Septal Perforation (Septum Hole)

The nasal septum is a rigid layer that separates the inside of the nose into two cavities, right and left. It consists of a sheet of bone and cartilage covered by mucosa on either side. Mucosa is the name for a moist skin-like cover comparable to the inside of the mouth. The septum is important for both form and function of the nose. If it is deviated, breathing problems may arise (see septoplasty). A hole within the septum is called nasal septal perforation. Although it creates an abnormal internal communication between the two sides of the nose, this by itself causes no harm. In fact, most septal perforations are asymptomatic and cause no problems to the patient. Larger septum holes may be more problematic – from a functional and medical standpoint.

What Causes Nasal Septal Perforations?

As a basis for appropriate treatment, it is important to investigate why a septal hole is present in the first place. Most commonly, the reason for its presence is easy to identify. Sometimes, the physician may need to do some more investigative work. There are three groups of underlying causes: trauma, medications/drugs and other diseases.

Trauma leading to septal perforation: The most common events that may lead to septal hole include surgery (i.e. septoplasty, removal of tumors from the nose, cauterization of the nose), nasal fracture with injury to the septum (i.e., fracture), collection of blood between mucosa and cartilage (nasal septal hematoma), foreign bodies within the nose (tubes such as feeding tubes or breathing tubes) and self-manipulation (i.e. nose picking).

Medications & Drugs: snorting of cocaine (common), nasal sprays and caustic fumes.

Other diseases: nasal cancers, lymphoma, inflammatory diseases and infections.

If the underlying problem that led to the perforation in the first place still exists, repair is not a good choice. Rather, the cause should be removed first before repair can be successfully executed.

Which Symptoms May a Nasal Septal Perforation Produce?

Ninety five percent of septal perforations occur in the cartilage part of the nose. Because this represents the front portion of the nose septum, it is easier traumatized and drugs placed inside the nose will affect the front most. In contrast to bone, cartilage does not have its own blood supply making it more susceptible to injury, infection and disease. Small holes maybe entirely asymptomatic and it may be first found through a doctor’s examination. These ‘dormant’ perforations are probably best left alone. Small perforations can also cause a whistling sound with inspiration which may be bothersome to the person. The edges of the hole can be fragile and cause frequent nose bleeds (a.k.a. epistaxis). Larger perforations can cause crusting, nasal obstruction, discharge and a poor odor from the nose. Septal perforations that interfere with the structural support of the nose may cause changes to the nasal shape, collapse and ‘saddle nose deformity’.

Medical Management of Nasal Septal Perforation

Again, septum holes that cause no problems can be managed by careful observation. It may be wise to ensure good nasal hygiene (nasal saline sprays, air humidifier) especially during the dry winter season.

For perforations that cause symptoms, medical treatment may represent an option to consider. First, the underlying cause should be addressed (i.e. stop medications, drugs, manipulation; treat disease etc.). The nose should be kept moist at all times. This becomes more important during the dry season (winter). Nasal saline sprays should be used frequently. They are available over the counter or can even be mixed at home. In addition, Vaseline jelly is helpful in softening nasal crusts and providing a longer-lasting protective layer over the fragile edges. Bacterial infections may contribute to nasal crusting and odors (atrophic rhinitis). Antibiotic ointments (i.e., Neosporin, Bacitracin, Bactroban) can therefore be helpful by treating these infections. If whistling is the main concern, soft ‘septal buttons’ made of silicone can be placed into the perforation as a simple office procedure.

Surgical Closure of Septum Holes

If the patient desires permanent correction and the perforation-causing factors are eliminated, surgical repair can be discussed. In general, closure of smaller perforations is easier. Large perforations are most commonly not closed entirely but reduced in size. Repair techniques require the use of mucosa flaps with a sturdy blood supply. Various techniques have been described. Smaller perforations can be repaired with flaps mobilized from the intact septum and advanced in order to cover the hole. Best results are usually achieved when this coverage is performed on both sides of the septum. For larger perforation, a combination of septal advancement flaps and other tissue flaps may be most beneficial. A staged repair may be necessary. Sometimes, complete closure may never be achieved.

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