Nasal septal abscess in an 11-year-old boy. The photograph was taken 4 weeks after nasal trauma and septal abscess that was treated with oral antibiotics by a general practitioner.
Adverse sequelae after reconstruction of the nasal septum with irradiated homologous cartilage. A, Frontal view of a 16-year-old boy with an underdeveloped nose and midface due to nasal septal abscess at the age of 2 years. Multiple nasal septal reconstructions were performed elsewhere with the use of homologous donor cartilage. Despite these reconstructions, the nose is short with a broad bony pyramid. B, Lateral view of the same patient. Because of the absence of the cartilaginous septum, the bony and cartilaginous dorsum was underdeveloped, and the columella was retracted with upward rotation of the nasal tip, causing an overlarge nasolabial angle (103°). The length of the nose was 4.1 cm (less than −2 SD), and the amount of nasal tip projection was 1.7 cm (−2 SD); both are too small for age and sex.
Perioperative view of a 5-year-old girl with complete loss of the cartilaginous septum. This photograph was taken 2 weeks after septal abscess that was treated with oral antibiotics by a general practitioner. The external approach provides maximal exposure of the nasal septum for optimal reconstruction and does not interfere with the normal outgrowth of the nose.
Same patient as in Figure 1. A, Perioperative view. Costal cartilage of the seventh rib was harvested to reconstruct the cartilaginous septum, which had completely disappeared. B, Two-millimeter sections of rib cartilage affixed to polydioxanone foil with polyglactin 4-0 soluble sutures. The polydioxanone plate was exactly the same shape as the absent septum. To avoid warping the graft, only the central part of the rib was used after removal of the outer layers, which have a greater tendency to warp. C, The rib implant on polydioxanone plate was positioned between the perpendicular plate, the vomer, and the upper lateral cartilages and was fixated between the mucoperichondrium layers with polyglactin 4-0 mattress sutures.
Same patient as in Figure 3. A, Perioperative view. Autologous auricular conchal cartilage was harvested through a posterior approach to avoid a visible scar of the left ear. Harvesting conchal ear cartilage does not interfere with the normal outgrowth or shape of the auricle. B, The cartilaginous nasal septum was reconstructed with 2 pieces of ear cartilage from the same auricular concha. The grafts were affixed to polydioxanone foil that matched the diameter of the lost septal cartilage with polyglactin 4-0 soluble sutures. C, Perioperative view of the reconstructed nasal septum after implantation of the auricular grafts on polydioxanone plate between the mucosal layers.
Patient 1 in Tables 1 and 2. A, Preoperative frontal view of a 3-year-old boy with complete loss of the cartilaginous part of the nasal septum. This photograph was taken 3 weeks after nasal trauma and the development of septal abscess. The abscess was treated elsewhere with oral antibiotics and drainage through a hemitransfixion incision. In the frontal view, the middle third of the nose was broad due to slight collapse of the upper lateral cartilages. B, Despite entire loss of septal cartilage, there was only slight overrotation of the nasal tip, so far without indications of saddle nose deformity. C and D, Postoperative frontal and lateral views of the same patient at the age of 8 years, 62 months after reconstruction of the nasal septum with autologous auricular cartilage on polydioxanone plate. The nose and midface had grown in proportion to the rest of the face. Examination and palpation of the nasal septum revealed intact cartilaginous septum with good support to the upper lateral cartilages and without development of saddle nose deformity. Follow-up will continue to the age of 18 years.
Menger DJ, Tabink IC, Trenité GJN. Nasal Septal Abscess in ChildrenReconstruction With Autologous Cartilage Grafts on Polydioxanone Plate. Arch Otolaryngol Head Neck Surg. 2008;134(8):842-847. doi:10.1001/archotol.134.8.842
To assess outgrowth and aesthetics of the nose in children after reconstruction of the cartilaginous nasal septum with autologous cartilage grafts on polydioxanone plate.
Prospective nonrandomized case series.
Six patients (5 boys and 1 girl), aged 3 to 11 years, with nasal septal abscess.
The nasal septa of 6 children with a history of nasal septal abscess and partial or complete destruction of nasal septal cartilage were reconstructed with autologous cartilage grafts of the auricle or rib fixed on polydioxanone plate.
Main Outcome Measures
Nasal outgrowth was measured by the length of the nose and by the amount of nasal tip projection and was compared with standardized growth curves. Aesthetic outcome variables included nasolabial angle, columellar retraction, and development of saddle nose deformity and were classified as normal, mild, or severe.
The duration of follow-up ranged from 10 to 68 months (mean follow-up, 38 months). Four children had complete loss of the cartilaginous septum. Areas 1 and 2 (caudal parts) had been destroyed in 2 children. Auricular cartilage was used in 5 children; costal cartilage was needed in 1 child. Compared with standardized growth curves, the length of the nose and the amount of nasal tip projection were within 1 SD in all children. None of the children developed saddle nose deformity. One child had mild columellar retraction; 3 children had mild overrotation of the nasal tip.
Total reconstruction of abscess-induced destruction of nasal septal cartilage with autologous cartilage grafts fixed on polydioxanone plate has, so far, resulted in normal development of the nose during follow-up, without expected aesthetic problems.
The nasal septum is an essential structure of the nose. Destruction of septal cartilage, partial or complete, can affect the function and shape of the nose. In the growing child, this can be accompanied by disturbance of the normal development of the nose and maxilla.1- 6 Total destruction of the cartilaginous septum will result in an underdeveloped and overrotated saddle nose deformity with columellar retraction and retroposition of the midface. Therefore, loss of septal cartilage in childhood is a serious condition that requires adequate surgical therapy to prevent functional and aesthetic problems in the future.5,6
Most frequently, destruction and loss of septal cartilage in childhood are a complication of septal hematoma or abscess due to sinusitis, nasal trauma, dental infections, or septorhinoplasty.2,7- 14 In normal circumstances, the metabolism of septal cartilage depends on the perichondrium. However, the formation of a hematoma between the cartilage surface and the perichondrium can result in insufficient oxygenation and sterile necrosis.15 Frequently, the process of necrosis and liquification is intensified by collagenases that are produced by Staphylococcus aureus, Haemophilus influenzae, or Steptococcus species strains. These microorganisms can contaminate the hematoma, resulting in an abscess through microlesions in the mucoperichondrium or hematogenously.1,9- 11,16,17 These children can become ill with fever and partial or complete blockage of the nasal passage (Figure 1). Life-threatening complications such as thrombosis of the cavernous sinus or brain abscesses are rare and are often associated with delayed diagnosis and management.13 There is no consensus in the literature regarding the management of nasal septal abscesses in children. Drainage, antibiotic use, needle aspiration, packing of the nose, and combinations of these have been described in the literature. The role of an intact cartilaginous septum in the normal development of the nose and midface has generally been underestimated.
To improve normal outgrowth of the nose and maxilla, the nasal septum has been reconstructed with homologous donor cartilage implants.5,6,18 The long-term postoperative results of these studies are conflicting. Huizing5 reported 2 cases of reconstruction with homologous cartilage resulting in normal outgrowth of the nose and midface. In contrast, Grymer and Bosch6 studied identical twin boys, one of whom developed a septal abscess that was reconstructed with homologous cartilage. During follow-up, he developed the expected long-term adverse sequelae of the nose and maxilla. This finding is in line with clinical evidence and animal models that have demonstrated replacement of original homologous cartilage grafts with fibrous tissue during follow-up.19,20 Homologous cartilage grafts are less suitable for the replacement of structures in the nose with support function such as the nasal septum.
To ensure normal development of the nose in a growing child, the reconstructed nasal septum should be able to grow. It is likely that chondrocytes from the perichondrium fail to migrate toward the matrix of homologous cartilage implants. A clinical example of adverse sequelae that can develop after reconstruction of the nasal septum with irradiated homologous cartilage is shown in Figure 2. At present, autologous cartilage is the implant material of choice, which is consistent with the objectives of optimal long-term postoperative results with limited risk of resorption, infection, or extrusion.21- 23 Dispenza et al24 used residual autologous septal cartilage in their technique of “mosaicplasty.” However, most children in our series with a septal abscess had complete or near-complete loss of the cartilaginous septum. In this case, large autologous cartilage grafts are needed, and we believe that auricular and costal cartilage are the donor sites of choice for septal reconstruction in these children.
Between June 5, 2001, and April 19, 2006, we performed rhinoplastic surgery on 6 children (5 boys and 1 girl) with partial or complete loss of the cartilaginous nasal septum. All children had a history of nasal trauma, septal hematoma, and septal abscess. Initially, 2 of these children were treated by a general practitioner for blockage of the nasal passage and fever that had developed a few days after the nasal trauma. Inferior turbinate hypertrophy or fever of unknown origin was assumed, so these children were treated with topical decongestants or systemic antibiotics. By the time of the initial visit at our department, these children still had a swollen nasal septum with complete or near-complete loss of the cartilaginous septum on palpation. Clinically, these children had a normal nasal profile with marginal flattening and broadening of the supratip area and slight columellar retraction. In 2 other children, nasal abscess had been diagnosed and drained elsewhere, including treatment with antibiotics, before being seen at our department. Temporary reconstruction with irradiated homologous rib cartilage (Tutoplast; Tutogen Medical GmbH, Neunkirchen am Brand, Germany) to prevent adhesions between the mucoperichondrium layers was performed elsewhere in the 2 other children. These children were seen at our department for reconstruction of the nasal septum with autologous cartilage grafts.
In all children, reconstruction of the nasal septum was performed using general anesthesia through an open rhinoplasty using a broken columellar incision. After opening the submucosal space, cultures were taken for microbiologic examination, and the abscess was drained. Only 2 children still had a purulent collection between the mucosal layers. At this phase, the diameter of absent septal cartilage was estimated to ensure total reconstruction of the septum (Figure 3). If the amount of cartilage needed for reconstruction was large, costal cartilage from the seventh rib was harvested on the right side (Figure 4A). Auricular conchal cartilage was used when the quantity needed was less than 1 auricular concha (Figure 5A). The next step was reconstruction of the nasal septum. The cartilage grafts were stabilized and fixed (using polyglactin 4-0 sutures) on polydioxanone plate (0.15 × 50 × 40 mm; Ethicon, Norderstedt, Germany). This thin but strong material ensures good tissue to tissue approximation of the cartilage grafts in a single large implant (Figures 4B and 5B). This implant was positioned precisely between the vomer, the upper lateral cartilages, and the perpendicular plate or remnants of the cartilaginous septum. Polydioxanone plate or foil degrades in 10 to 25 weeks and does not disturb the normal healing process. Studies25- 27 have shown that this material has a positive effect on the regeneration of septal cartilage in a rabbit model and in the regeneration of bone in the reconstruction of orbital defects.28,29 The next step was to fixate the implant with the use of soluble mattress sutures (Figures 4C and 5C). An internal nose dressing was applied for 1 or 2 days. Systemic broad-spectrum antibiotics (a combination of amoxicillin [50 mg/kg] and clavulanic acid [5 mg/kg], every 6 hours) were administered during 7 days. Depending on culture results, the antibiotic regimen is changed if necessary.
To evaluate the development of nasal growth, we compared the length of the nose and the amount of nasal tip projection in our children with standardized growth curves for central Europe. These growth curves were based on measurements of 2500 healthy individuals in Switzerland aged 0 to 97 years.30 All measurements of the length of the nose and the amount of nasal tip projection (nasal protrusion) were performed in accord with the recommendations by Zankl et al.30 In addition to measuring the length of the nose and the amount of nasal tip projection, we evaluated columellar retraction and the development of saddle nose deformity. These variables were analyzed and classified as normal, mild, or severe (Table 1). Finally, we measured the nasolabial angle and classified the angle as normal (<100° for boys and <115° for girls), mildly overrotated (>100° for boys and >115° for girls), or overrotated (>115° for boys and >130° for girls). Midfacial growth was not considered because cephalometrics were not performed during follow-up.
The ages at which septal abscess developed ranged from 3 to 11 years (mean age, 8 years). Four children had complete loss of the cartilaginous septum; in 2 children, only areas 1 and 2 (caudal parts) of the nasal septum were resorbed (Table 2). In 5 children, auricular conchal cartilage was adequate for total reconstruction, whereas costal cartilage was required in 1 child. Follow-up ranged from 10 to 68 months (mean follow-up, 38 months). Two children still had a purulent collection between the mucoperichondrium layers during surgery. In these children, microbiologic cultures were positive for H influenzae and Streptococcus milleri. None of the children developed postoperative infections or other complications. Compared with standardized growth curves, the length of the nose and the amount of nasal tip projection were within 1 SD in all children (Table 1 and Figure 6). None of the children developed saddle nose deformity; mild columellar retraction was noted in 1 child (patient 3 in Tables 1 and 2). The nasolabial angle was normal in 3 children; mild overrotation was observed in 3 children. Outgrowth of the nose was normal in all the children, without signs of underdevelopment or development of saddle nose deformity.
Septal hematomas and abscesses require prompt drainage and inspection and may necessitate reconstruction of the nasal septum. Frequently, there is no loss of septal cartilage. In such cases, adequate drainage and administration of antibiotics will be sufficient for a good long-term postoperative result without adverse sequelae such as underdevelopment or development of severe saddle nose deformity. The normal nasal septum has 2 major growing centers, which are thicker (3 mm) than the surrounding cartilage (0.75 mm). These include the sphenodorsal zone, which regulates the length and height of the nose, and the sphenospinal zone (basal), which stimulates the development of the anterior nasal spine and the maxilla. Smaller defects in the thinner anterior central part of the cartilaginous septum, located between the major growing centers, do not seem to interfere with nasal growth.31 Nevertheless, reconstruction of such small defects should be considered to avoid the development of septal perforation.
In children with complete or near-complete destruction of septal cartilage, reconstruction of the nasal septum is required. The fact that the operative field is infected with microorganisms does not detract from this statement. After careful rinsing of the subperichondrial space with large quantities of an isotonic sodium chloride solution, the risk of infection in the cartilage implant is low, especially after intravenous or oral administration of broad-spectrum antibiotics. In our case series, autologous cartilage grafts attached to polydioxanone plate for reconstruction of the nasal septum after septal abscess showed normal development of the length of the nose and the amount of nasal tip projection, both in accord with standardized growth curves of the nose. Little is known about the type of growth in the cartilage grafts. We do not know whether new chondrocytes derive from the perichondrium (appositional growth) or from within the lacuna of the graft (interstitial growth). Furthermore, it is not fully understood whether the histologic properties of the original implants change in time toward a hyaline type of cartilage. It is anticipated that future animal studies will answer these kinds of questions.
We are aware that our series of 6 children is small. Nevertheless, to our knowledge, it is the largest documented group in the literature and is the only report in which nasal growth is reported objectively according to standardized growth curves. Our clinical data are preliminary, as the children have not reached the age of 18 years, but, so far, the results of the described technique are promising and, in our view, represent the best alternative for children with complete loss of nasal septal cartilage. Follow-up will be continued during the pubertal growth spurt until our patients are 18 years of age.
In the growing child, reconstruction of partially or completely destructed septal cartilage is essential for normal development of the nose and maxilla. To achieve a successful long-term functional and aesthetic postoperative result, the implant material should provide sufficient support function and should be able to grow between the mucoperichondrium layers. Autologous cartilage grafts of the auricle or rib are, so far, the implant materials of choice in line with current medical practice to achieve these goals. The ideal solution would be to restore the septum with a single large cartilaginous implant instead of multiple smaller grafts. For this reason, the autologous cartilage grafts were affixed to polydioxanone plate, which ensured good tissue-to-tissue approximation of the individual grafts. The nasal septa of 6 children were reconstructed using this technique. This approach has, so far, resulted in normal development of the nose during follow-up in all children.
Correspondence: Dirk J. Menger, MD, Center for Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology–Head and Neck Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands (D.J.Menger@amc.uva.nl).
Submitted for Publication: August 9, 2007; final revision received November 11, 2007; accepted November 28, 2007.
Author Contributions: Drs Menger and Nolst Trenité had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Menger and Tabink. Acquisition of data: Menger. Analysis and interpretation of data: Menger and Nolst Trenité. Drafting of the manuscript: Menger. Critical revision of the manuscript for important intellectual content: Tabink and Nolst Trenité. Administrative, technical, and material support: Tabink. Study supervision: Menger and Nolst Trenité.
Financial Disclosure: None reported.