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Septal Perforation | Diseases of Nasal Septum | Nose | Otorhinolaryngology (Ear Nose Throat / E.N.T) | 4th Year (Fourth Year) | MBBS | Detailed Free Notes

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1. DEFINITION

  • Septal perforation is a full-thickness defect of the nasal septum involving:

    • Septal cartilage and/or bone

    • Both mucoperichondrial / mucoperiosteal layers

  • Results in communication between the two nasal cavities

  • Size may vary from:

    • Pin-point perforations

    • Large anterior defects involving most of cartilaginous septum

2. ANATOMICAL & FUNCTIONAL IMPORTANCE

2.1 Normal Septal Anatomy (Recall)

  • Septum consists of:

    • Quadrilateral cartilage (anterior)

    • Perpendicular plate of ethmoid (posterosuperior)

    • Vomer (posteroinferior)

  • Lined on both sides by:

    • Mucoperichondrium (cartilage)

    • Mucoperiosteum (bone)

2.2 Why Perforation Causes Symptoms

  • Normal septum ensures:

    • Laminar airflow

    • Proper humidification

    • Temperature regulation

  • Perforation causes:

    • Turbulent airflow

    • Drying of mucosa

    • Crusting

    • Whistling sound

3. EPIDEMIOLOGY

  • Commonly seen in:

    • Adults

    • Post-nasal surgery patients

    • Chronic nasal spray users

  • Rare but serious in:

    • Autoimmune disease patients

    • Cocaine abusers

  • Anterior perforations are:

    • More common

    • More symptomatic

4. ETIOLOGY (VERY HIGH-YIELD)

4.1 IATROGENIC CAUSES (MOST COMMON)

  • Septoplasty

  • Submucous resection (SMR)

  • Aggressive cauterization for epistaxis

  • Bilateral septal cautery

  • Nasal packing causing pressure necrosis

  • Repeated nasal surgeries

Exam pearl:

Most common cause of septal perforation is iatrogenic.

4.2 TRAUMATIC CAUSES

  • Nasal trauma

  • Untreated septal haematoma

  • Septal abscess

  • Repeated digital trauma (nose picking)

  • Burns / chemical injuries

4.3 INFLAMMATORY & INFECTIVE CAUSES

  • Chronic atrophic rhinitis

  • Tuberculosis

  • Syphilis

  • Leprosy

  • Fungal infections (rare)

4.4 AUTOIMMUNE & SYSTEMIC DISEASES (VERY IMPORTANT)

  • Granulomatosis with polyangiitis (Wegener’s)

  • Sarcoidosis

  • Systemic lupus erythematosus

  • Relapsing polychondritis

Clue:
Septal perforation + crusting + epistaxis + systemic symptoms → think autoimmune

4.5 DRUG-INDUCED CAUSES

  • Chronic topical decongestants

  • Intranasal steroid sprays (improper technique)

  • Cocaine abuse (classic cause of large anterior perforation)

4.6 MALIGNANCY (RARE)

  • Squamous cell carcinoma of septum

  • Extranodal NK/T-cell lymphoma

5. PATHOGENESIS

5.1 Core Mechanism

  • Bilateral damage to mucoperichondrium

  • Loss of nutritional supply to cartilage

  • Cartilage necrosis

  • Progressive tissue breakdown

  • Formation of permanent defect

5.2 Step-by-Step Development

  1. Injury to one mucosal layer

  2. Opposite side also injured or compressed

  3. Cartilage loses diffusion nutrition

  4. Chondrocyte death

  5. Necrosis + sloughing

  6. Hole enlarges due to airflow turbulence

5.3 Why Anterior Septum Is Most Affected

  • Exposed to:

    • Maximum airflow

    • Drying

    • Trauma

    • Surgical manipulation

  • Kiesselbach’s area → frequent cauterization

6. CLASSIFICATION

6.1 Based On LOCATION

  • Anterior perforation

    • Most common

    • Highly symptomatic

  • Posterior perforation

    • Less symptomatic

    • Often incidental finding

6.2 Based On SIZE

  • Small: < 1 cm

  • Medium: 1–2 cm

  • Large: > 2 cm

  • Subtotal / Total septal loss

6.3 Based On ETIOLOGY

  • Iatrogenic

  • Traumatic

  • Infective

  • Autoimmune

  • Drug-induced

7. CLINICAL FEATURES

7.1 SYMPTOMS

  • Nasal crusting (most common)

  • Recurrent epistaxis

  • Nasal obstruction (paradoxical)

  • Whistling sound during breathing

  • Nasal dryness

  • Foul smell

  • Headache

  • Postnasal drip

Important concept:
Large perforations may be less symptomatic than small anterior ones.

7.2 SIGNS

Anterior Rhinoscopy

  • Visible hole in septum

  • Crusts around margins

  • Dry mucosa

  • Bleeding edges

Nasal Endoscopy

  • Defines:

    • Size

    • Exact location

    • Condition of margins

    • Associated pathology

8. COMPLICATIONS

8.1 Local Complications

  • Recurrent epistaxis

  • Infection

  • Septal ulceration

  • Progressive enlargement

8.2 Functional Complications

  • Persistent nasal obstruction

  • Voice change (hyponasal / nasal twang)

  • Loss of humidification

8.3 Cosmetic Complications

  • Saddle nose deformity (if large cartilaginous loss)

  • External nasal collapse

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

9. DIAGNOSIS

9.1 Clinical Diagnosis

  • Made by:

    • Anterior rhinoscopy

    • Nasal endoscopy

9.2 Investigations To Find CAUSE

  • CBC

  • ESR, CRP

  • ANCA (suspected Wegener’s)

  • VDRL (syphilis)

  • Mantoux test

  • Chest X-ray (sarcoidosis, TB)

  • Biopsy of edge if malignancy suspected

10. MEDICAL (NON-SURGICAL) MANAGEMENT

Medical management is supportive, aimed at symptom control and prevention of enlargement. It does not close the perforation.

10.1 Indications For Medical Management

  • Small perforations with minimal symptoms

  • Posterior perforations

  • Patients unfit for surgery

  • Active systemic disease (e.g., Wegener’s)

  • Patient refusal of surgery

10.2 Measures

A. Nasal Humidification

  • Saline sprays

  • Saline douches

  • Steam inhalation

  • Room humidifiers

B. Lubrication

  • Water-based gels

  • Saline gel

  • Liquid paraffin (with caution)

  • Reduces crusting and bleeding

C. Crust Removal

  • Gentle suction under vision

  • Avoid forceful picking

D. Control Of Infection

  • Topical antibiotics if secondary infection

  • Short systemic antibiotics if cellulitis present

E. Treat Underlying Cause

  • Stop topical decongestant abuse

  • Proper technique for intranasal steroids

  • Control autoimmune disease with rheumatology input

  • Treat TB, syphilis if present

11. SEPTAL BUTTON (PROSTHETIC MANAGEMENT)

11.1 Definition

  • A silicone or acrylic prosthesis placed to occlude the perforation.

11.2 Indications

  • Moderate-to-large perforations

  • Patients unfit for surgery

  • Failed surgical repair

  • Autoimmune disease with active inflammation

11.3 Advantages

  • Immediate symptom relief

  • Non-surgical

  • Reversible

11.4 Disadvantages

  • Discomfort

  • Mucosal irritation

  • Crusting around edges

  • Dislodgement

  • Does not restore anatomy

12. SURGICAL MANAGEMENT — PRINCIPLES

12.1 Indications For Surgery

  • Symptomatic perforations

  • Recurrent epistaxis

  • Whistling noise

  • Crusting resistant to medical therapy

  • Cosmetic deformity

  • Patient preference

12.2 Contraindications

  • Active infection

  • Active autoimmune disease

  • Cocaine abuse (absolute contraindication)

  • Poor general condition

  • Large posterior asymptomatic perforations

12.3 Factors Affecting Surgical Success

  • Size of perforation

  • Location (anterior harder to close)

  • Etiology (iatrogenic best prognosis)

  • Mucosal condition

  • Surgeon experience

13. SURGICAL TECHNIQUES (ENT-PURE)

13.1 General Surgical Principles

  • Atraumatic handling

  • Preservation of mucosa

  • Tension-free closure

  • Bilateral flap elevation

  • Interposition graft when needed

13.2 Local Flap Techniques

A. Advancement Flaps

  • Mucoperichondrial flap advanced to close defect

  • Best for small perforations

B. Rotation Flaps

  • Flap rotated from adjacent septum

  • Requires good mucosal mobility

13.3 Bilateral Flap With Interposition Graft

  • Most commonly used technique

  • Graft placed between two mucosal flaps

Graft Options

  • Temporalis fascia

  • Perichondrium

  • Cartilage

  • Acellular dermis

13.4 Inferior Turbinate Flap

  • Pedicled flap from inferior turbinate

  • Useful for medium-sized anterior perforations

13.5 Endoscopic Repair

  • Better visualization

  • Less morbidity

  • Precise flap elevation

  • Preferred modern approach

13.6 Open Septorhinoplasty Approach

  • Required for:

    • Large perforations

    • Associated external deformity

  • Allows dorsal reconstruction simultaneously

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

14. POSTOPERATIVE CARE

  • Nasal splints for 1–2 weeks

  • Antibiotics

  • Saline irrigation

  • Avoid nose blowing for 3–4 weeks

  • Regular endoscopic follow-up

15. COMPLICATIONS OF SURGERY

  • Flap necrosis

  • Failure of closure

  • Re-perforation

  • Synechiae

  • Infection

16. SPECIAL SITUATIONS

16.1 Autoimmune Disease

  • Surgery only after disease control

  • High recurrence risk

16.2 Cocaine-Induced Perforation

  • Surgery contraindicated until complete abstinence

  • High failure rate

16.3 Pediatric Patients

  • Surgery avoided unless severe symptoms

  • Conservative management preferred

17. DIFFERENTIAL DIAGNOSIS

  • Nasal tumors

  • Septal ulcer

  • Atrophic rhinitis

  • Syphilitic gumma

  • Wegener’s granulomatosis

18. HIGH-YIELD VIVA POINTS

  • Most common cause: Iatrogenic

  • Most symptomatic perforations: Small anterior

  • Best initial management: Humidification + lubrication

  • Absolute contraindication for surgery: Cocaine abuse

  • Investigation of choice for etiology: Blood tests + biopsy if indicated

19. CLINICAL CASE (EXAM STYLE)

Case:
A 35-year-old female with history of septoplasty presents with crusting and whistling noise.

Diagnosis:
Iatrogenic anterior septal perforation.

Management:
Saline irrigation → septal button → surgical repair if symptomatic.

20. MCQs

1. Most common cause of septal perforation:
A. Trauma
B. Infection
C. Iatrogenic
D. Tumor
Correct Answer: C

2. Best non-surgical treatment:
A. Antibiotics
B. Steroids
C. Humidification
D. Surgery
Correct Answer: C

3. Surgery contraindicated in:
A. Iatrogenic perforation
B. Autoimmune disease (active)
C. Small perforation
D. Posterior perforation
Correct Answer: B

21. ADVANCED SURGICAL RECONSTRUCTION (ENT-PURE, HIGH-LEVEL)

21.1 Challenges In Surgical Repair

  • Poor vascularity of septal cartilage

  • Constant airflow turbulence

  • Crusting and infection risk

  • Tension on flaps

  • Large defects lack native support

Key Principle:

Success depends more on mucosal health than perforation size.

21.2 Three-Layer Repair Concept

  • Layer 1: Mucosal flap (one side)

  • Layer 2: Interposition graft

  • Layer 3: Mucosal flap (opposite side)

This recreates normal septal anatomy.

21.3 Common Interposition Grafts

A. Temporalis Fascia

  • Most commonly used

  • Thin, pliable

  • Good take rate

B. Cartilage Graft

  • Septal (if available)

  • Conchal cartilage

  • Provides structural support

C. Perichondrium / Periosteum

  • Good integration

  • Enhances mucosal healing

D. Acellular Dermis

  • Used in advanced centers

  • Expensive

  • Good biocompatibility

21.4 Inferior Turbinate Flap — Detailed

  • Pedicled flap maintains blood supply

  • Rotated medially to cover defect

  • Often combined with contralateral mucosal advancement

Advantages

  • Excellent vascularity

  • Higher success for anterior perforations

Disadvantages

  • Turbinate size reduction

  • Temporary nasal obstruction

21.5 Open Septorhinoplasty Approach

Indications

  • Large anterior perforations

  • Associated saddle nose deformity

  • External nasal collapse

Benefits

  • Wide exposure

  • Dorsal reconstruction possible

  • Simultaneous cosmetic + functional correction

22. RADIOLOGICAL CORRELATION

22.1 CT Scan (PNS)

Not routine, but indicated when:

  • Suspected malignancy

  • Extensive bone loss

  • Failed previous surgery

Findings

  • Septal defect margins

  • Bone erosion

  • Sinus involvement

22.2 MRI

  • Rarely required

  • Used for:

    • Autoimmune disease

    • Soft tissue tumors

23. HISTOPATHOLOGY (IN SELECT CASES)

23.1 When Biopsy Is Mandatory

  • Irregular margins

  • Progressive enlargement

  • Associated ulceration

  • Systemic symptoms

23.2 Histological Findings

  • Chronic inflammation

  • Granulomas (Wegener’s, TB)

  • Malignant cells (rare)

24. SPECIAL CLINICAL SCENARIOS

24.1 Septal Perforation In Children

  • Rare

  • Usually post-traumatic or post-abscess

  • Surgery avoided due to:

    • Growth center involvement

  • Conservative management preferred

24.2 Cocaine-Induced Perforation

  • Characteristic large anterior defect

  • Black crusts

  • Extensive tissue necrosis

Management

  • Absolute cessation mandatory

  • Surgery delayed for months

  • High recurrence rate

24.3 Autoimmune Disease

  • Treat systemic disease first

  • Surgery only in inactive phase

  • High failure risk

25. PREVENTION (VERY HIGH-YIELD)

25.1 During Nasal Surgery

  • Preserve bilateral mucoperichondrium

  • Avoid opposing tears

  • Gentle handling

  • Proper nasal packing

25.2 During Epistaxis Management

  • Avoid bilateral cauterization

  • Use chemical cautery judiciously

25.3 Patient Education

  • Avoid nasal picking

  • Correct nasal spray technique

  • Avoid prolonged decongestant use

26. MEDICOLEGAL IMPORTANCE

  • Common post-operative complication

  • Often attributed to:

    • Poor surgical technique

    • Inadequate counseling

Risk Reduction

  • Pre-operative consent

  • Documentation

  • Explain possibility of perforation

27. OSCE / PRACTICAL EXAM CHECKLIST

27.1 Examination Station

  • Inspect nose externally

  • Perform anterior rhinoscopy

  • Identify:

    • Size

    • Location

    • Crusting

  • Comment on symptoms

27.2 Management Station

  • Initial: Conservative

  • Symptomatic: Septal button

  • Definitive: Surgical repair

28. DIFFERENTIAL DIAGNOSIS (RECAP)

  • Atrophic rhinitis

  • Septal ulcer

  • Wegener’s granulomatosis

  • Nasal malignancy

  • Syphilitic gumma

29. HIGH-YIELD VIVA QUESTIONS (FINAL SET)

  • Most common cause of septal perforation?

  • Why are small perforations more symptomatic?

  • Absolute contraindication to surgery?

  • Role of septal button?

  • Why bilateral mucosal injury causes perforation?

  • Best graft material?

  • Why anterior septum most affected?

30. FINAL COMPARISON TABLE

Feature Septal Haematoma Septal Abscess Septal Perforation
Content Blood Pus Full-thickness defect
Fever No Yes No
Emergency Yes Yes No
Treatment Drainage Drainage + IV antibiotics Conservative / Surgery
Cosmetic Risk DNS Saddle nose Saddle nose

31. FINAL CLINICAL PEARLS

  • Most septal perforations are iatrogenic and preventable

  • Small anterior perforations cause maximum symptoms

  • Medical management is supportive only

  • Surgery requires excellent mucosal condition

  • Cocaine use = absolute red flag

  • Prevention is better than repair

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

Hunain Zia

Hunain Zia has previously achieved considerable success in the high-school educational stream, gaining a massive 154 Total A Grades and 7 Major Distinctions, a process in which he broke/ set 11 different world records, including the most A grades ever achieved, most subjects ever appeared in, most distinctions, gaining distinctions across two separate boards (Pearson Edexcel and CAIE) within the same year/ ever, and even 19 hours of constant examination. All records stand intact today. Hunain pursued his Honors Accounting Degree from the prestigious Bentley University, and then completed an LLB (in Honors) from University of London. Currently, he manages multiple social and commercial projects, has founded digital streams and works tirelessly in the education sector.

Educate A Change focuses on truly bringing change in the educational sector worldwide. All our courses are designed to ensure success, and provide complete preparation without requiring any other external material. Therefore, it takes away the expense of academies, books, past paper compilations and other miscellaneous items. Instead, by just the courses we offer, the student can prepare fully for the best grades in their CAIEs, Edexcel and other high-school exams. The earnings from our course-sales are invested in social projects and growing the free educational activities of Educate A Change.