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Traumatic nasal septal perforation — Clinical Guidelines

Overview

Nasal septal perforation is a condition characterized by a hole or tear in the nasal septum, often resulting from traumatic injury, iatrogenic causes, or less commonly, idiopathic factors. It can lead to symptoms such as crusting, epistaxis, and nasal obstruction 1.

Diagnosis

Key Diagnostic Criteria: Presence of a visible or palpable hole in the nasal septum.

Symptoms: Crusting, epistaxis, nasal obstruction, whistling during inspiration 1 5.

Recommended Tests: Clinical examination under nasal endoscopy; measurement of perforation size using specialized devices for accurate assessment 2.

Management

First-Line Treatments:

- Conservative Management: Pharmacological treatment to manage symptoms like epistaxis and crusting. - Mechanical Obturation: Insertion of silicone nasal septal buttons for symptom relief in smaller perforations 5 7.

Surgical Approaches:

- Endoscopic vs. External Approaches: Both methods are commonly used with similar success rates 3. - Repair Techniques: Mucosal flaps (bilateral intranasal mucosal advancement flaps preferred), cartilage grafts, and novel techniques like tragal cartilage inferior turbinate mucoperiosteal sandwich grafts 3 6.

Closure Rates: Higher success for smaller perforations (<1 cm: 84%, 1-2 cm: 64%, >2 cm: 31%) 3.

Special Populations

Pediatrics: Common etiologies include traumatic and iatrogenic causes; surgical repair closure rates remain high 1.

Comorbidities: Caution with acute infections, chronic septal diseases (e.g., Wegener's granulomatosis), and neoplasia; contraindications for prosthetic insertion 5.

Key Recommendations

Primary Management for Small Perforations (<3-4mm): Consider conservative treatment or insertion of silicone septal buttons to manage symptoms effectively (Evidence: Moderate) 5 7.

Surgical Repair for Larger Perforations: Opt for mucosal flap techniques or cartilage grafts, with endoscopic approaches showing comparable success to external methods (Evidence: Moderate) 3 6.

Avoid Surgical Intervention for Minimal Perforations: Less than 3-4mm perforations may not warrant surgical repair due to lower success rates and potential complications (Evidence: Expert opinion) 4.

References

1 Sharma A, Mamoun L, Punjabi N, Qu R, Peterson JD, Inman JC. Paediatric Nasal Septal Perforations Systematic Review: Etiologies, Symptoms, and Treatment Outcomes. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery 2025. link 2 Hamilton S, Rotenberg BW, Sowerby LJ. Evaluation of septal perforation size using a novel measuring device. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2022. link 3 Delaney SW, Kridel RWH. Contemporary Trends in the Surgical Management of Nasal Septal Perforations: A Community Survey. Facial plastic surgery : FPS 2019. link 4 Passali D, Spinosi MC, Salerni L, Cassano M, Rodriguez H, Passali FM et al.. Surgical treatment of nasal septal perforations: SIR (Italian Society of Rhinology) experts opinion. Acta otorrinolaringologica espanola 2017. link 5 Mullace M, Gorini E, Sbrocca M, Artesi L, Mevio N. Management of nasal septal perforation using silicone nasal septal button. Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale 2006. link 6 Hussain A, Kay N. Tragal cartilage inferior turbinate mucoperiosteal sandwich graft technique for repair of nasal septal perforations. The Journal of laryngology and otology 1992. link 7 al-Khabori MJ. Simple method of insertion of Xomed one piece septal button. The Journal of laryngology and otology 1992. link

Traumatic nasal septal perforation