From the Guidelines
Nasal septum perforation is most commonly caused by trauma, medical procedures, drug use, and certain diseases, with vasculitic diseases such as Granulomatosis with polyangiitis (GPA) and Eosinophilic granulomatosis with polyangiitis (EGPA) being significant contributors, as noted in the european position paper on rhinosinusitis and nasal polyps 2020 1. The causes of nasal septum perforation can be categorized into several factors, including:
- Trauma: physical trauma from nose picking, nasal surgery, or facial injuries
- Medical procedures: septoplasty, cauterization for nosebleeds, or nasal intubation
- Drug use: substance abuse, particularly cocaine, due to its vasoconstrictive properties
- Certain diseases: inflammatory conditions like Wegener's granulomatosis, sarcoidosis, lupus, and tuberculosis
- Chronic infections: untreated syphilis or severe sinusitis
- Industrial chemicals: occupational exposures to chemicals like chromium compounds According to the european position paper on rhinosinusitis and nasal polyps 2020 1, vasculitic diseases like GPA and EGPA can cause septal perforation, with GPA being strongly associated with anti-neutrophil cytoplasmic antibodies (ANCA). Additionally, the use of topical a-adrenergic nasal decongestant sprays, such as oxymetazoline and phenylephrine, can lead to rhinitis medicamentosa, which may result in nasal septal perforation, as noted in the diagnosis and management of rhinitis: an updated practice parameter 1. It is essential to identify and address the underlying cause of nasal septum perforation to provide appropriate treatment and prevent further complications, with a focus on managing vasculitic diseases and avoiding harmful substances, as recommended in the most recent and highest quality study 1.
From the Research
Causes of Nasal Septum Perforation
The causes of nasal septum perforation (NSP) can be varied and include:
- Trauma or post-surgery 2, 3, 4, 5
- Inflammatory diseases such as Wegener's granulomatosis, systemic lupus erythematosus, antiphospholipid syndrome, sarcoidosis, and cryoglobulinaemia 3, 4, 6
- Abuse of substances such as illicit drugs and intranasal steroid use 2, 5
- Infections such as tuberculosis, syphilis, and fungal infections 4, 6
- Malignancy 4, 6
- Piercings and exposure to industrial chemicals 5
- Systemic diseases such as lupus erythematosus and vasculitis 3, 6
Pathophysiology and Progression
The pathophysiology and progression of NSP are not fully understood, but it is thought to involve ischemic, infectious, or inflammatory mechanisms 3, 5. The progression from epistaxis to ulceration to NSP is not well substantiated by the literature 5.
Diagnosis and Treatment
Diagnosis of NSP often requires thorough investigations and multiple tissue specimens from various sites 6. Treatment of NSP depends on the cause and severity of the condition, and may include conservative management such as nasal irrigation and topical use of antibiotic or lubricant ointments, or surgical approaches such as endoscopic septal repair 2, 5.