What is Septal Perforation?
A nasal septal perforation is a complete hole through the nasal septum, which is the wall dividing your right and left nostrils. This wall has three layers: two mucoperichondrial leaflets -pads that cover the inner surfaces of the nostril – and a structural middle layer made of several types of cartilage. The hole usually happens in the front part of the cartilaginous septum. You might experience blocked nose, whistling sounds, nosebleeds, crust formation, pain, runny nose, long-lasting sinus infection, or a bad smell as symptoms.
What Causes Septal Perforation?
The hole that can occur in the wall of your nose, known as nasal septal perforation, can be caused by several things. These include physical injuries, autoimmune diseases such as granulomatosis with polyangiitis (GPA), certain infections like syphilis, fungal diseases, or tuberculosis, and the presence of abnormal tissue growth, also known as neoplastic.
People with weaker immune systems might be more likely to get infections, such as fungal infections, that can also lead to this condition. It can also occur as a result of patients’ own actions, like nose picking, or after certain medical procedures like those to stop nosebleeds, or septoplasty which is surgery to straighten the nasal septum.
It is reported that about 0.5% to 3.1% people may develop a nasal septal perforation after undergoing a septoplasty. Other potential causes include the abuse of certain drugs through the nose, the use of steroid nasal sprays or sprays that narrow the blood vessels in your nose.
Risk Factors and Frequency for Septal Perforation
People with certain jobs are more likely to suffer from certain health problems. For example, in the past, chrome platers often suffered from inflammation, erosion, and tissue damage after being exposed to harmful chromic mist. Nowadays, woodworkers and metal workers who are exposed to nickel dust have a higher risk of developing intranasal carcinoma, a type of cancer that occurs within the nasal cavity.
Signs and Symptoms of Septal Perforation
A healthcare provider needs to ask the patient about several different factors to diagnose a hole, or perforation, in the nasal septum. It is important to learn about any prior injuries to the nose, use of drugs administered via the nose (including prescribed, over-the-counter, and illegal substances), nose cleaning behaviors, lung-related symptoms, kidney-related symptoms, and autoimmune diseases. Detailed information about when the symptoms started, how long they have been occurring, their timing and severity, as well as any treatments previously tried should also be collected.
In a physical examination of the nose, the healthcare provider should measure both the size and the height of the hole in the nasal septum. This can be done in a clinic with a headlight, a nasal speculum, and a cotton swab with marks indicating measurement units. Observing the height of the septum can hint at the quantity of the layer of tissue lining the cartilage of the septum, which can be used in potential repair surgery. It’s also important to note if the bridge of the nose appears to be collapsed, as bigger holes can jeopardize the structural support of the nose. Conditions that cause inflammation could lead to the formation of granulation tissue or excessive crusting around the hole. The healthcare provider should also inspect for foreign substances, as this could suggest illegal drug use. Checking inside the mouth can help to rule out involvement of the roof of the mouth. Finally, examining the ear or the area near the temple can provide useful information about where tissue could be taken from, if repair surgery is required.
Testing for Septal Perforation
The steps taken to investigate a hole in the nasal septum, or septal perforation, can differ based on each patient’s specific situation. For example, if a patient has had a previous surgery to correct a deviated septum (known medical parlance as a septoplasty), and the perforation was discovered after, there typically isn’t a need for a biopsy or further laboratory tests.
Nevertheless, when the cause isn’t as clear, a biopsy, which is a procedure where a small piece of tissue is removed for examination, may be carried out on the perforation. Patients should be informed that this procedure may expand the size of the hole in their nasal septum. The area towards the back of the septum is generally selected for biopsy because enlarging the hole in that direction does not usually affect the options available for repairing the perforation.
Patients may also need to undergo blood tests to check for certain antibodies or markers such as ANCA, ANA, RF, ESR, CRP, FTA-ABS, and ACE. These help to investigate the possibility that the septal perforation was caused by an autoimmune disease or inflammation.
Imaging tests such as a chest x-ray or a CT scan of the sinuses can also be added to the workup to get a clearer picture of the problem. If there’s a suspicion that the imfection is caused by tuberculosis, tests for this disease may be needed.
Treatment Options for Septal Perforation
Nasal septal perforation, or a hole in the wall separating your nostrils, can be treated through various medical and surgical methods. For less severe cases, medical treatments could involve keeping the inside of the nose moist to ease discomfort, minimize crusting, and reduce nosebleeds. However, you should be careful when using products that contain petroleum in the nose to avoid inhaling it, which can lead to a type of pneumonia. Products like saline and water-based gels are generally safer for this purpose.
For those who are not suitable for general anesthesia or full repair surgery, nasal septal prostheses are an option. These are devices made from medical-grade synthetic material that cover the hole in the septum. People’s comfort levels with these prostheses can vary, and it’s best to keep the area moist for maximum comfort. The risk of infection with prostheses is relatively low.
There are also various types of surgeries that can repair a nasal septal perforation. These range from creating a flap of tissue in the nose to cover the hole, using a graft from elsewhere in the body, or even using a synthetic graft. It’s important to note, however, that larger perforations (more than 20mm) are more difficult to repair and have a higher chance of not being successful. If the perforation is large or the patient is not a good candidate for repair, a procedure to remove the back wall of the perforation may be beneficial to lessen the symptoms.
If the patient has an autoimmune disease, this may affect the decision to proceed with surgery. Recent research advises against repairing nasal septal perforations in patients with certain autoimmune diseases, even if the disease is currently inactive.
What else can Septal Perforation be?
When a doctor identifies a septal perforation, they need to consider and rule out three main causes, which are:
- Cancer (neoplasm)
- Infectious disease
- Autoimmune disease
Each of these conditions signifies a treatable system-wide disease. These require careful consideration and need more comprehensive treatment than just addressing the symptoms or repairing the damage.
Surgical Treatment of Septal Perforation
If a biopsy reveals a neoplasm (an abnormal growth of cells, which can be benign or malignant), further specialist guidance is needed. The most common type of neoplasm found in the nasal septum (the bone and cartilage dividing your nose into two nostrils) is called squamous cell carcinoma. Other types of abnormally growing cells in this area can include adenocarcinoma and malignant melanoma.
The recommended first line of treatment is surgical removal of this abnormal growth, ensuring a clear area around it to prevent spreading. There may be situations where radiation therapy could be beneficial as well. If there is a need for repair after the surgical removal of the nasal septum neoplasm, it should be planned and carried out carefully, ideally in consultation with an oncologist or oncologic surgeon, who are specialists in understanding, surveilling, diagnosing, and treating different types of cancer.
What to expect with Septal Perforation
A hole in the nasal septum, or ‘septal perforation’, can produce a number of uncomfortable symptoms including persistent scabbing, nosebleeds, nose pain, a foul smell, and even a collapsed nasal structure, sometimes known as a ‘saddle nose deformity’. These conditions can significantly lower an individual’s quality of life.
However, by using humidifiers regularly, these perforations can be controlled medically. This approach can keep the perforation stable for many years, lessening symptoms and improving daily life.
Possible Complications When Diagnosed with Septal Perforation
Not diagnosing a disease that affects the entire body or a tumour in time could result in delayed treatment. Some complications could arise from repairing a hole in the wall separating the nostrils. These complications may include:
- The hole not fully closing
- Scarring from the donor site
- Nosebleeds
- A wound not healing correctly
- Feeling like your nose is blocked
- The need for additional surgeries
- Ozena, a condition characterized by a foul smell from the nose
- Worsening of symptoms
- Dryness and scabbing in the nose
- A whistling sound when breathing through the nose
Preventing Septal Perforation
Using nasal sprays that narrow the blood vessels too much can damage the tender tissue inside the nose and might lead to a hole in the nasal separator, known as septal perforation. For those who use steroid-based nasal sprays, it’s crucial to direct the spray nozzle to the side rather than directly at the nasal septum, the wall separating the nostrils. Direct spray can thin the tissue of the septum.
Treatment for septal perforation involves not picking or scratching the nose and keeping the nasal passage moist using a humidifier. After the hole is repaired, one should avoid blowing their nose for about a month following the procedure. This helps the healing process and avoids re-injury.
