You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > NASAL AND SINUS DISEASES Septal Perforation: Medical AspectsArticle Last Updated: Mar 14, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Rami K Batniji, MD, Private Practice, Batniji Facial Plastic Surgery Rami K Batniji is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, California Medical Association, and Triological Society Coauthor(s): James F Chmiel, MD, Clinical Assistant Professor, Department of Otolaryngology, State University of New York at Buffalo Editors: J David Kriet, MD, FACS, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Director of Facial Plastic and Reconstructive Surgery, University of Kansas School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: nasal septal perforation, perforated septum, nose trauma, cocaine use, nose picking, nasal trauma, nasal spray, lupus erythematosus, Wegener granulomatosis, illicit drug use, sarcoidosis, nasal silastic buttons, sinonasal malignancy, septal hematoma, nasal-septal fracture, septoplasty, sinonasal tumors INTRODUCTIONSection 2 of 11
  BackgroundSeptal perforations are a diagnostic challenge because various potential causes are possible. Therefore, elucidating the cause of the septal perforation requires the obtainment of a thorough history. Although several surgical options are available for the treatment of symptomatic septal perforations (see Septal Perforation: Surgical Aspects), this article focuses on the medical management of septal perforations. PathophysiologyThe nasal septal mucoperichondrium provides the blood supply to the septal quadrangular cartilage. Any insult (eg, chemical, physical, iatrogenic) to this normal anatomy can lead to the development of a perforation. Mortality/MorbiditySeptal perforations can cause significant morbidity. The symptoms associated with septal perforations include nasal congestion or obstruction, nasal crusting and drainage, recurrent epistaxis, and a whistling sound from the nose. In addition to the symptoms related to nasal septal perforations, manifestations of the disease process that caused the perforation (eg, lupus, Wegener granulomatosis) may also carry significant morbidity. CLINICALSection 3 of 11
HistorySeptal perforations are usually asymptomatic. However, some patients may present with a history of nasal obstruction, crusting, intermittent episodes of epistaxis, malodorous discharge from the nose, or a whistling sound during nasal breathing. A thorough medical history is essential in the evaluation because septal perforations are associated with many systemic diseases. Inflammatory diseases such as collagen vascular diseases, sarcoidosis, and Wegener granulomatosis may cause septal perforations. In addition, infectious processes such as tuberculosis, syphilis, and fungal diseases may result in septal perforations. Rarely, septal perforation is the initial finding of sinonasal malignancy. Traumatic causes of septal perforation may be divided into external, self-inflicted, and iatrogenic causes. External trauma includes nasal-septal fracture. A septal hematoma results in elevation of the mucoperichondrium from the quadrangular cartilage, ischemia, and subsequent necrosis of the cartilage, with resultant perforation. Self-inflicted trauma, such as digital manipulation, may cause a septal perforation. Iatrogenic trauma includes a history of septoplasty, nasal packing or cauterization for epistaxis, and nasotracheal intubation. Medication usage should be reviewed. Chronic use of vasoconstrictive nasal sprays and steroid nasal sprays may cause septal perforations. In addition, the use of cocaine may result in septal perforations. Exposure to industrial fumes, wood dust, nickel-refining processes, and leather tanning may result in sinonasal malignancy and the development of septal perforation. Exposure to mineral oils, chromium, lacquer paint, soldering, and welding have also been associated with an increased incidence of sinonasal malignant tumors. PhysicalPhysical examination of the nose begins with an evaluation of the external nose. Large perforations may result in loss of support to the dorsum of the nose and subsequent saddle nose deformity. Most septal perforations are identified incidentally during routine physical examination. Thorough intranasal examination with anterior rhinoscopy is essential. Anterior rhinoscopy may demonstrate severe crusting; all crusting should be removed to attain a thorough evaluation of the septum. Topical nasal decongestants may further assist in the intranasal inspection of the entire septum. The location of septal perforations is important because posterior perforations are typically asymptomatic compared with anterior perforations. Nasal endoscopy may assist in the evaluation of the entire septum. The position and diameter of the perforation should be noted. Palpation of the septum with a cotton-tipped applicator provides valuable information regarding the integrity of the quadrangular cartilage in the remainder of the septum. Crusting of the entire septum, edematous mucosa, or inflammation of the mucosa should alert the physician to systemic diseases as the etiology of the perforation. In patients with an identifiable cause of the septal perforation, no further workup may be necessary. However, patients with an unidentifiable cause should undergo further investigation (see Workup). CausesThe causes of septal perforation are many and varied. Attempting to find the inciting cause, or at least ruling out many of the dangerous causes, is important. If one can successfully surgically close a septal perforation but cannot alter the course of the initial inciting cause, then the perforation is often doomed to recur. Additionally, by closing the perforation, the physician may hide a manifestation of an undiagnosed disease process. The causes of septal perforations can be conveniently placed into several categories that can help the physician more easily determine the causative agent or process. A good history, physical examination, and select laboratory studies can help focus the investigation.
DIFFERENTIALSSection 4 of 11
Complications of Rhinoplasty Congenital Malformations, Nose Disorders of Taste and Smell Epistaxis Foreign Bodies of the Airway Fractures, Nasal and Septal Local Anesthetics Malignant Tumors of the Nasal Cavity Malignant Tumors of the Sinuses Mucosal Melanomas of the Head and Neck Nasal and Sublabial Approaches to the Pituitary Nasal Implants Nasal Physiology Nasal Polyps, Nonsurgical Treatment Nasal Polyps, Surgical Treatment Nasal Reconstruction Pathology: Sarcomas of the Head and Neck Pathology: Squamous Cell Carcinoma Rhinoplasty, Postrhinoplasty Nasal Obstruction Rhinoplasty, Saddle Nose Septal Perforation: Surgical Aspects Snoring and Obstructive Sleep Apnea, CPAP Snoring and Obstructive Sleep Apnea, Surgery
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| Drug Name | Oxymetazoline 0.05% (Dristan, Allerest, Afrin) |
|---|---|
| Description | Topical vasoconstrictor; decreases swelling and congestion in the nose. |
| Adult Dose | 2-3 puffs each nostril q12h, not to exceed more than 5 d |
| Pediatric Dose | Not established |
| Contraindications | Angle-closure glaucoma; caution in patients with hyperthyroidism, cardiovascular disease, hypertension, diabetes, or eye injuries |
| Interactions | Hypotensive action of guanethidine may be reversed; concurrent administration with methyldopa may result in an increased vasopressor response; concurrent use of MAOIs and ephedrine may result in hypertensive crisis; pressor sensitivity to mixed-acting agents (eg, ephedrine) may be increased; guanethidine potentiates effects of epinephrine and inhibits effects of ephedrine Phenothiazines may reverse action of nasal decongestants; TCAs potentiate vasopressor response and may result in dysrhythmias |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Caution in hyperthyroidism, coronary artery and ischemic heart disease, diabetes mellitus, increased intraocular pressure, or prostatic hypertrophy; because of increase in vasoconstriction, patients with hypertension may experience change in blood pressure; do not use topical decongestants for longer than 3-5 d |
These agents are used to induce trophic changes in nasal mucosa (thickening of thin, delicate nasal mucosa).
| Drug Name | Conjugated estrogen (Premarin) |
|---|---|
| Description | When mixed with nasal saline, can be applied topically to thicken nasal mucosa to decrease epistaxis; 25 mg of conjugated estrogen (Premarin Secule kit) mixed with 1 bottle of saline nasal spray; keep refrigerated and discard after 30 d; discuss with patient that this is an off-label use of the drug. Discuss risks and benefits of using this drug; only for use in patients with severe epistaxis due to the perforation. |
| Adult Dose | 25 mg of conjugated estrogen mixed with 1 bottle of nasal saline spray; apply to nasal tissue, 2 puffs each side of nose tid; base duration of therapy on clinical response |
| Pediatric Dose | Not recommended |
| Contraindications | Documented hypersensitivity; pregnancy and lactation; children; patients with endometrial cancer, thromboembolic disorders, breast cancer, undiagnosed vaginal bleeding, or liver dysfunction |
| Interactions | May reduce hypoprothrombinemic effect of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P-450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins |
| Pregnancy | X - Contraindicated; benefit does not outweigh risk |
| Precautions | Certain patients may develop undesirable manifestations of excessive estrogenic stimulation (eg, abnormal or excessive uterine bleeding, mastodynia); may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia |
These agents, when applied to nasal mucosa, can keep tissue moist. Drying of nasal mucosa can induce epistaxis.
| Drug Name | Mupirocin topical 2% (Bactroban cream) |
|---|---|
| Description | Apply topically to nasal septal mucosa to keep nasal tissue moist. |
| Adult Dose | Apply to nasal mucosa tid |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Prolonged use may result in growth of nonsusceptible organisms |
Deterrence/Prevention:
| Media file 1: Proposed algorithm for a systematic evaluation of newly diagnosed septal perforations. | |
 | View Full Size Image | Media type: Graph |
| Media file 2: A simple technique to modify an oxygen nasal cannula that helps to prevent the cannula tip from rubbing against the nasal septum. Two wooden sticks are taped to the hub of the nasal cannula. This technique can also be used in patients with preexisting septal perforations to decrease crusting and epistaxis. | |
 | View Full Size Image | Media type: Photo |
| Media file 3: To assess the size of a perforation, barium paste is applied to the edges of the perforation and a lateral 6-foot plain film is obtained of the head. Technique described by Rettinger and Rosemann. | |
 | View Full Size Image | Media type: X-RAY |
Septal Perforation: Medical Aspects excerpt
Article Last Updated: Mar 14, 2008
