What is the diagnosis and treatment for a patient presenting 7 days post-nasal trauma with severe bilateral nasal obstruction, pain over the nasal bridge, fever with chills, frontal headache, and smooth bilateral swelling of the nasal septum with fluctuation and congested septal mucosa?

Provisional Diagnosis: Infected Nasal Septal Hematoma (Nasal Septal Abscess)

This patient has a nasal septal abscess—a purulent collection between the nasal septum and its mucoperichondrium—which requires emergency surgical drainage within hours to prevent catastrophic complications including septal necrosis, saddle nose deformity, cavernous sinus thrombosis, meningitis, and death. 1, 2, 3

Clinical Reasoning

The 7-day post-trauma timeline with progressive symptoms is classic for evolution from septal hematoma to abscess:

• Bilateral smooth septal swelling with fluctuation is pathognomonic for septal abscess—the bilateral nature occurs because infection dissects through both sides of the perichondrium 1, 2
• Fever, chills, and frontal headache indicate systemic infection and potential intracranial extension 4, 3
• Severe bilateral nasal obstruction results from the expanding abscess occluding both nasal passages 5
• Congested septal mucosa reflects the inflammatory response to underlying infection 2

The timing is critical: most septal hematomas become infected within 3-7 days if untreated, exactly matching this presentation 3, 6.

Differential Diagnoses

1. Acute Bacterial Rhinosinusitis with Complications

• Would present with purulent rhinorrhea, maxillary/frontal sinus tenderness, and symptoms persisting >10 days or worsening after initial improvement 4
• However, the bilateral septal fluctuance is incompatible with uncomplicated sinusitis 4
• Frontal headache and fever could represent frontal sinusitis, but anterior rhinoscopy findings point definitively to septal pathology 4

2. Nasal Septal Cellulitis (without abscess formation)

• Would show erythema and edema but lack fluctuance on palpation 2
• The presence of fluctuation confirms purulent collection requiring drainage 1, 5
• Cellulitis alone would not cause the degree of bilateral obstruction seen here 6

Treatment Plan: Emergency Protocol

Immediate Actions (Within 1-2 Hours)

1. Obtain urgent maxillofacial CT with IV contrast 1, 5

• Confirms abscess extent and identifies septal cartilage involvement
• Rules out intracranial extension (epidural abscess, cavernous sinus thrombosis, meningitis) 3, 6
• Assesses for concurrent sinusitis requiring additional intervention 4

2. Start broad-spectrum IV antibiotics immediately—do not wait for imaging 2, 3

• First-line: Vancomycin 15-20 mg/kg IV Q8-12h PLUS piperacillin-tazobactam 3.375g IV Q6h (or cefepime 2g IV Q8h) 2, 6
• Rationale: Must cover methicillin-resistant Staphylococcus aureus (most common pathogen), Streptococcus species, and anaerobes 2, 3, 6
• Community-acquired MRSA is increasingly reported in septal abscesses, even without healthcare exposure 2

3. Emergency otolaryngology consultation for surgical drainage 1, 3, 6

• Incision and drainage must occur within 2-4 hours of diagnosis to prevent cartilage necrosis 3, 6
• Bilateral incisions with through-and-through drainage and placement of Penrose drains or nasal packing 1, 2
• Send purulent material for Gram stain, aerobic/anaerobic cultures, and antibiotic sensitivities 2, 6

Perioperative Management

4. Supportive care 4

• IV fluids for hydration
• Acetaminophen or NSAIDs for pain and fever control 4
• Nasal saline irrigation is contraindicated until after surgical drainage 4

5. Hospital admission for IV antibiotics and monitoring 3, 6

• Minimum 48-72 hours inpatient observation for clinical improvement 3
• Monitor for complications: worsening headache, visual changes, altered mental status, cranial nerve deficits 4, 3

Post-Drainage Protocol

6. Antibiotic duration: 10-14 days total 4, 3

• Continue IV antibiotics until afebrile for 24-48 hours and clinically improving 3, 6
• Transition to oral antibiotics based on culture results (typically linezolid 600mg PO Q12h for MRSA or amoxicillin-clavulanate 875mg PO Q12h for susceptible organisms) 4, 2

7. Daily wound care and drain management 1, 2

• Remove drains at 3-5 days if drainage minimal 2
• Nasal saline irrigation after drain removal to prevent re-accumulation 4

8. Follow-up at 1 week, 1 month, and 3 months 3, 6

• Assess for septal perforation, saddle nose deformity, or residual abscess 3, 6
• Delayed septal reconstruction may be needed if significant cartilage loss occurs 3

Critical Pitfalls to Avoid

• Never attempt needle aspiration alone—inadequate drainage leads to recurrence and progression 1, 2
• Do not delay drainage for imaging—if clinical diagnosis is clear and OR is available, proceed directly to drainage 3, 6
• Do not use narrow-spectrum antibiotics—empiric coverage must include MRSA until cultures prove otherwise 2, 6
• Do not discharge without confirming clinical improvement—septal abscesses can rapidly progress to life-threatening complications 3, 6
• Do not miss intracranial extension—any neurologic symptoms, severe headache, or visual changes mandate immediate neurosurgical consultation 4, 3