Introduction
Septal abscess is the accumulation of pus in the space between the cartilage or bony septum and mucoperichondrium or mucoperiostium. This complication often occurs after septal hematoma caused by trauma. Other risk factors include surgery, foreign bodies, sinusitis, furunculosis, and dental infections [1]. The possibility of local infection and septal abscess after septoplasty has been reported to be 0.4-12%, which emphasizes the necessity of taking prophylactic antibiotics [2]. Type 2 diabetes can cause immune disorders and, as a result, increase the possibility of some infections. Uncontrolled diabetes can be considered as one of the risk factors for abscess without history of trauma [3]. Nasal blade cautery for the treatment of epistaxis as the cause of abscess has not yet been confirmed, but there are reports of septal abscess formation following cauterization or radiofrequency [4]. Septal abscess can cause irreparable health and cosmetic complications. By timely diagnosis and early action, these complications can be prevented. This study aims to investigate the frequency of nasal septal abscess and its related factors in patients referred to a hospital in north of Iran.

Methods
This retrospective descriptive study with a cross-sectional design was conducted on the patients referred to Amir Al Mo’menin Hospital in north of Iran from March 2021 to August 2022 and received inpatient or outpatient services. A checklist was used to collect information (age, gender, history of nose surgery, history of trauma, history of immunodeficiency diseases and diabetes, smoking, type of outpatient or inpatient treatment, duration of hospitalization, number of hospitalizations, need for surgical evacuation and its number of times, and the result of smear and cultures) based on the patients’ medical files. The smear and culture results, if not included in the file, were extracted from the laboratory files. Data was analyzed in SPSS software, version 25. Quantitative data was described using Mean±SD, and qualitative data was described using frequency and percentage.

Results
In this study, 37 patients had septal abscess who were included in the study. They were 20(54.1%) males and 17(45.9%) females, with a mean age of 46.24±16.6 years, ranged from 10 to 74 years. Ten patients (27%) were smokers. All patients had received broad-spectrum antibiotics and had undergone surgical drainage. In 5 cases, the severity of the disease was low and after ambulatory drainage and receiving a bolus dose of intravenous antibiotics, the patients were managed on an outpatient basis. The mean length of hospitalization was 4.5±2.86 days, ranged from 1 to 14 days. In three patients, surgical drainage was performed two times, and one patient needed three times of surgical drainage.
The most common risk factor identified was a history of septoplasty or septorhinoplasty (35.1%), followed by diabetes mellitus (21.6%). No underlying risk factor was identified in two patients. Two patients with abscess mentioned the history of COVID-19 disease in the last 2-3 weeks and were treated on an outpatient basis. Three patients who suffered from septal abscess after cauterization had hypothyroidism. Hypothyroidism was also seen in two patients with a history of septoplasty. One of the abscess patients with septoplasty also had a history of controlled diabetes.
The average time interval from nose blade surgery to onset of symptoms was 50.57 days; after cauterization, 26.25 days; and after trauma and nasal fracture, 44.57 days. In 46% of patients (n=17), cellulitis of the dorsum or tip of the nose was evident at the time of admission, but leukocytosis and fever were observed only in 21.6% and 5.4%, respectively. Four patients had saddle nose deformity due to septal abscess.
In the examination of the culture samples, positive culture results were reported in only 5 patients where 3 had Staphylococcus saprophyticus and 2 had Pseudomonas saprophyticus. Fourteen cases (37.8%) due to the return of symptoms against oral antibiotic treatment after discharge, were re-hospitalized and treated with intravenous antibiotics and, if necessary, underwent surgical drainage of the abscess.

Conclusion
After review of the medical files of patients who underwent surgery (3072 septorhinoplasty surgeries and 769 septoplasty with or without endoscopic sinus surgery) as well as those of patients referred to the emergency room, the frequency of septal abscesses was found to be 37. According to the findings of this study and similar studies and taking into account the average time interval of procedures related to the nose and the occurrence of abscess symptoms, it is recommended that, for timely diagnosis and treatment, patients should be closely monitored with periodic examinations for at least two months after nasal blade surgery (without or with rhinoplasty/endoscopic sinus surgery), at least one and a half months after nasal fracture fixation, and at least one month after cauterization. Also, the long-term study of patients with septal abscess, according to the risk factors and underlying diseases, can be helpful in the treatment of patients. On the other hand, all diabetic patients should be warned to avoid nose manipulation for the diabetic patients with nasal folliculitis symptoms and evidence of cellulitis and swelling, the treatment with broad-spectrum antibiotics should be started as soon as possible, and daily visits should be considered to ensure the improvement of the disease.

Ethical Considerations

Compliance with ethical guidelines
This research was approved by the Ethics Committee of Guilan University of Medical Sciences (Code: IR.GUMS.REC.1401.446). In this study, all principles and standards of the National Ethics Committee have been observed and also all ethical principles of Declaration of Helsinki was complied. The people's information participated in the study is also was kept confidential.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization, study design, supervision, statistical analysis and critical revision: Sevil Nasirmohtaram and Maryam Akbari; Data collection, analysis and interpretation: Sevil Nasirmohtaram, Maryam Akbari and Maliheh Akbarpour; Initial draft preparation: All authors.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank the experts at Otorhinolaryngology Research Center, Guilan university of Medical Sciences.




References