A nasal septal perforation refers to a defect in the nasal septum resulting in a communication between the two nasal cavities. It may affect either the bony, or cartilaginous septum. Most commonly it affects the anterior septal cartilaginous area although with syphilis it characteristically affects the bony septum.
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Epidemiology
Prevalence is variable but with many publications reporting at around 1% of the population 7.
Clinical presentation
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 crust.
The diagnosis of septal perforation is often established based on the results of a routine physical examination, The physical examination, in some select circumstances, may help establish the cause of the septal perforation and often influences the choice of treatment.
Pathology
Etiology
Unfortunately, the majority of nasal septal perforations are iatrogenic in origin and usually occur as a complication of septal surgery, particularly when the Killian submucous resection technique is used. Although the septoplasty procedure does not give complete immunity against this complication, perforations are rare following this operation.
Causes of septal perforation can be summarized under the following categories:
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trauma
surgical
repeated cautery
digital trauma (nose picking)
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malignant disease
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malignant tumors
malignant granuloma
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chronic inflammatory conditions
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poisons
industrial
cocaine: chronic (>3 months) use 4
topical corticosteroids
topical decongestants
idiopathic
Alternatively, mnemonics can be employed.
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. Small anterior perforations are more likely to cause whistling. Larger, anterior perforations are more likely to crust and create nasal congestive symptoms. Posterior perforations are less likely to cause symptoms; therefore, patients with these perforations may only need a focussed search for an etiology and conservative observational treatment.
In general, medical therapy is directed at minimizing symptoms associated with nasal septal perforations, such as epistaxis, crusting, and nasal congestion, and treating causative medical conditions, including lupus and sarcoidosis.
Nasal silastic buttons are available for insertion. Some patients tolerate the buttons for many years; however, many do not. Some companies offer silastic buttons that can be custom fitted to the patient.
Surgical management aims to close the perforation with different types of flaps and grafts.