. Seventeen (70.8%) among the patients had documented aspirate microbiological results, with 7 (41.2%) reporting growth of microorganisms. The organisms cultured were Staphylococcus aureus in 5 patients, 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%) patients. Follow-up was for a minimum of six months; range was 6 to 15 (median 9) months. Five (20.8%) developed complications including nasal deformity in 3 patients, facio-orbital cellulitis in one patient and intracranial infection in another patient.
The clinical parameters were compared between patients who did not have and those who had complications, to explore the factors associated with the complications in Table 1. In the comparative analyses, any clinical factor with p value of <0.05 (statistically-significant) was associated with complications of septal collection. Increased age especially above 45 years, presence of a co-morbidity, longer duration before presentation, presence of an abscess, and culture positive aspirate, were all significantly associated with complications of nasal septal collections.
The nose is the most prominent facial structure. A small percentage of patients with nasal trauma will develop septal hematoma (13). Nasal septal collections can thus be described as an uncommon sequalae of nasal trauma. While some studies had reported nasal septal collections to be more common in children (4), this study found almost a total adult occurrence of 95.8%. Cheng et al, had also reported a preponderance of adults in a study on septal abscess (11). Septal collections were twice as common in males compared with females in this study, similar to what was reported in other studies (3, 14). A previous study had however reported there was no sex preponderance with septal abscess (11).
The nasal bone is the most commonly fractured bone in the human body (15). Thus, nasal trauma is by far the most common cause of septal collections, as estimated that nearly 75% of cases were secondary to trauma (5). Two thirds (66.7%) of the patients evaluated in this study had antecedent nasal trauma which predisposed them to septal hematoma as seen in 62.5% of our patients. While common causes and mechanisms of nasal trauma had been mentioned, one of our patients had an unusual etiology of domestic violence in a gravid state. Since nasal trauma can sometimes lead to septal hematomas, any patient presenting with acute nasal obstruction after facial or nasal trauma should be suspect for septal hematoma (16). Sometimes hematoma formation may be delayed after a nasal trauma, thus re-evaluation for septal hematoma 48 to 72hours after nasal trauma is recommended (17).
Septal abscesses are rarely seen, as they are often complications of hematoma from secondary infection (5). One major predisposition to abscess formation is delayed or prolonged accumulation of blood in the nasal septum. Clinicians have advocated early drainage of septal collections as further delay increases the probability of abscess formation and tendency to develop complications (18). The median duration of presentation of our patients was four days, and the propensity to develop abscess was theoretically high. The major presenting symptoms of nasal obstruction and blockage found in this study were similar to those reported by other authors. While this finding is almost pathognomonic of a septal collection, septal tumor or other forms of chronic granulomatous infections can present in a similar manner (19, 20).
Diagnosis of nasal septal collection is largely on clinical evaluation as investigation may be limited to aspiration of the collection for bacteriological evaluation. The main treatment was incision and drainage of the septal collection. Surgical drainage should be performed as soon as possible because delay may affect the outcome of the procedure (16). The median duration of waiting before drainage of the septal collections in this study was 4 hours.
All the septal aspirated fluids were subjected to bacteriological examination; although results could not be found in seven patients, seven others had culture positive results. The main microorganism cultured was indigenous skin bacteria Staphylococcus aureus, in 71.4% of the culture positive specimens. Other studies (6, 21) also reported similar findings. Less frequently, some species of Streptococcus, Klebsiella and occasionally anaerobes had been cultured (6, 11). We did not get any positive culture for anaerobes despite our request. Similarly, there was no culture of Methicillin-resistant Staphylococcus aureus (MRSA), although this was not specifically requested for. The expanding spectrum of severe infections caused by MRSA had been noted (1, 22), it has thus been suggested that patients who are at increased risk for MRSA colonization should be administered antibiotics against MRSA initially (11). MRSA is also associated with severe complications of nasal collections. Toxic shock syndrome is another life-threatening systemic condition associated with Staphylococcus infection (23), but it was not found in this study.
The complication rate of 20.8% reported was relatively high. All the patients that developed complications had septal abscess as their final diagnoses. The main complication was nasal bridge deformity in 33.3%, while one patient each (11.1%) among the nine patients with septal abscess developed facio-orbital cellulitis and intracranial infection. This is similar to the 33.3% of cases of septal abscess that developed saddle nose deformity reported in Taiwan (11). Factors predisposing to development of saddle nose deformity include a septal perforation at surgery, resorption of the septal cartilage from loss of vascular supply, infection, or a combination of these (24). Our patients who had nasal bridge deformities were co-managed with the plastic surgeon for septoplasty. One patient developed a facio-orbital cellulitis and was treated with parenteral antibiotics in addition to other supportive treatments. A patient developed an intracranial infection thirteen days after the initial drainage of the septal abscess, and was referred to a neurosurgical facility.
Exploration of factors associated with development of complications provided insights for management considerations. Notably, increased age may be linked with presence of co-morbidities. Two of our patients were diagnosed of diabetes after the incision and drainage of the septal collections had been performed. Uncontrolled diabetes has been noted as an immuno-compromised condition that may predispose patients to development of spontaneous septal abscess (11). Thus, it is imperative that patients with septal abscess should, among other investigations, have their blood sugar profile checked. Retroviral screening should also be performed on such patients for the same reason. One of our patients was retroviral positive and was managed accordingly.
Delayed presentation is associated with complications because irreversible damage to the septum with a subsequent septal perforation may occur within 3 to 4 days if it is devoid of its blood supply (24). Some of our patients were already at risk of development of complications by the time they presented in the hospital. Septal abscess especially those that were culture positive had active bacterial infection within the nose, which could easily drain through the veins into the face and intracranially. Consequently, any diagnoses of a septal abscess should also be treated aggressively with appropriate parenteral antibiotics for a reasonable period of time. Although drainage of nasal septal abscess with concomitant antibiotic administration prevent the early complications, it is not enough guarantee for satisfactory functional and cosmetic effect in the future (2).
Satisfactory surgical outcome is guaranteed if there are no late complications, thus patients must be followed up for a reasonable period of time. Complications like saddle nose deformity may not be recognizable until a few months after the nasal and facial swellings have completely subsided. We followed our patients up for a minimum of six months after the septal collections had been drained. Our standard follow-up protocol emphasized the possibility of recurrence or complications, and intimated patients on the necessity and importance of keeping follow-up appointments. The home and telephone contacts of the patients were collected, and the surgeon’s number given to the patients for communication. With this we were able to achieve a reasonable follow-up course.
Despite our management protocol, some limitations were obvious in this study. The retrospective nature of the study had inherent tendency for loss and missing information or data. The fact that patients’ clinical case records were assessed during the study made it difficult to perform an objective (rather than subjective) functional assessment of nasal performance. These limitations could however not invalidate the findings of the study.
Nasal septal collections were often hematoma, and more common in adult males with antecedent nasal trauma. All patients were managed by surgical drainage and antibiotics administration. One-fifth developed complications especially nasal bridge deformity. Factors associated with complications were increased age, presence of co-morbidity, longer duration of septal collection before drainage, and septal abscess particularly those that were culture positive
The authors wish to acknowledge the efforts of Dr Taofeeq Mabifah for assisting in retrieving some of the case note records of patients that were studied.
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