In the days of SMR operations, the iatrogenic septal perforations were very common. But after the septoplasty procedure came into being, the incidence of septal perforation is much less.( Iatrogenic means caused by surgeons). The next common cause is trauma, after septal hematoma.
Nasal Septal Perforation is defect in the nasal septum which is the structure between the nostrils that separates the nasal passages. Any damage to the mucoperichondrium reduces blood supply in the septum, the cartilage begins to die, and a hole develops.
Traumatic causes of septal perforation may be divided into external, self-inflicted, and iatrogenic causes. External trauma includes nasal-septal fracture. A septal hematoma results in elevation of the mucoperichondrium from the quadrangular cartilage, ischemia, and subsequent necrosis of the cartilage, with resultant perforation. Self-inflicted trauma, such as digital manipulation, may cause a septal perforation. Iatrogenic trauma includes a history of septoplasty, nasal packing or cauterization for epistaxis, and nasotracheal intubation. Chronic use of vasoconstrictor nasal sprays and steroid nasal sprays may cause septal perforations. In addition, the use of cocaine may result in septal perforations. Chronic use of vasoconstrictor nasal sprays and steroid nasal sprays may cause septal perforations. In addition, the use of cocaine may result in septal perforations.
Small perforations refer to those with a diameter of ≤ 0.5 cm; medium perforations with a diameter ranging between 0.5-2 cm; large perforations with a diameter > 2 cm.
The symptoms associated with septal perforations include nasal congestion or obstruction, nasal crusting and drainage, recurrent epistaxis, and a whistling sound from the nose.
Many perforations do not need to be closed. Septal perforations are difficult to repair especial medium to large size perforations. Surgery is indicated in the presence of symptomatic perforations while surgical repair is not usually recommended for perforations not presenting subjective and functional disorders.
Small perforations may need only frequent rinsing with saline and applying lubricating gels.
Surgery aimed at correcting nasal septal perforations is based on two main principles: repairing the perforation using mucosal mucoperichondrial and/or mucoperiosteal flaps from the internal nasal cavity, and connective tissue autografts interposed between the mucosal flaps.
Surgical repair of septal perforation can be carried out using either the closed technique or open technique. The advantage of the former is that it does not leave any external scar. However, drawbacks related to difficulties due to the narrow operating field may be encountered. Many surgeons prefer the open rhinoplasty technique, as it offers a wider operating field, thus allowing better access. Surgeon may use cartilage tissue from inside your nose or from another part of your body (autograft) to stitch into the hole. One can raise tissue flap to cover the perforation.
Contraindications for surgery include chronic nasal inflammatory processes including Sarcoidosis, Wegener Granulomatosis, TB, Syphilis etc..
As far as concerns perforation size, regardless of the case, technique and material used, small and medium perforations are generally treated successfully. Although many techniques for repairing septal perforations have been described, no standardized surgical protocol has been established.
