The nasal septum is the thin wall of cartilage and bone that divides the nasal cavity into two separate passages. A septal perforation is a full-thickness hole that develops in this dividing wall, disrupting the normal three-layer structure. This defect alters the natural flow of air through the nose, leading to several bothersome symptoms. Common patient complaints include a whistling sound when breathing, chronic crusting around the hole’s edges, and recurrent nosebleeds (epistaxis). Medical professionals address this condition through strategies aimed at relieving symptoms or achieving definitive closure of the defect.
Understanding Septal Perforations
A septal perforation forms when the blood supply to the septum’s lining is compromised, causing the underlying cartilage to lose nourishment and ultimately break down. The most frequent cause is previous nasal surgery, such as a septoplasty, which can inadvertently damage the delicate mucosal lining that supplies blood to the cartilage. Chronic use of inhaled substances, including illicit drugs like cocaine or excessive use of certain steroid nasal sprays, can also constrict blood vessels and lead to tissue death.
Physical trauma from excessive nose picking or a direct injury to the nose is another common pathway for perforation development. Certain inflammatory and autoimmune conditions, such as Granulomatosis with Polyangiitis, can cause systemic inflammation that destroys nasal tissue. When symptoms like chronic, persistent bleeding, significant crusting, or a noticeable change in nasal shape occur, intervention is usually required.
Non-Surgical Management Options
For patients with small perforations or those who are not candidates for surgery, non-surgical management focuses on alleviating symptoms and preventing the hole from getting larger. Since the perforation disrupts laminar airflow and causes dryness, the primary goal is to keep the nasal passages moist. Regular saline irrigation or nasal rinses help clear away dried mucus and crusting that can irritate the perforation’s edges.
Applying topical emollients, such as petroleum jelly or specialized nasal ointments, to the inside of the nose can further lubricate the mucosa and reduce bleeding. Using a bedside humidifier, particularly at night, adds moisture to the air and helps manage chronic dryness. For moderate-sized perforations or those causing significant whistling, a prosthetic septal button can be placed. This device is typically made of medical-grade silicone and is custom-fitted to physically plug the hole, normalizing airflow and reducing crusting.
Surgical Repair Techniques
Surgical repair offers definitive closure of the defect. The primary surgical goal is to bridge the hole with healthy tissue that has a reliable blood supply. The success of the procedure often depends on the size and location of the perforation, with smaller defects being easier to close.
The surgeon begins by raising mucosal advancement flaps, which are sections of the nasal lining carefully separated and mobilized from the surrounding septum. These flaps are designed to be rotated or advanced from both sides of the septum to meet over the defect, providing a new mucosal covering.
Because the perforation has a full-thickness loss of cartilage, a structural interposition graft is placed between the two mucosal layers to provide support and encourage healing. Common graft materials include cartilage harvested from the septum, ear (auricular perichondrium), or rib, as well as fascia taken from the temple (temporalis fascia). The graft material is secured within the defect, and the mucosal flaps are then sutured closed over it. The procedure may be performed using an endonasal approach or an open approach, which provides better visualization for larger or more complex perforations.
Recovery and Post-Procedure Care
The recovery phase is crucial for ensuring the success of the perforation repair. Immediately following surgery, the nose is typically packed or silicone splints are placed to support the repaired septum and hold the flaps and grafts in place. These supports are usually removed by the surgeon during the first post-operative visit, often within one week. Patients can expect nasal drainage, congestion, and discomfort in the initial days, managed with prescribed pain medication.
To promote healing and prevent crust formation, patients must begin frequent saline rinses shortly after the splints are removed. Patients are advised to avoid strenuous exercise, heavy lifting, and activities that increase blood pressure for several weeks. It is also important to refrain from blowing the nose forcefully during the initial healing period. Complete healing and the final outcome of the repair typically take two to three weeks, though the internal tissues continue to mature for several months.