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

Septal Perforation: Medical Aspects: Treatment & Medication

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

Treatment

Medical Care

Although several surgical options are available for the treatment of septal perforations, this article focuses on the nonsurgical management.

Abstinence of the causative agent is of utmost importance in the medical management of septal perforations if the patient has a history of drug abuse (such as cocaine) or the use of nasal decongestants or nasal steroid sprays.

Perforations of the posterior septum are typically asymptomatic and, as such, rarely require treatment. However, intranasal crusting may be problematic for the patient, especially if the edges of the perforation are not well healed. These patients may benefit from medical treatments aimed at keeping the nose moist. These include the daily application of petroleum jelly on a cotton-tipped applicator to the inside of the nose, the application of a nasal emollient such as Ponaris oil, or nasal irrigations. In addition, a humidifier in the home may benefit the patient.

Perforations of the anterior septum may cause the sensation of nasal obstruction or result in a whistling sound upon nasal breathing. A silicone button prosthesis may relieve these symptoms. In the office, a silicone button prosthesis may be placed with the help of a local anesthetic.

In individuals who remain symptomatic despite the aforementioned nonsurgical treatments, surgical management may be of benefit (see Septal Perforation: Surgical Aspects).

Consultations

If the cause of the nasal septal perforation is not clear, consider obtaining a consultation with a medical specialist or rheumatologist.

Medication

The medications used in the treatment of nasal septal perforations generally involve the topical application of agents that clean and humidify the nose or that alter the nasal mucosa.

Topical decongestants

These agents are used to shrink nasal mucosa to allow better visualization, to allow easier insertion of nasogastric tubes with less trauma, and to provide temporary management of epistaxis.


Oxymetazoline 0.05% (Dristan, Allerest, Afrin)

Topical vasoconstrictor; decreases swelling and congestion in the nose.

Adult

2-3 puffs each nostril q12h, not to exceed more than 5 d

Pediatric

Not established

Hypotensive action of guanethidine may be reversed; concurrent administration with methyldopa may result in an increased vasopressor response; concurrent use of MAOIs and ephedrine may result in hypertensive crisis; pressor sensitivity to mixed-acting agents (eg, ephedrine) may be increased; guanethidine potentiates effects of epinephrine and inhibits effects of ephedrine
Phenothiazines may reverse action of nasal decongestants; TCAs potentiate vasopressor response and may result in dysrhythmias

Angle-closure glaucoma; caution in patients with hyperthyroidism, cardiovascular disease, hypertension, diabetes, or eye injuries

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, coronary artery and ischemic heart disease, diabetes mellitus, increased intraocular pressure, or prostatic hypertrophy; because of increase in vasoconstriction, patients with hypertension may experience change in blood pressure; do not use topical decongestants for longer than 3-5 d

Topical hormones

These agents are used to induce trophic changes in nasal mucosa (thickening of thin, delicate nasal mucosa).


Conjugated estrogen (Premarin)

When mixed with nasal saline, can be applied topically to thicken nasal mucosa to decrease epistaxis; 25 mg of conjugated estrogen (Premarin Secule kit) mixed with 1 bottle of saline nasal spray; keep refrigerated and discard after 30 d; discuss with patient that this is an off-label use of the drug. Discuss risks and benefits of using this drug; only for use in patients with severe epistaxis due to the perforation.

Adult

25 mg of conjugated estrogen mixed with 1 bottle of nasal saline spray; apply to nasal tissue, 2 puffs each side of nose tid; base duration of therapy on clinical response

Pediatric

Not recommended

May reduce hypoprothrombinemic effect of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P-450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins

Documented hypersensitivity; pregnancy and lactation; children; patients with endometrial cancer, thromboembolic disorders, breast cancer, undiagnosed vaginal bleeding, or liver dysfunction

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Certain patients may develop undesirable manifestations of excessive estrogenic stimulation (eg, abnormal or excessive uterine bleeding, mastodynia); may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia

Topical antibiotics

These agents, when applied to nasal mucosa, can keep tissue moist. Drying of nasal mucosa can induce epistaxis.


Mupirocin topical 2% (Bactroban cream)

Apply topically to nasal septal mucosa to keep nasal tissue moist.

Adult

Apply to nasal mucosa tid

Pediatric

Not established

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Prolonged use may result in growth of nonsusceptible organisms

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
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References

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Further Reading

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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

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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

 
 
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