Nasal Cellulitis

Nasal cellulitis is infection of the skin and subcutaneous tissue of the external nose and nasal vestibule, usually by Staphylococcus aureus or streptococci after nose picking, piercing, trauma, folliculitis or vestibulitis. Venous drainage through the angular vein to the cavernous sinus makes the nose part of the danger triangle of the face.

• Risk factors: nasal carriage of S. aureus, diabetes, HIV, nose picking, nasal surgery, piercing, furunculosis.

Painful, red, swollen tip or side of the nose with crusting at the nostril, fever and tender submandibular nodes; furuncle with a pustule.

• Differential diagnosis: nasal vestibulitis, furuncle, nasal septal abscess or haematoma, erysipelas, herpes simplex, rosacea (rhinophyma), lupus pernio, nasal fracture, NK/T cell lymphoma, mucormycosis, leishmaniasis.
• Complications: abscess, nasal septal abscess and cartilage necrosis (saddle deformity), cavernous sinus thrombosis, orbital cellulitis, meningitis, brain abscess, sepsis.

Clinical.

• Nasal swab and pus culture; full blood count, CRP, blood cultures if febrile; glucose, HIV test.
• CT or MRI with venography if orbital signs, headache, drowsiness or cranial nerve palsies.
• Examine the septum for haematoma or abscess.

Antibiotics, no squeezing, and decolonisation.

• Supportive: warm compresses, analgesia (paracetamol 1 g), no picking or squeezing, elevate the head, cut nails short.
• Pharmacological: mild: mupirocin 2 percent ointment to the nostril three times daily for 7 days with flucloxacillin 500 mg four times daily for 7 days (cefalexin or clindamycin 300 mg three times daily if allergic). Moderate or severe: flucloxacillin 2 g IV every 6 hours; MRSA: vancomycin 15 to 20 mg/kg IV every 12 hours. Cavernous sinus thrombosis: ceftriaxone 2 g IV every 12 hours with vancomycin and metronidazole 500 mg IV every 8 hours for 3 to 4 weeks, with anticoagulation under specialist care. Recurrent carriage: mupirocin 2 percent twice daily for 5 days with chlorhexidine 4 percent wash.
• Procedures: drainage of septal abscess urgently (to protect cartilage); incision of furuncle.
• Special groups: pregnancy, flucloxacillin and mupirocin are acceptable; children, flucloxacillin 12.5 to 25 mg/kg four times daily and low threshold to admit; diabetes and HIV, admit for IV therapy.
• Red flags: eyelid oedema, proptosis, headache, drowsiness, rapid spread, septal swelling, fever above 39 degrees Celsius.
• Follow-up: review at 24 to 48 hours; decolonise carriers; ENT review for septal complications.