Large Nasal Septum Perforation

Big Septal Hole

Large nasal septum perforation, Big septal hole, Perforated nose septum
In the photo above, intranasal endoscopic examination photos of the patient who had a nose operation in a different clinic and subsequently developed a large perforation (6x4 cm) in the nasal septum are shown. Red areas are seen on the patient's perforation edges.

A large nasal septum perforation refers to a significant opening or hole in the nasal septum, which is the cartilaginous and bony partition that separates the two nasal passages. The nasal septum plays a crucial role in maintaining the structure and function of the nose, including airflow regulation, filtering of air, and humidification.

A nasal septum perforation can occur due to various reasons, including trauma, chronic inflammation, previous nasal surgeries, drug abuse (such as cocaine or methamphetamine use), autoimmune conditions, or certain medical treatments like radiation therapy. When the perforation becomes large, it may have a more significant impact on an individual's overall nasal function and quality of life.

Nasal septum perforation can be classified according to its size as follows:
  • small (less than 1 centimeter)
  • medium (1 to 2 centimeters)
  • large (greater than 2 centimeters) 
Symptoms associated with a large nasal septum perforation can vary depending on the size and location of the hole. Common symptoms may include:

1. Nasal obstruction: The airflow through the nose may be disrupted, leading to difficulty breathing through the affected nostril(s). The larger the perforation, the more pronounced the obstruction may be.

2. Whistling sound: Air passing through the hole can produce a whistling sound during breathing, which can be bothersome and may affect sleep quality.

3. Nasal dryness and crusting: The absence of the protective barrier provided by the nasal septum can result in excessive dryness and crusting within the nasal passages.

4. Recurrent nosebleeds: The exposed blood vessels in the perforation can be prone to bleeding, leading to recurrent nosebleeds.

5. Altered sense of smell: The olfactory function may be affected, resulting in a diminished sense of smell or taste.

6. Sinus infections: The disrupted nasal airflow and altered nasal secretions can contribute to an increased risk of developing sinus infections.

7. Social and psychological impact: A large nasal septum perforation can significantly impact a person's self-esteem and confidence, affecting their social interactions and overall quality of life.

Treatment options for a large nasal septum perforation depend on the severity of symptoms and the underlying cause. Conservative management may include nasal saline irrigations, humidification, and the use of nasal lubricants to alleviate symptoms and prevent crusting. However, these measures may not be sufficient for significant perforations.

Surgical interventions may be considered for cases where conservative measures fail to provide relief. The specific surgical techniques vary but generally involve repairing or reconstructing the nasal septum using tissue grafts or implants. In some instances, closure of the perforation may require more complex procedures, including a septal flap or free tissue transfer.

It is essential to consult with an ear, nose, and throat (ENT) specialist or a rhinologist for an accurate diagnosis and to discuss the most appropriate treatment options for a large nasal septum perforation. They can evaluate the size and extent of the perforation, assess symptoms, and provide individualized recommendations for managing the condition effectively.

Nasal septum anatomy

The nasal septum is a vital structure in the anatomy of the nose. It is composed of both cartilage and bone, forming a partition that separates the two nasal passages. The cartilaginous part of the septum, called the quadrangular cartilage, is located at the front and extends back to the bony part. The bony part consists of the perpendicular plate of the ethmoid bone in the upper portion and the vomer bone in the lower portion.

The nasal septum is covered by a thin layer of mucous membrane on both sides, which helps to moisten and protect the nasal passages. It contains blood vessels, nerves, and specialized cells responsible for the sense of smell. The septum plays a crucial role in maintaining the structural integrity of the nose and supporting normal nasal function.

The anterior (front) part of the nasal septum is called the columella, which helps to shape the external appearance of the nose. The posterior (back) part of the septum connects to the nasal cavity and is important for proper airflow and ventilation. The septum also serves as a barrier, separating the airflow and preventing the mixing of air between the two nasal passages.

While the nasal septum is ideally straight and centered, it can sometimes deviate to one side, leading to a condition called a deviated septum. A deviated septum can cause nasal obstruction, difficulty breathing, and other symptoms. In cases where the deviation is severe or causes significant problems, surgical intervention may be recommended to correct the alignment of the septum.

Understanding the nasal septum anatomy is crucial for healthcare professionals, especially otolaryngologists (ENT specialists), who diagnose and treat various nasal conditions. It helps guide surgical procedures, such as septoplasty, rhinoplasty, or septal perforation repair, to optimize nasal function and overall patient well-being.

Nasal septum perforation causes

Nasal septum perforation, also known as a septal perforation, refers to a hole or opening in the nasal septum, which is the thin wall of tissue that separates the two nostrils. Several factors can contribute to the development of nasal septum perforation, including:

1. Trauma: One of the most common causes of nasal septum perforation is physical trauma to the nose. This can occur due to a direct blow to the nose, such as during sports injuries, accidents, or physical altercations. The forceful impact can damage the delicate tissues of the nasal septum, leading to a hole or perforation.

2. Chronic nose picking: Habitual and forceful nose picking can result in repeated trauma to the nasal septum, leading to thinning and eventual perforation. People who frequently engage in nose picking, especially with sharp or pointed objects, are at a higher risk.

3. Nasal surgery: Certain surgical procedures performed on the nasal septum, such as septoplasty (to correct a deviated septum) or nasal polyp removal, carry a small risk of developing a perforation. Although these surgeries are generally safe and effective, there is a slight chance that the tissues may not heal properly, resulting in a hole.

4. Chemical irritants: Exposure to certain irritants and chemicals can damage the nasal septum, causing it to deteriorate and potentially perforate. Frequent use of nasal sprays containing steroids or other irritant substances, long-term use of illicit drugs like cocaine, or exposure to certain workplace chemicals can all contribute to septal perforation.

5. Infections: Severe or chronic infections of the nasal septum, such as fungal infections or syphilis, can weaken the tissues and lead to the formation of a perforation. These infections can cause tissue damage, necrosis, and erosion, resulting in a hole in the septum.

6. Autoimmune conditions: Certain autoimmune conditions, such as granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis), can cause inflammation and damage to the nasal septum. Over time, the repeated inflammation and tissue destruction can lead to a perforation.

It's important to note that the presence of a nasal septum perforation can vary in size and severity. Smaller perforations may be asymptomatic or cause minimal issues, while larger perforations can lead to symptoms like nasal obstruction, crusting, bleeding, whistling sounds during breathing, and recurrent infections.

If you suspect you have a nasal septum perforation or are experiencing related symptoms, it's crucial to consult with an otolaryngologist (ear, nose, and throat specialist) for an accurate diagnosis and appropriate management. Treatment options depend on the size and symptoms associated with the perforation and may include conservative measures, such as nasal saline irrigations, nasal moisturizers, and avoidance of irritants, or in some cases, surgical repair.

Iatrogenic nasal septum perforation

Iatrogenic nasal septum perforation refers to a perforation of the nasal septum that is caused unintentionally as a result of medical intervention or treatment. This type of perforation can occur during various medical procedures involving the nasal cavity. Some common examples include:

1. Nasal surgeries: Surgical procedures performed on the nasal cavity, such as septoplasty, rhinoplasty, or sinus surgery, carry a risk of nasal septum perforation. While these procedures are generally safe and effective, complications can occur, and perforation is one of them. The risk may be higher if the surgeon encounters unexpected anatomical variations, the procedure is complex, or if there are complications during the surgery.

2. Nasal endoscopy: Nasal endoscopy is a diagnostic procedure in which a flexible or rigid endoscope is inserted through the nostril to examine the nasal passages and sinus cavities. In some cases, the instrument can accidentally puncture the nasal septum, resulting in a perforation. This can happen if the endoscope is not maneuvered carefully or if there are anatomical abnormalities that make the procedure more challenging.

3. Nasal packing: Nasal packing is sometimes used to control bleeding or support healing after nasal surgery or trauma. However, if the packing material is not inserted properly or removed too forcefully, it can cause damage to the nasal septum and lead to perforation.

4. Nasal drug administration: In certain medical treatments, medications or substances may be administered through the nasal cavity. For example, nasal sprays for allergy treatment or decongestion may occasionally cause irritation or damage to the nasal septum, resulting in perforation. This is more likely to occur if the spray is used excessively or if it contains irritant substances.

It's important to note that iatrogenic nasal septum perforation can have significant consequences for the patient, leading to symptoms such as nasal obstruction, crusting, bleeding, and recurrent infections. The size and location of the perforation can also affect the severity of symptoms experienced.

If iatrogenic nasal septum perforation occurs, it is crucial for the healthcare provider to address the issue promptly and inform the patient about the complication. Depending on the size and symptoms associated with the perforation, treatment options may include conservative measures, such as nasal saline irrigations, nasal moisturizers, and avoidance of irritants. In some cases, surgical repair may be necessary to close the perforation and restore nasal function.

Prevention of iatrogenic nasal septum perforation involves careful technique and appropriate training for healthcare professionals performing procedures involving the nasal cavity. Proper evaluation of the patient's anatomy, careful handling of instruments, and meticulous surgical technique can help minimize the risk of this complication.

Large septum perforation surgical treatment difficulties

Large septum perforations can pose significant challenges in surgical treatment. The size and location of the perforation can make it more difficult to achieve successful closure and restore nasal function. The surgeon may need to employ advanced techniques, such as septal flaps or free tissue transfer, to reconstruct the septum adequately. As the diameter of the area with tissue loss in the nasal septum grows, the chance of surgical success decreases with a single operation. Due to the long-term accelerated air flow, the epithelium at the edges of the perforation becomes dry and unhealthy, the remaining nasal mucosa becomes dry and unhealthy in the same way, and the intranasal graft areas are reduced. is decreasing.

Nasal septal button does not provide definitive treatment in septal perforations!

A nasal septal button is a medical device that is sometimes used as a temporary measure to manage symptoms associated with nasal septum perforations. It is a silicone or plastic button that is inserted into the nasal cavity to occlude the perforation and provide support to the nasal septum. While the nasal septal button can offer some relief and improve symptoms in certain cases, it does not provide definitive treatment for septal perforations.

Here are a few reasons why a nasal septal button may not provide definitive treatment:

1. Failure to address the underlying cause: The nasal septal button serves as a temporary solution by covering the perforation and reducing symptoms such as nasal obstruction, crusting, and bleeding. However, it does not address the underlying cause of the perforation. The button does not promote healing of the perforation or repair the damaged nasal tissues. Therefore, if the cause of the perforation is not addressed, the symptoms may persist or recur even with the button in place.

2. Limited effectiveness: Nasal septal buttons vary in size and design, and their effectiveness in managing symptoms can vary as well. While some patients may experience relief from symptoms with a properly fitted button, others may find it uncomfortable or ineffective. The button may not provide a complete seal, allowing air, dust, or other irritants to pass through the perforation and still cause symptoms.

3. Potential complications: Although nasal septal buttons are generally considered safe, they can be associated with certain complications. These include nasal discomfort, irritation, and difficulty with breathing. In some cases, the button may migrate or get dislodged, requiring repositioning or removal. Prolonged use of a nasal septal button may also increase the risk of infections or the development of granulation tissue around the perforation site.

4. Need for definitive treatment: While a nasal septal button can provide temporary relief, it is not a substitute for definitive treatment in cases of septal perforation. Depending on the size, location, and symptoms associated with the perforation, surgical repair may be necessary to close the perforation and restore proper nasal function. Surgical options for septal perforation repair can include various techniques, such as septal flap repair, grafting procedures, or even nasal reconstruction in more complex cases.

It is important for individuals with nasal septum perforations to consult with an otolaryngologist (ear, nose, and throat specialist) for a comprehensive evaluation and appropriate management. The healthcare provider can assess the size and severity of the perforation, identify any underlying causes, and recommend the most suitable treatment approach. While a nasal septal button may provide temporary relief, it should be considered a short-term measure rather than a definitive treatment option for septal perforations.

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Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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