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Nasal Septal Perforation

Dr. Sam Rizk, a NYC rhinoplasty specialist, limits his practice to rhinoplasty and facial plastic surgery.  Dr.  Sam Rizk is double board certified in plastic and reconstructive surgery of the nose and face and is one of a handful of surgeons in New York who specialize in this area.  Dr. Rizk will discuss in the following text that sometimes septal perforations (hole in the nasal septum) can be repaired if they are small but large perforations may not be repairable.  Dr. Sam Rizk will explain some of the etiology and treatment options (both surgical and non-surgical) for septal perforation.

What is Nasal Septal Perforation?

The nasal septum describes the structure which divides the right and left cavities of the nose. It is composed of cartilage, bone, and 2 layers of mucous membranes on either side of it. Dr. Sam Rizk explains that repairing the septal perforation surgically requires a cartilage graft to replace lost cartilage as well as replacement of the soft tissue on the cartilage on either side either with Alloderm or temporalis fascia or both.  In Dr Sam Rizk's opinion sometimes alloderm with a pds plate can repair nasal septal perforation endonasally but some in some cases, it requires an open rhinoplasty approach depending on the size of the perforation. See picture on the right for example of a septal perforation in the cartilage portion of the nasal septum.

What causes septal perforations?

According to Dr. Sam Rizk, a revision rhinoplasty and NYC rhinoplasty surgeon, who specializes in the nose, septal perforations can result from the following conditions.

  1. Trauma/nasal fracture
  2. Inhaled chemicals such as cocaine or other chemicals with sulfuric acid, mercury or phosphorous.
  3. Previous septoplasty/nasal surgery
  4. Inflammation/Infections-such as tuberculosis, syphilis, Wegner granulomatosis, or Sarcoidosis.
  5. Malignant or cancer
  6. Prolonged use of nasal steroid sprays over years-usually greater than 10 years
  7. Epistaxis, chronic
  8. Chronic nose picking

How do inhaled chemicals lead to development of the septal perforation?

It is believed that the inhaled chemicals first leads to vasoconstriction (narrowing) of the blood vessels which then results in tissue ischemia (diminished blood supply to the cartilage and membranes).  Tissue ischemia results in loss of the tissue of the cartilage and membranes and then perforating.

What are some of the signs and symptoms of septal perforation?

Perforations deeper in the nose tend to cause less functional or cosmetic symptoms than perforations closer to the nostrils. Dr. Sam Rizk divides these symptoms into functional and cosmetic issues. Functional problems vary depending on the size of the septal perforation and may include crusting, bleeding, infection, whistling, and runny nose (rhinorrhea).  Cosmetic deformity may include a saddle or collapse of the cartilage portion of the nasal dorsum or bridge (so called saddle-nose deformity). This saddle nose deformity is resulting directly from loss of structural support from the septum.  The patient whose picture is shown to the right is an example of a severe cartilaginous saddle nose deformity secondary to a large septal perforation. When perforations are small, they sometimes whistle but as perforations enlarge the whistling disappears. When perforations are in an area deep in the nose, they do not usually cause a cosmetic deformity and may be asymptomatic.

How is septal perforation treated?

Management of septal perforation can be divided into cosmetic repair of the collapsed bridge (ie; saddle nose) which is a different reconstructive rhinoplasty procedure than actually repairing the septal perforation. Repairing the cosmetic saddle nose deformity can be done using either ear cartilage or rib cartilage grafts.   The symptoms of septal perforation can be improved medically by creating a moist environment in the nose using AYR saline spray or gel or using over the counter ointments which inhibits bacterial growth such as Borofax ointment.  A septal button (a plastic prosthesis) may also be inserted into the hole to reduce the symptoms of the septal perforation.  Dr. Sam Rizk, a Rhinoplasty and septoplasty specialist warns that septal buttons are usually not tolerated well by most patients but some patients do tolerate them for a few years.  The septal buttons can be placed in the nose as an office procedure by the surgeon (see pictures of buttons below).  Finally, septal perforation repair surgery can be performed but is a very complex operation.  The success of the septal perforation surgery depends on the size of the perforation.  Larger perforations have a lower success rate of repair.  Septal perforation repair entails rebuilding 3 different components of cartilage and mucous intranasal membranes on both sides of the cartilage and sutured into the remaining septum. Small perforations less than 5mm may be repaired endonasally with alloderm and a pds plate-success rate varies depending on how nose takes the alloderm and pds plate.

Why does septal perforation surgery have a high failure rate?

Septal perforation surgery may fail due to inadequate blood supply in the area of the septum repaired or due to extensive scar tissue which prevents the grafted cartilage and membranes from taking and integrating into the remaining nasal septum, according to Dr. Sam Rizk. Failure rates vary from 60%-40%, with worse failures attributed to larger perforations.

So when do I decide if I want surgical intervention?

Dr. Sam Rizk recommends the following criteria for patients to decide if they are surgical candidates:

  1. If patient has failed medical management and symptoms do not improve or are getting worse.
  2. If the septal perforation has resulted in a cosmetic deformity such as a saddle nose defect
  3. If the patient understands and is willing to accept a possible failure of the septal perforation surgery.
  4. Most septal perforations are asymptomatic if deeper in the nose and those may be left alone.

For more information about the causes, symptoms and treatments of Nasal Septal Perforation, click here.