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Oxycodone Insufflation Resulting in Nasal Septal Abscess
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.09.032
Visual Diagnosis in Emergency Medicine
OXYCODONE INSUFFLATION RESULTING IN NASAL SEPTAL ABSCESS Michael S. Pulia, MD and Chris Reiff, BS Division of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Reprint Address: Michael S. Pulia, MD, Division of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, F2/203 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792
CASE REPORT A 41-year old female presented to the emergency department (ED) for evaluation of difficulty with nasal breathing associated with severe internal nasal pain for 3 days. She has a history of chronic opioid abuse via nasal insufflation of crushed oxycodone. Two days before symptom onset, she completed a 10-day course of amoxicillin/clavulanate for a clinically diagnosed maxillary sinusitis. A
Figure 2. Computed tomography scan of the sinuses demonstrating paranasal sinusitis and a rim-enhancing fluid collection within the nasal septum (arrow).
Figure 1. View of internal nares with patient in neck extension demonstrating bulging of septum into left naris (arrow).
RECEIVED: 11 June 2013; ACCEPTED: 26 September 2013 1
2
M. S. Pulia and C. Reiff
complete review of symptoms was unremarkable, including the absence of fever, vision changes, or headache. Her physical examination was notable for significant swelling and exquisite tenderness of the nasal septum (Figure 1). Laboratory studies revealed a leukocytosis. A computed tomography scan of the sinuses revealed paranasal sinusitis and a rim-enhancing fluid collection within the nasal septum (Figure 2). Parenteral clindamycin was initiated in the ED and otolaryngology was consulted. The patient was taken to the operating room the subsequent day for incision and drainage, which revealed purulence and septal necrosis. The wound cultures obtained during surgery did not reveal a causative organism. DISCUSSION Nasal septal abscesses develop via accumulation of purulence between the septal cartilage and overlying mucoperichondrium (1). In the majority of cases (75%), a recent history of nasal trauma is present. However, nasal septal abscesses are also known complications of nasopharyngeal necrosis resulting from chronic insufflation of cocaine or opioids (2,3). The most common causative organisms are Staphylococcus and
Streptococcus species (1). Methicillin-resistant Staphylococcus aureus also should be considered when choosing antibiotic therapy (4). Optimal treatment requires early diagnosis, parenteral antibiotics, and surgical drainage (5). Late diagnosis and treatment is associated with major complications, including necrosis of septal cartilage, chronic nasal deformities, and serious infectious complications, including cavernous sinus thrombosis and meningitis (1,6).
REFERENCES 1. Huang YC, Hung PL, Lin HC. Nasal septal abscess in an immunocompetent child. Pediatr Neonatol 2012;53:213–5. 2. Glauser J, Queen JR. An overview of non-cardiac cocaine toxicity. J Emerg Med 2007;32:181–6. 3. Rosenbaum CD, Boyle KL, Boyer EW. Nasopharyngeal necrosis after chronic opioid (oxycodone/acetaminophen) insufflation. J Med Toxicol 2012;8:240–1. 4. Cheng L-H, Kang B-H. Nasal septal abscess and facial cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus. J Laryngol Otol 2010;124:1014–6. 5. Canty PA, Berkowitz RG. Hematoma and abscess of the nasal septum in children. Arch Otolaryngol Head Neck Surg 1996;122:1373–6. 6. Dispenza C, Saraniti C, Dispenza F, Caramanna C, Salzano FA. Management of nasal septal abscess in childhood: our experience. Int J Pediatr Otorhinolaryngol 2004;68:1417–21.
http://dx.doi.org/10.1016/j.jemermed.2013.09.032
Visual Diagnosis in Emergency Medicine
OXYCODONE INSUFFLATION RESULTING IN NASAL SEPTAL ABSCESS Michael S. Pulia, MD and Chris Reiff, BS Division of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Reprint Address: Michael S. Pulia, MD, Division of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, F2/203 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792
CASE REPORT A 41-year old female presented to the emergency department (ED) for evaluation of difficulty with nasal breathing associated with severe internal nasal pain for 3 days. She has a history of chronic opioid abuse via nasal insufflation of crushed oxycodone. Two days before symptom onset, she completed a 10-day course of amoxicillin/clavulanate for a clinically diagnosed maxillary sinusitis. A
Figure 2. Computed tomography scan of the sinuses demonstrating paranasal sinusitis and a rim-enhancing fluid collection within the nasal septum (arrow).
Figure 1. View of internal nares with patient in neck extension demonstrating bulging of septum into left naris (arrow).
RECEIVED: 11 June 2013; ACCEPTED: 26 September 2013 1
2
M. S. Pulia and C. Reiff
complete review of symptoms was unremarkable, including the absence of fever, vision changes, or headache. Her physical examination was notable for significant swelling and exquisite tenderness of the nasal septum (Figure 1). Laboratory studies revealed a leukocytosis. A computed tomography scan of the sinuses revealed paranasal sinusitis and a rim-enhancing fluid collection within the nasal septum (Figure 2). Parenteral clindamycin was initiated in the ED and otolaryngology was consulted. The patient was taken to the operating room the subsequent day for incision and drainage, which revealed purulence and septal necrosis. The wound cultures obtained during surgery did not reveal a causative organism. DISCUSSION Nasal septal abscesses develop via accumulation of purulence between the septal cartilage and overlying mucoperichondrium (1). In the majority of cases (75%), a recent history of nasal trauma is present. However, nasal septal abscesses are also known complications of nasopharyngeal necrosis resulting from chronic insufflation of cocaine or opioids (2,3). The most common causative organisms are Staphylococcus and
Streptococcus species (1). Methicillin-resistant Staphylococcus aureus also should be considered when choosing antibiotic therapy (4). Optimal treatment requires early diagnosis, parenteral antibiotics, and surgical drainage (5). Late diagnosis and treatment is associated with major complications, including necrosis of septal cartilage, chronic nasal deformities, and serious infectious complications, including cavernous sinus thrombosis and meningitis (1,6).
REFERENCES 1. Huang YC, Hung PL, Lin HC. Nasal septal abscess in an immunocompetent child. Pediatr Neonatol 2012;53:213–5. 2. Glauser J, Queen JR. An overview of non-cardiac cocaine toxicity. J Emerg Med 2007;32:181–6. 3. Rosenbaum CD, Boyle KL, Boyer EW. Nasopharyngeal necrosis after chronic opioid (oxycodone/acetaminophen) insufflation. J Med Toxicol 2012;8:240–1. 4. Cheng L-H, Kang B-H. Nasal septal abscess and facial cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus. J Laryngol Otol 2010;124:1014–6. 5. Canty PA, Berkowitz RG. Hematoma and abscess of the nasal septum in children. Arch Otolaryngol Head Neck Surg 1996;122:1373–6. 6. Dispenza C, Saraniti C, Dispenza F, Caramanna C, Salzano FA. Management of nasal septal abscess in childhood: our experience. Int J Pediatr Otorhinolaryngol 2004;68:1417–21.