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].

• 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]

• Asymptomatic

  We present a case of asymptomatically nasal septum perforation in a 46-year-old woman, patient diagnosed with systemic lupus erythematosus two years previously. [tmj.ro]

  Asymptomatic forms are frequent. Biopsy of nasal septum is poorly useful for the diagnosis except when granuloma or vasculitis is found. Pathophysiologic mechanisms of nasal septal perforation are ischemic, infectious or inflammatory. [ncbi.nlm.nih.gov]

  Technologies A nasal septal perforation can vary in size and location, and it may be asymptomatic or cause a variety of symptoms. [inhealth.com]

  In some patients who are asymptomatic, or the perforation is posteriorly located medical treatment with nasal saline, gels can be helpful. [shahfacialplastics.com]

  CONSUMERS: Click here for the Consumer Version Topic Resources Deviations of the nasal septum due to developmental abnormalities or trauma are common but often are asymptomatic and require no treatment. [msdmanuals.com]

• Surgical Procedure

  Iatrogenic causes include nasal surgical procedures (prior septal surgery is the most common cause of septal perforations) and nasal intubation or nasogastric tube placement. [doctorsgates.blogspot.com]

  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. [symptoma.com]

  Given the proper surgical procedure and appropriate post-operative care, you can anticipate a successful result, and return your nose to a closer-to-normal physiologic state. [fairbanksplasticsurgery.com]

  Septoplasty is the preferred surgical treatment to correct a deviated septum. This procedure is typically not performed on young children, unless the problem is severe, because facial growth and development are still occurring. [entnet.org]

• 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]

• Anemia

  Hematologic disorders (hemolytic anemia or leukopenia or lymphopenia or thrombocytopenia); 10. Immunologic disorders (anti-dsDNA or anti-Sm or antiphospholipid antibodies); 11. Antinuclear antibodies. [tmj.ro]

• Nasal Disorder

  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. [northshore.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. [uwhealth.org]

• Sore Throat

  Since 1960, she had had episodes of erythematous rash, alopecia, sore throat, polyarthritis, fever and weight loss. In 1 episode 2 months before admission. .. [nejm.org]

  You may breathe through the mouth, but you will soon get a sore throat because of drying of the tissues. [newhealthadvisor.com]

• Pharyngitis

  […] years (including six patients who also had a history of cocaine abuse), the following damage had occurred [3] : Nasal septum necrosis (five patients) Nasal perforation (11 patients) Nasal erythema or ulceration (five patients) Palate damage (5 patients) Pharyngeal [emedicine.medscape.com]

  耳鏡検査 ototoxicity聴器毒性 p pansinusitis汎副鼻腔炎 papillary [adeno]carcinoma乳頭［腺］癌 paranasal sinus (paranasal cavity) 副鼻腔 parapharyngeal space副咽頭間隙 parotid gland耳下腺 parotitis耳下腺炎 perforation of the eardrum鼓膜穿孔 perilymph fistula外リンパ瘻 peritonsillar abscess扁桃周囲膿瘍 pharyngitis [tokyo-med.ac.jp]

• Overeating

  Childhood cutaneous tuberculosis: A study over 25 years from Northern India. Int J Dermatol 2001;40:26-32. 2. Khandpur S, Reddy BS. Lupus vulgaris: unusual presentations over the face. J Eur Acad Dermatol Venereol 2003;17:706-10. [ PUBMED ] 3. [ijpd.in]

  Untreated septal perforations typically enlarge over time and become more symptomatic effecting the normal functions and structure of the nose. [perforatedseptum.com]

  To protect your nose as it heals, it’s best to: Not lift heavy things or bend over Not pick your nose or blow it too hard Rinse with saline as often as your doctor tells you to Sneeze with your mouth open Stay away from contact sports Most of the time [webmd.com]

  Treatment involves the use of nasal wetting agents, placement of a plastic button over the perforation, and surgical repair. Repair with surgery is very difficult and failure to close the perforation is common. [doctorsgates.blogspot.com]

  In cases like these where the perforation is too large to allow for closure, we focus on reconstructing a stable, well supported nose that will not collapse over time. [beverlyhillsprofiles.com]

• Ulcer

  I have had oral and nasal ulcers from the get go but, at the end of last year, I discovered a hole in my nasal septum. ( The gristle wall that divides the nose into Two.) The hole appeared when I had "back to back" ulcers in both sides of my nose. [healthunlocked.com]

  (five patients) Palate damage (5 patients) Pharyngeal ulceration (three patients) Exposure to industrial fumes, wood dust, nickel-refining processes, and leather tanning may result in sinonasal malignancy and the development of septal perforation. [emedicine.medscape.com]

  Medicated ointment or saline nasal spray for ulcers Rarely surgery for perforations For septal ulcers, bacitracin ointment or mupirocin ointment reduces the crusting, as may saline nasal spray. [merckmanuals.com]

  Progression from epistaxis to ulceration to NSP could not be substantiated by the literature. CONCLUSION: Depending on the patient, NSP may be viewed as desirable (nose rings), problematic (whistling, congestion), or inconsequential. [ncbi.nlm.nih.gov]

  IN the two patients described below, ulceration and subsequent perforation of the nasal septum developed at the same time as acute exacerbation of systemic lupus erythematosus. Review of records from this institution revealed a third, similar case. [nejm.org]

• 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]

  Thrasher III, MD Tagged with: abuse, button, cocaine, deviated, endoscopic, epistaxis, fracture, nasal, nose, obstruction, perforation, reconstruction, repair, rhinoplasty, rhinorrhea, septal, septum, trauma Posted in: Nose [enttx.com]

• Facial Pain

  Other symptoms may include facial pain, headaches, and noisy night breathing. Septal deviation is usually evident on examination, although a flashlight and examination of the anterior nasal passage may not be sufficient. [msdmanuals.com]

  Facial pain. If a perforation is present, some people may even hear a whistling sound when air passes through the perforated septum. Treatment for a Deviated Septum The standard treatment for a deviated septum is surgical. [luxury.rehabs.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 [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.

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]

Treatment can range from rinsing with a saline solution to complex surgery. [zwivel.com]

Conservative treatment If the patient has perforation of the nasal septum, strongly recommended treatment at home, using the methods of alternative medicine and self-selected medications. [medicalj-center.info]

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 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]

In some parts of the world, leprosy is still prevalent and is an acknowledged etiology of PNS. [symptoma.com]

Perforation of Nasal Septum Etiology of nasal septal perforations can be classified into these 4 main categories: traumatic, iatrogenic, inflammatory/malignant, and cocaine use. [doctorsgates.blogspot.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]

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]

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]

Prevention Prevention of nasal septum perforation can be carried out considering the causal factors resulting in the formation of the defect. [medicalj-center.info]

However, the best preventative and maintenance treatment is eliminating the primary cause of your deviated septum – chronic cocaine or meth use. [luxury.rehabs.com]

Alternative treatment Saline nasal sprays may be sufficient to control symptoms and prevent the need for surgery. [medical-dictionary.thefreedictionary.com]

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.