nasal septal abscess in children - copy pdf
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abses septum nasi pada anakTRANSCRIPT
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NASAL SEPTAL ABSCESS IN CHILDREN
By
Putu Vira Rikakaya
Scientific Advisor
dr. Luh Made Ratnawati, Sp.THT-KL
2014
Case report
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INTRODUCTION
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Introduction
Nasal Septal Abscess (NSA) defined as a collection of pus between the cartilaginous or bony nasal septum and its overlying mucoperichondrium or mucoperiosteum
Predisposing factors : nasal trauma (75% of cases) by accident, fall, fighting, nose picking ; nasal surgery, sinusitis, furuncle of nasal vestibule, dental infection, foreign body and immune deficiency
One of the rhinology emergency septalperforation destruction of the cartilaginous saddle nose but also intracranial infections prompt diagnosis and treatment is very important
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Introduction
Nasal septal abscess is a rare entity, it is not frequently and has been documented rarely in the literature. Based on data at ENT Policlinic Sanglah Denpasar General Hospital from 2010-2013 was only 3 cases
A case of nasal septal abscess on a child, male 9 years old, that treated with incision and drainage, systemic antibiotics with a good results has been reported in Sanglah hospital
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Incidence and Distribution
Uncommon condition
Major medical centers < 10 cases per year
116 pediatric cases over a period of 6 years in Russia ; 43 cases from Toronto, Canada 8 years ; 16 cases in USA 10 years
Male > female = 2 : 1
Nasal trauma most common during childhood
More common in children than in adults
16-35 years old 43% ; < 15 y.o and > 35 y.o 28,5%
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Anatomy
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Anatomy
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Predisposing factors and Etiology
Accident, falls, fights, nose picking, injury by NGT
Most common up to 75% of cases
Nasal trauma
Ethmoiditis, sphenoiditis, furunculosis
Infected impacted incisors teeth
Dental or sinonasalinfections
Immunocompromised or immunocompetent patients
Spontaneous
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Pathophysiology
Nasal trauma
Tear the sub mucosal vessels
Bleeding between septum and
mucoperichondrium
Hematoma
Cartilage perfusion , cartilage pressure ,
ideal medium for growth of bacteria
NSA formation bilateral or unilateral
Cartilage ischemia and avascular
necrosis
Cartilage damage
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Pathophysiology
Necrosis intensified by collagenases that are produced by the insulting bacteria S.aureus, H.influenzae, Streptococcus strain
Activities of Cathepsin D enzyme degrading intracellular acidic enzyme naturally and distributed in the chondrocytes cartilage enhance cartilage degradation
Bilateral is more common than unilateral
In sinusitis/dental infections direct spread under periosteum/through bone fissures/hematogenous venous (thrombophlebitis)
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Microbiology
Most common bacteria aerobic Staphylococcus aureus 70 %
Streptococcus pneumoniae, Streptococcus mileri, Streptococcus viridans, Staphylococcus epidermidis, Haemophilus influenzae, Streptococcus -hemolyticus group A, Klebsiellapneumoniae, Enterobacteriaceae and anaerobic bacteria
Fungal infection rare
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Diagnosis
History of nasal trauma
Nasal obstruction, pain, headache, malaise, fever
Anamnesis
Cherry like swelling of nasal septum
Tenderness and fluctuation
Physical examination
Needle aspiration pus
Culture and sensitivity test
Laboratorium leukocytosis
Additional examination
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Diagnosis
Clinically difficult to distinguish between hematoma and NSA
NSA larger, more painful, the mucosa may be inflamed, covered with exudates, accompanied by fever and leukocytosis
NSA can be unilateral or bilateral bilateral is more common
NSA usually involves the anterior cartilaginous nasal septum, but it can be at posterior of the nasal septum
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Treatment
Incision and drainage
Various incision : Killians transverse one
or L shape fluctuation or near with
nasal floor
Bilateral non opposing incision if cartilage is intact and pus
couldnt be drained
Empirical systemic broad spectrum
antibiotics
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Treatment
Systemic antibiotics directed at the most common pathogens 3-5 days
Some clinicians advised the addition Gentamycin to cover gram(-) bacteria
Metronidazole recommended when the infection is dental in origin and anaerobic bacteria is expected
After culture is finished antibiotics based on culture and sensitivity
The antibiotics continued orally for 7-10 days following discharge
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Complications
NSA complication
Local
-deviated nasalseptum
-saddle nose-nasal valve
collapse-sinusitis
-facial celullitis/abscess
-nasal vestibulitis
Systemic
-bacteremia-sepsis
Orbital
-orbital cellulitis-sub periosteal
abscess-orbital abscess
Cranial-cavernous sinus
thrombosis-epidural abscess
-meningitis-intracranial abscess
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Case report
Patient AS, male, children with 9 years old, class 3 of elementary school, from Banyuwangi came to ENT clinic on April 16 2013 with main complaint mass on both nasal cavity that just noticed 5 days before
Initially the size was as small as pimple that enlarge gradually
Tenderness and nasal obstruction
History of nose picking (+), cough and runny nose (-)
Fever (+), trauma or accident (-), dental infection (-)
No history of treatment
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Case report
ENT examination :
Ear and throat : within normal
Nose :both of nasal cavity were narrow
Bilateral nasal septalswelling, round, erythema (+), soft, tenderness and fluctuation
Aspirate pus 2 cc culture and sensitivity test
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Case report
Diagnosis : nasal septalabscess
Incision and drainage with local anesthesia
Vertical incision on the left side pus + blood
Evaluation on the right nasal cavity has defleted
Drain and nose packed
Patient then admitted for hospitalization Ampicillin 4x500 mg (iv), metronidazole 3x250 mg (iv), paracetamolforte syrup 3xcth1
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Case report
WBC 15,2 g/dl ; Hb 11,3 g/dl Plt 506,5 g/dl ; GDS 101 mg/dl
April 16 2013
Nose pack removed Mucosa hyperemi, swelling (+), drainage pus (+)
Drain and nose pack was reinserted
April 18 2013
Nose pack removed Mucosa is minimal hyperemi and swelling,
fluctuation (-), drainage pus (-)
April 20 2013
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Case report
Minimal hyperemi, swelling (-), septal perforation sign (-), the incision has closed
Culture Staphylococcus aureus 1st
generation of cephalosporin Patient was discharge Cefadroxil forte syrup
2xcth1 and paracetamol forte syrup 3xcth1
April 21 2013
Patient controlled pain (-), nasal cavity was wide, hyperemi (-), septal perforation (-)
Antibiotics continued for 7 days
April 23 2013
Patient controlled no complaintApril 30
2013
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Case report
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DISCUSSION
Literature CaseNSA is uncommon condition Male , 9 years old
16-35 years old ; < 15 years old ; > 35 yearsold
Male > female
Diagnosis : anamnesis, physical and additional examination
Same
Anamnesis : history of nasal trauma, nose picking, obstruction, pain, headache and fever
Physical examination : cherry like swelling,hyperemi, soft, fluctuation, tenderness
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Discussion
Literature CaseUsually involves the anterior septum and more common bilateral
Same
Additional examination : aspiration pus culture and sensitivity test
Same
Laboratorium : leukocytosis Same, leukocyte 15,2 g/dl
Treatment should be directed incision and drainage abscess local or general anesthesia
Same with local anesthesia
Incision : Killians transverse one or L shape or near the nasal floor
Vertical incision
Incision is made at the one side drain and nose packed
Same
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Discussion
Literature CaseEmpirical systemic antibiotics advised to start with broad spectrum that covers the most pathogens Staphylococcus aureus Penicillin
Ampicillin and metronidazole
Antibiotics treatment based on culture result
Staphylococcus aureus 1st generation of cephalosporin Cefadroxil
Most common complications nasal septal perforation and saddle nose
Adequate medical management prevent such complications
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CONCLUSSION
A case of nasal septal abscess on a child, male 9 years old, that treated with incision and drainage, systemic antibiotics with a good results has been reported
NSA is uncommon condition
With symptom nasal septal swelling, hyperemi, fluctuation and tenderness
NSA rhinology emergency prompt diagnosis incision and drainage directed adequate systemic antibiotic prevent complications
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Thank you