The septum divides the nose into cavities and is made up predominantly of cartilage towards the front of the nose and some bone towards the back. The blood supply comes in from the lining of the septum and any insult on both sides opposite each other will interrupt the blood supply cause death of the usually cartilage and a resulting perforation. If the hole is towards the back of the nose, the patient has very few symptoms. If the perforation is towards the front, the patient may present with blockage, nasal crusting, nose bleeds, a whistling sound when breathing, pain and a discharge. Other symptoms may be there depending if there is a multi-organ disease.
CAUSES
The main cause is traumatic which can either be extrinsic, for instance when there is nasal trauma. This trauma from a fractured nose can result in a blood clot of the septum, interruption of blood supply and a possible hole developing. The trauma can be self-inflicted as in picking of the nose. The trauma can also be iatrogenic which means after nasal cautery or even septal surgery. Other causes are medication, for instance vaso-constrictor nose sprays and drug abuse being mainly cocaine. Industrial fumes, for instance wood dust, paint fumes and others may lead to malignancy and a hole in the middle of the nose. Other causes include inflammatory ones, for instance Wegeners, Lupus and Sarcoid. Various infections may also occur in the middle of the nose including tuberculosis, fungi and syphilis. Malignancy of the middle of the nose e.g. T Cell lymphoma is rare but can occur. The history taking is very important and this will probably lead you to the cause. One can ask about previous surgery, drug abuse and others such as coughing up blood and joint pain which may indicate a systemic condition. Clinically, a hole will be seen in the front of the nose with crusting and there may be a saddle nose deformity with loss of support of the nasal structure. If there is systemic disease such as sarcoid the mucosa of the rest of the nose and septum will be abnormal with bloody crusting. All of this is assessed using a rigid nasal telescope.
Investigations are done if one suspects a tumour or systemic disease and these would include blood tests, a chest x-ray and a biopsy.
MANAGEMENT
Medical management of an isolated perforation includes humidification, ointments, emollients and saline sprays. Obviously, the patient must avoid the causative agent. Surgical options include the use of a silicone button which is placed in the hole to decrease the symptoms. Surgery if indicated is fairly complicated and involves using healthy mucosal flaps from the back of the septum covering the hole anteriorally.
CONCLUSION
Septal perforations are usually traumatic or drug abuse in origin and result in relatively mild symptoms that can be controlled using saline douches. Rarely surgery is indicated and rarely tumours are found. One must always be aware of uncommon systemic conditions which can manifest in the nose.