Preoperative Clinical Evaluation of Patient

Fabio Ferreli, Paolo Castelnuovo

Summary

A preoperative overview for nasal septal perforations requires both an anatomical local evaluation and specific diagnostic test. The assessment begins with carefully assessing patient’s medical history. The physical examination starts with the inspection of the nasal pyramid for any alterations regarding the structural deficit. The nasal endoscopy allows the definition of the size and site of the perforation. The septum should be palpated with a sticker or with a cotton-tip in order to discern persistent cartilage between mucosal flaps and to determine whether cartilage extends close to the edges of the defect. CT scan with bone details can provide information about the structure of the residual septum and quantify the exact measurements of bone/cartilage defect. Lab tests should also be considered.

The causes of nasal septal perforations (NSPs) are numerous and can be either related to local or systemic conditions. Therefore, a preoperative overview requires both an anatomical local evaluation and specific diagnostic test.

It is essential, before proposing any surgical treatment, to clarify the etiopathogenesis of NSP.

The assessment begins with assessing the patient’s medical history carefully. Patients may present the major symptoms of NSP, such as crusting, bleeding, whistling, nasal obstruction, and, sometimes, pain and rhinorrhea. It is necessary to investigate the onset of the NSP and any previous intranasal procedures eventually associated with septoplasty, and septal cauterization for anterior epistaxis. The possibility of septal damage can be linked to particular events, such as trauma, cocaine, nasal foreign-body injuries, and decubitus by nasogastric tube.

Some patients’ habits can be considered, such as excessive use of nasal decongestants or topic steroid, and frequent digital trauma to remove intranasal crust. Finally, some risk factors related to occupational exposure, such as chemical irritants, and to specific diseases, for instance tuberculosis or syphilis, should be investigated. ¹

The physical examination starts with inspection of the nasal pyramid for any alterations regarding the structural deficit. Indeed, large NSP can result in loss of support of the nasal dorsum and consequent “saddle nose,” sometimes associated with a deviation of the caudal edge of the septum. The nasal endoscopy with rigid fiber optics (30 degrees) is a key step of the physical examination. The use of topical decongestants and local anesthetics can make it easier and tolerable, especially in cases where the removal of crusts by an underlying mucosa, easily bleeding areas, or a biopsy is expected.

Upon physical examination of the nose, a full diagnosis cannot be made until all crusts have been removed and decongestion of the turbinates has taken place, making it possible to visualize the entire nasal septum. The nasal endoscopy allows appreciating the configuration of the NSP, the presence or absence of adherent crusts on the edges of the defect ( ▶ Fig. 6.1), any easily bleeding areas ( ▶ Fig. 6.2), and the state of the remaining mucosa, which may present some aspects regarding ischemic conditions (cocaine abuse) ( ▶ Fig. 6.3).