Delayed Presentation of Nasal Septal Abscess in a Pediatric Patient Following Infectious Mononucleosis and Acute Bacterial Sinusitis

Introduction: The clinical presentation of infectious mononucleosis includes several head and neck manifestations, but does not commonly include sinonasal manifestations. In addition, it is rare for a nasal septal abscess to develop as sequelae of sinusitis. We report a unique case where a pediatric patient developed acute bacterial sinusitis and a nasal septal abscess following an episode of infectious mononucleosis. This is the first reported case of infectious mononucleosis resulting in complicated acute sinusitis with nasal septal abscess. Case presentation: A 16-year-old otherwise healthy Caucasian female presented with infectious mononucleosis and subsequently developed acute bacterial sinusitis. She then developed persistent nasal pain, nasal obstruction, and on exam was found to have bilateral septal fullness with nasal obstruction consistent with a nasal septal abscess. Emergent surgical intervention to drain the abscess followed by systemic antibiotics and delayed reconstructive rhinoplasty. Conclusion: This case shows that even in the absence of trauma, nasal septal abscess must be considered in patients presenting with persistent nasal pain, obstruction and congestion. This is important for primary care providers, emergency medicine physicians and other health care professionals triaging patients with this constellation of symptoms so that prompt referral may be made to a specialist for appropriate care. This case also suggests that infectious mononucleosis can leave a patient more susceptible to bacterial super infection via inflammatory immune modulation. Citation: Merrill T, Francom C, Kris RJ and Chiang T. Delayed Presentation of Nasal Septal Abscess in a Pediatric Patient Following Infectious Mononucleosis and Acute Bacterial Sinusitis. Inter J Otorhinolaryngology. 2017;4(1): 3. Inter J Otorhinolaryngology 4(1): 3 (2017) Page 02 ISSN: 2380-0569 appearing, and her fever was 37.6 degrees Celsius. Due to her clinical improvement and benign lumbar puncture, it was determined that she could safely be treated on an outpatient basis. She was prescribed a ten-day course of Cefdinir and fluticasone for her sphenoethmoidal sinusitis and discharged home with outpatient follow up in the pediatric otolaryngology clinic. Within one week the patient called reporting worsening headaches, nasal obstruction, and nasal drainage. She presented acutely to the pediatric otolaryngology clinic for evaluation. Physical exam at this time revealed bilateral nasal obstruction due to septal fullness that was tender and fluctuant on palpation, consistent with a NSA. Given the atypical presentation of infectious mononucleosis, acute bacterial sinusitis and NSA, repeat sinus CT was performed for peri-operative planning to identify the primary source of infection and to rule out intracranial spread. Her white blood cell count was elevated to 14,100/ mL. CT demonstrated fluid tracking from the posterior ethmoid air cells and right sphenoid sinus to the nasal septum (Figure 1). CT was also noted to show symmetric enhancement of the cavernous sinuses. MRI was then obtained at the recommendation of neurosurgery to further evaluate the potential of intracranial involvement. MRI showed that there was no fluid or empyema in either the epidural or subdural spaces. She was taken to the operating room that day for intervention, which consisted of incision and drainage of the NSA with endoscopic sinus surgery. Incision and drainage of the abscess with evacuation of purulent fluid was performed and cultures were obtained. A standard hemitransfixion incision was used. The abscess cavity was full of necrotic debris and the cartilaginous septum was absent. It was thoroughly irrigated until clear. Endoscopic sinus surgery was then performed, addressing the primary site of infection in the sphenoid and ethmoid sinuses. The septal mucosal flaps were approximated and the incision was loosely closed to permit drainage. Cultures grew methicillin susceptible S. aureus, Prevotella, Candida and Fusobacterium. The pediatric infectious disease team assisted with antibiotic management and clinical surveillance. The patient was started on intravenous ampicillin/sulbactam and fluconazole while inpatient and recovered without complication. She was discharged six days postoperatively on oral amoxicillin/clavulanate and fluconazole for four weeks until her Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) normalized and her clinical symptoms resolved. Within two weeks of discharge, her white blood cell count had normalized to 6,600/mL. Despite septoplasty at the time of drainage of the NSA, early follow up demonstrated lack of tip support consistent with saddle nose deformity. Subsequent reconstructive rhinoplasty to correct her saddle nose deformity was completed on postoperative day 67 with a rib autograft.