What is the treatment for unilateral septal ulceration?

Treatment for Unilateral Septal Ulceration

Conservative medical management should be the first-line treatment for unilateral septal ulceration, including nasal saline irrigation, topical intranasal corticosteroids, nasal lubricants, and regular debridement of crusts. 1

Initial Conservative Management

The cornerstone of treatment involves intensive medical therapy before considering any surgical intervention:

• Nasal saline irrigation should be performed regularly to maintain moisture and facilitate crust removal 1
• Topical intranasal corticosteroids reduce inflammation and promote healing of the ulcerated mucosa 1
• Nasal lubricants (such as petroleum-based ointments or saline gels) prevent desiccation and further tissue breakdown 1
• Regular debridement of crusts by a clinician prevents accumulation that can perpetuate the ulceration 1
• Long-term oral co-trimoxazole with topical anti-staphylococcal creams may be considered for persistent cases to address potential bacterial colonization 1

Diagnostic Evaluation for Unilateral Lesions

Unilateral nasal septal ulceration warrants investigation to exclude underlying pathology, particularly when associated with bleeding, pain, or failure to respond to conservative treatment. 2

Key diagnostic considerations include:

• Nasal endoscopy should be performed to fully visualize the ulceration and assess for concerning features such as irregular borders, friable tissue, or mass lesions 2
• Biopsy is indicated if malignancy is suspected, ANCA or ACE tests are abnormal, or the lesion has atypical features—though routine biopsy of simple ulcerations typically yields non-specific findings in 55% of cases 3
• ANCA testing should be obtained to screen for Wegener's granulomatosis (granulomatosis with polyangiitis), which successfully identifies this condition in symptomatic patients 3
• ACE testing may support a diagnosis of sarcoidosis in appropriate clinical contexts 3

The appearance and location of septal ulceration does not reliably predict the underlying diagnosis, making targeted laboratory testing more valuable than empiric biopsy 3.

Duration of Conservative Treatment

A minimum trial of 3-6 months of appropriate medical therapies is necessary before considering surgical intervention for septal ulceration. 1

This extended conservative period is critical because:

• Most septal ulcerations respond to intensive medical management without requiring surgery 1
• Premature surgical intervention carries risks of complications including septal perforation, infection, and tissue necrosis 2
• Adequate time allows differentiation between ulcerations that will heal with medical therapy versus those requiring advanced treatment 1

Surgical Options for Refractory Cases

If conservative management fails after an adequate trial period, surgical options include:

Extracellular Matrix Scaffold Repair

• MatriStem® or similar extracellular matrix scaffolds provide a framework for healthy mucosal in-growth over ulcerated areas 4
• This approach achieved complete symptom relief in patients who failed both conservative management and prior surgical attempts 4
• The technique is particularly useful for unilateral partial septal mucosal defects 4

Mucosal Flap Reconstruction

• Unilateral inferior meatal mucosal flaps can be used for larger ulcerations (5-26 mm) with success rates of 85-100% 5
• Endoscope-assisted endonasal approaches with unilateral advanced mucosal flaps and temporalis fascia grafts achieve closure in 85.7% of cases 6
• These techniques avoid external incisions and minimize operative time 6

Advanced Pedicled Flaps

• Anterior ethmoidal artery flaps or greater palatine artery pedicled flaps combined with interposition grafts achieve success rates >90% for symptomatic perforations 7
• The surgical approach should be based on osseocartilaginous support and defect location 7

Critical Pitfalls to Avoid

Bilateral cautery or bilateral surgical manipulation should be avoided to prevent septal perforation. 2

• Unilateral cautery for epistaxis associated with septal ulceration showed no septal perforations in randomized trials 2
• Clinical experience strongly suggests that simultaneous bilateral septal cautery or surgery significantly increases perforation risk 2
• If cautery is needed for bleeding from the ulceration, bipolar electrocautery is preferable to chemical cautery as it is less painful, promotes faster healing, and is more effective 2

Surgical repair should be considered a last resort due to the complexity of the procedures and potential for complications 1. The high success rates reported in recent literature apply to carefully selected patients who have exhausted conservative options and are managed by experienced surgeons 7.