Septal Perforation - Coping Strategies and Support

Introduction:

Our nose is divided into two nostrils, right and left, by the cartilaginous structure called the nasal septum. Any defects (hole or perforation) in the nasal septum result in abnormal communication between the two nasal passages. Perforation defects can involve either the bony or the cartilaginous part of the nasal septum. Few smaller perforation heals on their own by conservative management, but the larger perforations need surgical attention as they can lead to multiple complications.

What Is the Prevalence of Septal Perforation?

The prevalence of septal perforation is around one percent of the general population.

What Is the Incidence of Septal Perforation After Nasal Septum Surgery?

The incidence of septal perforation after nasal septum surgery varies from 0.5 to 3 percent of the total cases reported.

What Are the Types of Septal Perforation?

The size of the septal perforation helps to plan the treatment accordingly. Septal perforations are of three types based on their sizes:

• Small: Nasal septum perforation of size within one centimeter.

• Medium: Septal perforation of size measuring from one to two centimeters.

• Large: Septal perforation of size more than two centimeters.

What Are the Causes of Nasal Septum Perforation?

Causes for nasal septum perforation are:

• Accidental Trauma: Direct trauma to the nose while falling or in road accidents.

• Infections: Like syphilis (sexually transmitted bacterial infection), tuberculosis (TB), and fungal infections.

• Trauma During Surgery: Trauma to the nasal septum during nose surgery.

• Cancerous Conditions: Like non-Hodgkin's lymphoma (cancer affecting the lymphatic system of the body).

• Nasal Drug Abuse: Frequent inhalation of drugs like cocaine, overuse of intranasal steroids sprays, and nasal decongestants (drugs used to treat nasal blockage).

• Industrial Exposure: Long-term exposure to chemical fumes like powdered glass or sulphuric acid.

• Inflammatory Disorders: Like rheumatoid Arthritis (disease causing swelling of the bones and joints) and Wegener's granulomatosis (disease affecting blood vessels of ear, nose, throat, and lungs).

What Are the Signs and Symptoms of Nasal Septum Perforation?

Signs and symptoms related to nasal septum perforation are:

• The nasal tone in the voice.

• Nasal crusting (excess mucus accumulation in the nose due to abnormal drainage).

• Nasal obstruction or blockage.

• Epistaxis (bleeding from the nose).

• Discharge from the nose.

• Whistling sound from the nose due to disturbed airflow from the nose.

• Swelling of the mucous membrane of the nose.

• Altered smell sensation (cacosmia).

• Pain in the nose.

• Headaches.

How Can We Diagnose Nasal Septum Perforation?

Different diagnostic modalities of nasal septum perforation are:

• History and Clinical Examination: A detailed history of the patient for the presenting symptoms like nose bleeds, any underlying diseases, intranasal drug uses, and a history of nasal surgery is recorded. A clinical examination of the nose is done by an ENT (ear, nose, and throat specialist) to check for the presence of any defects in the nasal septum.

• Nasal Endoscopy: Endoscopic (a telescope-like apparatus with an attached camera used to see the internal structures of the body) examination of the nose is done to rule out any perforation present. The size of the perforation, along with the surrounding mucosa, is evaluated to rule out any abnormal changes due to any underlying disease or infections.

• Biopsy: For any abnormal changes observed in the nasal mucosa, a tissue biopsy is performed to rule out the suspected cancerous lesion. In this procedure, a sample of the diseased tissue along with a healthy margin is cut by a surgical blade, and the collected sample is sent to the laboratory for confirmation of the underlying disease.

• Blood Test: It is done to check for antineutrophil cytoplasmic antibodies (ANCA) to diagnose and confirm any underlying disease like Wegener's granulomatosis.

• Computed Tomography (CT) Scan: It is done to rule out sinus (empty cavities present within the skull) infections, location, and extent of the septal perforation. It helps to plan the treatment accordingly.

What Are the Protocols for the Management of Nasal Septum Perforation?

Various treatment modalities used to manage perforated nasal septum are:

Conservative Management

• Humidification: Nasal humidification is done by inhalation of the hot water steam to clear the nasal blockage or congestion.

Medicinal Therapy

• Nasal Emollients: The application of nasal emollients (moisturizing lotion) helps to prevent nasal dryness, crusting, and nosebleeds.

• Nasal Saline Rinses: Rinsing of the nasal cavities with saline (salt water) solutions helps to clear nasal congestion.

• Antibiotics: It is prescribed to control or treat the underlying disease or infections.

Nasal Obturators: Nasal buttons made of silastic or small nasal silicone prosthesis (artificial device) that are readily available, or a prefabricated synthetic material prosthesis can be used to close the nasal septum perforations. It is a preferred procedure for patients who are not systemically sound to undergo surgical procedures under general anesthesia.

Surgical Management:

• Surgical Repair: Surgical repair of the nasal perforation can be done under general anesthesia by using a mucoperichondrium flap (flap or tissue composed of mucous membrane and perichondrium) with a cartilaginous graft. It is done to treat larger perforations. However, the chances of treatment failure are great for large perforation cases.

Oncologist Consultation: The patient is referred to an oncologist (cancer specialist) in cases where the septal perforation is suspected due to malignant (cancerous) changes for further management with surgical removal of the involved mucosa and radiotherapy sessions if required.

Complications Associated With Surgical Repair of Septal Perforations

• Failure of the treatment in cases of larger perforations.

• The scar on the donor area (the area from where tissue graft is used).

• Nosebleeds.

• Need for revision surgery.

Precautions Need to Be Taken After the Surgical Repair of Septal Perforations

Precautions to be followed after surgical repair of septal perforation are:

• Avoid blowing the nose.

• Use saline solution to rinse the nose to avoid nasal blockage.

• Avoid strenuous exercises for a few weeks.

• Avoid digital (nails or fingers) trauma by nose picking.

• Take all the medications as prescribed by the doctor.

What Is the Current Research Ongoing for Perforated Nasal Septum Repair?

Various clinical trials are ongoing to study the efficacy of the collagen membrane and stem cells in the repair of septal perforations.

Conclusion:

Septal perforations are more commonly seen in people with previous nasal surgeries; however, they can also be associated with underlying inflammatory disease, cancerous conditions, nasal drug abuse, or bacterial infections. Early diagnosis and management of septal perforations are important for satisfactory treatment outcomes and to prevent the worsening of the symptoms associated with septal perforations.