1. Nasal septal perforations
Definition : through & through defect or defects of the nasal septum.
The majority of perforations involve the anterior quadrilateral cartilage of the septum. The most
common cause of the perforation in the UK is trauma( selfinduced or nasal instrumentation). Injuries
to the cartilaginous skeleton of the nose may result in perforation through a compound fracture of
the quadrilateral cartilage in absence of any external deformity.
Recreational drugs, for example crack or cocaine snorted nasally increasingly cause of septal
ncerosis.
Aetiology of nasal septal perforations:
Traumatic Surface irritants Infections Neoplastic Inflammatory
Nasal surgery
Cocaine insufflations,
Syphilis
Melanoma,
Nose pricking
Heroine inhalation,
Typhoid
Squamous
Septal
Decongestant nasal
Diphtheria
cell
cauterization(bilateral)
sprays,
Tuberculosis
carcinoma,
Septal
Lime,cement, glass, salt,
Rhinoscleroma,
Lymphoma
haematoma/abscess
dust,tar, paste,
Rhinosporidiosis
Crysurgery
Fumes(chromic/sulfuric
Leishmaniasis
Intubation(nasogastric)
Arsenicals,mercurials,
Actinomycosis
Radiation
calcium
Candidiasis
Stab& gunshot wounds
nitrate,cyanide,sodium
Aspergillosis.
Foreign body( button
carbonate.
batteries)
Sarcoidosis
Wegener’s
granulomatosis,
Systemic lupus
erythematosus
Symptomatology
The principle symptoms associated with perforations are crusting ,epistaxis& whistling. Size &
position of perforation has a direct relation on the presence of symptoms. Anterior & large
perforations where the anterior margin is in front of the nasal valve appear to be most troublesome.
This probably relates to the relatively slow mucociliary clearance from anterior septum. The
accumulation of large crusts around the margin of the perforation produces a sensation of blockage.
With large stable perforation, patient may complain of blockage due to turbulence of airflow in the
nasal vestibule.
Huge perforations produce a common nasal cavity resulting in rhinolalia & inability to clear
secretion.
Inflammation in the perforation margin leads to recurrent epistaxis, often triggered when the crust
separates or is removed.

2. Clinical assessment
An overall assessment of the external & internal nose skeleton should be made together with nasal
endoscopy.
Endoscopy is the best method to assess the margin & state of residual septum.
Special investigations
Full blood count & ESR
Urea & electrolytes
Urine analysis
C-ANCA
Treponemal antibodies
ACE titre
X-Ray chest
A nasal swab
Routine biopsy of septal perforation to cxclude vasculitis & malignancy(irregular margin).
Management
The majority of septal perforation are asymptomatic & require no specific treatment. The
management can be divided into three groups.
1)Prevention
Meticulous attention to technique is required in elevation of mucoperichondrial flap in correct plain,
particularly avoiding overlapping bilateral mucosal tears. Starting the dissection on the easier
(usually the concave) side to raise one intact flap first &using an autograft of cartilage or ethmoid
plate to support any tears, is good practice.
Septal ulcer or inflammation should be treated by withdrawing the source of the irritant,
eradication of pathogens, avoidance of aggressive cleaning & use of mucosal protectants(petroleum
jelly for 6 to 8 weeks)
2)Nonsurgical
This , essentially is aimed at reducing the drying effect in the nasal mucosa to alleviate crusts &
epistaxis.
Alkaline nasal douches(twice daily), normal saline sprays & petroleum-based ointments are
commonly used for 6 to 8 weeks will be effective in maturing the margins of a perforation.
Obturation: Inert sheet(usually silastic sheet) is placed to prevent drying & encourage
epitheliazation over bone or cartilage septum to create a mature mucosal edge. The main benefit of

3. obturator appears to be the control of whistling &epistaxis. The main disadvantage are patient
interference & movement of the mobile membranous septum against the edge of the obturator can
lead to granuloma formation.
3)Surgical repair of septal perforation
The varity of repair may be classified as:
a)Free grafts: simple or composite autografts.
b)Pedicle flaps: local nasal mucosal, buccal mucosal, composite septal cartilage& mucosa,
c)Rotation /advancement of mucoperichondrial or mucoperiosteal flaps:
When there is sufficient residual mucosa in the nasal fossa which can be mobilized & transported
allowing direct suturing of the mucosal defect.
The second is the routine use of a connective tissue interposition graft to support the repair &
epitheliazation. Bilateral mucosal flaps with the main blood supply derived from the sphenopalatine
vessels form the basis of most techniques.
Interposition grafts using temporal fascia, mastoid periosteum, cartilage(septal, auricular, rib
cartilage) bone(either locally or from rib or iliac crest).
Small defects can be closed with bipedical flaps, by making relieving incisions either superiorly or
inferiorly.
Large defects upto 2 cm require larger flaps which are pedicled only posteriorly based on
sphenopalatine vessels & are effectively transposition/rotation flaps.