Septal Perforation - Medical Aspects Clinical Presentation

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.

In addition to the possibility of cocaine abuse, a study by Peyrière et al indicated that in patients with nasal damage who abuse drugs, clinicians should also determine whether the patient has been inhaling heroin. In the study, the investigators found that among 24 patients with a history of chronic nasal inhalation of heroin (median daily consumption, 5 g) over a period of two months to more than ten years (including six patients who also had a history of cocaine abuse), the following damage had occurred ^[5] :

• Nasal septum necrosis (five patients)

• Nasal perforation (11 patients)

• Nasal erythema or ulceration (five patients)

• Palate damage (5 patients)

• Pharyngeal ulceration (three patients)

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.

Taylor et al developed a scale that distinguishes between nasal obstruction and nasal septal perforation. The Nasal Obstruction Symptom Evaluation (NOSE) scale was used as a basis for this tool (the NOSE-Perf scale), with seven non-obstruction questions added to assess septal perforation symptoms. It was found that the NOSE-Perf scale was able to distinguish between patients with nasal septal perforation, individuals with nasal obstruction alone, and persons with no rhinologic complaints, while the NOSE scale by itself could not distinguish between perforation and obstruction. ^[6]

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).

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

  • Sarcoidosis

  • Wegener granulomatosis

  • Systemic lupus erythematosus

  • Tuberculosis

  • Syphilis

  • AIDS

  • Diphtheria

  • Crohn disease

  • Dermatomyositis

  • Rheumatoid arthritis

• 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 failure ^[7]

A study by Hulterström et al found that in patients with symptomatic perforation of the nasal septum, the nasal mucosa had a high prevalence of Staphylococcus aureus compared with that of controls (88% vs 13%, respectively), indicating that S aureus can sustain chronic inflammation in such patients. In addition, the S aureus strains were genetically heterogeneous in patients and controls, suggesting no association between septal perforation and a specific S aureus genotype. ^[8]