Septal Perforation - Medical Aspects

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]

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]  

Because of the varied etiologies of nasal septal perforations, performing a detailed laboratory evaluation on every patient is cost prohibitive. Because of this, an algorithm (as seen in the image below) is proposed to guide the physician when obtaining more detailed laboratory and other studies:

Proposed algorithm for a systematic evaluation of newly diagnosed septal perforations.

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

• A significantly elevated erythrocyte sedimentation rate can indicate an underlying rheumatologic disorder. Unfortunately, a value within the reference range does not rule out a rheumatologic or inflammatory disorder. The erythrocyte sedimentation rate can be elevated significantly in dermatomyositis-polymyositis, rheumatoid arthritis, sarcoidosis, lupus, Wegener granulomatosis, temporal arteritis, and many other disorders.

• 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 can also be performed to assess for this disease.

• If any of the results are positive, consult with a rheumatologist regarding further testing.

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.

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

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, 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).

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

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.

Class Summary

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.

Class Summary

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.

Class Summary

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

Mupirocin (Bactroban cream)

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

Prevention of nasal septal perforations is directed at removing or minimizing stressors known to irritate the nasal septum. These preventive measures need to be tailored to the individual patient.

Patient-related prevention techniques (alteration in social habits)

• Stop cocaine use.

• Stop or minimize use of topical nasal decongestants.

• Run a humidifier in the bedroom.

• Frequently use nasal saline sprays.

• Use nasal emollients (especially before bedtime).

• Decrease digital nasal trauma. Parents may want to place mittens on their young children's hands at night.

• Discontinue the use of aspirin or nonsteroidal anti-inflammatory drugs.

Physician-related prevention techniques

• Prescribe heated, humidified continuous positive airway pressure devices for patients with obstructive sleep apnea.

• Minimize steroid use in patients.

• During septoplasty, minimize resection of cartilage and use meticulous technique to avoid bilateral tears in the mucosa.

• Minimize nasal trauma during the insertion of nasogastric tubes by (1) decongesting the nose with oxymetazoline or phenylephrine prior to nasogastric tube insertion, (2) inserting the nasogastric tube along the floor of the nose parallel to the hard palate and perpendicular to the plane of the face, and (3) lubricating the tip of the nasogastric tube.

• Modify the nasal cannula in patients on long-term supplemental oxygen and humidify the supplemental oxygen. Taping 2 wooden toothpicks to the hub of the cannula (the thickened plastic part where the prongs are attached) modifies the nasal cannula. This directs the oxygen straight into the nose and away from the nasal septum.

• When cauterizing the nasal septum for epistaxis, avoid cauterizing both sides simultaneously.