Nasal septal abscesses are associated with a high level of morbidity from cartilage loss and may even be life threatening due to intracranial spread of the infection. It is generally agreed upon in the literature that treatment of these abscesses should not be delayed.1, 2 Standard treatment involves incision and drainage of the abscess, with or without drain placement, and culture-directed antibiotic treatment.1, 3 Previous reports favor treatment of intranasal abscesses either in the operating room or under moderate sedation with local anesthetic.1, 4 Here, we describe a novel method for bedside drainage and treatment of nasal septal abscesses without the need for sedation or general anesthetic. The technique presented has been used across all age groups at our institution to effectively treat several nasal and septal abscesses as well as an intranasal hematoma.
After determining that a fluid collection is present, the patient is anesthetized with topical anesthetic followed by infiltration of local anesthetic along the septum or the nasal mucosa. A large-gauge needle is then used to obtain a sample of the fluid collection for culture and a single, small incision (approximately 2 mm) is made through the nasal mucosa with care to preserve the underlying cartilage. The soft tissue pocket is then suctioned and flushed with sterile saline using an angiocatheter to direct the flow of saline. Care is taken to avoid excessive irrigation force that may result in further dissection of the overlying soft tissue from the nasal framework.
A piece of tubing is then procured from a 21-gauge winged infusion set (BD Vacutainer; Becton, Dickinson and Co., Franklin Lakes, NJ), and a diagonal cut is made along the distal end of the tubing piece to thin the distal segment (Fig. 1). The distal end of the tubing is then advanced through the incision to the most posterior edge of the soft tissue pocket. The distance from the distal edge of the abscess pocket to the mucosal incision is measured. The drain tubing is removed, and a 3-0 Prolene or nylon suture is secured to the drain in a through-and-through fashion such that the suture lies at the mucosal incision site after drain insertion. We prefer to secure the suture to the drain prior to drain insertion; however, this step could be performed with the drain in place within the soft tissue pocket. The drain is then sutured to the nasal mucosa and trimmed to allow for patient comfort and mobility (Fig. 2). This tubing allows for continued drainage from the abscess or hematoma pocket and prevents abscess reaccumulation or seroma formation.
The nose presents unique challenges in that space is limited and pressure to prevent fluid reaccumulation cannot be easily applied without occluding the nasal passageway or causing increased pain and morbidity. Previously, we attempted the placement of a vessel loop along the nasal septum to prevent fluid reaccumulation following drainage of a nasal septal abscess. Although the vessel loop was appropriately secured, this technique proved ineffective secondary to the flimsy (extreme flexibility) nature of the vessel loop. It slipped from the submucosal pocket, resulting in seroma formation and the need for a repeated incision and drainage of the area. Others have reported both abscess reaccumulation and seroma formation following drainage of a nasal septal abscess with the use of a Penrose drain.1
The infusion drain described above not only aids in continuous drainage but also allows for daily flushing with antibiotic-infused sterile saline. In our experience, the infusion tubing did not occlude, and flushing was easily accomplished using a 22-gauge angiocatheter for days at a time (Fig. 3). Our patients were noted to actively drain for 2 to 5 days, and no reaccumulation of fluid was noted along the septum after drain removal. Additionally, intranasal packing was not required while the drain remained in place or following drain removal.
We recently successfully applied this technique in the case of an alar hematoma following nasal trauma in a 5-year-old child. The hematoma was drained intranasally with a single injection of local anesthetic. The child tolerated the bedside procedure without any difficulty and required no sedation. Drain removal was performed 2 days later, at which time the patient continued to have evidence of mucosal edema but no evidence of reaccumulation of fluid.
Intranasal abscesses and fluid collections must be treated efficiently and effectively to prevent immediate or long-term sequelae of the disease.1 Treatment involves drainage of the abscess or fluid collection along with antibiotic treatment, and most importantly, prevention of reaccumulation.3, 5 Previous attempts at bedside treatment of nasal septal abscesses under moderate sedation are reported. In one report, 18% of abscesses drained under local anesthetic subsequently required redrainage in the operating room.1
We describe a bedside technique that has been used effectively in both the drainage and prevention of reaccumulation of intranasal fluid collections. The use of an infusion tubing as a drain within the nose has the benefit of being very small (21 gauge) but rigid, such that the drain will remain relatively secure within the abscess or hematoma pocket. In an area with very little space for drain placement, a Penrose drain can be impractical to place at the bedside, and a vessel loop is too flimsy and does not reliably remain in place against the forces of gravity. Placement of the infusion tubing drain can reliably be performed at the bedside and only requires a small amount of injected local anesthetic. The infusion drain allows for continued drainage and prevention of reaccumulation of fluid, and can be used to instill topical antibiotics within the wound bed. Overall, we have found this drain to be very user friendly and effective in the bedside treatment of intranasal fluid collections.