MRSA Nasal Abscess after Elective Septorhinoplasty

Kate Perry, MD1; Richard Wright MD1; Oscar Trujillo, MD3; Bryan Ambro, MD1
1University of Maryland Medical Center, 3Weil Cornell Medical Center
ABSTRACT
Objectives: Present a case of a MRSA nasal
abscess after elective septorhinoplasty.
Discuss the role for MRSA screening and
decolonization prior to elective
septorhinoplasty.
Methods: We will present the case of a patient
who underwent elective septorhinoplasty
complicated by a nasal abscess. Current
literature regarding MRSA surgical site
infections and role for preoperative
decolonization is discussed.
Results: A 33 year-old male with nasal airway
obstruction underwent open functional
septorhinoplasty. Mupirocin-coated intranasal
splints were placed, and he received seven
days of oral cephalexin. Six days postoperatively, he presented with a nasal
abscess. He was taken to the OR for washout
and debridment. Six months post-operatively
he underwent revision septorhinoplasty. He
was treated pre-operatively with intranasal
Mupirocin ointment for two weeks and
chlorhexidine body washes. He experienced
no further infectious complications. Despite
MRSA being a well-documented cause of
surgical infections, there are few reports of
such infections in septorhinoplasty. There are
no clear guidelines regarding the role of MRSA
screening and decolonization prior to
septorhinoplasty.
Conclusion: Despite the well-documented role
of MRSA in surgical site infections in other
specialties, such infections following
septorhinoplasty are extremely rare with only
one previously published case. We will present
a case of a nasoseptal abscess causing
significant morbidity following elective
functional septorhinoplasty. This case
highlights the need for research and guidelines
regarding the utility of MRSA screening and
decolonization prior to elective
septorhinoplasty.

CONTACT
Kate Perry
University of Maryland Medical Center
kperry@smail.umaryland.edu
Poster Design & Printing by Genigraphics - 800.790.4001

INTRODUCTION
MRSA is a well-known cause of morbidity and mortality and is the
predominant causative organism of skin and soft tissue infections.
Surgical site infections due to MRSA have been well described in the
literature in patients undergoing vascular surgery, cardiac surgery, and
orthopedic surgery.1 MRSA-related surgical site infections following
rhinological surgery, however, are extremely rare, with only one
published case of a MRSA abscess following rhinoplasty, 2 and one
small series of MRSA-related sinusitis following endoscopic sinus
surgery.3 We describe a case of a nasoseptal abscess presenting six
days following an open septorhinoplasty performed for correction of
nasal airway obstruction. Bacterial culture at the time of surgical incision
and drainage revealed MRSA as the causative organism.

METHODS AND MATERIALS

We will discuss a case of a nasoseptal abscess presenting six days
after septorhinoplasty causing significant morbidity.

RESULTS
A 33 year-old Caucasian male was referred to the Otolaryngology
department for evaluation of severe bilateral nasal airway obstruction.
The patients past medical history was significant only for an
intracranial astrocytoma. He did not have any apparent risk factors for
MRSA colonization. Upon physical examination he was found to have
septal deviation, internal nasal valve narrowing, dynamic external nasal
valve collapse, and inferior turbinate hypertrophy. The patient
underwent a functional septorhinoplasty via an open trans-columellar
approach, including left-sided spreader graft, bilateral alar batten grafts,
a columellar strut graft, and submucous resection of the inferior nasal
turbinates. Grafts were fashioned from harvested septal cartilage. At
the end of the procedure bilateral Doyle splints coated in Mupirocin
ointment were placed intranasally, and an external nasal splint was
applied. The patient was discharged to home the evening of surgery on
seven days of oral cephalexin. On post-operative day six, he presented
to the Otolarygology clinic with a two-day history of subjective fever,
facial discomfort and nasal pressure. On physical examination the
patient was afebrile with normal vital signs, and was found to have a
tender, edematous and erythematous nasal dorsum. Needle aspiration
of the nasal soft tissues produced frank purulence that was sent for
culture and sensitivities. After the intranasal splints were removed,
examination of the septum did not reveal mucosal bulging or fluctuance
indicative of septal abscess. He was admitted to the hospital for
intravenous antibiotics and operative drainage and washout. All labs
obtained on admission were within normal limits, including a white blood
cell count of 8.7K.
Broad-spectrum antimicrobial therapy was initiated, consisting of
Ampicillin/Sulbactam at a dose of 3g intravenously every six hours. A
CT scan was obtained to delineate the extent of the abscess, which
demonstrated the collection to now extend into the septum.

RESULTS
The patient was taken to the operating room for incision and drainage of
a nasal soft tissue and septal abscess by partially reopening the left
marginal and left hemitranfixion incisions. A significant amount of
purulent fluid was evacuated from the surgical site and sent for culture.
At the time of operative exploration the previously placed septal
cartilage grafts and a significant portion of the remaining septal cartilage
appeared non-viable and were removed. The abscess cavity was
copiously irrigated with a Clindamycin containing solution. The incisions
were loosely closed with Penrose drains in place, and Mupirocin-coated
silastic splints were placed intranasally. Bacterial culture revealed
MRSA to be the causative organism. The Infectious Disease service
was consulted, and recommended Vancomycin at 15mg/kg twice daily.
Based on culture sensitivities the patient was then treated as an
outpatient with Daptomycin 8mg/kg intravenously for two weeks,
followed by Linezolid 600 mg by mouth twice daily for one week. The
patient experienced no further infectious complications.
Postoperative follow-up visits demonstrated progressive bilateral nasal
airway obstruction and external saddle nose deformity with mid-vault
collapse resulting in severe bilateral airway obstruction. At six months
post-op it was felt that the saddling had reached its maximum, and
revision surgery was offered. Based on recommendations from the
Infectious Disease service, the patient was treated with intranasal
Mupirocin ointment twice a day for two weeks, as well as once a day
chlorhexidine body washes for one week prior to revision surgery. A
single dose of intravenous Vancomycin was administered 30 minutes
preoperatively. Revision rhinoplasty was carried out using costal
cartilage to fashion a tongue-and-groove L-strut complex consisting of a
dorsal onlay graft, and bilateral batten grafts. Mupirocin-cotaed Doyle
splints and an external nasal splint were applied. He was discharged to
home on the evening of surgery, and completed a ten-day course of
oral Bactrim DS to cover for MRSA. To date he has recovered well from
revision surgery without further infectious complications.

DISCUSSION

CONCLUSIONS

In general, post-operative infectious complications following

septorhinoplasty are uncommon, occurring in less than 2% of cases.4
One suggested explanation for this low incidence is the highly vascular
nature of the nose and septum.4 Specifically, surgical-site infections in
rhinoplasty patients due to MRSA are extremely rare despite the fact
that the prevalence of MRSA colonization is increasing among the
general population, and the nares are the primary bacterial reservoir in
MRSA carriers.5 To our knowledge, there is only one other report in the
literature, and this occurred over 25 years ago.

At this time, there is no consensus recommendation among the

otolaryngology community regarding pre-operative MRSA screening for
patients undergoing nasal surgery. Some have suggested screening
those at high risk for colonization, although this is not widely practiced.
Given the low cost of screening for nasal MRSA carriage and the
efficacy of nasal decolonization with topical antibiotic therapy, these
steps may be justified in order to prevent similar infectious
complications in future patients, although further research in this area is
needed.

In response to the increasing incidence of MRSA colonization and the

severity of MRSA surgical site infections, surgeons have sought to
reduce these infections by screening patients for MRSA carriage
preoperatively. Numerous publications have demonstrated a decrease
in the number and severity of surgical-site infections following the
implementation of MRSA screening and targeted preoperative
decolonization, combined with appropriate choice of anti-MRSA
intraoperative antibiotics. To our knowledge, there have been no
prospective studies investigating the role of MRSA decolonization in
patients undergoing nasal surgery.

REFERENCES

This case of a severe infectious complication caused by MRSA

following septorhinoplasty raises a number of important questions.
Could pre-operative screening for MRSA followed by decolonization
have prevented this complication and need for revision surgery? Can
the lessons learned from other surgical specialties be applied to the
field of rhinological surgery? Or does the low incidence of postoperative infections following rhinoplasty, prevent screening and
decolonization in this patient population from being cost-effective?

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Figure 1.
Axial CT scan demonstrating nasoseptal
abscess
Figure 2.
Coronal CT scan demonstrating nasoseptal
abscess
Figure 3.
Six months post incision and drainage of
nasoseptal abscess demonstrating saddle
nose deformity
Figure 4.
Six months post costal cartilage graft
nasal reconstruction
Figure 1.

Figure 2

Figure 3

Figure 4