What is the treatment for nasal septal perforation?

Treatment for Nasal Septal Perforation

The primary treatment for nasal septal perforation includes conservative management with nasal irrigation, topical intranasal corticosteroids, and nasal lubricants, as surgical repair has limited success and should be considered only after conservative measures fail. 1

Conservative Management (First-Line)

• Nasal irrigation with saline solution helps remove crusts and maintain mucosal moisture 1
• Topical intranasal corticosteroid sprays or creams (e.g., triamcinolone) reduce inflammation and prevent further damage 1
• Nasal lubricants such as 25% glucose and glycerine drops, honey ointment, or aqueous gel prevent dryness and crusting 1
• Regular debridement of crusts helps maintain nasal patency and comfort 1
• Long-term oral co-trimoxazole (trimethoprim-sulfamethoxazole) and topical anti-staphylococcal creams may be beneficial due to the potential role of Staphylococcus aureus in maintaining perforation 1

Mechanical Options

• Septal buttons (prosthetic devices) can be offered to patients with symptomatic perforations, though they may increase crusting in some cases 1
• These devices physically occlude the perforation and can provide symptomatic relief when conservative measures fail 2

Surgical Management

• Surgical repair of septal perforation is unlikely to be successful in the long term and should be considered a last resort 1
• Endoscopic surgery has very limited role and is associated with poor outcomes, increased scarring, and adhesions 1
• When surgery is attempted, success rates vary significantly:
  • Recent techniques using temporalis fascia grafts with silicone films report success rates approaching 90% in selected cases 3
  • Combined flap and graft techniques have shown success rates over 90% in some series 4
  • Complete closure rates of 81.3% have been reported for perforations with average diameter of 15.1 mm 2

Surgical Technique Considerations

• The "open technique" offers better visualization for repair of large or posterior perforations 5
• Successful surgical approaches often include:
  • Bilateral bipedicled mucoperichondrial flaps 6
  • Interposition of autogenous graft material between mucosal flaps 2, 6
  • Postoperative splinting for 6 weeks to protect the repair site 3

Patient Selection for Surgery

• Key factors affecting surgical success include:
  • Size of perforation relative to septum (smaller perforations have better outcomes) 2
  • Health of surrounding mucosa 2
  • Patient's systemic health and age 2
  • Location of perforation (anterior perforations are more symptomatic but may be more accessible surgically) 7

Special Considerations

• Cosmetic improvement of external nasal deformity related to septal perforation should only be attempted after the disease has been quiescent for at least one year 1
• For perforations caused by autoimmune conditions like granulomatosis with polyangiitis, treatment of the underlying condition is essential before considering local repair 1
• Septal perforations may be asymptomatic and require no intervention if they don't cause symptoms 2

Common Pitfalls to Avoid

• Attempting surgical repair without adequate conservative management trial 1
• Overlooking underlying causes (autoimmune, cocaine use, trauma) that may lead to repair failure 1
• Excessive cautery during other nasal procedures, which can lead to septal perforation 1
• Performing septoplasty in patients with active inflammation, which increases perforation risk 8, 7