Surgical Management of the Septal Perforation

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Evaluation

Although most septal perforations are iatrogenic, traumatic or drug-induced, there are a few cases that are caused by inflammatory conditions, malignancy, and infectious disease (Box 1). It is prudent to determine the underlying etiology before recommending a surgical repair.

This process begins with a careful history. The chief complaint may include nasal airway obstruction, an audible whistle during nasal breathing, nasal crusting, intranasal pain, epistaxis, or foul and copious nasal

Nasal Hygiene

Initial management of septal perforation begins with improving nasal hygiene and counseling the patient to avoid digital cleaning. Routine nasal irrigation with saline solution or regular humidification can help reduce the build-up of crusts. Antibiotic ointment or any petroleum-based ointment can prevent the drying and hardening of crusted material, as long as the ointment is applied intranasally a few times daily. In the setting of visible mucosal inflammation, an antibiotic-based ointment

Surgical treatment

First and foremost the surgeon and patient should remember that septal perforation repair is elective. With appropriate and conservative methods of intranasal irrigation and ointment application, a patient can minimize some of their symptoms, and may slow or prevent further enlargement of the perforation. However, there is always the potential for the defect to worsen with time, and create additional problems for the patient. Because small perforations have higher rates of successful surgical

Aesthetic considerations

Larger septal perforations or those close to the columella may contribute to saddle-nose deformity or tip collapse. Fortunately, nasal structure defects can be corrected at the time that the perforation is repaired. Anecdotally, nasal reconstructive surgeons have preferred the use of autologous cartilage to rebuild the nasal structure. In a few cases, there may be adequate septal cartilage remaining that can be harvested for structural grafting. Auricular cartilage grafts are an option;

Summary

Successful management of septal perforation begins with a careful history and examination. After the etiology has been determined and the predisposing condition dealt with, a treatment plan can be developed for the patient. Options for surgical closure of the perforation are related to the size and location of the perforation. The majority of small, anterior septal perforations less than 0.5 cm can be successfully closed endonasally. Larger defects benefit from the open rhinoplasty approach.

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