Overview
Perforations of the nasal septum (see images below) are often asymptomatic but can lead to a host of distressing symptoms. Large anterior lesions are more likely to disrupt nasal laminar air flow and be symptomatic.
Posterior perforations tend to be less troublesome as humidification of the nasal mucosa and turbinates is maintained. Crusting and epistaxis are the most frequently noted symptoms, but difficulty breathing, pain, rhinorrhea, and postnasal discharge are also common.
Small anterior lesions may cause a whistling sound with inspiration.
Improvement in sleep apnea parameters, specifically supine Apnea-Hypopnea Index (AHI) and time spent in REM sleep have been reported to improve in patients with nasal septal perforations after placement of a septal button.
Endoscopic view of a septal perforation from the left nasal airway.
Endoscopic view of a septal perforation from the right nasal airway.
Approximately 40% of perforations in adults are iatrogenic. External and intranasal trauma, cocaine use, cautery, and chemical inhalants are less frequent etiologies. Infection, systemic lupus erythematosus, granulomatosis with polyangiitis (formerly known as Wegener granulomatosis), sarcoidosis, and Osler-Weber-Rendu disease should also be considered; rheumatological conditions can be identified with biopsy.
Perforations in children are rare and typically the result of trauma.
Evidence suggests that systemic disease is more likely to result in a posterior perforation, whereas trauma, in particular nose-picking, is likely to result in an anterior perforation.
Rarely, septal perforation can be the initial presenting symptom of natural killer/T-cell lymphoma, which stresses the need for biopsy of suspicious lesions or perforations.
The initial management of septal perforations is to correct the underlying causative process and encourage natural healing of the lesion. Conservative treatment consists of emollients, nasal irrigations, and humidification.
(See Septal Perforation – Medical Aspects.) For patients with persistent symptoms, surgical closure or placement of a septal prosthesis are available options (see image below).
(See Septal Perforation – Surgical Aspects) The techniques and success rates of different closure techniques vary considerably in the literature.
Nasal septal perforation prosthesis. Courtesy of InHealth Technologies (https://www.inhealth.com/category_s/162.htm).
Septal buttons have been commonly used since the 1970s and may be placed in an office setting under local anesthesia or in the operation room. Buttons have been made from acrylic and plastic in the past but are now primarily made of soft silicone (Silastic; see image below).
Prefabricated buttons are typically 1-piece units with a flexible hub and pliable discs, which allows them to adapt to the curvatures and irregularities of the septum.
Two-piece units are increasingly available and tend to be easier to insert. Buttons may be placed as temporary or long-term treatment and do not preclude future surgical closure. Septal buttons are also an option for those in whom surgery may be contraindicated because of age, comorbidities, or underlying pathology.
Nasal septal button.
Prefabricated buttons are excellent options for many septal perforations. Most patients experience improvement or resolution of epistaxis, difficulty breathing, pain, and whistling after placement of nasal septal buttons.
However, less than half experience improvement in rhinorrhea and postnasal drainage,
while improvement in crusting is variable.
Patient intolerance is usually due to local irritation, nasal obstruction, or accumulation of inspissated secretions. Patients who request removal usually do so within the first 6 months.
Imprecise fit of a nasal septal button may result in increased crusting, obstruction, foreign body sensation, and button dislodgement. Custom-fit button prostheses may provide more comfortable and more reliable fit.
Several recent studies have examined outcomes when using computed tomography (CT) to custom-fit septal buttons. These techniques are particularly useful for large (>3 cm) perforations in which adjacent soft tissue to secure the button in place is limited. A precise fit is necessary to avoid movement of the button, which can enlarge the perforation and allow the button to be dislodged.
Button loss after 5 years is often due to button breakdown, but this exceeds the normal wearout period for Silastic.
Additionally, CT-fabricated buttons may improve symptoms to a greater degree than traditional obturators.
Other more recently described techniques for generating a custom-fit septal button prosthetics include a handled silicone septal button prosthesis fashioned using an alginate mould and plaster cast,
as well as a magnet-based 2-piece button prosthesis.
Advantages of these buttons include patient comfort and ease of insertion and removal, including the ability for the patient to be able to do so on their own.
Relevant Anatomy
The septum is a midline structure that divides the nose into 2 similar halves. The majority of the anterior septum is made up by the quadrangular cartilage. The posterior aspect of the septum is predominantly bony and includes the perpendicular plate of the ethmoid bone superiorly and the vomer inferiorly. The septum also receives bony contributions along its periphery from the maxillary, palatine, frontal, and nasal bones. Perforations, in particular those that are symptomatic, typically occur in the anterior half of the nose and correspond to the cartilaginous portion of the septum. The blood supply to the cartilage is dependent on flow from the nasal mucosa to the perichondrium, unlike bone, which has its own internal blood supply. This makes the anterior portion of the septum more susceptible to perforation secondary to mucosal insults than the posterior, bony portion. Mucosal injuries typically need to be opposing on both sides of a given segment of cartilage to fully degrade the blood supply and lead to necrosis and subsequent perforation.
Along the lateral nasal wall lie three finger-like projections referred to as the superior, middle, and inferior turbinates. The turbinates are instrumental in humidifying air during nasal breathing. They are important surgically both as landmarks and targets for reduction to improve nasal airflow and reduce congestion. They border the superior, middle, and inferior meatuses, respectively. The superior meatus is the drainage area for the posterior ethmoid cells and the sphenoid sinus. The middle meatus provides drainage of anterior ethmoid and the maxillary and frontal sinuses. The inferior meatus provides drainage of the nasolacrimal duct.
The internal nasal valve involves the area bounded by upper lateral cartilage, septum, nasal floor, and anterior head of the inferior turbinate. This makes up the narrowest portion of the nasal airway in the leptorrhine nose.
For more information about the relevant anatomy, see Nasal Anatomy.