Initial management of a septal perforation involves medical intervention, but there are several surgical options available. Deciding to proceed with a surgical repair is dependent on the etiology of the defect, how the symptoms impact the patient, the extent of damage or impending destruction to the nasal support, and the absence of any active disease process. The literature describes several methods for septal perforation repair; each has its technical challenges because of the tenuous nature of the tissues and limited surgical exposure of the area. This article reviews the diagnostic work-up of septal perforations, the medical management, and the surgical treatment options, with emphasis placed on the open rhinoplasty approach.
Nasal septal perforations are relatively common, affecting up to 0.9% of the general population. The challenge for the rhinologic or nasal reconstructive surgeon is to identify those cases that require additional work-up and to select the medical and surgical treatments most appropriate for the patient at hand.
Most symptomatic perforations are located at the anterior septum, which is composed of three layers: the anterior part of the quadrangular cartilage and the bilateral layers of mucoperichondrium. Although the blood supply to this region is redundant and includes branches from both the external carotid and internal carotid arteries, vasculitis or trauma to the terminal branches of the septum can devitalize the nasal septal mucosa. When the mucoperichondrium becomes ischemic, the underlying cartilaginous septum quickly necroses. After a perforation has formed, the mucosal edges quickly epithelialize, and this process prevents closure of the defect during normal healing.
In the presence of a perforation, the normal intranasal laminar airflow becomes altered, producing symptoms that include whistling, crusting, and nasal airway obstruction. Furthermore, the persistence of dry nasal crust, coupled with chronic manipulation of it, can lead to progressive enlargement of the defect.
Complications can arise from undiagnosed, severe, or inadequately treated cases of septal perforation. Low-grade perichondritis can occur in cases associated with poor hygiene. Epistaxis can result from a patient picking at or removing crusted, dried mucous secretions that collect at the edges of the perforation, or from granulation tissue at this site. Finally, the progression of an enlarging anterior septal perforation will eventually cause deterioration of the dorsal and caudal septal support of the nose. The impact of this effect is not only a functional problem of nasal airway obstruction from vestibular stenosis or internal nasal valve collapse, but it is also an aesthetic issue of nasal tip collapse and/or saddle-nose deformity.
Evaluation
Although most septal perforations are iatrogenic, traumatic or drug-induced, there are a few cases that are caused by inflammatory conditions, malignancy, and infectious disease ( Box 1 ). It is prudent to determine the underlying etiology before recommending a surgical repair.
Iatrogenic
Septoplasty
Rhinoplasty
Nasal cautery
Nasal intubation
Traumatic
Mucosal laceration
Digital trauma
Septal hematoma
Foreign body
Inflammatory
Sarcoidosis
Churg-Strauss syndrome
Wegener’s granulomatosis
Lupus
Infectious
Invasive fungal infection
Septal abscess
Tuberculosis
Syphilis
Malignancy
Lymphoma
Inhalants
Intranasal steroids
Cocaine
Sulfuric acid fumes
Glass dust
Mercurials
Phosphorus
Vasoconstrictive nasal sprays
This process begins with a careful history. The chief complaint may include nasal airway obstruction, an audible whistle during nasal breathing, nasal crusting, intranasal pain, epistaxis, or foul and copious nasal discharge. Advanced cases may present with a saddle-nose deformity. The onset of the perforation and attributing circumstances should be explored. Pertinent details include any prior nasal procedures including cautery, septoplasty, and cosmetic surgery. The inquiry should include events of prior trauma, cocaine use, excessive use of vasoconstrictors, or intranasal injury from foreign bodies. A complete evaluation should inquire about risk factors for tuberculosis and syphilis, as well as occupational exposures, including chemical irritants and particulates. The patient should be queried about their nasal hygiene habits; whether they perform sinonasal irrigation, apply ointment intranasally, use intranasal sprays, or digitally remove nasal crusts.
After a complete head and neck examination, nasal endoscopy is recommended to provide the surgeon with improved visualization of the anatomic details. The edges of the perforation can be assessed for active ulceration (associated with raw granulation or fibrinous tissue) or evidence of healing with well-epithelialized edges. The size of the perforation should be determined as this can influence the selection of repair technique for some surgeons. Measurements of the perforation can be performed in several ways. The diameter of the endoscopic lens can be used as a measuring tool from one edge of the perforation to the other. The end of a centimeter-etched Cottle elevator can be carefully inserted and slid against the septum to determine the size of the perforation. The disposable paper ruler found in some surgical pen packs can be trimmed and introduced into the nose to obtain an accurate measurement. Finally, a trained eye can provide a close estimate of the defect. If the perforation is not uniformly circular, it is helpful to measure the vertical height of a perforation as well as the anterior–posterior dimension, because this may also affect the choice of surgical repair. The final feature to take note of is the location of the perforation: anterior, posterior, low near the floor or high near dorsum.
Further laboratory evaluation can be useful after the history and physical examination help to narrow the differential diagnosis. Churg-Strauss syndrome is identified by an elevated perinuclear-staining antineutrophil cytoplasmic antibodies (p-ANCA) and peripheral blood eosinophilia. Patients with Wegener’s granulomatosis often have elevated antineutrophil cytoplasmic autoantibody (c-ANCA) levels, as well as elevated erythrocyte sedimentation rate (ESR) and rheumatoid factor (RF), but these latter tests are less specific. The serum angiotensin-converting enzyme (ACE) level is elevated along with serum calcium levels in patients with sarcoid. They may also exhibit mediastinal adenopathy on chest radiograph. In patients who have active and inflamed lesions of the septum, the posterior edge of the perforation should be biopsied; the tissue can be sent for pathology as well as acid-fast bacilli and fungal cultures. Biopsies of the superior margin of the perforation should be avoided because they contribute to the vertical diameter of the defect and increase the difficulty of the eventual closure. Finally, a sinus CT scan can be helpful to look for co-existing sinus disease and serve as an aid in preoperative sizing of the perforation.
Nonsurgical treatment
Nasal Hygiene
Initial management of septal perforation begins with improving nasal hygiene and counseling the patient to avoid digital cleaning. Routine nasal irrigation with saline solution or regular humidification can help reduce the build-up of crusts. Antibiotic ointment or any petroleum-based ointment can prevent the drying and hardening of crusted material, as long as the ointment is applied intranasally a few times daily. In the setting of visible mucosal inflammation, an antibiotic-based ointment might be preferable. Patients who have complaints of pain and dryness at the perforation site often experience improved comfort when the ointment is used to lubricate and soothe the mucous membranes within the nasal vestibule and anterior septum. Despite these measures, some of the symptomatic complaints of the patient may remain unresolved, and the risk of progressive enlargement of the perforation is always present.
Nasal Septal Button
Temporary closure of the perforation can be achieved with a nasal septal button. This prosthetic device can be inserted into position during an office visit with the aid of local or topical anesthesia and decongestant. To facilitate proper placement, one side of the disk is folded and passed or pulled through the perforation with alligator or bayonet forceps. An endoscopic view of the nasal cavity may facilitate this maneuver. The flanges should fit into the region of the internal nasal valve superiorly and come in contact with the nasal floor inferiorly. These buttons are commercially available in various sizes. After a septal button is inserted, it can remain in place for one year or more, but this duration is very dependent on the patient’s diligence with good nasal hygiene and proper care of the prosthesis. Indications for device removal include: the need to size-up the prosthesis; the relief of chronic discomfort from the button; and to enable ongoing cleaning and maintenance.
Unfortunately, septal buttons have been associated with several complications. In some patients, they increase the frequency of epistaxis, can allow crusted material to collect around the flanges, cause intranasal pain, and may contribute to a steady erosion of the perforation edges and eventual enlargement of the defect.
Nonsurgical treatment
Nasal Hygiene
Initial management of septal perforation begins with improving nasal hygiene and counseling the patient to avoid digital cleaning. Routine nasal irrigation with saline solution or regular humidification can help reduce the build-up of crusts. Antibiotic ointment or any petroleum-based ointment can prevent the drying and hardening of crusted material, as long as the ointment is applied intranasally a few times daily. In the setting of visible mucosal inflammation, an antibiotic-based ointment might be preferable. Patients who have complaints of pain and dryness at the perforation site often experience improved comfort when the ointment is used to lubricate and soothe the mucous membranes within the nasal vestibule and anterior septum. Despite these measures, some of the symptomatic complaints of the patient may remain unresolved, and the risk of progressive enlargement of the perforation is always present.
Nasal Septal Button
Temporary closure of the perforation can be achieved with a nasal septal button. This prosthetic device can be inserted into position during an office visit with the aid of local or topical anesthesia and decongestant. To facilitate proper placement, one side of the disk is folded and passed or pulled through the perforation with alligator or bayonet forceps. An endoscopic view of the nasal cavity may facilitate this maneuver. The flanges should fit into the region of the internal nasal valve superiorly and come in contact with the nasal floor inferiorly. These buttons are commercially available in various sizes. After a septal button is inserted, it can remain in place for one year or more, but this duration is very dependent on the patient’s diligence with good nasal hygiene and proper care of the prosthesis. Indications for device removal include: the need to size-up the prosthesis; the relief of chronic discomfort from the button; and to enable ongoing cleaning and maintenance.
Unfortunately, septal buttons have been associated with several complications. In some patients, they increase the frequency of epistaxis, can allow crusted material to collect around the flanges, cause intranasal pain, and may contribute to a steady erosion of the perforation edges and eventual enlargement of the defect.
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