Nasal Tip Abscess in Diabetes: A Rare Encounter

ABSTRACT

Most nasal infections resolve with local mupirocin and oral antibiotics, without requiring surgical intervention. However, in this case, a well‐formed abscess was already present, necessitating prompt surgical drainage along with appropriate antibiotics and strict glycemic control to prevent complications and preserve nasal form and function.

1. Introduction

The nose is a complex anatomical structure that plays a vital role in both facial aesthetics and respiratory function [1]. The nasal tip, in particular, is highly susceptible to infection due to its rich vascular supply, dense sebaceous glands, and hair follicles [2]. Infections involving the nasal tip commonly present with acute localized swelling, erythema, pain, and tenderness and may significantly compromise both function and appearance if not managed promptly [3]. Nasal furunculosis is among the most frequent causes of nasal tip infection and is typically caused by Staphylococcus aureus . It presents as a painful, erythematous swelling that may become fluctuant due to pus formation. Predisposing factors such as diabetes mellitus increase susceptibility by impairing host immune responses [4]. Nasal abscesses may also develop following trauma, surgery, or inflammatory conditions and often involve deeper soft tissues, increasing the risk of complications. The Rudolph sign—characterized by diffuse erythema and swelling of the nasal tip, sometimes extending to the columella—is a useful clinical indicator of nasal vestibular infection [5]. Associated symptoms such as fever, pain, and purulent discharge warrant prompt evaluation to exclude conditions such as cellulitis or abscess formation. While Staphylococcus aureus remains the predominant pathogen, infections may also involve Gram‐negative organisms or anaerobes, particularly in post‐surgical or foreign body–related cases [6].

Surgical procedures, including rhinoplasty and thread rhinoplasty, can predispose patients to nasal tip infections due to tissue manipulation or reactions to implanted materials such as sutures or grafts. Management depends on the severity and extent of infection and typically involves systemic antibiotics, with incision and drainage reserved for abscesses or deep‐seated infections. Imaging modalities such as contrast‐enhanced computed tomography are valuable in assessing disease extent and guiding surgical planning [7, 8]. Early diagnosis and timely intervention are essential to prevent complications such as nasal deformity, septicemia, or airway compromise [4]. This case study presents the management of a severe nasal tip infection in a diabetic patient, emphasizing clinical presentation, diagnostic evaluation, surgical treatment, and the importance of postoperative care and long‐term follow‐up.

2. Case History/Examinations

A 63‐year‐old male patient with a history of recently diagnosed uncontrolled type‐2 diabetes mellitus presented with worsening symptoms of pain, swelling, and redness of the nose (Figure 1). Initially, the patient sought treatment from a local pharmacist, where he was prescribed oral medications for presumed nasal irritation or mild infection. However, despite this treatment, the symptoms progressively worsened, prompting the patient to seek medical attention at the otolaryngology and head and neck surgery outpatient department for further evaluation.

FIGURE 1.

Pre‐operative image showing swelling and redness of the nose.

On clinical examination, the most notable finding was a significant swelling at the tip of the nose, which was red, warm to the touch, and tender. The erythema, often referred to as the “Rudolph sign,” extended from the nasal tip to the root of the nose, indicating the spread of inflammation across the nasal structures. The swelling was characterized by fluctuating consistency, suggesting the presence of an abscess or pus collection. Further examination revealed asymmetric nasal vestibules, indicating localized distortion, along with a deviated and edematous columella. The nasal septum was also noted to be deviated to the right, likely due to the surrounding swelling. Additionally, edema was evident in the Cottle‐I area, an anatomical region of the nose that includes the lower lateral cartilages and their surrounding structures. These clinical signs suggested a severe infection involving the nasal structures, possibly with a risk of spreading to deeper tissues or causing complications such as cartilage damage.

3. Methods (Differential Diagnosis, Investigations, and Treatment)

The differential diagnosis considered for this patient included several possibilities. The most likely diagnosis was an infectious etiology, particularly a nasal furuncle or abscess. These conditions are often caused by Staphylococcus aureus , a bacterium that can be particularly problematic in patients with diabetes due to their predisposition to infection. The patient's fluctuating consistency and the presence of purulent material suggested a collection of pus, which supported the possibility of an abscess. Other potential diagnoses included rhinophyma, a chronic condition that causes thickening and enlargement of the nasal skin due to rosacea, but this condition usually develops gradually and is less likely to cause acute pain and fluctuating swelling. Nasal trauma or a foreign body reaction could have caused similar symptoms, but the patient's history did not support this, and there were no indications of prior nasal injury. Cellulitis of the nasal soft tissues, potentially complicating an untreated nasal infection, was also considered, but the localized nature of the swelling and the characteristic fluctuating consistency pointed more toward an abscess.

To assess the full extent of the condition and evaluate for possible complications, a contrast‐enhanced computed tomography (CECT) of the head was performed. The CT scan helped assess the involvement of deeper nasal and facial structures, providing a clearer view of the extent of the infection and any potential spread to surrounding tissues. The scan confirmed that the infection was confined to the nasal structures, without evidence of extension to the sinuses or deeper facial structures (Figure 2).

FIGURE 2.

CECT showing radiological evidence of nasal tip abscess.

Laboratory investigations revealed a white blood cell count of 14.2 × 10³/μL, with a predominance of neutrophils (85%), indicating an ongoing bacterial infection. Hemoglobin was 10.20 g/dL, and hematocrit and platelet counts were all within normal limits, suggesting no significant blood loss or coagulopathy. The fasting glucose level of 210 mg/dL confirmed that the patient's diabetes was poorly controlled, which likely contributed to the severity of the infection. Anti‐HIV antibodies were negative, ruling out HIV as a complicating factor. Purulent material was aspirated from the tip and columella septum and sent for culture and sensitivity testing to guide antibiotic selection.

Given the severity of the infection and the potential for further complications, the treatment approach involved surgery. A modified right Hemi‐transfixion incision was made, extending up to the roof of the nasal cavity to provide access to the infected areas. This approach allowed for more extensive drainage of the abscess while minimizing the risk of damage to the underlying nasal structures. Soft‐tissue pockets containing purulent material were accessed, and blunt dissection was performed over the alar cartilages, columella, nasal tip, and dorsum, ensuring that the cartilage and delicate nasal structures were preserved. After the abscess was drained and debrided, the wound was irrigated with antiseptic betadine solution to help reduce bacterial load and prevent further infection. The wound was left open for continued irrigation and secondary closure, which allows for better drainage and healing. Nasal packing and strapping were applied to manage edema and help stabilize the nasal structures during the healing process. The patient was started on intravenous antibiotics consisting of amoxicillin, metronidazole, and ciprofloxacin to cover a broad range of potential pathogens, including both aerobic and anaerobic bacteria. Daily debridement and wound lavage were carried out for 3 days before the patient was discharged on the 10th postoperative day.

4. Results and Conclusions (Outcome and Follow‐Up)

The culture of the purulent material aspirated during the procedure confirmed the presence of Staphylococcus aureus , which was sensitive to the antibiotics administered. The patient showed no signs of infection recurrence or complications during his hospital stay or follow‐up visits (Figure 3). His condition improved steadily after surgery, with no further complications related to wound healing or infection.

FIGURE 3.

Follow‐up image showing no signs of infection.

At 6 months of follow‐up, the patient remained asymptomatic, with no signs of nasal deformity or significant scarring. Both the skin and cartilage of the nose were intact, and there was no evidence of damage or long‐term complications such as tissue necrosis or abnormal scarring. The nasal function was preserved, and the patient did not report ongoing nasal obstruction or discomfort. The patient's diabetes was better managed after the initial episode, and regular follow‐up ensured tighter control of his blood glucose levels, which likely contributed to the favorable outcome.

This case highlights the importance of early intervention in severe facial and nasal infections, especially in patients with underlying conditions such as diabetes, which can compromise immune function and increase the risk of more complicated infections. The surgical intervention, combined with appropriate antibiotic therapy and close post‐operative care, proved successful in resolving the infection and preserving nasal function. The patient's full recovery without any residual deformity or scarring underscores the importance of prompt and effective treatment in preventing long‐term complications. It also demonstrates that with appropriate management, even complicated infections can have favorable outcomes.

5. Discussion

This case presents an unusual but clinically significant example of a nasal abscess involving the tip of the nose in a patient with poorly controlled type‐2 diabetes mellitus. The novel aspect of this case lies not only in the severity of the infection but also in the timely intervention and management that resulted in a favorable outcome without complications or deformities. The patient's presentation of Rudolph sign and fluctuating consistency at the nasal tip, suggestive of an abscess, was promptly diagnosed and treated with a combined approach of surgical drainage and antibiotic therapy. This case stands out in the context of the existing literature for several reasons, including the rare occurrence of a severe nasal abscess in a diabetic patient and the use of an extensive Hemi‐transfixion incision to drain the abscess, which helped avoid damage to underlying nasal structures.

The management of nasal abscesses typically involves prompt incision and drainage (I&D) to avoid complications like septicemia or cartilage necrosis. This case highlights how early intervention, coupled with effective antibiotic therapy, can result in a positive outcome, even in patients with chronic comorbid conditions like diabetes mellitus. While Staphylococcus aureus remains the most common causative pathogen of nasal furuncles and abscesses, the case underscores the complexity of managing infections in diabetic patients, who are often immunocompromised and at a higher risk of developing more severe infections or delayed wound healing [1, 2].

The patient's condition was complicated by poor glycemic control, which is known to impair immune function, reducing the body's ability to fight infections and increasing susceptibility to bacterial colonization. Diabetic patients are also more likely to develop infections that are difficult to manage due to microvascular damage, impaired neutrophil function, and increased levels of circulating glucose, which provide a favorable environment for bacterial growth. Therefore, controlling blood sugar levels is paramount in preventing infections in diabetic patients. While there are numerous reports of nasal infections in diabetic patients, this case emphasizes the critical role of timely intervention and the need for multidisciplinary management in such cases [3].

In comparison with other reported cases of nasal abscesses and furuncles, this case adds significant value due to its emphasis on both the surgical and medical aspects of treatment. For instance, Teymoortash et al. reported a case of a nasal tip abscess due to a reaction to prolene sutures used during a rhinoplasty procedure. Although the pathophysiology differed—being related to a foreign body response rather than an infection caused by a pathogen—the clinical presentation of pain, swelling, and erythema at the nasal tip was similar [9]. However, the approach in this case, which involved surgical drainage and debridement, was more aggressive and required careful dissection to preserve underlying cartilage. This differed from other cases, where less invasive management or antibiotics alone were sufficient.

Similarly, rhinophyma, a condition often mistaken for a simple infection, can cause significant thickening and swelling of the nasal tip, leading to complications if left untreated. While rhinophyma was considered in the differential diagnosis, the patient's acute symptoms and fluctuating abscess were distinct, making the diagnosis of a bacterial abscess more likely. A case of nasal furunculosis reported by Bakshi emphasized how early recognition and antibiotics could effectively manage these infections before they progressed to more serious complications [5]. In contrast, this patient required more extensive surgical intervention, reflecting the severity of the infection and the need to fully drain the abscess.

In a similar vein, Jaafar reported a nose abscess following thread rhinoplasty, a procedure that has gained popularity in aesthetic surgery but carries its own risks of infection. The abscess in this case was managed conservatively with antibiotics [7]. The severity of infection in our case, however, warranted more invasive management to avoid structural damage to the nasal framework, showing a clear distinction in severity compared to other aesthetic‐related abscesses. Furthermore, the use of a Hemi‐transfixion incision for drainage, as done in this case, provides a more thorough surgical approach for draining larger abscesses, something that may not always be indicated in milder cases.

In contrast to these cases, the patient's diabetes mellitus played a central role in both the diagnosis and treatment strategy. Studies have shown that diabetic patients are at a higher risk for skin and soft‐tissue infections (SSTIs), particularly those caused by Staphylococcus aureus , due to their compromised immune response [6]. Moreover, the patient's history of poor glycemic control made the infection more difficult to manage and raised concerns about delayed wound healing. In fact, delayed healing and recurrence of infection are frequent concerns in diabetic patients, especially those with uncontrolled blood sugar levels. Therefore, an aggressive treatment plan, including regular debridement and daily wound lavage, was implemented to mitigate these risks [8].

The modified right Hemi‐transfixion incision used in this case is worth discussing for its utility in managing nasal abscesses. This incision is typically employed in more complex cases, allowing greater access to deeper tissue pockets. While other reports, such as those by Lee and Jaafar, focus on less invasive approaches to drainage, this case highlights the importance of a thorough surgical approach when dealing with severe abscesses that involve multiple nasal structures, such as the columella, alar cartilages, and the septum [4]. The decision to leave the wound open for secondary closure was made to allow for continued drainage and prevent the accumulation of pus, reducing the risk of abscess recurrence [5].

6. Conclusion

This case of nasal abscess in a diabetic patient underscores the importance of early diagnosis and intervention in preventing complications such as septicemia, cartilage necrosis, and permanent nasal deformities. The novel aspect of this case lies in the combination of surgical intervention with aggressive antibiotic therapy, which resulted in a favorable outcome without the risk of long‐term deformities or scarring. Comparisons with other reported cases of nasal infections reveal a trend toward less invasive management in milder cases, but the aggressive approach taken here, combined with careful postoperative care, highlights the importance of tailored management strategies, particularly in diabetic patients. This case serves as a reminder of the need for timely intervention and vigilant management of underlying comorbidities to prevent the progression of severe infections.

Author Contributions

Sushil Raj Shrestha: conceptualization, writing – original draft. Shiva Bhusan Pandit: conceptualization. Rahul Mahato: conceptualization. Diwash Sunar: conceptualization. Ashish Raj Bista: writing – original draft. Sajjad Ahmed Khan: writing – original draft, writing – review and editing. Shubu Parajuli: writing – original draft.

Funding

The authors have nothing to report.

Consent

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data will be provided by the corresponding author upon reasonable request. Images uploaded in the separate files.