In patients presenting several days from a related trauma, distinguishing uncomplicated septal hematoma from nasal septal abscess can be very difficult—though nasal septal abscesses tend to be larger and more painful. In addition, there may be inflammation of the overlying mucosa, occasionally with exudates. In untreated cases, infection can extend into the cavernous sinus causing intracranial infections or cavernous sinus thrombosis. The most common complication of septal abscess is cartilage necrosis that can result in nasal structural collapse and “saddle-nose” deformity. Complications, including meningitis, can develop quickly (ie, within 3 to 4 days).6
The structural complications associated with septal abscess result from the avascular nature of the septal cartilage, which receives blood from the adherent mucoperichondrium. Hematoma and abscess can expand and obstruct the blood vessels that supply the nasal cartilage. Pressure of the hematoma on the septum causes progressive avascular necrosis.6
Patients with confirmed nasal septal abscess should obtain otolaryngology or OMFS consultation in the ED. Due to the high risk of complications and need for follow up, immediate drainage should also be directed by otolaryngology or OMFS. All patients should be discharged on oral broad-spectrum antibiotics, with a referral to an otolaryngologist or OMFS within 24 hours for evaluation and possible removal of nasal packs.7
Dr Yusuf is an academic chief resident, John Peter Smith Emergency Medicine Residency Program, Fort Worth, Texas. Dr Kirk is associate residency director and ultrasound director, department of emergency medicine, John Peter Smith Health System, Fort Worth, Texas.