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.
Epidemiology
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. [1]
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). [2]
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Proposed algorithm for a systematic evaluation of newly diagnosed septal perforations.
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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.
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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.
