Septal Perforation Evaluation and Treatment

by Dr. Christopher Chang, last modified on 4/13/21.

Please be aware that our office can evaluate septal peforations, but will refer out if surgical correction desired/needed.

Uncommonly, a patient may have a condition known as a septal perforation which essentially is a hole in the nasal septum. In the image, the septal perforation is denoted by the purple arrow. Normally, an intact nasal septum is a flat, straight, hole-less wall inside the nose approximately 3 X 1.5 inch, that divides the right side of the nasal cavity from the left side. The nasal septum is composed of cartilage in the front and bone in the back of the nose. Ideally, this nasal septum should be straight to allow symmetric airflow into both sides of the nose. If the nasal septum is "crooked," it would be called a deviated septum which may lead to nasal obstruction and other symptoms.

Generally speaking, a septal perforation causes minimal if any symptoms. However, if symptoms are present, patients typically complain of:

Recurent nosebleeds
Excessive nasal crusting
Whistling when breathing in/out of the nose

Watch Video on Septoplasty (Real) or Animation

What can cause a perforated septum?

There are many causes for a septal perforation, including:

Nasal trauma
Deviated septum
Constant nose-picking
Repeated nasal cauterization for nosebleeds
Nasal spray overuse, most commonly nasal decongestant nasal sprays like Afrin
Illegal drug use, most commonly snorting cocaine
Inflammatory autoimmune disorders, typically Wegener's granulomatosis, lupus, and relapsing polychondritis
Infection (ie, syphilis, tuberculosis)
Prior nasal surgery, most commonly septoplasty
Cancer (this is rare)

When a septal perforation is detected, it is important to determine the cause of the perforation so appropriate medical intervention can be pursued, especially if the trigger is still ongoing. Assuming no obvious nasal insult due to trauma, surgery, or nasal spray abuse based on history, a workup may include bloodwork to check for any underlying autoimmune disorder, nasal endosopic examination to closely examine the nasal lining and cavity. and intra-nasal biopsy to evaluate for cancer if any suspicious lesions are detected.

Assuming absent triggering insult, management is often only conservative nasal care to minimize nosebleeds and crusting which are the main symptoms of a perforated septum. More rarely, patients may complain of nasal obstruction, dryness, whistling with breathing. Nosebleeds typically occur along the back edge of the septal perforation where excessive drying out can occur from normal nasal breathing. When this happens, the mucosa may crack and bleed (kind of like chapped lips). Excessive crusting may buildup for the same reason. To minimize or eliminate such problems, patients often have to regulary use saline nasal sprays and oil-based nasal emollients like ponaris.

That said, the vast majority of patients do not require any treatment or management since most do not have any symptoms due to the perforation.

What if I want the perforated septum FIXED?

Beyond conservative management, surgical correction can be pursued, but patients must be made aware that surgical correction is very difficult and the chance of successful closure is not very high, even if performed by an experienced surgeon.

There are two basic surgical approaches for septal perforation closure.

Septal Button

The least invasive approach is to plug the perforation with a soft, pliable plastic button. Think of it as a nasal implant. The implant is not visible, does not hurt, typically stays in for as long as needed, and can be removed at any time. Unfortunately, crusting can still occur and if not fitted properly, may actually cause the septal perforation to enlarge.

Naso-Septal Flap

The main reason why surgical repair is so difficult is twofold. First is finding sufficient tissue coverage to span the perforated opening, especially if the hole is large. Simply placing a large tissue graft (like a skin graft) often fails as the mucosal graft often will die due to insufficient capillary blood supply which is the second reason for low success rates for perforated septum repairs. If there is insufficient blood supply, the tissue dies and the perforation recurs, sometimes even larger than before the surgical procedure.

As such, the current state-of-the-art in septal perforation repairs is to use a vascularized pedicled naso-septal muco-perichondrial flap based off the anterior ethmoid artery. Essentially, a very large naso-septal mucosa is freed (typically from septum and nasal cavity floor) and mobilized to cover the septal perforation while keeping the entire flap still attached superiorly where a robust blood flow is present from the anterior ethmoid artery. The flap is advanced and/or rotated into the septal perforation. Depending on the surgeon based on patient factors, the repair may require a three-layer closure which would include widely mobilized muco-perichondrial flaps on both sides with an interposed collagen fibrous sheet (usually temporalis fascia).

Not many surgeons have expertise in performing this complex surgery with a high success rate. Oddly enough, an endoscopic skull base surgeon are the doctors who have the most experience and right skill set to perform this operation well.

At least in our office, we refer patients interested in surgical correction to a tertiary care center.

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Septal Perforation Evaluation and Treatment

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