Practice Essentials

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.^[1]

Signs and symptoms of septal perforation

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.

Workup in septal perforation

In patients without a likely cause for septal perforation or in patients with rheumatologic complaints, the following laboratory studies may be performed:

A significantly elevated erythrocyte sedimentation rate can indicate an underlying rheumatologic disorder
In patients with cough, hemoptysis, sinusitis, bloody nasal discharge, or eye abnormalities (episcleritis or conjunctivitis), an antineutrophil cytoplasmic autoantibody (C-ANCA) test should be obtained to assess for Wegener granulomatosis
The rheumatoid factor level may be elevated in persons with rheumatoid arthritis, mixed connective tissue diseases, lupus, scleroderma, or other disorders
Elevated angiotensin-converting enzyme (ACE) levels can indicate the presence of sarcoidosis

Chest radiography may be performed to assess for sarcoidosis. A biopsy of the perforation edge to rule out sinonasal malignancy may be indicated if malignancy is suspected based on history or constitutional symptoms.

Management of septal perforation

Abstinence from 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 use) 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, patients with intranasal crusting may benefit from medical treatments aimed at keeping the nose moist.

A silicone button prosthesis may relieve the sensation of nasal obstruction or the occurrence of a whistling sound upon nasal breathing, that can accompany perforations of the anterior septum.

In individuals who remain symptomatic despite nonsurgical treatments, surgical management may be of benefit.

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.

A study by Li et al found that in patients with nasal septal perforation, wall shear stress and heat flux were significantly higher, particularly along the posterior perforation margin, in symptomatic individuals than in asymptomatic ones. The report indicated that a wall shear stress cutoff of 0.72 Pa has an 87% sensitivity and 100% specificity in separating asymptomatic from symptomatic perforations.^[2]

Frequency

Using facial bone computed tomography (CT) scans from 3708 patients, a study by Gold et al found the prevalence of nasal septal perforation in an urban population to be 2.05%. A history of drug abuse was the predominant risk factor, with cocaine being the most commonly used drug.^[3]

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.

A retrospective cohort study by Leong and Webb found that nasal septal perforation and chronic rhinosinusitis (CRS) have similar effects on quality of life, as measured using the Sino-Nasal Outcome Test-22 (SNOT-22). Patients in the CRS cohort had a higher mean total SNOT-22 score (57.2) than did those in the septal perforation cohort (50.2), but the difference was not statistically significant. Lack of statistical significance was also seen for differences in the mean scores for rhinologic and ear/facial symptoms and for the psychological and sleep dysfunction domains. However, the mean score for extranasal rhinologic symptoms was significantly higher for the CRH patients than for those with perforation (11.2 vs 6.4, respectively).^[4]

Clinical Presentation

Media Gallery

Proposed algorithm for a systematic evaluation of newly diagnosed septal perforations.
A simple technique to modify an oxygen nasal cannula that helps to prevent the cannula tip from rubbing against the nasal septum. Two wooden sticks are taped to the hub of the nasal cannula. This technique can also be used in patients with preexisting septal perforations to decrease crusting and epistaxis.
To assess the size of a perforation, barium paste is applied to the edges of the perforation and a lateral 6-foot plain film is obtained of the head. Technique described by Rettinger and Rosemann.

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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, 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, American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dominique Dorion, MD, MSc, FRCSC, FACS Dean, Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Université de Sherbrooke, Canada

Dominique Dorion, MD, MSc, FRCSC, FACS is a member of the following medical societies: Canadian Society of Otolaryngology-Head & Neck Surgery

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan, Ryte, Neosoma, MI10<br/>Received income in an amount equal to or greater than $250 from: , Cliexa;;Neosoma<br/> Received ownership interest from Cerescan for consulting; for: Neosoma, eMedevents, MI10.

Additional Contributors

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: Society of University Otolaryngologists-Head and Neck Surgeons, AO Foundation, 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

Disclosure: Received honoraria from AO North America for speaking and teaching.