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.
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 . Perforations can either be anterior or posterior and anterior ones are more likely to be symptomatic than the posterior defects  . Furthermore, the size of the perforation also plays a role in the presentation . 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  . Traumatic events such as excessive nose picking, injury by foreign bodies and nasal fractures have been described .
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 . The long-term use of steroids has also been linked to PNS, and the concomitant intake of both steroids and decongestants compounds the risk  . Females are more affected by this . 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 . 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 . Malignancies are another factor in the development of a perforation, notably squamous cell carcinoma .
Entire Body System
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. [myhealth.alberta.ca]
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]
Foul Smelling Discharge
Patients that seek help with septal perforations typically present with symptoms such as nasal obstruction, crusting, foul-smelling discharge, intermittent nasal bleeding and occasionally, a whistling sound when breathing through the nose. [neilmed.com]
Centers for Disease Control and Prevention Intersex (Medical Encyclopedia) [ Read More ] Nose Injuries and Disorders Also called: Nasal disorders Your nose is important to your health. [icdlist.com]
Acute and chronic nasal disorders. In JB Snow Jr, PA Wackym, eds., Ballenger's Otorhinolaryngology: Head and Neck Surgery, 17th ed., pp. 557–566. Hamilton, ON: BC Decker. [baltimorecity.md.networkofcare.org]
Acute and chronic nasal disorders. In JB Snow Jr, PA Wackym, eds., Ballenger's Otorhinolaryngology: Head and Neck Surgery, 17th ed., pp. 557-566. Hamilton, ON: BC Decker. [northshore.org]
skin on your hands. [enttx.com]
The subcutaneous nodule of rheumatoid arthritis. J. Pathol. Bacteriol. 1937, 45, 97. CrossRef Google Scholar 25. Bennett, G.A., Zeller, J.W., Bauer, W. Subcutaneous nodules of rheumatoid arthritis and rheumatic fever: A pathologic study. Arch. [link.springer.com]
Face, Head & Neck
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]
difficulty breathing, nasal pressure, and discomfort Rhinorrhea Epistaxis Infection OPTIONS TO FIT Available in multiple round and oval shapes, sizes and thicknesses. [inhealth.com]
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]
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 . 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 . 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.
- Tasca I, Compadretti GC. Closure of nasal septal perforation via endonasal approach. Otolaryngol Head Neck Surg. 2006; 135(6):922-927.
- Coleman Jr JR, Strong EB. Management of nasal septal perforation. Curr Opin Otolaryngol Head Neck Surg. 2000;8(1):58-62.
- Foda HM, Magdy EA. Combining Rhinoplasty with Septal Perforation repair. Facial Plast Surg. 2006;22(4):281-288.
- Metzinger SE, Guerra AB. Diagnosing and treating nasal septal perforations. Aesthet Surg J. 2005;25(5):524-529.
- Pedroza F, Patrocínio LG, Arevaldo . A review of 25-year experience of nasal perforation repair. Arch Facial Plast Surg. 2007;9(1):12-18.
- Re M, Paolucci L, Romeo R, Mallardi V. Surgical treatment of nasal septal perforations: our experience. Acta Otorhinolaryngol Ital. 2006;26(2):102-109.
- Døsen LK, Haye R. Nasal septal perforation 1981-2005. Changes in etiology, gender and size. BMC Ear Nose Throat Disord. 2007;7:1.
- 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
- 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.
- Reed Group. Nasal Septal Perforation. MDGuidelines. http://www.mdguidelines.com/nasal-septum-perforation. Accessed May 22, 2017.
- Batniji RK, Chmiel JF. Septal Perforation - Medical Aspects. Medscape. http://emedicine.medscape.com/article/863325. Updated February 24, 2016. Accessed May 22, 2017.