Nasal Septal Perforation Surgery

What Is A Nasal Septal Perforation?

The nasal septum is the wall that divides your nose into left and right nasal airway passages. The nasal septum is made up of cartilage and thin bone which is covered on both sides by a thin layer of soft tissue. You can feel the nasal septum as the middle structure when you pinch the tip of your nose. A nasal septal perforation is a hole through the nasal septum. The hole may range in size depending on the cause of the perforation. The following illustrates the causes, symptoms, and ultimate treatments for a nasal septal perforation repair when necessary.

 

What Are The Symptoms Of A Septal Perforation?

Septal perforations cause disruption in how air moves through the nasal passages, making airflow more turbulent and less smooth. The air passes from one side to the other of the nose instead of straight back into the airway. As a result, having a septal perforation may cause you to experience some if not all of the following symptoms:

• Bleeding: The turbulent airflow causes the inner lining of the nose to become dry. As a result, the lining may form scabs and crusts that when dislodged can cause bleeding. The bleeding is usually temporary but may require minor procedures to prevent further episodes of bleeding.
• Crusting: The exposed edges of the hole in the septum prevent the delicate lining of the septum from staying moist as well as preventing humidification of the air that is inhaled. As a result, crusts and scabs form along the septal perforation and may form in other parts of the nose. This crusting can progress and cause difficulty breathing. Scabs and crusts may also cause the remaining nasal septum to become infected, requiring antibiotic treatments. Nasal crusting is usually prevented with humidifiers and nasal irrigation. However, if crusting is significant it may require a physician to remove.
• Nasal Obstruction: Large nasal perforations may give the sensation of not being able to breathe properly. This is because the sensors in the nose that detect air movement may be missing. You may be breathing properly, but it feels like you are obstructed. Large crusts may also block one or both sides of the nose.
• Whistling: Small perforations, especially near the nostrils, may be bothersome as they can cause a whistling noise from the nose. This is because air can move between either side of the perforation at a higher speed than other parts of the nose. As a result, a high pitched whistling noise forms.
• Nasal Collapse: A large septal perforation can decrease support of the outside of the nose and cause the nose to collapse. This “saddling” is dramatic externally and will usually block the upper nasal airway.

 

Causes Of A Septal Perforation

Nasal septal perforations are caused by disruption of blood flow to the nasal septum. Because the nasal septum has a delicate blood supply, any factor that decreases this blood flow may result in a septal perforation. Some of the most common causes of septal perforations include:

• Surgery: Nasal surgery can cause significant disruption of the blood flow to the septum as the tissues inside the nose are manipulated decreasing blood flow. A tear in the nasal septum mucosa on both sides will prevent blood flow to the cartilage and a hole may be formed. The risk of septal perforation increases if there is a previous history of nasal surgery.

• Cocaine: Long-term cocaine use is a significant risk factor for developing a nasal septal perforation. Cocaine causes the blood vessels inside the nose to shrink. The more cocaine used over a period of time, the more the vessels shrink. If the vessels decrease in size enough, it may cause a hole to form.
• Infection: Infection may result in what is called tissue necrosis, a term used to refer to tissue death. Such infections may result in a collection of pus in the septum. As the pus collects, it may compromise the vascular blood flow to the septum.
• Medical Conditions: Some medical conditions may cause nasal septal perforations. More specifically, autoimmune conditions such as Wegener’s disease and Sarcoidosis may result in diseased blood vessels, especially in the nose. It is an important consideration for your doctor to make sure that an undiagnosed illness is not recognized. Individuals with septal perforations without an obvious cause should have an autoimmune workup.
• Self-manipulation: Excessive scratching inside the nose can create a hole in the septum. Using instruments in the nose like Q-tips or bobby pins can traumatize the soft tissue and disrupt the nasal septum blood supply.
• Trauma: Trauma to the nose may result in blood collection in the septum, known as a hematoma. As the hematoma expands it disrupts the blood flow which can lead to a septal perforation.
• Nasal Medications: Long-term use of nasal sprays such as steroids or over the counter nasal sprays may also decrease the size of the blood vessels along the septum leading to perforation.

Because of the complex and potentially interconnected causes of a nasal septal perforation, it is important to speak with a specialist.

 

Can A Septal Perforation Heal On Its Own?

Sometimes, depending on the size of the septal perforation, it may heal on its own. However, as the size increases, the likelihood of spontaneous resolution decreases. A proper nasal septal perforation repair is important because of the delicate nature of the tissue.

 

What Makes Someone A Nasal Septal Perforation Repair Specialist?

Specific surgeons are more equipped to handle and treat septal perforations. Typically, Otolaryngologists (or ENT surgeons) have the skills needed to repair such perforations of the septum. More complex and large perforations may require specialists such as Facial Plastic surgeons in order to repair the defect. Wherever the nasal septal perforation repair is done make sure you feel comfortable and confident in the specialist you are working with.

 

How Are Nasal Septal Perforations Treated?

The goals of managing septal perforations are to reduce the bothersome symptoms that result from nasal dryness. Therefore management involves measures that are designed to increase humidification of the passing nasal air, to prevent nasal crusting, bleeding, scabbing, and airway obstruction. Nasal creams such as vaseline ointment or antibacterial ointment applied to the nostrils are designed to prevent drying of the tissue. Nighttime dryness may be an issue, particularly while you sleep. Therefore, oftentimes we may recommend the use of a bedside humidifier. Use of nasal saline irrigation can also help wash away crusting, and prevent the build-up of scabs while maintaining a moist environment.

However, such measures are limited as they are designed to only address symptoms and not to correct the perforation itself. For persistently bothersome perforations, there are surgical options.

 

Preparation For A Septal Perforation Repair

Perforations that have the symptoms including bleeding, crusting, obstruction whistling or nasal collapse should be evaluated for surgical intervention when symptoms become burdensome. The success of repairs depends on maintaining good blood flow in the post-operative period. Patients are encouraged to discontinue smoking for a minimum of 6 weeks before and then 2 weeks after surgery. Also, patients may need to discontinue supplements or over the counter medications that may impair healing.

 

How Do You Repair A Septal Perforation?

Depending on the size of the perforation, and its exact location in the nose, there are various surgical options for repair:

Septal Button

This type of repair involves the placement of a prosthetic to plug the whole. Such a repair may be bothersome as a foreign object is placed in the nose. This may also cause infections, and require frequent visits to the doctor for a replacement. These have fallen out of favor by most doctors and patients.

Local Flap

For small perforations (less than 2.5 cm) local flaps may be used to repair the perforation. This type of repair uses neighboring tissue in the region of the perforation to seal the hole and cover it. This procedure usually involves the same day surgery at an ambulatory surgery center. Post-operatively you may experience some discomfort during the healing process. As the size of the perforation increases, the success rate of a local flap decreases. However, this type of repair is less symptomatic for patients than using a septal button as no foreign material is placed in the nose that needs to be replaced, or that can become infected.

Regional Flap

For perforations (2.5 – 3.5cm), tissue in the region may not be enough to close the perforation. Other options include using tissue from the face or mouth to cover and seal the hole.

Free Flap

For larger perforation (>3.5 cm), a free flap may be performed that uses transplanted tissue from the scalp and is used to reconstruct the missing tissue.

 

After Surgery and Recovery

Depending on the type of surgery you have, you will likely have nasal packing/splints in your nose. These are placed by Dr. Mourad to allow for proper healing of the internal nasal structures, like an “internal cast” for the nose. These typically are removed at your first postoperative visit, one week later. You will also likely have a nasal cast on the outside of the nose. This also helps reduce swelling and keep everything in place. This remains on the nose also for 1 week following surgery. Depending on your work, Dr. Mourad typically recommends taking a minimum of 3 days off before returning to work. He also discourages his patients from any heavy lifting as this can alter the structure of the nose through straining. If you wear glasses, you may require some alterations as to not provide pressure on the nasal bones. Dr. Mourad will provide you with pain medications, ointments, nasal sprays, all to help maximize your results.

You will see Dr. Mourad one week after surgery where he will remove all casting materials and splints. Your nose may be swollen for a temporary period of time, so don’t stress! The nose is a small area, and all that surgery causes swelling that eventually is reduced with time. Depending on the patient this swelling typically lasts for 2-3 weeks but can last up to two months in rare circumstances. To help reduce the swelling Dr. Mourad will re-apply tape to the nose that will be there until your second post-operative visit. This pressure dressing reduces the amount of swelling. The second postoperative visit will involve removing all the tape. Dr. Mourad will then see you in visitations two weeks later, and then one month after that. Dr. Mourad enjoys the continued visitation of his patients and will see them in follow up for many years thereafter.

Associated Risk

• Anesthesia: Depending on the type of anesthesia administered, patients may have a reaction. This is exceedingly rare, and it is important to discuss your personal risk with your anesthesiologist.
• Infection: In rare circumstances patients may develop an infection following septal perforation procedures. These are usually managed with intraoperative and postoperative antibiotics.
• Bleeding: Although rare, patients may have bleeding episodes following nasal surgery. Your surgeon will likely order blood work to make sure you are healthy enough to undergo the procedure. Your surgeon should also go over all medications and supplements that you take to minimizing bleeding risk.
• Need for secondary and revision surgeries: Depending on the complexity of the surgery and size of the perforation, sometimes multiple surgeries are required to ensure the best outcomes.
• Scarring (Synechia) and Poor wound healing: Some patients with underlying medical conditions or more prone to poor wound healing and scarring. It is important to understand these risks prior to embarking on a treatment strategy.
• Local Reactions: Sometimes you may experience local reactions to the ointments, sutures, taping material, and nasal packing used during surgery and postoperatively. This is rarely seen, but may occur. If you have any allergies to certain materials or adhesives you should discuss with your surgeon.
• Changes in nasal sensation: Patients may experience altered sensations in their nose (pain or numbness). This is exceedingly rare, and if it occurs it is most often temporary.
• Persistent or Recurrent Septal Perforation: Although the goal of surgery is to repair the septal perforation, sometimes the perforation may persist after surgery or be made worse. This may be related to underlying medical issues (e.g. asthma, or nasal polyps). The larger the initial perforation, the higher the likelihood of a persistent or recurrent septal perforation.
• Persistent, New, or Recurrent Nasal Airway Obstruction: Altering the nose may result in changes to breathing. Sometimes patients may develop new, persistent or recurrent airway problems. This is rare, but oftentimes is due to poor wound healing or scarring (see above). This may require secondary surgeries to optimize outcomes.

 

How Can Dr. Mourad Help With Septal Perforations?

Dr. Mourad is an Otolaryngologist and Facial Plastic Surgeon with extensive experience in all sizes of septal perforation repair. After a thorough history and examination, you will learn how big your perforation is and what options for closure exist. We will check your medical benefits to let you know what to expect so there are no surprises. If you think we can help please give our office a call.