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Septal Perforation

In severe cases, septal perforations that continue to enlarge must be treated through surgery to prevent further complications.

The septum is a structure comprised of cartilage, bone, and a thin membrane that separates the two nasal passages. If a perforation — hole — develops in the septum it may need to be repaired.

Treatment can range from rinsing with a saline solution to complex surgery. The urgency and type of treatment depends on what caused perforation, the extent of the damage, whether or not it is irritating, and whether or not it is causing any health problems. If a septal perforation causes no issues, it may not need to be treated.

Common septal perforation causes

The most common causes of septal perforations are as follows:

  • Previous nasal surgery – Sometimes perforations are made accidentally by surgeons during procedures such as rhinoplasty and septoplasty. It’s also possible for a perforation to develop following sinus surgery. These perforations often require corrective surgery.
  • Trauma – A nasal fracture can perforate the septum. In some cases the patient doesn’t notice the perforation until symptoms develop or the hole becomes larger.
  • Infection – A small perforation can become larger due to infection.
  • Cocaine Use – It doesn’t take much cocaine use to cause a septal perforation. Cocaine use decreases the supply of blood to nose which can lead to a host of problems. Moreover, cocaine is often mixed with abrasive substances that can erode the septum’s membrane and cartilage. In extreme cases, the septum may collapse altogether and may not be salvageable.
  • Overuse of decongestants or nasal steroids – Irritation cause by steroid nasal sprays can lead to septal perforations.
  • Excessive nose picking – If you have a habit of picking your nose, be careful. This seemingly harmless habit can cause a septal perforation if you get carried away.
  • Autoimmune diseases – Certain autoimmune diseases can lead to septal perforations. These include kidney disease, vasculitides, rheumatoid arthritis, lupus, polychondritis, Wegener’s granulaomatosis and sarcoidosis.

Septal perforation symptoms

A patient with a septal perforation can have any number of symptoms. Some patients experience only one of the following symptoms, while others experience several:

  • Nasal crusting
  • Nasal bleeding
  • Whistling sound
  • Difficulty breathing
  • A runny nose

Obviously, such symptoms do not always mean that you have a septal perforation, but if they become chronic or bothersome you should see a nasal specialist.

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Getting an expert opinion

Some septal perforations have no associated symptoms and do not require septal perforation repair surgery or any other treatment. However, “septal perforations that continue to enlarge can result in loss of support of the nose and can collapse,” says Dr. Edwin Williams, a Latham, NY based board-certified facial plastic surgeon and the past president of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).

As a result, Williams advises anyone who thinks that they might have a septal hole to seek help from a nasal specialist.

This sentiment is echoed by Dr. Douglas Henstrom, a board-certified facial plastic surgeon and otolaryngologist based in Salt Lake City. “As soon as a patient is aware they have a septal perforation, they should seek professional help and opinion. It is important to first establish a diagnosis of why the perforation occurred, then discuss possible treatment options for each individual,” says Henstrom. “Depending on the cause, perforations can get bigger and you may want to do something about it before it’s too big.”

Also, some septal perforations can be hard to treat, so if you have a perforation, do everything you can to prevent it from worsening. “If a perforation occurs because of nasal steroids, decongestants, or cocaine, the perforation can get worse, so it is in your best interest to stop using the offending drug completely,” says Dr. Stephen Warren, a board-certified plastic surgeon in New York City.

Septal perforation repair

As a septal perforation becomes bigger, or if it is located near the tip of the nose, symptoms typically worsen and become more irritating, requiring nasal septal perforation treatment.

There are a number of options for nasal septal perforation repair.

“Non-surgical treatments such as petroleum jelly, rinsing with salt water, and humidification are helpful,” says Warren. “If the perforation does not heal and it is symptomatic, then using a silicone button or surgery should be considered.”

Most people prefer surgical septal perforation treatment, according to Warren. “There are many different surgical techniques, but all techniques basically move the patient’s own tissue to cover the hole or use outside graft material to patch the hole.”

Many nasal specialists believe that surgery — as opposed to continuous nasal irrigation or placement of a septal button — leads to better long-term outcomes because it has a better chance of restoring proper nasal function. If you are considering surgery, it is imperative that you find an expert to perform the procedure.

“Septal perforation repair is a technically demanding procedure and there are only a handful of plastic and reconstructive surgeons and otolaryngologists that are skilled in these methods, especially for larger defects,” says Dr. Matthew Kaufman, a board-certified plastic surgeon and otolaryngologist based in New Jersey.

Septal perforation repair surgery is usually successful, but some large perforations can be difficult to close. Kaufman and his colleagues have developed a method of septal perforation repair for septal perforations that are so large that they cause a problem called “saddle nose deformity” or “nasal collapse,” because they extend from the top of the nose all the way to the bottom; essentially an entire loss of the septum.

“This method involves extensive mobilization of nasal linings and use of bone and cartilage grafting,” Kaufman explains. The procedure has resulted in successful repair of septal perforations, normalization of nasal function, and correction of the saddle nose deformity in patients with these very large defects, according to Kaufman.

It’s important to understand that not all septal perforations are treatable. “Perforations should not be treated when patients cannot safely undergo general anesthesia,” says Warren. “Patients with autoimmune diseases (e.g. sarcoidosis or Wegener granulomatosis) should not undergo surgical treatment. Patients still actively using nasal steroids, decongestants or cocaine should not undergo surgery. Finally, patients with very large perforation may require a surgical procedure so large that it may not be worth undergoing the procedure.”

It should be noted that the success rate of septal perforation repair surgeries is lower than many other types of surgery. The success of this surgery is not only impacted by the severity of the perforation, but also on what caused it.

“A perforation induced from an inflammatory disorder or from severe exposure to chemicals or trauma with subsequent scarring and decrease in blood supply will have a higher chance for failure despite surgery,” says Dr. Matthew E. Jung a New Jersey otolaryngologist. “In general, smaller perforations have a high success rate around 90%, and 70 to 80% with larger perforations.”

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The recovery process

After treatment your doctor will most likely instruct you to rinse your nose several times a day with a saline solution; your doctor will provide you with instructions on how to use the solution. You should expect to experience some drainage following septal perforation surgery, and you may need to visit your doctor to have your nose cleaned a few times.

Recovery time will depend on how the perforation was treated. While patients that receive a septal button to plug the perforation see results immediately and don’t require much downtime, those that undergo surgery can expect roughly a week to ten days of downtime.

Surgical recovery also requires having nasal packing and splinting in place for up to a month. Swelling may persist for weeks or even months.

During your septal perforation repair recovery, avoid blowing your nose, as well as vigorous exercise and bending over. Also, be careful to avoid injuring your nose during recovery.

Warren points out that while people usually can’t tell that you’ve been operated on, this doesn’t mean the recovery will be easy. He says that patients often feel tired, have pain from the surgery for a few days, and experience stuffiness, crusting, oozing, a runny nose, and impaired airflow for days or weeks after surgery.

It is very important that you locate a surgeon with the appropriate training, skill, and experience. Either a board-certified plastic surgeon, facial plastic surgeon or otolaryngologist who specializes in nasal surgeries are ideal choices. Be sure to follow all of you surgeon’s instructions very closely for the best possible results.

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