Successful Closure of a 6×3.5 cm Nasal Septum Perforation | Endoscopic Video

Nasal Septum Perforation Repair (6×3.5 cm): Surgical Outcome on Endoscopy

The video above shows endoscopic nasal examination footage of a patient who underwent septoplasty for nasal septum deviation at a different clinic 20 years ago. The patient visited various doctors after experiencing increasing nasal dryness, crusting, and inflammatory discharge following the nasal surgery. They stated that their symptoms worsened progressively from the date of the operation. The patient said they first learned about the perforation in their nasal septum approximately 5 years ago. During the examination, we found a nasal septum perforation, approximately 6 x 3.5 centimeters in size, ellipsoid-shaped, with bleeding, crusting, inflammation, and discharge along the edges, as shown in the video above. Endoscopic examination, if viewed in slow motion, reveals that the tissue at the very back of the perforation is almost at the point of tearing from both the top and bottom, leaving only a thin, dark-colored mucosal area. The patient's history does not include any nasal trauma, cocaine use, or use of medications that cause nasal dryness. Unfortunately, the resulting septal perforation had grown over time, and the patient was unaware of it. In patients with large septal perforations, surgical success can be reduced, especially when the epithelial tissue at the edges of the perforation is unhealthy and bleeding, as seen in this case. After providing the patient with all this information, an open nasal septal perforation closure operation was performed using rib cartilage and temporal fascia from the left side. At the end of the surgery, an internal silicone nasal splint was placed inside the nose, and the patient was advised that these splints would not be removed for almost 4 months, that the nasal mucosa might close the tissue defect during this period, and therefore, that they should only rinse the inside of the nose with a mixture containing rifampicin and sterile isotonic saline. The video above shows the patient's preoperative endoscopic examination video and the endoscopic video 4 months later after the silicone splints were removed from the nose (I'm narrating in Turkish in the video, and I apologize for that :( ). 

Large Nasal Septum Perforation Repair: Endoscopic Findings Before and After Surgery

The video shows that after the silicone nasal packing was removed, the nasal mucosa was quite healthy, transformed into a pink and moist mucosa, and the septal perforation was completely closed. However, I would like to add that a weak, light-transmitting area is visible in front of the perforation. Perhaps a few millimeters of opening may reappear here. This is because the area where the procedure was performed was a very unhealthy, thin, dry mucosal area, and a 100% complete closure could not be guaranteed before the surgery. However, almost all of the other patients whose cases I have shared on this website have experienced complete closure. What made us happy was learning that the patient's complaints were almost completely reduced and that they were breathing much more comfortably through their nose. In fact, the surgery performed here is almost like creating new tissue, but the nasal septal perforation seen in the initial examination had a thin mucosa on top of the cartilage graft that was placed. This thin mucosa was in contact with the outside air for the first time. It will begin and symptoms such as nasal congestion, crusting, and dryness may occur in the nose for a few months. During this period, we especially recommend the following to our patients: drinking plenty of water orally if possible, consuming vegetables and fruits with high water content, eating healthy, Mediterranean-style foods, especially boiled or steamed foods, avoiding excessively salty foods, and staying away from strong coffee, tea, and other medications that dry out the nasal mucosa and have a diuretic effect. Another very important piece of advice we recommend to our patients is to absolutely avoid mechanically cleaning the inside of the nose with a tissue, finger, or cotton swab. Because after such a delicate and difficult surgery, any mechanical trauma to the graft area where a nasal septum perforation was placed can cause re-perforation. We will monitor our patients and check for recurrence of perforation with endoscopic nasal examination.

Why can a nasal septum perforation spontaneously enlarge over time?

Nasal septum perforation refers to a defect in the septum, the structure that divides the nasal cavity into two. Normally, each nasal cavity functions independently. As the diameter of the nasal septum increases, this cavity becomes a single space, and changes in airflow within the nose become more pronounced. Especially in patients with large nasal septum perforations, since the nasal cavity becomes a single space, the accelerated, cold, dry, and contaminated airflow reaches every part of the nose and can reach the lower respiratory tract. Unfortunately, in patients with nasal septum perforations, the rapid airflow through the perforation makes the mucosa around the edges of the perforation drier and unhealthier over time. The airflow is even faster in patients with perforations located closer to the front of the nose; in smaller perforations, patients often describe this as a whistling sound. Over time, the nasal mucosa becomes unhealthier, drier, more prone to bleeding, and more crusted, leading to widening of the perforation edges. If surgery has been performed previously and cartilage tissue has been removed from the nasal septum, leaving only a thin layer of mucosa – meaning only bilateral cartilage and nasal mucosa remain – then the rapid airflow through the hole can enlarge the septal perforation much faster. In other words, if only a thin and unhealthy nasal septum remains, and the perforation is near the front, and there is a high volume of airflow, the perforation can naturally grow faster. Besides these, various external factors can cause the perforation to grow rapidly, such as the use of various medications that dry out the nasal mucosa, corticosteroid nasal sprays, diuretics, and various systemic medications. Mechanically cleaning the septal perforation can also accelerate its growth very quickly. We have many patients who make this mistake. For example, when small holes that appear after nasal surgery make a whistling sound when breathing, patients may try to clean the crusts by inserting a cotton swab, tissue, or finger into the septal hole, or they may do this habitually. Regular mechanical trauma to the already dry nasal mucosa in this way can cause the perforation to grow much faster. Similarly, using substances that reduce blood flow and cause significant tissue loss in the nose, such as cocaine, can accelerate perforation. Furthermore, exposure to cigarette smoke, industrial gases, excessively cold and dry environments, or excessively hot and dry environments can cause the nasal mucosa to lose its health much faster, leading to more rapid perforation. We especially recommend that patients with septal perforation keep the inside of their nose as moist as possible, drink plenty of water, eat a healthy diet, and use a humidifier such as a cold mist humidifier or wear a nasal mask when the outside air is very dry. In some patients, various autoimmune diseases that cause the hole in the septum to enlarge, such as Wegener's disease and granulomatous dysplasia, can lead to spontaneous enlargement of the nasal septum perforation without any intervention. Early intervention, addressing the problem early, allows for a less complex and minimally invasive procedure, and also ensures more successful treatment of septum perforation surgery. As the size of the hole increases, the likelihood of complete closure decreases. 

If you have a nasal septum perforation, be careful when going to places with cold mountain air. Such places, such as ski resorts, can cause very rapid moisture loss from the nasal mucosa and dryness. Prolonged stay in these areas can worsen the nasal septum perforation. Bringing natural ocean or seawater with you and wearing a nasal mask will be beneficial.

This website contains links to a page prepared by Dr. Murat Enöz regarding different techniques and patient photos related to nasal septum perforation (please click "More Posts" at the bottom of the page for more articles) >> https://www.ent-istanbul.com/search?q=nazal+septum+perforation

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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