95 Septal Perforation

A septal perforation is most commonly located in the anterior, cartilaginous septum except for that caused by syphilis, which normally occurs more posteriorly in the bony septum. Most perforations are either due to trauma, most commonly from nose picking, or iatrogenic, usually as a complication of septal surgery, particularly when the Killian incision is used. Septal perforations are usually preceded by ulceration except when following a septal haematoma or abscess when an area of ischaemia occurs. Patients with a septal perforation are commonly used in the rhinology section of examinations.

95.1 Aetiology

1. Trauma

a. Iatrogenic.

– Septal surgery. A perforation may arise from torn, opposing mucoperichondrial flaps where cartilage has been removed, from a septal haematoma or septal abscess.

– Nasal packing that has been traumatically placed or from epistaxis balloons left in situ for a prolonged period or at too high a pressure.

– Nasal cautery. There are two important points to mention. First, the mucosa over Little’s area is quite thick inferiorly but thin at midheight. Therefore, if the latter area has bilateral nasal cautery, this can result in bilateral opposing septal burn ulceration, predisposing to a septal perforation. Secondly, nasal cautery to Little’s area is contraindicated in the presence of Little’s nasal vestibulitis. This is because the vestibulitis may be the cause of the epistaxis, so the vestibulitis should be treated medically and this may obviate the need to perform nasal cautery. Finally, cauterising infected tissue causes more necrosis and may allow infection to spread to cartilage, increasing the risk of a septal perforation from the vestibulitis.

– Nasal cannulas are used for patients with chronic obstructive pulmonary disease (COPD) requiring long-term oxygen delivery or intensive therapy unit (ITU)/coronary care unit (CCU) patients requiring short-term oxygen delivery. They can cause trauma to the anterior nasal septum.

b. Self-inflicted nasal trauma (nose picking).

Trauma from nose picking may cause ulceration to mucosa over Little’s area, which then becomes infected with Staphylococcus aureus. This causes infected crusts and may lead to cartilage necrosis and a perforation.

c. Injury (assault, road accident and sport injury).

Trauma may cause a septal haematoma. Haematoma in contact with septal cartilage causes cartilage resorption and mucosal ischaemia. The haematoma may become infected and the resulting septal abscess causes septal cartilage necrosis and mucosal infection. These scenarios may cause a septal perforation and a dorsal nasal saddle if the cartilage necrosis extends to the superior margin of the quadrangular cartilage.

2. Infection Syphilis, tuberculosis, Mycobacterium kansasii and invasive fungal sinusitis.

3. Neoplasm Squamous cell carcinoma, adenocarcinoma, basal cell carcinoma, T-cell lymphoma (midline nasal granuloma) and malignant melanoma.

4. Inflammatory Wegener’s granulomatosis, sarcoidosis, polyarteritis nodosa, systemic lupus erythematosus, chronic relapsing poly-chondritis and cryoglobulinaemia.

5. Chemicals Cocaine (see Chapter 20, Epistaxis), button batteries (see Chapter 31

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