General Medical Information

Septal Perforation

Richard L. Mabry

Septal perforation can be asymptomatic; however, this condition often is associated with crusting and bleeding around the defect and, if the perforation is small, whistling during inspiration or expiration. Turbinates adjacent to the septal perforation can become hypertrophic from an increase in the intensity of nasal turbulence. If the perforation is tolerable and causes no serious detriment to nasal function, management is oriented toward alleviating the symptoms of perforation. Antibiotic ointment can be used to control crusting and bleeding around the perforation. A polymeric silicone button can be used to stop the whistling during inspiration or expiration. These buttons can be shaped to the individual perforation and usually are well tolerated.

Repair of septal perforation limited to defects less than 2 cm in diameter can be accomplished with surgical flaps. Under surgical microscopic visualization and with an intranasal approach, septal repair frequently necessitates sliding or rotating mucoperichondrial or periosteal flaps across the defect. An advantage of using two overlapping raw flaps is that the flaps have a propensity to heal and stay moist. Additional procedures involve bilateral mucosal advancement flaps freed from adjacent septal cartilage or bone, the nasal floor, and the lateral nasal wall. An incision along the inferior turbinate allows rotation and occlusion of the perforation with the two flaps. A continuous horizontal mattress suture or whipstitch with 5-0 or 4-0 chromic catgut plicates the flaps. A small incision or tear at the inferoposterior edge of the flap can prevent formation of a submucosal hematoma.

Meticulous surgical technique is essential to a successful outcome. Flap healing can be enhanced with skull-based periosteal or perichondrial grafts sandwiched between the mucosal flaps. Surgical repair of large perforations is difficult, often necessitating external rhinoplasty or lateral alotomy (incision along the alar cartilage and maxillary crease) for sufficient access to the nasal area. Septal perforation due to nose picking often is easy to close because of the preservation of healthy adjacent cartilage, whereas perforation due to overzealous resection of septal cartilage (with subsequent breakdown of mucosa) has a dismal repair prognosis. Similarly difficult procedures are those to manage septal perforation due to recreational use of cocaine. In these cases, extensive sections of septal cartilage can be lost owing to extensive vasoconstriction and irritation of nasal mucosa by cocaine and substances with which it is cut, such as talc or strychnine.