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Septal Abscess | Diseases of Nasal Septum | Nose | Otorhinolaryngology (Ear Nose Throat / E.N.T) | 4th Year (Fourth Year) | MBBS | Detailed Free Notes

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SEPTAL ABSCESS — PART 1

Diseases of Nasal Septum

MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

(Delivered in pure ENT style, Option-3 ultra-expanded, 3500+ words total over multiple parts, bullet-point structure, no intro/no outro, credit line inserted mid-topic only.)

1. DEFINITION

  • Septal abscess = collection of pus between the septal cartilage/bone and its mucoperichondrium/mucoperiosteum, resulting from infection of a septal haematoma or direct spread of bacteria.
  • URGENT ENT EMERGENCY, because:
    • Pus lifts perichondrium → chondritis → cartilage necrosis
    • Rapid spread to sinuses, orbit, cavernous sinus, or brain
    • High risk of saddle nose deformity
    • High morbidity in children

2. PATHOGENESIS

2.1 Initial Event

  • Trauma causes septal haematoma formation.
  • Blood accumulates in subperichondrial pocket.

2.2 Secondary Infection

  • Stagnant blood acts as ideal medium for bacterial growth.
  • Mucoperichondrium becomes inflamed.
  • Pus replaces blood → abscess.

2.3 Cartilage Destruction

  • Septal cartilage depends entirely on diffusion of nutrients from mucoperichondrium.
  • With pus lifting the perichondrium:
    • Cartilage becomes ischemic
    • Chondrocyte death occurs rapidly (24–48 hours)
    • Necrotic cartilage may be completely lost

2.4 Structural Collapse

  • Loss of quadrilateral cartilage →
    • Saddle nose deformity (classic, irreversible)
    • Nasal valve collapse
    • Persistent obstruction
    • Cosmetic disfigurement

2.5 Spread of Infection

  • Infection spreads through:
    • Emissary veins
    • Lymphatics
  • May lead to:
    • Facial cellulitis
    • Orbital cellulitis
    • Cavernous sinus thrombosis
    • Meningitis
    • Brain abscess

3. ETIOLOGY

3.1 Most Common Cause

  • Infected septal haematoma (post-traumatic)

3.2 Other Causes

  • Spontaneous in immunocompromised patients
  • Nasal furunculosis
  • Dental infections (via venous plexus)
  • Nasal surgery (septoplasty, SMR)
  • Upper respiratory tract infection
  • Foreign body trauma in children

3.3 Organisms (High-Yield for Exams)

  • Staphylococcus aureus (most common)
  • Streptococcus species
  • Haemophilus influenzae (children)
  • Gram-negative organisms (diabetics)
  • Anaerobes (rare, in dental spread)

4. RISK FACTORS

  • Untreated septal haematoma
  • Recurrent nasal trauma
  • Poorly drained prior surgery
  • Diabetes mellitus
  • HIV/AIDS
  • Chronic steroid therapy
  • Pediatric age group (loose mucoperichondrial attachments)

5. CLINICAL FEATURES

5.1 Symptoms

  • Severe nasal obstruction (often bilateral)
  • Throbbing localized pain
  • Fever
  • Headache
  • Nasal discharge (purulent)
  • Change in nasal shape
  • Malaise and irritability (especially in children)
  • Mouth breathing
  • Snoring, sleep difficulty
  • Occasionally, foul smell

5.2 Signs

A. Anterior Rhinoscopy

  • Bulging, red, tense swelling on septum
  • Bilateral swelling causing:
    • Narrow slit-like airway
    • Severe obstruction
  • Swelling is:
    • Fluctuant
    • Tender
    • Does NOT reduce with decongestant spray

B. Palpation

  • Severe tenderness on probing
  • Ballotability in bilateral swelling

C. General Examination

  • Fever
  • Toxic appearance
  • Lymphadenopathy may be present

D. Septal Abscess vs Haematoma

Feature Haematoma Abscess
Pain Mild/moderate Severe, throbbing
Fever Absent/low High
Colour Bluish/red Red, inflamed
Systemic signs Minimal Prominent
Pus Absent Present

6. INVESTIGATIONS

6.1 Clinical Diagnosis

  • MOST IMPORTANT
  • Made by anterior rhinoscopy
  • Do not delay treatment for investigation

6.2 Needle Aspiration

  • Pus aspiration confirms diagnosis
  • Helps differentiate haematoma vs abscess

6.3 Culture & Sensitivity

  • Mandatory after drainage
  • Helps guide antibiotic therapy

6.4 Laboratory Tests

  • CBC
  • CRP
  • ESR
  • Blood sugar (in diabetic patients)

6.5 Radiology (Only if Complications Suspected)

  • CT PNS → orbital extension, sinusitis
  • MRI → cavernous sinus thrombosis, intracranial involvement

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

7. MANAGEMENT (LIFE-SAVING)

7.1 Principles

  • Immediate surgical drainage
  • Antibiotics
  • Prevent recurrence
  • Reconstruct if cartilage lost

7.2 Surgical Drainage – Step-by-Step

1. Anesthesia

  • Adults: Local anesthesia
  • Children: General anesthesia preferred

2. Incision

  • Horizontal incision over most fluctuant part
  • Bilateral swelling → drain both sides separately

3. Evacuation

  • Suction all pus
  • Break loculations with a probe
  • Irrigate cavity with:
    • Sterile saline
    • Antibiotic solution (optional)

4. Culture

  • Send pus for C/S

5. Counter Opening

  • A small drainage opening may be made on opposite side to allow free drainage

6. Packing

  • Soft nasal packing
  • Ribbon gauze or Merocel
  • Apply pressure to prevent re-accumulation

7. Quilting Sutures

  • Reduce dead space
  • Prevent hematoma/abscess recurrence

8. ANTIBIOTIC THERAPY

8.1 Empirical (Start Immediately)

  • IV amoxicillin-clavulanate
    OR
  • IV ceftriaxone + metronidazole
    OR
  • IV clindamycin (if penicillin allergy)

8.2 Switch to targeted therapy after C/S

8.3 Duration

  • 7–10 days in adults
  • 10–14 days in children

9. POSTOPERATIVE CARE

  • Pain control (NSAIDs)
  • Nasal decongestants (for mucosal edema)
  • Saline irrigation after removal of packs
  • Avoid nose blowing for at least 1 week
  • Monitor for:
    • Re-accumulation
    • Persistent fever
    • External deformity
    • Septal perforation

10. COMPLICATIONS OF SEPTAL ABSCESS

A. Local Complications

  • Septal cartilage necrosis
  • Saddle nose deformity
  • Septal perforation
  • Persistent DNS
  • Synechiae formation

B. Regional Complications

  • Facial cellulitis
  • Orbital cellulitis
  • Cavernous sinus thrombosis
  • Osteomyelitis of nasal bones

C. Intracranial Complications

  • Meningitis
  • Brain abscess
  • Dural sinus thrombosis

D. Pediatric Complications

  • Midfacial growth retardation
  • Dental arch deformities
  • Permanent nasal collapse

11. HISTOPATHOLOGY & MICROSCOPIC CHANGES

11.1 Early Stage (Inflammatory Phase)

  • Subperichondrial space filled with:

    • Neutrophils

    • Proteinaceous exudate

    • Fibrin strands

  • Mucoperichondrium:

    • Edematous

    • Hyperemic

    • Beginning separation from cartilage

  • Cartilage:

    • Viable initially

    • Early ischemic changes at periphery

11.2 Established Abscess

  • Dense polymorphonuclear infiltrate

  • Liquefaction necrosis replaces hematoma

  • Bacterial colonies visible on Gram stain

  • Perichondrium:

    • Thickened

    • Loss of adherence

  • Cartilage:

    • Chondrocyte death

    • Matrix breakdown

11.3 Late Stage (Destructive Phase)

  • Complete cartilage necrosis

  • Absence of chondrocytes

  • Fibrosis replaces necrotic areas

  • Potential fistula formation

  • Predisposition to:

    • Septal perforation

    • Dorsal collapse

12. PEDIATRIC SEPTAL ABSCESS (EXAM-CRITICAL)

12.1 Why Children Are High-Risk

  • Septal cartilage is a primary facial growth center

  • Faster progression from hematoma → abscess

  • Poor symptom localization and delayed reporting

  • Loose mucoperichondrial attachment

12.2 Pediatric Clinical Clues

  • Fever with nasal obstruction after minor trauma

  • Refusal to feed (obligate nasal breathing in infants)

  • Irritability, excessive crying

  • Bilateral nasal blockage with minimal external signs

12.3 Pediatric Management Differences

  • General anesthesia mandatory

  • Wider drainage incision

  • More aggressive antibiotic coverage

  • Longer inpatient observation

  • Scheduled long-term follow-up to monitor:

    • Midface growth

    • Dorsal nasal development

    • Dental arch alignment

13. DIFFERENTIAL DIAGNOSIS (DETAILED)

13.1 Septal Abscess vs Septal Hematoma

  • Abscess:

    • Fever present

    • Severe throbbing pain

    • Pus on aspiration

  • Hematoma:

    • Afebrile or low-grade fever

    • Mild pain

    • Blood on aspiration

13.2 Septal Abscess vs Acute Rhinitis

  • Rhinitis:

    • Diffuse mucosal edema

    • Responds to decongestants

    • No fluctuant swelling

  • Abscess:

    • Localized septal bulge

    • No response to decongestants

13.3 Septal Abscess vs Septal Tumor

  • Tumor:

    • Firm, non-fluctuant

    • Progressive over weeks/months

    • May ulcerate

  • Abscess:

    • Acute onset

    • Tender, fluctuant

    • Systemic toxicity

14. EXTENDED MANAGEMENT PRINCIPLES

14.1 Key ENT Rules

  • Never delay drainage for imaging

  • Drain both sides if bilateral

  • Always send pus for culture & sensitivity

  • Combine surgery with systemic antibiotics

  • Prevent re-accumulation with quilting sutures

14.2 Drainage Technique — Refinements

  • Incision length sufficient to prevent early closure

  • Gentle suction to avoid mucosal tears

  • Copious irrigation until cavity walls are clean

  • Avoid excessive cautery (causes further necrosis)

15. ANTIBIOTIC STRATEGY (ADVANCED)

15.1 Empirical Coverage

  • Must cover:

    • Gram-positive cocci

    • Gram-negative bacilli (diabetics)

    • Anaerobes (suspected dental source)

15.2 Common Regimens

  • IV Amoxicillin-Clavulanate

  • IV Ceftriaxone + Metronidazole

  • IV Clindamycin (penicillin allergy)

  • Add Vancomycin if MRSA suspected

15.3 Duration

  • Uncomplicated: 7–10 days

  • Pediatric/severe: 10–14 days

  • Complicated (intracranial spread): ≥ 3 weeks

16. COMPLICATIONS — MECHANISMS & CLINICAL IMPACT

16.1 Saddle Nose Deformity

  • Mechanism:

    • Loss of dorsal septal cartilage

    • Collapse of nasal dorsum

  • Clinical impact:

    • Cosmetic disfigurement

    • Nasal valve collapse

    • Chronic obstruction

16.2 Septal Perforation

  • Mechanism:

    • Bilateral mucoperichondrial necrosis

  • Symptoms:

    • Whistling sound

    • Crusting

    • Recurrent epistaxis

16.3 Cavernous Sinus Thrombosis

  • Spread via angular and ophthalmic veins

  • Signs:

    • High fever

    • Proptosis

    • Ophthalmoplegia

  • High mortality without early treatment

16.4 Meningitis & Brain Abscess

  • Hematogenous spread

  • Presents with:

    • Neck rigidity

    • Altered sensorium

    • Severe headache

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

17. RECONSTRUCTIVE SURGERY AFTER SEPTAL ABSCESS

17.1 Timing

  • Acute phase: No reconstruction

  • Definitive reconstruction:

    • After infection resolution

    • Usually 3–6 months later

17.2 Reconstruction Options

  • Autologous cartilage grafts:

    • Septal (if residual)

    • Conchal

    • Costal (severe collapse)

  • Dorsal onlay grafts

  • Septorhinoplasty for combined functional + cosmetic correction

18. FOLLOW-UP & LONG-TERM MONITORING

18.1 Short-Term

  • Inspect septum after pack removal

  • Look for re-accumulation

  • Assess pain and fever resolution

18.2 Long-Term

  • Monitor nasal airflow

  • Assess dorsal support

  • Pediatric patients:

    • Growth monitoring till adolescence

19. HIGH-YIELD VIVA POINTS

  • Septal abscess is a surgical emergency

  • Most common cause: infected septal hematoma

  • Most common organism: Staphylococcus aureus

  • Most feared complication: saddle nose deformity

  • Management: Immediate drainage + IV antibiotics

  • Children require GA and long-term follow-up

20. CLINICAL CASE SCENARIOS

Case 1

Child with fever and bilateral nasal obstruction after nasal injury.

  • Diagnosis: Septal abscess

  • Management: Urgent drainage under GA + IV antibiotics

  • Complication if delayed: Midface growth disturbance

Case 2

Adult diabetic with painful septal swelling and fever.

  • Diagnosis: Septal abscess

  • Management: Drainage + broad-spectrum antibiotics

  • Watch for: Cavernous sinus thrombosis

21. MCQs (EXAM-ORIENTED)

  1. Most common organism in septal abscess:
    A. E. coli
    B. Streptococcus pneumoniae
    C. Staphylococcus aureus
    D. Pseudomonas
    Correct Answer: C

  2. Definitive treatment of septal abscess:
    A. Antibiotics alone
    B. Observation
    C. Incision and drainage
    D. Nasal decongestants
    Correct Answer: C

  3. Most common late deformity:
    A. DNS
    B. Septal perforation
    C. Saddle nose
    D. Turbinate hypertrophy
    Correct Answer: C

22. RADIOLOGICAL CORRELATION (ENT-PURE, EXAM-RELEVANT)

22.1 When Imaging Is Required

  • Imaging is NOT routine

  • Indicated only when:

    • Complications are suspected

    • Poor response to drainage + antibiotics

    • Orbital or intracranial extension suspected

    • Diabetic / immunocompromised patient

    • Associated facial trauma

22.2 CT Scan (PNS & Brain)

Findings In Septal Abscess

  • Hypodense or mixed density collection along septum

  • Bulging mucoperichondrium

  • Loss of normal septal contour

  • Possible cartilage destruction (indirect sign)

Associated Findings

  • Ethmoid sinusitis

  • Orbital cellulitis

  • Bone erosion (advanced cases)

CT Is Preferred Because

  • Fast

  • Widely available

  • Excellent bone detail

  • Detects complications early

22.3 MRI (Rare, Advanced Cases)

Indications

  • Cavernous sinus thrombosis

  • Intracranial spread

  • Brain abscess

MRI Findings

  • T1: Hypointense or mixed signal pus

  • T2: Hyperintense abscess cavity

  • Rim enhancement after contrast

  • Edema in adjacent structures

23. MICROBIOLOGY & ANTIBIOTIC RATIONALE

23.1 Why Culture Matters

  • Empirical antibiotics may fail

  • Increasing MRSA prevalence

  • Diabetics prone to gram-negative infection

23.2 Common Organisms Recap

  • Staphylococcus aureus (most common)

  • Streptococcus species

  • Haemophilus influenzae (children)

  • Gram-negative bacilli (diabetics)

  • Anaerobes (dental origin)

23.3 Antibiotic Failure — Causes

  • Delayed drainage

  • Inadequate incision

  • Poor penetration into abscess cavity

  • Resistant organism

  • Immunocompromised host

24. MEDICOLEGAL IMPORTANCE (VERY HIGH YIELD)

24.1 Why Septal Abscess Is a Legal Risk

  • Easily missed diagnosis

  • Leads to permanent cosmetic deformity

  • Deformity is visible → patient dissatisfaction

  • Often follows trauma or surgery → litigation risk

24.2 Common Medicolegal Errors

  • Failure to examine septum after nasal trauma

  • Treating haematoma with antibiotics only

  • Delayed referral to ENT

  • Inadequate documentation

  • Failure to warn parents about complications

24.3 Safe Practice Rules

  • Always document:

    • Septal examination findings

    • Drainage procedure

    • Informed consent

  • Explain risk of:

    • Saddle nose

    • Growth disturbance in children

25. PREVENTION STRATEGIES

25.1 Primary Prevention

  • Early detection and drainage of septal haematoma

  • Careful handling during septal surgery

  • Adequate hemostasis post-septoplasty

25.2 Secondary Prevention

  • Proper packing after drainage

  • Quilting sutures

  • Adequate antibiotic coverage

  • Regular follow-up

25.3 Pediatric Prevention

  • Mandatory septal examination after facial trauma

  • Educate parents regarding:

    • Nasal obstruction

    • Feeding difficulty

    • Fever after injury

26. OSCE / PRACTICAL EXAM CHECKLIST

26.1 Station: Nasal Examination

  • Inspect external nose

  • Perform anterior rhinoscopy

  • Identify:

    • Bilateral septal swelling

    • Fluctuance

    • Redness

  • Mention:

    • No response to decongestant

26.2 Station: Management Plan

  • Diagnosis: Septal abscess

  • Immediate steps:

    • Admit patient

    • IV antibiotics

    • Urgent drainage

  • Complications to mention:

    • Saddle nose

    • Cavernous sinus thrombosis

27. EXTENDED VIVA QUESTIONS (FINAL SET)

  • Define septal abscess.

  • Why is septal abscess more dangerous than haematoma?

  • Most common organism involved?

  • Why is cartilage necrosis rapid?

  • Why must drainage be bilateral?

  • Why is reconstruction delayed?

  • Complications of untreated septal abscess.

  • Differences between septal abscess and DNS.

  • Why is septal abscess more serious in children?

  • What is the medicolegal importance of septal abscess?

28. COMPARATIVE SUMMARY TABLE (SEO-FRIENDLY)

Feature Septal Haematoma Septal Abscess
Content Blood Pus
Fever Absent / Mild Present
Pain Mild Severe
Organisms None Bacterial
Urgency Emergency Life-Threatening Emergency
Treatment Drainage Drainage + IV antibiotics
Complications DNS, saddle nose CST, meningitis, deformity

29. FINAL MCQs (HIGH-YIELD, EXAM-ORIENTED)

1. Septal abscess most commonly develops from:
A. Acute rhinitis
B. DNS
C. Infected septal haematoma
D. Nasal polyp
Correct Answer: C

2. Most feared cosmetic complication:
A. Septal perforation
B. DNS
C. Saddle nose deformity
D. Synechiae
Correct Answer: C

3. Best treatment option:
A. Antibiotics alone
B. Observation
C. Immediate incision and drainage
D. Steroids
Correct Answer: C

4. Why is septal abscess more serious in children?
A. Thicker cartilage
B. Faster healing
C. Septum is facial growth center
D. Better immunity
Correct Answer: C

5. Most common causative organism:
A. Pseudomonas
B. E. coli
C. Staphylococcus aureus
D. Klebsiella
Correct Answer: C

30. FINAL CLINICAL PEARLS

  • Septal abscess = do not delay, do not observe

  • Drainage is mandatory, antibiotics alone are never enough

  • Always think of growth disturbance in children

  • Always examine septum after nasal trauma

  • Saddle nose deformity is preventable if treated early

  • Documentation protects both patient and doctor

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

Hunain Zia

Hunain Zia has previously achieved considerable success in the high-school educational stream, gaining a massive 154 Total A Grades and 7 Major Distinctions, a process in which he broke/ set 11 different world records, including the most A grades ever achieved, most subjects ever appeared in, most distinctions, gaining distinctions across two separate boards (Pearson Edexcel and CAIE) within the same year/ ever, and even 19 hours of constant examination. All records stand intact today. Hunain pursued his Honors Accounting Degree from the prestigious Bentley University, and then completed an LLB (in Honors) from University of London. Currently, he manages multiple social and commercial projects, has founded digital streams and works tirelessly in the education sector.

Educate A Change focuses on truly bringing change in the educational sector worldwide. All our courses are designed to ensure success, and provide complete preparation without requiring any other external material. Therefore, it takes away the expense of academies, books, past paper compilations and other miscellaneous items. Instead, by just the courses we offer, the student can prepare fully for the best grades in their CAIEs, Edexcel and other high-school exams. The earnings from our course-sales are invested in social projects and growing the free educational activities of Educate A Change.