A septal perforation is a hole in the septum, which is the vertical structure that divides the nose into left and right. The septum is made up of bone and cartilage and is covered on each side by the mucous membranes.
The most common causes of septal perforation include:
- Previous nasal surgery
- Previous nasal trauma
- Repeated cauterizations of the nose for nose bleeds
- Topical drug use-nasal decongestants sprays as well as recreational nasal drugs
Symptoms of septal perforation:
Patients with a septal perforation may have a multitude of symptom all of which can be very annoying and affect not only ones nasal function but overall quality of life. Common symptoms include:
- Difficulty breathing through the nose.
- Constant congestion along with “crusting” around the perforation.
- Recurrent nose bleeds.
- Whistling of the nose.
- A change to the external bridge of the nose often referred to as a saddle nose.
Often small perforations may not even be noticed by patients and may be noticed until a detailed examination of the nose is performed. If the perforation is asymptomatic, meaning that it is not bothering the patient, it is not necessary to repair it. However, it should probably be monitored periodically by a specialist to ensure that the perforation is not increasing in size over time.
Each patient at the Utah Center for Better Nasal Breathing will undergo a thorough history and physical focusing on factors that affect nasal breathing. A combination of 3 modalities are used to accurately diagnose each patient’s cause of restricted nasal airflow.
A simple anterior (speculum) examination will often detect septal deviations, especially those that are located more anteriorly. A nasal endoscopy is performed by sliding a tiny camera mounted on a slender telescope and passing it through the nostrils. This procedure is well tolerated, and although some patients may prefer a numbing nasal spray prior to the procedure, generally an endoscopy can be completed with no special medications at all. This procedure is necessary in approximately a third of patients during their initial consultation.
In cases of more complex septal deviations, a CT scan may be necessary. The CT scanner will create a high quality image of the nose, sinuses and surrounding structures and provides the most complete radiological evaluation of nasal function.
Medical treatments will never actually straighten a septum but for some patients can provide symptomatic relief. There are many medications available and some time just some trials of different medications will be necessary to determine if medical therapy is right for you. Medications can be used to ease symptoms. Some options include: Decongestants (Sudafed, Mucinex-D), Antihistamines (Allegra, Claritin, Clarinex, Zyrtec, Xyzal), Nasal steroids (Nasonex, Nasacort, Veramyst, Omnaris, Flonase), Nasal Antihistamines (Astepro, Patanase).
If allergies are exacerbating the deviation, then patients may benefit from allergy treatment. Treating allergies will decrease the swelling of the lining of the septum and surrounding tissue. Patients will notice less congestion, but it is important to keep in mind that this will not alter or fix the septal deviation.
Medical treatments can be affective in approximately half of patients. However, many of these medications must be taken more or less for life. And a common side effect of these medications is nasal drying which can lead to other problems such as a dry irritated nose and recurring nose bleeds. Utah is one of the driest states in the nation and as such many patients find the daily use of medications just not a practical long-term solution.
Septoplasty, or nasal- septal reconstruction, is a procedure meant to straighten the deviated cartilage and bone that make up the nasal septum. In short, the mucosal lining covering the septum is temporary lifted off of the cartilage and bone. The areas of deviation are usually removed and then replaced back in the midline of the nose. While each case is unique Dr. Mobley tends to avoid techniques that involve a technique called “scoring”. Some surgeons will say they simply ‘score’ the septal cartilage and thereby weaken it, instead of actually removing the deviated segment.
Scoring the cartilage means that the surgeon makes partial cuts into the cartilage with the goal straightening the septum. Unfortunately, cartilage has what is called ‘memory’ – meaning it wants to go back to its original shape if left intact. In some cases where scoring is performed’ over time the cartilage will often times simply bend back to its crooked position once the healing process takes place. This is why some patients (and surgeons) mistakenly say their septum ‘grew back’ after a prior septoplasty. In fact, what happened is that the septal memory caused the septum to return to original and deviated position. This is a common cause of needing a revision septoplasty- a procedure where Dr. Mobley has particular expertise.
Septoplasty is performed as an outpatient procedure and usually takes under one hour. Certain patients, such as those with symptoms of sleep apnea or older patients may be encouraged to spend an overnight stay in the hospital just for extra close postoperative monitoring.
Our medical director, Steven Mobley, MD has gained national and international recognition for taking on some of the most complicated cases of nasal septum reconstruction. This type of operation, referred to as “Extracorporeal Septoplasty” is a technique initially developed in Germany but Dr. Mobley performs it routinely for many of the challenging cases sent to him by other ENTs around Utah and around the nation. You can learn more about the specifics of Dr. Mobley’s Extracorporeal Technique for those that want a more detailed explanation of the procedure.
Recovery time can vary based on how much septal reconstruction is performed. For patients with more office type occupations or “telecommuters”, patients can be back at work in as little as 2-3 days. For patients with more physically demanding jobs a period of 7-10 days of recuperation can be more appropriate. One of the many reasons Dr. Mobley continues to get such excellent results is that he follows his patients very closely post operatively. There is flexibility to when you schedule these post op visits, but patients are normally seen the day after surgery, one week after surgery and then a final visit 2 months after surgery. For our many patients from out of town, we can customize the post op visits to fit your overall ability to return to the office.
While each patient’s recovery is unique, in general, recovery from septal perforation repair will involve downtime of 2-4 days simply to recover from having had general anesthesia. Internal nasal splints are placed that are typically removed 3 weeks post-operatively during a routine office visit. Also, patients who need more advanced septal perforation correction will often have a more swollen nose for 2-8 weeks post op.
In either case, Dr. Mobley rarely packs noses so most people wake up from surgery already feeling the benefits of his corrective surgery. Vigorous physical activity can be fully resumed in 2 weeks and contact sports engaged in after 6-8 weeks of recovery.