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Perforated Nasal Septum

Septal Perforation

A perforated nasal septum is a condition caused by a number of iatrogenic, traumatic, infectious events. It is a clinical diagnosis, however, the etiology may be more challenging to determine.


Presentation

Perforated nasal septum (PNS) can occur due to different reasons like infection, trauma, and inhalation of substances. The majority of patients presenting with septum perforation experience no symptoms [1]. Perforations can either be anterior or posterior and anterior ones are more likely to be symptomatic than the posterior defects [2] [3]. Furthermore, the size of the perforation also plays a role in the presentation [4]. Frequent complaints include wheezing, epistaxis, nasal obstruction, olfactory dysfunction, and pain. Scabs and crusting can be seen. In the case of a small perforation, or uninterrupted hydration of the septum, symptoms are likely to be less severe. Patients may experience whistling sounds during respiration.

Ultimately PNS results from disruption of perfusion of the septal area, leading to ischemia and tissue necrosis. Iatrogenic causes are common and can be due to various surgical procedures, indwelling nasogastric tubes and nasal packing [1] [5]. Traumatic events such as excessive nose picking, injury by foreign bodies and nasal fractures have been described [6].

PNS has been associated with the chronic use of inhaled substances, such as cocaine and nasal decongestants, which over time lead to perforation due to local vasoconstriction [2]. The long-term use of steroids has also been linked to PNS, and the concomitant intake of both steroids and decongestants compounds the risk [4] [7]. Females are more affected by this [8]. Occupational exposure to some industrial chemicals such as cement dust, platinum salts, arsenic, and mercury leads to PNS.

Syphilis, human immunodeficiency virus (HIV) infection and tuberculosis are among the many bacterial, fungal and viral diseases that can affect the airway and predispose to PNS [6]. In some parts of the world, leprosy is still prevalent and is an acknowledged etiology of PNS. There are systemic inflammatory conditions that contribute to the occurrence of PNS, and these are systemic lupus erythematosus (SLE), Wegener's granulomatosis and sarcoidosis [9]. Malignancies are another factor in the development of a perforation, notably squamous cell carcinoma [4].

Severe Pain
  • Severe pain. Mild pain is expected. Pus. A foul smell coming from the nose. A persistent headache. Sometimes the perforation may reopen and need another surgery.[healthlinkbc.ca]
Falling
  • The longer healing process is going to involve seeking professional psychiatric assistance in beating my skin picking disorder so my nose doesn’t fall apart again.[themighty.com]
  • The whistling has stopped but now my septum is sore and I live everyday wondering if it will fall out. My septum without the plug is unbelievably uncomfortable to live with.[plasticsurgery4u.com]
Camping
  • Seven months later, in July 2015 during a camping trip for the 4th of July, I discovered I could whistle through my nose. After about 30 minutes of thinking this was a cool party trick, panic set in.[themighty.com]
Weakness
  • However, the main weakness of this approach is limited by the amount of surrounding tissue in the nose.[shahfacialplastics.com]
Increased Susceptibility to Infections
  • Symptoms range in type and severity depending on the location and size of the perforation from whistling, foul smelling nasal discharge, nasal crusting, nose bleeds, obstructed nasal breathing, snoring, increase susceptibility to infections, and nasal[perforatedseptum.com]
Dry Skin
Epistaxis
  • , difficulty breathing, nasal pressure, and discomfort Rhinorrhea Epistaxis Infection OPTIONS TO FIT Available in multiple round and oval shapes, sizes and thicknesses.[inhealth.com]
  • Crusting around the margins and repeated epistaxis, which can be severe, may result. Small perforations may whistle. Anterior rhinoscopy or fiberoptic endoscopy can be used to view septal perforations.[msdmanuals.com]
  • Iatrogenic trauma includes a history of septoplasty, nasal packing or cauterization for epistaxis, and nasotracheal intubation. Medication usage should be reviewed.[emedicine.medscape.com]
  • Symptoms include a nasal discharge, nasal congestion (loss of laminar airflow associated with a septal perforation causes symptoms of nasal congestion), nasal whistling sound (heard in persons with small anterior septal perforations), epistaxis and nasal[radiopaedia.org]
  • The symptoms associated with septal perforations include nasal congestion or obstruction, nasal crusting and drainage, recurrent epistaxis, and a whistling sound from the nose. Many perforations do not need to be closed.[drpaulose.com]
Excitement
  • An exciting new development in septal perforation repair is the use of the PDS plate, approved by the FDA in 2010. This is a very thin (0.15 mm), perforated plate which dissolves slowly over a few months.[realself.com]
Insomnia
  • I am on claritin D which helps temporarily but keeps me awake ( insomnia side effect). I would like to get another opinion. should I request my records?? Is this normal or could it be malpractice? Please advise. signed, Desparate Dr.[plasticsurgery4u.com]

Workup

Diagnosis of a perforated nasal septum is by visualization of the defect on physical examination. Rhinoscopic exploration is needed to determine the extent of the lesion. Further investigation is warranted in order to reveal the underlying disease process. This is achieved by first obtaining a thorough patient history [10]. Other laboratory and imaging studies may be carried out, and the choice of test is guided by clinical suspicion based on all the symptoms that a patient may present with [11]. The following are examples of such tests:

  • Full blood count, inflammatory and rheumatic markers such as erythrocyte sedimentation rate (ESR), antineutrophil cytoplasmic autoantibody (ANCA), rheumatoid factor: These are useful in granulomatous, systemic inflammatory and rheumatic conditions.
  • Toxicology and drug screens: This helps to obtain information on substance use or exposure.
  • Specific tests for certain diseases, for example, syphilis.
  • Biopsy: To analyze the tissue for signs of infection or malignancy, if suspected.
  • Chest X-ray: Obtained if signs of tuberculosis or sarcoidosis are present.
  • Computerized tomography (CT) scan: May be conducted if granulomatous disease suspected.

Treatment

  • Treatment and prognosis Information on the size and position of the perforation is important when planning treatment. Small perforations are often repaired with different approaches and techniques than larger perforations.[radiopaedia.org]
  • Treatment can range from rinsing with a saline solution to complex surgery.[zwivel.com]
  • Septal Perforation Surgery: A nasal septal prosthesis or button may be placed as a temporary or permanent treatment. This prosthesis fits into the perforation to improve nasal airflow.[drdavidbrayjr.com]
  • After a thorough evaluation, our surgeons will discuss treatment options with you and help you decide which treatment option is best for you. All of our physicians are affiliated with Raleigh Capitol Ear, Nose & Throat.[raleighsinuscenter.com]

Prognosis

  • Treatment and prognosis Information on the size and position of the perforation is important when planning treatment. Small perforations are often repaired with different approaches and techniques than larger perforations.[radiopaedia.org]
  • After four years from diagnosis the patient’s prognosis was good without complications.[tmj.ro]

Etiology

  • In some parts of the world, leprosy is still prevalent and is an acknowledged etiology of PNS.[symptoma.com]
  • Pictures of Septal Perforation This page was last updated: October 4, 2014 The etiology of nasal septal perforations can be classified into the following 4 main categories: traumatic, iatrogenic, inflammatory/malignant, and cocaine use.[ghorayeb.com]
  • Posterior perforations are less likely to cause symptoms; therefore, patients with these perforations may only need a focused search for an etiology and conservative observational treatment.[radiopaedia.org]
  • Although the etiology of NSP is overwhelmingly iatrogenic, there is an association with a number of medical diseases in addition to use of illicit drugs and/or prescription nasal sprays.[ncbi.nlm.nih.gov]
  • One common etiology associated with septal perforation is corrective surgery for septal deviation (deviated septum). Figure 1: Schematic representation of the nasal cavity including the septum.[ohninewnose.com]

Pathophysiology

  • Pathophysiologic mechanisms of nasal septal perforation are ischemic, infectious or inflammatory. FUTURE PROSPECTS AND PROJECTS: Systemic disease may be suspected in unclear nasal septal perforation.[ncbi.nlm.nih.gov]
  • SEPTAL PERFORATION BRIEF FACTS This document briefly discusses the pathophysiology of septal perforations and the benefits of early septal perforation repair. Definition: Septal perforation is a hole in the nasal septum, caused by an injury.[perforatedseptum.com]

Prevention

  • Using a humidifier in a room helps to prevent dryness and formation of crust. Patients suffering from any kind of respiratory tract disease should be treated adequately and timely.[privatehealth.co.uk]
  • The nostrils should be frequently cleansed with saline solution to prevent bacterial and debris buildup. A gel is also recommended to maintain the nasal environment and prevent excessive crusting of the mucous membranes.[drsamrizk.com]
  • We must know the cause of the septal perforation to prevent further recurrence after treatment.[perforatedseptum.com]
  • The processed tissue matrix is preserved with a patented freeze-drying process that prevents damaging ice crystals from forming.[enttoday.org]
  • Also, some septal perforations can be hard to treat, so if you have a perforation, do everything you can to prevent it from worsening.[zwivel.com]

References

Article

  1. Tasca I, Compadretti GC. Closure of nasal septal perforation via endonasal approach. Otolaryngol Head Neck Surg. 2006; 135(6):922-927.
  2. Coleman Jr JR, Strong EB. Management of nasal septal perforation. Curr Opin Otolaryngol Head Neck Surg. 2000;8(1):58-62.
  3. Foda HM, Magdy EA. Combining Rhinoplasty with Septal Perforation repair. Facial Plast Surg. 2006;22(4):281-288.
  4. Metzinger SE, Guerra AB. Diagnosing and treating nasal septal perforations. Aesthet Surg J. 2005;25(5):524-529.
  5. Pedroza F, Patrocínio LG, Arevaldo . A review of 25-year experience of nasal perforation repair. Arch Facial Plast Surg. 2007;9(1):12-18.
  6. Re M, Paolucci L, Romeo R, Mallardi V. Surgical treatment of nasal septal perforations: our experience. Acta Otorhinolaryngol Ital. 2006;26(2):102-109.
  7. Døsen LK, Haye R. Nasal septal perforation 1981-2005. Changes in etiology, gender and size. BMC Ear Nose Throat Disord. 2007;7:1.
  8. Cervin A, Andersson M. Intranasal steroids and septum perforation - an overlooked complication? A description of the course of events and a discussion of the causes. Rhinology. 1998;36(3):128-132
  9. Baum ED, Boudousquie AC, Li S, Mirza N. Sarcoidosis with nasal obstruction and septal perforation. Ear Nose Throat J. 1998;77(11):896-898,900-902.
  10. Reed Group. Nasal Septal Perforation. MDGuidelines. http://www.mdguidelines.com/nasal-septum-perforation. Accessed May 22, 2017.
  11. Batniji RK, Chmiel JF. Septal Perforation - Medical Aspects. Medscape. http://emedicine.medscape.com/article/863325. Updated February 24, 2016. Accessed May 22, 2017.

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Last updated: 2019-07-11 20:43