eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Septal Perforation: Medical Aspects

Author: Rami K Batniji, MD, Private Practice, Batniji Facial Plastic Surgery
Coauthor(s): James F Chmiel, MD, Clinical Assistant Professor, Department of Otolaryngology, State University of New York at Buffalo
Contributor Information and Disclosures

Updated: Jan 2, 2009

Introduction

Background

Septal perforations are a diagnostic challenge because various potential causes are possible. Therefore, elucidating the cause of the septal perforation requires obtaining a thorough history. Although several surgical options are available for the treatment of symptomatic septal perforations (see Septal Perforation: Surgical Aspects), this article focuses on the medical management of septal perforations.

Pathophysiology

The nasal septal mucoperichondrium provides the blood supply to the septal quadrangular cartilage. Any insult (eg, chemical, physical, iatrogenic) to this normal anatomy can lead to the development of a perforation.

Mortality/Morbidity

Septal perforations can cause significant morbidity. The symptoms associated with septal perforations include nasal congestion or obstruction, nasal crusting and drainage, recurrent epistaxis, and a whistling sound from the nose. In addition to the symptoms related to nasal septal perforations, manifestations of the disease process that caused the perforation (eg, lupus, Wegener granulomatosis) may also carry significant morbidity.

Clinical

History

Septal perforations are usually asymptomatic. However, some patients may present with a history of nasal obstruction, crusting, intermittent episodes of epistaxis, malodorous discharge from the nose, or a whistling sound during nasal breathing.

A thorough medical history is essential in the evaluation because septal perforations are associated with many systemic diseases. Inflammatory diseases such as collagen vascular diseases, sarcoidosis, and Wegener granulomatosis may cause septal perforations. In addition, infectious processes such as tuberculosis, syphilis, and fungal diseases may result in septal perforations. Rarely, septal perforation is the initial finding of sinonasal malignancy.

Traumatic causes of septal perforation may be divided into external, self-inflicted, and iatrogenic causes. External trauma includes nasal-septal fracture. A septal hematoma results in elevation of the mucoperichondrium from the quadrangular cartilage, ischemia, and subsequent necrosis of the cartilage, with resultant perforation. Self-inflicted trauma, such as digital manipulation, may cause a septal perforation. Iatrogenic trauma includes a history of septoplasty, nasal packing or cauterization for epistaxis, and nasotracheal intubation.

Medication usage should be reviewed. Chronic use of vasoconstrictive nasal sprays and steroid nasal sprays may cause septal perforations. In addition, the use of cocaine may result in septal perforations.

Exposure to industrial fumes, wood dust, nickel-refining processes, and leather tanning may result in sinonasal malignancy and the development of septal perforation. Exposure to mineral oils, chromium, lacquer paint, soldering, and welding have also been associated with an increased incidence of sinonasal malignant tumors.

Physical

Physical examination of the nose begins with an evaluation of the external nose. Large perforations may result in loss of support to the dorsum of the nose and subsequent saddle nose deformity.

Most septal perforations are identified incidentally during routine physical examination. Thorough intranasal examination with anterior rhinoscopy is essential. Anterior rhinoscopy may demonstrate severe crusting; all crusting should be removed to attain a thorough evaluation of the septum. Topical nasal decongestants may further assist in the intranasal inspection of the entire septum.

The location of septal perforations is important because posterior perforations are typically asymptomatic compared with anterior perforations. Nasal endoscopy may assist in the evaluation of the entire septum. The position and diameter of the perforation should be noted. Palpation of the septum with a cotton-tipped applicator provides valuable information regarding the integrity of the quadrangular cartilage in the remainder of the septum. Crusting of the entire septum, edematous mucosa, or inflammation of the mucosa should alert the physician to systemic diseases as the etiology of the perforation.

In patients with an identifiable cause of the septal perforation, no further workup may be necessary. However, patients with an unidentifiable cause should undergo further investigation (see Workup).

Causes

The causes of septal perforation are many and varied. Attempting to find the inciting cause, or at least ruling out many of the dangerous causes, is important. If one can successfully surgically close a septal perforation but cannot alter the course of the initial inciting cause, then the perforation is often doomed to recur. Additionally, by closing the perforation, the physician may hide a manifestation of an undiagnosed disease process.

The causes of septal perforations can be conveniently placed into several categories that can help the physician more easily determine the causative agent or process. A good history, physical examination, and select laboratory studies can help focus the investigation.

  • Traumatic causes
    • Previous surgery
    • Cauterization for epistaxis
    • Nose picking
    • Nasogastric tube placement
    • Septal hematoma that results from any blunt trauma
    • Battery or other foreign body in nose
    • Chronic nasal cannula use
    • Turbulent airflow
  • Inflammatory or infectious causes
  • Neoplastic causes
    • Carcinoma
    • T-cell lymphomas
    • Cryoglobulinemia
  • Other causes
    • Inhaled substances (eg, cocaine, topical corticosteroids, long-term oxymetazoline or phenylephrine use)
    • Chromic acid fumes
    • Lime dust exposure
    • Renal failure1

More on Septal Perforation: Medical Aspects

Overview: Septal Perforation: Medical Aspects
Differential Diagnoses & Workup: Septal Perforation: Medical Aspects
Treatment & Medication: Septal Perforation: Medical Aspects
Follow-up: Septal Perforation: Medical Aspects
Multimedia: Septal Perforation: Medical Aspects
References
[ CLOSE WINDOW ]

References

  1. Adler D, Ritz E. Perforation of the nasal septum in patients with renal failure. Laryngoscope. Feb 1980;90(2):317-21. [Medline].

  2. Avcin T, Silverman ED, Forte V. Nasal septal perforation: a novel clinical manifestation of systemic juvenile idiopathic arthritis/adult onset Still's disease. J Rheumatol. 2006;33(1):199-200.

  3. Baum ED, Boudousquie AC, Li S, et al. Sarcoidosis with nasal obstruction and septal perforation. Ear Nose Throat J. Nov 1998;77(11):896-8, 900-2. [Medline].

  4. Echeverria-Zumarraga M, Kaiser C, Gavilan C. Nasal septal carcinoma: initial symptom of nasal septal perforation. J Laryngol Otol. Sep 1988;102(9):834-5. [Medline].

  5. Fairbanks DNF, Fairbanks GR. Nasal Septal Perforations: Management and Prevention. Aesthetic Plastic Surgery Rhinoplasty. 631-642.

  6. Greene D. Total necrosis of the intranasal structures and soft palate as a result of nasal inhalation of crushed OxyContin. Ear Nose Throat J. Aug 2005;84(8):512, 514, 516. [Medline].

  7. Ibanez-Bermudez F, Castillo Ceballos A, Gallardo Avila A, et al. [Wegener's granulomatosis of the nasal fossa]. Acta Otorrinolaringol Esp. Sep-Oct 1995;46(5):361-4. [Medline].

  8. Kim DW, Egan KK, O'Grady K, et al. Biomechanical strength of human nasal septal lining: comparison of the constituent layers. Laryngoscope. Aug 2005;115(8):1451-3. [Medline].

  9. Kridel RW. Considerations in the etiology, treatment, and repair of septal perforations. Facial Plast Surg Clin North Am. Nov 2004;12(4):435-50, vi. [Medline].

  10. Kriskovich MD, Kelly SM, Jackson WD. Nasal septal perforation: a rare extraintestinal manifestation of Crohn's disease. Ear Nose Throat J. Jul 2000;79(7):520-3. [Medline].

  11. Mathews JL, Ward JR, Samuelson CO, et al. Spontaneous nasal septal perforation in patients with rheumatoid arthritis. Clin Rheumatol. Mar 1983;2(1):13-8. [Medline].

  12. Neville E, Mills RG, Jash DK, et al. Sarcoidosis of the upper respiratory tract and its association with lupus pernio. Thorax. Dec 1976;31(6):660-4. [Medline].

  13. Rejali SD, Simo R, Saeed AM, et al. Acquired immune deficiency syndrome (AIDS) presenting as a nasal septal perforation. Rhinology. Jun 1999;37(2):93-5. [Medline].

  14. Rettinger G, Hosemann W. Measuring the size of nasal septal perforations. A simple radiological method. Rhinology. Sep 1988;26(3):157-9. [Medline].

  15. Robson AK, Burge SM, Millard PR. Nasal mucosal involvement in lupus erythematosus. Clin Otolaryngol Allied Sci. Aug 1992;17(4):341-3. [Medline].

  16. Smith I, Smith M, Mathias D, et al. Cryoglobulinaemia and septal perforation: a rare but logical cause. J Laryngol Otol. Jul 1996;110(7):668-9. [Medline].

  17. Teichgraeber JF, Riley WB, Parks DH. Nasal surgery complications. Plast Reconstr Surg. Apr 1990;85(4):527-31. [Medline].

  18. Vargas-Aguayo AM, Lopez-Perez VM. [Centrofacial lymphoma, cause of middle line granuloma syndrome. Report of a case]. Gac Med Mex. Nov-Dec 1998;134(6):743-6. [Medline].

  19. Williams N. A survey of respiratory and dermatological disease in the chrome plating industry in the West Midlands, UK. Occup Med (Lond). Dec 1996;46(6):432-4. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

septal perforation, septum, nasal septal perforation, perforated septum, nose trauma, cocaine use, nose picking, nasal trauma, nasal spray, lupus erythematosus, Wegener granulomatosis, illicit drug use, sarcoidosis, nasal silastic buttons, sinonasal malignancy, septal hematoma, nasal-septal fracture, septoplasty, sinonasal tumors

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Rami K Batniji, MD, Private Practice, Batniji Facial Plastic Surgery
Rami K Batniji, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, California Medical Association, and Triological Society
Disclosure: Nothing to disclose.

Coauthor(s)

James F Chmiel, MD, Clinical Assistant Professor, Department of Otolaryngology, State University of New York at Buffalo
James F Chmiel, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy and American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

J David Kriet, MD, FACS, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Director of Facial Plastic and Reconstructive Surgery, University of Kansas School of Medicine
J David Kriet, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, AO Foundation, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.