A 10-year-old boy from a Tsunami rescue camp was brought to our hospital with history of high grade intermittent fever for one week. At admission, he was looking depressed, not talking but obeying commands. He was febrile and there was marked peeling of his palms and soles. His respiratory rate was normal and his lungs were clear on auscultation. The other systems were also normal on examination. A diagnosis of staphylococcal scalded skin syndrome was considered based on the extensive exfoliation. However, there was no obvious focus of infection, except for a slightly abnormal broad nose. Examination of the nose revealed a tense bulging nasal septum and a diagnostic aspirate yielded thick pus from which Staphylococcus aureus was later isolated. The septal abscess was drained under general anesthesia. Intra operative examination revealed a near total necrosis of his membranous septum. He was adequately treated with intravenous cloxacillin for two weeks and discharged home in a healthy condition. Appropriate psychotherapy and antidepressants were also provided. The final diagnosis was abscess of the nasal septum with staphylococcal scalded skin syndrome and post traumatic stress disorder. Probably he had sustained a hematoma of the nasal septum during the tsunami which subsequently got infected with staphylococcus. As he was depressed, he never revealed the pain in his nose and the septal abscess was missed early.

Nasal septal abscess (NSA) is uncommon among children. Nasal obstruction, throbbing nose pain, general malaise, fever, headache, and tenderness over the perinasal area are the common symptoms and Staphylococcus aureus is the most common organism cultured from NSA. Infection of a septal hematoma, direct extension along the tissue planes as seen with sinusitis, infections of dental etiology and venous spread from the orbits or cavernous sinus may result in the development of a NSA. There is usually an inciting traumatic event causing rupture of the small vessels that supply the nasal septum. The hematoma formed separates the mucoperichondrium from the septal cartilage. Cartilage destruction follows as a result of ischemic and pressure necrosis. The static blood forms an adequate medium for bacterial growth and subsequent abscess formation(1). The drainage and immediate reconstruction of the nasal septum are the golden standard in the treatment of NSA(2). The complications of a NSA include meningitis, saddle nose deformities, sepsis, bacteremia, and in younger patients maxillary hypoplasia. Staphylococcal scalded skin associated with NSA as noted in this boy is also rare.

Adhisivam B.,
Mahadevan S.,
Department of Pediatrics,
JIPMER,
Pondicherry 605 006, India.
E-mail: [email protected]

1. Santiago R, Villalonga P, Maggioni A. Nasal septal abscess: A case report. Int Pediatr 1999; 14: 229-231.

2. Dispenza C, Saraniti C, Dispenza F, Caramanna C, Salzano FA. Management of nasal septal abscess in childhood: Our experience. Int J Pediatr Otorhinolaryngol 2004; 68: 1417-1421.