Septal Perforation

A septal perforation is a hole in the nasal septum —the wall that separates the nasal cavities. It can occur as a result of previous nasal surgery, a nasal trauma, excess use of a drug that constricts blood vessels, such as cocaine, Afrin or nasal steroid spray. Patients without a history of any of these risks need to have an autoimmune condition ruled out (link to Wegener’s Granulomatosis).

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The photo to the right is an example of a perforation of the nasal septum.

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Symptoms:

crusting
bleeding
whistling while breathing
nasal congestion
chronic nasal infection

Treatment

Non-surgical options:

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Moisturize the nasal cavities with nasal saline spray, saline gel, Vaseline, saline irrigation or humidifier.
A small plastic plug, called a septal button, can be placed in the office. It fills the perforation. Some patients tolerate a button for years; however, many others do not. The cost of the button (approximately $130) is usually covered by your medical insurance.

Surgical Repair:

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The goal is to close the perforation with your own nasal mucosa. In that way the nose will return to its normal condition and feel. To accomplish this, your doctor must move mucous membrane from one part of the inside of the nose to another.

When the new layers are in place, they are sutured together and two plastic splint are placed to protect the repair and left in place for weeks. The nose also is filled with some temporary nasal packing so that there is not too much bleeding from where all of the tissues were cut. All of these factors may require three hours of surgery.

Surgery can be a very satisfactory resolution of this problem, but the success depends on the cause of the perforation and its size. Smaller perforations are easier to repair. Large perforations can be a complex operation and the risk of a persistent hole are greater.

Why are septal perforations so difficult to repair?

A nasal septal perforation is not just a one-layered hole. Your surgeon must try to recreate three pre-existing layers: the membrane on each side and the cartilage in between.
The repair can be technically difficult to carry out because the space is tight for seeing and for using instruments. Separation of the mucosal layers around the perforation may take an hour due to scar tissue. In some cases, the space is so tight that it is necessary to improve the access by cutting and lifting the skin away from the tip of the nose.
Finally, after all of the tissues are carefully placed, they must survive while much of the normal source of blood, oxygen and nutrition to these tissues have been compromised.