What is Perforated Nasal Septum: Symptoms, Causes, Diagnosis, Treatment, Recovery, Outlook

What is Perforated Nasal Septum?

The nasal septum is made up of cartilage and bone and is located between the two cavities of your nose. In fact, the septum separates the two nasal cavities and also helps in ensuring proper airflow in your nasal passages.1 There is a common type of injury that affects many people. This happens when a hole develops in the septum. Known as a perforated septum, this condition can cause various symptoms, ranging from mild to severe. To a large extent, the symptoms of perforated septum depend on the exact size of the hole that has developed in the septum. There are many types of treatments available for a perforated septum, including home remedies, surgeries to repair the septum, and prosthesis. Here’s everything you need to know about treating a perforated nasal septum.

Symptoms of a Perforated Nasal Septum 

The symptoms of having a perforated nasal septum vary from person to person and also depends on the size of the hole in the septum. The hole in the septum is typically classified as follows: 

  • Small Hole: Size of the hole is smaller than 1 centimeter
  • Medium Hole: Size of the hole is between 1 to 2 centimeters
  • Large Hole:  Size of the hole is bigger than 2 centimeters 

When you first visit your doctor, they will begin by determining the size of the hole in the septum. 

However, some people may never even realize that they have a perforated septum. Many people do not experience any symptoms of a perforated nasal septum.2 In people who experience symptoms, these symptoms will vary in severity. Common symptoms may include: 

  • Frequent nosebleeds
  • Wheezing sound through the nose
  • Crusting of the nose
  • Feeling an obstruction in the nose
  • Scabbing in the nose
  • Frequent runny nose
  • Experiencing pain in the nose
  • Headache
  • Having a bad smell in the nose

Causes of a Perforated Nasal Septum:

There are many causes of why a person develops a perforated nasal septum. Some of the potential causes include:3 

  • Trauma to the nose, including a fractured or broken nose
  • Having surgery on the nose
  • Use of intranasal oxymetazoline, steroid, or phenylephrine spray4
  • Frequent cocaine use
  • Certain diseases like syphilis, tuberculosis, lupus, and some types of cancer
  • Damage to the nose caused by picking it too much
  • Certain infections
  • Some types of chemotherapy5
  • Autoimmune disorders, especially Wegener granulomatosis with polyangiitis6 

There are also certain factors that increase the risk of developing a perforated nasal septum. People who work with certain chemicals like cement, mercury fulminate, arsenic, and chemicals that are used in chrome plating are at a high risk of having a perforated septum.7 If you work in an environment where you regularly handle these chemicals, there are some steps you can take to reduce the risk of developing a perforated septum. These include: 

  • Use the right protective equipment to guard yourself
  • If possible, change the toxic chemicals that are used
  • Practice good hygiene at your place of work
  • Reduce chromic acid mist 

You can also reduce the risk of a perforated nasal septum by the following tips: 

  • Use a saline-based nasal spray
  • Avoid doing cocaine8,9
  • Avoid excessive picking of your nose
  • Use a humidifier in your bedroom to add moisture to the air

How is a Perforated Septum Diagnosed? 

Many people do not experience any symptoms of having a perforated nasal septum. Due to this, they may not have any reason to visit the doctor. However, if you suspect you may have a perforated septum or you are experiencing nose-related symptoms and having trouble breathing, you should schedule a visit with your doctor. 

If you have a perforated septum, your visit to your doctor may involve the following: 

  • A complete examination of the outside and inside of your nose. The interior of your nose may be examined by a nasal endoscopy, rhinoscopy, or palpation of the septum.10,11
  • Questions about your symptoms and a complete medical history, including details about any prior surgeries, medications you are on, as well as your habits, including drug use.
  • Biopsy of the perforation.
  • Laboratory testing if your doctor suspects an underlying medical condition as the cause.

How to Treat a Perforated Nasal Septum? 

Once you have been diagnosed with a perforated nasal septum, your doctor will discuss a treatment plan with you. The primary aim of your doctor will be to treat the underlying cause of the perforated septum if it can be determined. Your doctor will also try to reduce the symptoms caused by the perforation, and then try to close the hole if necessary or possible. 

There are numerous first-line treatments that help alleviate the symptoms of a perforated nasal septum. These including: 

  • Using a humidifier
  • Irrigating the nasal passages with saline sprays
  • Applying an antibiotic ointment to prevent any infections 

There is also a non-surgical treatment option which includes the use of a prosthesis in the nose that will plug the hole in the septum. This is commonly known as a prosthetic button, and your doctor can easily insert this button by using local anesthesia.12 This nasal prosthetic can be customized to the size of your nose and the hole, or it can be a generic-sized button. These prosthetic buttons help seal up the perforated septum and helps decrease your symptoms. There are many types of buttons available on the market, and some can even be removed daily to be cleaned and reinserted.13 

In some cases, it might be necessary to carry out surgery to repair the septum and fix the hole. Usually, though, it is likely that your doctor is only able to repair a small hole in the septum. Surgery for fixing a perforated nasal septum is a complicated procedure, and only specialized surgeons can perform it. Such a surgery also requires general anesthesia, and you will need to stay overnight at the hospital for monitoring and recovery. Your doctor may choose to cut your nose from the underside and then move some tissue to fill up the hole in the septum. The other approach is that your doctor may use cartilage from the ribs or the ears to repair the hole in the septum. Then a flap of new tissue is put on each side of the hole. While some surgeons believe the flap is enough, others will add further support with cartilage, bone, or tissue taken from other parts of the body.14,15 

While surgery can fix a perforated septum, there is no guarantee that it will work, and sometimes it may not even be needed. Smaller holes are always easier to fix by surgery than larger perforations. 

The entire surgery takes around one to three hours. Some surgeons prefer to use the closed surgery option to treat perforated septum, where they go in through your nostrils, while others prefer to open up the nose to get better access. The exact approach your doctor will pick will depend on how big the hole is, where it is located, and of course, on the expertise and experience of the surgeon.

Recovering from a Perforated Nasal Septum 

If you have had surgery to repair a perforated septum, it is likely that there will be thin splints in the nose to cover and help protect the flaps that have been put in. These splints will remain in place for a week or two. To keep your nose safe as it heals, it is recommended that you follow these tips: 

  • Do not bend over or lift heavy things
  • Do not blow your nose too hard
  • Do not pick your nose
  • Try to sneeze with your mouth open
  • Rinse the nasal passage with saline as often as your doctor has recommended
  • Avoid doing any contact sports 

In most cases, you will start feeling like your usual self within a couple of weeks. You will need to come back for a follow-up visit with your doctor a week after your surgery, during which your doctor will do the following:16 

  • Check that the splints are in position and if they need to be taken out.
  • Clean out the nose if there is any crusting.
  • Make sure that the flaps are healing well. 

There will be another checkup at two weeks after the surgery, and then again at six weeks and 12 weeks after surgery. You will get to know by six weeks after surgery whether the procedure worked or not. 

There are certain risks associated with any surgery, and you need to be careful of some things as you heal. You should call your doctor immediately if you notice any of the following signs and symptoms: 

  • Fever
  • Bleeding
  • Pain and swelling that is getting worse
  • Lot of fluid draining from the nose
  • Redness on the outside of the nose
  • If you are having trouble breathing 

It is essential to realize that surgery is usually not the first step in the treatment of a perforated nasal septum. Your doctor is more likely to recommend that you use an antibiotic ointment or practice regular saline rinsing. If this helps relieve your symptoms, you will be required to keep getting routine checkups to check if the hole has grown. If the perforation becomes too big, the nose will no longer be stable, and this may make the middle or tip of the nose begin to droop.17 

You also need to understand the underlying cause of the perforation. If the hole were caused by an ongoing medical issue, such as infection, tumor, or drug use, your doctor would focus on treating these issues first and then think about how to treat the perforated septum.

Outlook for a Perforated Nasal Septum 

It is quite possible for a person to have a perforated septum and not experience any symptoms. You may also be very much aware of your condition due to the significant symptoms caused by a perforated septum. Your doctor will diagnose the condition and work together with you to find the best treatment. Treatment for a perforated nasal septum also depends on the severity of your symptoms, how big the hole is, and where the hole is located. In some cases, surgical intervention may be required, but surgery usually works best when the perforation is small.

References:

  1. Beeson, W.H., 1987. The nasal septum. Otolaryngologic Clinics of North America, 20(4), pp.743-767. 
  2. Fornazieri, M.A., Moreira, J.H., Pilan, R. and Voegels, R.L., 2010. Perforation of nasal septum: etiology and diagnosis. Int Arch Otorhinolaryngol, 14, pp.1-10. 
  3. Trimarchi, M., Bondi, S., Della Torre, E., Terreni, M.R. and Bussi, M., 2017. Palate perforation differentiates cocaine-induced midline destructive lesions from granulomatosis with polyangiitis. Acta Otorhinolaryngologica Italica, 37(4), p.281. 
  4. Jewers, W.M., Rawal, Y.B., Allen, C.M., Kalmar, J.R., Fox, E., Chacon, G.E. and Sedghizadeh, P.P., 2005. Palatal perforation associated with intranasal prescription narcotic abuse. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 99(5), pp.594-597. 
  5. Mailliez, A., Baldini, C., Van, J.T., Servent, V., Mallet, Y. and Bonneterre, J., 2010. Nasal septum perforation: a side effect of bevacizumab chemotherapy in breast cancer patients. British journal of cancer, 103(6), pp.772-775. 
  6. Trimarchi, M., Sinico, R.A., Teggi, R., Bussi, M., Specks, U. and Meroni, P.L., 2013. Otorhinolaryngological manifestations in granulomatosis with polyangiitis (Wegener’s). Autoimmunity reviews, 12(4), pp.501-505. 
  7. Aiyer, R.G. and Kumar, G., 2003. Nasal manifestations in chromium industry workers. Indian Journal of Otolaryngology and Head and Neck Surgery, 55(2), pp.71-73. 
  8. Deutsch, H.L. and Millard, D.R., 1989. A new cocaine abuse complex: involvement of nose, septum, palate, and pharynx. Archives of Otolaryngology–Head & Neck Surgery, 115(2), pp.235-237. 
  9. Mattson-Gates, G., Jabs, A.D. and Hugo, N.E., 1991. Perforation of the hard palate associated with cocaine abuse. Annals of plastic surgery, 26(5), pp.466-468. 
  10. Aziz, T., Biron, V.L., Ansari, K. and Flores-Mir, C., 2014. Measurement tools for the diagnosis of nasal septal deviation: a systematic review. Journal of Otolaryngology-Head & Neck Surgery, 43(1), p.11. 
  11. Benninger, M.S., 1997. Nasal endoscopy: its role in office diagnosis. American journal of rhinology, 11(2), pp.177-180. 
  12. Mullace, M., Gorini, E., Sbrocca, M., Artesi, L. and Mevio, N., 2006. Management of nasal septal perforation using silicone nasal septal button. Acta otorhinolaryngologica italica, 26(4), p.216. 
  13. Eliachar, I. and Mastros, N.P., 1995. Improved nasal septal prosthetic button. Otolaryngology—Head and Neck Surgery, 112(2), pp.347-349. 
  14. Goh, A.Y. and Hussain, S.S., 2007. Different surgical treatments for nasal septal perforation and their outcomes. In Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. Centre for Reviews and Dissemination (UK). 
  15. Watson, D. and Barkdull, G., 2009. Surgical management of the septal perforation. Otolaryngologic Clinics of North America, 42(3), pp.483-493. 
  16. Watson, D. and Barkdull, G., 2009. Surgical management of the septal perforation. Otolaryngologic Clinics of North America, 42(3), pp.483-493. 
  17. Re, M., Paolucci, L., Romeo, R. and Mallardi, V., 2006. Surgical treatment of nasal septal perforations. Our experience. Acta otorhinolaryngologica italica, 26(2), p.102.

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