Facial plastic surgeons usually discover septal perforations during their examinations of the nose as an incidental finding in a patient without symptoms, or they are presented with a patient complaining of symptoms whose cause they find to be a perforation.
There may be a history of prior nasal surgery. A number of septal perforations are asymptomatic if they are located posteriorly within the nose where there is good humidification. The more anterior the perforation, the more likely the patient is to seek evaluation and treatment of symptoms. The major symptoms of septal perforation are crusting, bleeding, whistling, nasal obstruction, and, sometimes, pain or rhinorrhea.
Crusting and bleeding usually occur with septal perferltions at the edge of the circumference of the perforation, because of the inability of the mucosa to heal well over the exposed cartilage. If'there is no exposed circumferential cartilage at the edge of the perforation and there are just two adherent mucoperichondral naps, the perloration is less likely to crust or bleed (Fig. 1). When there is septal cartilage right up to the edge of the perferations, however, the mllcosa has a more difficult time healing, and there is usually a low-grade chondritis present that creates an inflammatory response, leading to crusting and bleeding in this nonhealing area. Some patients present with increasing frequency of epistaxis, and, on examination, one finds huge amounts of crusts and dried blood, which are extremely difficult to remove from the perforation without causing further bleeding. These patients need to be put on emollients and irrigations and then brought back into the office after a week or such treatment for improved evaluation.
Fig. 1. An endoscopic view of a septal perforation in a patient who had a previous septoplasty with removal of almost all of the septal cartilage and bone. Note the paper-thin adherent flaps with a small bridge of tissue within the petforation.
Presence of dried blood and crusts certainly can lead to airway obstruction, which may improve when the crusts are removed. Obstruction can be a major presenting symptom, however, even in a clean nasal perferation. The septum divides the nasal cavity into two distinct chambers through which normal lamellar airllow takes place [1]. When a perforation is present, the lamellar airflow is disturbed and turbulence occurs, decreasing the flow of air and producing a definite sense of nasal obstruction [2]. Whistling in the nose is a common nuisance noted usually in the smaller perforations because of the noise created secondary to the aerodynamics of flow through a small opening. Whistling usually is noted during sleep by a partner, but can also be embarrassing and troublesome to the patient during the day. Pain may be noted in conjunction with bleeding and crusting associated with chondritis; in severe cases, especially in the cocaine abuser, pain is caused by the cellulitis and inflammation. The larger the perforation, the more turbulent the airflow, the greater the incidence of rhinorrhea. A dried nose attempts to rehydrate itself through increased secretions. However, long-term septal perforations with turbulent airflow result in further destruction of respiratory epithelium within the nose, with loss of cilia and loss of function. Normal respiratory epithelium changes into dry mucosa, so that eventually most of the internal structure of the nose is extremely dry.
On physical examination of the nose, a full diagnosis cannot be made until all crusts have been removed and decongestion of the turbinates has taken place, making it possible to visualize the entire nasal septum. Examination of some patients with a bend in the septum and enlarged turbinates is difficult, and a posterior perforation may be missed. When a perforation is noted, its circumferential size and relative position should be documented. An ominous sign is crusting that is observed not only around the edge of the perforation but all over the nasal septal and turbinate mucosa. Such a finding occurs more often in patients with causes suggestive of a granulomatous or vascilitis process. Findings of overall crusting in a cocaine user or in a patient with a granulomatous process make the prognosis for long-term operative success more guarded.
The septum should be palpated with a cotton-tip applicator to discern persistent cartilage between the mucosal flaps and to determine whether cartilage extends close to the edges of the perforation. In perforations that have occurred after septoplasty, there is usually very little cartilage left, and this makes dissection of the flaps more difficult. If one finds extensive membrane swelling and inflammation or sees synechia or collapse of the nose internally as well as externally, one should consider the possibility of an ongoing disease process or the active use of cocaine. Previous cocaine use usually results in a clean-edged perforation with cartilage present almost all the way to the edges of the mucosal perforation. A thorough head and neck and generalized examination is necessary to rule out any other system involvement.
Patients often have very little understanding of the internal nasal anatomy, do not know what the septum is, and know little about the complexity of septal perforation repair. Most patients, moreover, have no idea that they have a septal perforation when presenting their symptoms and are understandably unsettled to learn that operative attempts to repair this perforation are not always successful. It is often helpful to use an in-office endoscope attached to a monitor or to a color printer to educate the patient as to the extent of the problem (Fig. 2). Anatomic models or diagrams are especially useful in helping the patient understand what may need to be done [3]. An even more difficult situation occurs when the patient presents to the facial plastic surgeon for revision rhinoplasty after unsuccessful cosmetic surgery elsewhere and learns that the external deformity is accompanied by a crippling internal airway defect.
Fig. 2. A paper ruler is placed in the nose to show the patient the size and shape of the perforation.
