Injury Extra (2004) 35, 12

CASE REPORT

Nasal septal haematoma with abscess: an unusual

complication of nasal injury
Menachem Gross*, Ron Eliashar
Department of Otolaryngology/Head & Neck Surgery, Hadassah University Hospital,
Jerusalem 91120, Israel
Accepted 10 November 2003

Case history

Conclusion

A 32-year-old woman appeared at the Ear, Nose,

and Throat Out-Patient Clinic with a 5-day history of
nasal swelling, bluish discoloration of the skin on
the nasal bridge, and increasing nasal pain, since
she struck her nose after an episode of syncope. She
also complained of bilateral nasal congestion and
obstruction.
Initially, at the time of injury, the patient was
evaluated at the Emergency Department and was
discharged. On physical examination, her nose was
swollen and tender with haematoma on the skin of
the nasal bridge. Anterior rhinoscopy revealed
bilateral dull purple swelling and tenderness of
the nasal septum, that bulged into the nasal cavity
and narrowed both nasal cavities. The clinical
impression was nasal septal abscess. Computer
tomography (CT) of the nose showed a displaced
fracture of the nasal bone (Fig. 1) and a swollen
nasal septum with hypodensic area surrounded by a
rim enhancement that is compatible with haematoma and abscess (Fig. 2). The patient underwent
bilateral incision, drainage and suction of blood
and pus from the nasal septal abscess. Anterior
nasal packing was inserted for 72 h and intravenous
amoxicillin and clavulanic acid was initiated. Follow-up at hospitalisation did not reveal recurrent
collection.

Minor and major traumas to the nose are frequent

injuries that may cause injury to the nasal septum.
Nasal septal abscess resulting from nasal trauma
is an uncommon complication of nasal trauma.1
Nasal septal abscess results from a collection of
purulent material between the cartilaginous or
bony nasal septum and its normally applied mucoperichondrium or mucoperiosteum. Nasal septal
abscess resulting from trauma usually develops in
a pre-existing septal haematoma. Direct injury to

*Corresponding author. Tel.: 972-2-6776469;

fax: 972-2-6468800.
E-mail address: drgrossm@hotmail.com (M. Gross).

Figure 1 Axial CT scan of the nose showing displaced

fracture of the nasal bone (arrow).

15723461 2003 Elsevier Ltd. Open access under the Elsevier OA license.
doi:10.1016/j.injury.2003.11.007

M. Gross, R. Eliashar

Figure 2 Axial (a) and coronal (b) CT scan of the nose demonstrating nasal septum haematoma and abscess (arrows).

the nose causes tearing of blood vessels in the

mucoperichondrium. Blood then collects between
the mucoperichondrium and the septal cartilage,
forming septal haematoma. The haematomas
separating the mucoperichondrium from the septal
cartilage deprive the cartilage of its blood supply.
Ischaemia and pressure from the haematoma lead
to necrosis and cartilage destruction. This provides
an ideal environment for bacterial colonisation and
subsequent abscess formation. A unilateral abscess
often becomes bilateral as the cartilage dissolves
rapidly. The most common organism cultured from
nasal sepal abscess is Staphylococcus aureus.3 Other
organisms such as Streptococcus species, Hemophilus infulenza, anaerobes, and coliforms are less
frequently isolated.1,3
Nasal septal abscess arises after nasal trauma.
Other rare causes for such condition are nasal surgery, furuncles of nasal vestibule, sinusitis, dental
infection. It may also occur spontaneously mainly in
an immunocompromised patient.2,3
The time interval between the nasal injury and
the presenting symptoms is 57 days. The most
common symptoms of nasal septal haematoma
and abscess are nasal obstruction and nasal congestion. Other complaints are nasal pain, swelling,
erythema over the nasal skin, headache, fever,
and malaise. Physical examination reveals a tender,
erythematous, and swollen nasal bridge. Anterior
rhinoscopy typically demonstrates tenderness and
fluctuation by palpation of unilateral or bilateral
swelling of the nasal septum that narrows the nasal

cavity. Aspiration by puncture of the swollen nasal

septum will reveal purulent material.
A patient with septal haematoma and abscess
should be referred immediately to otorhinolaryngologist for surgical treatment. Incision and complete drainage of the collection with bilateral nasal
packing is the initial treatment. Systemic antibiotics based on culture and sensitivity results are
continued for about 2 weeks. The nasal packing
is recommended for 4872 h to prevent re-accumulation. After removal of the nasal packing, close
observation is needed to detect recollection which
usually occurs within 3 days after nasal packing
removal.
Delayed diagnosis and management of nasal septal abscess results in a compromised vascular supply
to the cartilaginous nasal septum and suddle nose
deformity as a final cosmetic complication. Other
serious complications are sepsis, meningitis, orbital
cellulitis, cavernous sinus thrombosis, and intracranial abscess.1

References
1. Erlich A. Nasal septal abscess: an unusual complication of
nasal trauma. Am J Emerg Med 1993;11:14950.
2. Henry K, Sullivan C, Crossley K. Nasal septal abscess due to
Staphylococcus aureus in a patient with AIDS. Rev Infect Dis
1988;10:42830.
3. Matsuba HM, Thawley SE. Nasal septal abscess: unusual causes,
complications, treatment and sequelae. Ann Plast Surg 1986;
16:1616.