FIRST CLINICAL CASE REPORT An unusual cause of necrosis and nasal septum perforation after septoplasty: Enterobacter cloacae M. Binar 1 , F. Arslan 1 , H. Tasli 1 , O. Karakoc 1 , A. Kilic 2 and U. Aydin 1 1) Department of Otolaryngology, Head and Neck Surgery and 2) Department of Medical Microbiology, Gulhane Military Medical Academy, Ankara, Turkey Abstract A 20-year-old man with nasal obstruction underwent septoplasty due to nasal septal deviation. Nasal packs were inserted at the end of surgery and removed 48 hours after surgery. Twenty-four hours after removal of nasal packs, there was necrosis in both sides of septal mucosa and in bilateral inferior turbinates. Nasal swab culture was performed from both nasal cavities. Enterobacter cloacae was isolated from samples. Two weeks after surgery, nasal septum perforation was unavoidable. To our knowledge, this is the first case in literature describing septal mucosal necrosis caused by this pathogen after septoplasty. Mucosal necrosis and perforation as septoplasty complications should be kept in mind, the result of causes both common and, as in the present case, unusual. New Microbes and New Infections © 2015 The Authors. Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases. Keywords: Antibiotics, Enterobacter cloacae, necrosis, septal perforation, septoplasty Original Submission: 24 March 2015; Revised Submission: 2 July 2015; Accepted: 7 July 2015 Article published online: 16 July 2015 Corresponding author: M. Binar, Department of Otolaryngology, Head and Neck Surgery, Gulhane Military Medical Academy, Etlik 06018, Ankara, Turkey E-mail: mbinar4@yahoo.com Introduction Septoplasty is one of the most performed surgical procedures in rhinology practice, and complications after this surgery are well known. Bleeding, septal hematoma, septal perforation and synechial bands can occur after surgery, although most of these are easy for surgeons to overcome [1,2]. Rare but severe complications such as toxic shock syndrome, endocarditis, osteomyelitis, meningitis and cavernous sinus thrombosis have been described after septoplasty [3,4]. Prophylactic antibiotics are usually sufficient for preventing postoperative infections, but sometimes different pathogens can cause difficult situations for both surgeon and patient. In this report, we present the case of a patient who underwent septoplasty, which was complicated by tissue necrosis and nasal septal perforation by an unusual pathogen, Enterobacter cloacae. Case Report A 20-year-old man with severe nasal obstruction applied to our Otolaryngology, Head and Neck Surgery Department. After rhinoscopic examination and detailed endoscopic eval- uation, septal deviation was diagnosed and a septoplasty pro- cedure offered. The surgery was performed under general anaesthesia following standard sterilization procedures. A Killian incision was preferred for septal deviation, and nasal packs (Merocel standard nasal dressing; Medtronic Xomed, Jacksonville, FL, USA) were inserted into the nasal cavities at the end of surgery. A single dose of 1 g cefazolin iv was administrated on the evening of the day of the operation, and a 2 × 500 mg dose of cefuroxime axetil was provided for the next 7 days. Forty-eight hours after surgery, the Merocel packs were removed. The first thing we observed after the packs’ removal was oedema of the nasal mucosa and turbinates, as is routinely seen after nasal septal surgery. No perforation of the nasal septum was observed. Twenty-four hours after removal, there were nasal purulent discharge and color change of mu- cosa to greyish on both sides of septum and in the inferior turbinates (Fig. 1A, B). New Microbe and New Infect 2015; 8: 150– 153 New Microbes and New Infections © 2015 The Authors. Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) http://dx.doi.org/10.1016/j.nmni.2015.07.002