Perforated Setpum

Contemporary Management of Septal Perforations:
The Hamilton Method for Surgical Repair

Summary: The septum is the central partition in the nose, which is made up of wafer thin cartilage and bone protected by a delicate mucosal membrane. Septum perforations occur most commonly from an insult to this delicate septal mucosa, which supplies blood, oxygen, and vital nutrients to the underlying cartilage, which has no blood supply of its own. The most common injuries are trauma, surgery, and medication or illicit drug abuse.

Symptoms include nosebleeds, foul odors, crusting, infection and nasal deformity and instability. Treatment options are poor and most institutions and private physicians’ success rates hover around 10-45%. Dr. Jason S. Hamilton, MD, Director of Facial Plastic and Reconstructive Surgery at the Osborne Head and Neck Institute, in Los Angeles, California, has developed a method for surgical repair of septal perforations with a success rate over 99% for small and large septum perforations.

This document briefly discusses the pathophysiology of septal perforations and the benefits of early septal perforation repair.

Key Points:

Definition: Septal perforation is a hole in the nasal septum, caused by an injury.

Symptoms: Whistling, nosebleeds, foul smelling crust, recurrent infections, nasal congestion, sinusitis, and nasal collapse deformity are the most common symptoms associated with septal perforation.

Treatment: Treatment options vary based on the size of the septal perforation. Generally all perforations, regardless of their size, should be treated aggressively to prevent complications. Medical, minimally invasive, and surgical options are selected based on the size of the perforation at initial diagnosis. Dr. Hamilton’s preference is to intervene before symptoms lead to complications.

Recommendations: Currently we permanently repair all septal perforations and have had a 100% success rate in eliminating symptoms.

septal perforation

Figure 1a, 1b: The septum divides the nose into right and left nasal passages. The arrow shows a septal deviation to the patients left side or blockage of the left nasal passage way. A deviated septum is the most common reason to have septum surgery called septoplasty. Errantly performed septoplasty is also the most common cause of septal perforation.

NASAL ANATOMY

What is the nasal septum? It may be helpful at first to define the nasal septum. The nasal septum divides the nose into right and left nasal passages and is made up of delicate skin, mucosa, cartilage and paper thin bones that provide the central support and foundation for the nose. Functionally, the normal septum insures that air flowing through the nose is moving through the nasal passages gently in a laminar fashion without turbulence and is evenly distributed between the nasal passages. This is important because functionally speaking your nose is simply a compact humidifier for the air that you breathe.

perforated septum

Figure 2a: The septum is the central partition of the nasal air passage. It is made up of wafer thin cartilage and bone fused and covered with mucosa (the pink lining of the nose). The quadrangular cartilage anteriorly (in the front) fuses to the bony septum posteriorly (in the back of the nose)

perforated septum treatment

Figure 3: Frontal view in the nasal and sinus cavities. The septum divides the middle of the nasal passage and directs air to the left and right turbinates (stars) that warm and humidify the air we breathe.

septum perforation

Figure 4: Nasal endoscopic view of the right nasal cavity.

SEPTAL PERFORATION

A septal perforation is a through-and-through hole in the central partition of the nose (nasal septum). Septal perforations are caused by an injury to the nasal septum. The septum is very delicate and can be easily injured by trauma (nasal fracture), infection (MRSA), medication or drug abuse (nasal decongestants, nasal steroids, or cocaine), autoimmune conditions and by prior surgery such as septoplasty or rhinoplasty. A hole in the septum is diagnosed as a septal perforation, or perforated septum.

perforated septum surgery

Figure 5: The septum is responsible for maintaining laminar airflow through the nose. A perforated septum causes abnormal airflow in the nasal passages. This leads to over drying, crusting, infection, and if untreated, enlargement of the perforation which intensifies the symptoms.

septal perforation treatment

Figure 6: Nasal endoscopic view of the right nasal passage showing a large septal perforation.

perforated septum surgery los angeles

Figure 7a: Septal perforation. A septal perforation is easily identified as a hole in the nasal septum. The opposite nasal cavity is easily visible and turbinates can be identified on both sides of the nose through the perforation. Figure 7b: Normal nasal passage. Notice the intact septum only allows visualization of nasal anatomy on one side of the nose.

perforated septum

Figure 8a, 8b: Nasal endoscopy at left demonstrates examination of a patient preoperatively, which demonstrates a large septal perforation with crusting and some dried blood (see outline). Postoperative exam on the right shows a well-healed septum with intact turbinate and normal septal mucosa covering the previous perforation. This patient had the Hamilton Method of septal perforation repair, which requires no skin grafts, no cartilage grafts, and leaves the nasal turbinates undisturbed. Pre and postoperative exam are performed 4 weeks apart.

symptoms of a septal perforation

Untreated septal perforations typically enlarge over time and become more symptomatic effecting the normal functions and structure of the nose. Symptoms range in type and severity depending on the location and size of the perforation from whistling, foul smelling nasal discharge, nasal crusting, nose bleeds, obstructed nasal breathing, snoring, increase susceptibility to infections, and nasal collapse and cosmetic deformity. The severity of symptoms can vary from mild to severely debilitating. Typically patients may also have other nasal conditions that further exacerbate their symptoms such as nasal obstruction from failed rhinoplasty, a deviated septum, enlarged turbinates, sinus disease, and allergy. Symptoms of a perforation include:

  • Chronic whistling from the nose while breathing
  • Nosebleeds
  • Foul-smelling crust
  • Recurrent infections
  • Nasal congestion
  • Sinusitis
  • Nasal collapse/deformity
hole septum surgery

Figure 9. The physiology of airflow through the nose is not complicated. Air flows uniformly over the nasal turbinates, which add heat and moisture to the air. By the time the air reaches our lungs it is warmed and humidified. Supporting comfortable breathing. When the septum is perforated air recirculates and “steals” more than its fair share of moisture from the nose causing excessive drying.

surgery for nose hole

Figure 10. Illustration represents the turbulent airflow through the nasal septum. Swirling dry air robs more than their fair share of moisture from the nasal mucosa causing drying, crusting, foul smelling infections and nosebleeds.

Functional Nasal Physiology

The physiology of airflow through the nose is not complicated. Inspired air flows uniformly over the nasal turbinates, which add heat and moisture to the air. By the time the air reaches our lungs it is warmed and humidified supporting comfortable breathing. The nose is nature’s humidifier. When we are congested (such as with a cold) and we breathe through our mouth at night we awake with a sore dry throat. The nose is not necessary for breathing, just to do so comfortably. When the septum is perforated the normal pattern of airflow through the nose is disrupted. Inspired air beings to recirculate, swirling through the nose, much like calm flowing water turning to rapids in a stream.

The recirculation of inspired air “steals” more than its fair share of moisture and heat on its way back out of the nose through the perforation causing excessive drying of the delicate nasal mucosa. Alternately inspired air may simply become trapped in the perforation like a whirlpool. This abnormal airflow through the nose leads to excessive drying of the mucosal membrane. The septal perforation itself becomes crusted, bloody, and occasionally infected with bacteria that easily penetrate the damaged mucosa and cartilage. Patients often present to their physician with blocked nasal passages from excessive crusts, foul smelling pus in the nose, and nosebleeds. If the septal perforation is left untreated the crust, infection, and bleeding damage more cartilage and the septal perforation slowly becomes larger destabilizing the nose leading to potential collapse and worsening symptoms.

perforated septum correction

Figure 11. Repair of the nasal septum by the Hamilton Method restores the nose to normal function. The repair is also physiologic; meaning the lining of the new septum produces mucus just like the native septum. The above illustration demonstrates the normal and desired airflow pattern through the nasal passages. Note that the air flows parallel to the nasal septum without swirling currents or recirculation. Hamilton’s method allows not only the septum to function normally but also allows the rest of the nose to heal preventing recurrent nose bleeds.

TREATMENT OPTIONS SEPTAL PERFORATION

Dr. Hamilton has designed several treatment regiments for patients based on size, symptoms, and individual patient goals. Comprehensively Dr. Hamilton’s goal to is make the patient symptom free and restore the nose functionally and structurally to its normal state and appearance. Treatment regiments typically included some or all of the following: a nasal disinfectant cleansing and debridement, increased humidification and moisture, correction or control of other concomitant nasal conditions, prevention of increase in the size of the perforation, surgical closure of the septal perforation, reconstruction of the normal nasal architecture.

treatment hole nose

Figure 12a, 12b: The nasal septum is the central support for the nasal skeleton. It is the foundation of a normal strong profile. Figure 12a represents the septum in profile supporting the overlying nasal structure. Figure 12b highlights how the overall nasal profile mirrors that of the septum profile.

septum surgery perforation

Figure 13: Frontal view. The nasal septum is the central support for the nasal cartilaginous skeleton. Note how the central septum (blue) share attachments to all nasal tip cartilage and the middle vault of the nose. Septal perforation cause loss of support and the nose may collapse leading to a saddle nose deformity.

perforated septum nose

Figure 14a, 14b, 14c, and 14d: The nasal septum stabilizes the nose much like a foundation supports and stabilizes a home or a skyscraper. Without a strong foundation a building will collapse. The nose is no different. Septal perforations can destabilize the nose and lead to nasal collapse. This collapse most commonly occurs in the middle vault leading to what is termed a saddle nose deformity. It is the foundation of a normal strong profile. Figure 14a,c demonstrates a normal septum and accompanying normal nasal profile. Figure 14b,d highlights the effects of a nasal septum perforation. The middle nasal vault is destabilized and the nose collapses leaving a saddle nose deformity.

nasal septum perforation surgery

Figure 15a, 15b: In rare cases patients who have a septal perforation and symptoms of chronic infection may have weakening of the entire nasal structure. The entire nose may collapse especially with inspiration. This is referred to as nasal valve collapse. Figure 15a illustrates the nostrils during normal respiration. Figure 15b illustrates collapse of the nostrils with inspiration. This is a rare complication seen most commonly with a septal perforation associated with heavy cocaine abuse.

All perforations should be treated to prevent long-term complications.

The algorithmic management of a septal perforation is guided by the size of the perforation and severity of symptoms. Smaller perforations (<1cm) can be managed initially with humidification, antibiotic ointments and irrigation. Septal perforations 1-2cm in size should be initially managed with a septal button implant if symptoms are severe. The septal bottom covers the perforation and allows the lining around the perforation to heal. In many institutions the septal button is left in permanently if the patient is comfortable and can tolerate the implant. If the patient cannot tolerate the implant, it can be used temporarily to stabilize the nose, prior to a permanent surgical repair.

Septal perforations over > 2cm need to be repaired surgically and are not candidates for septal buttons. Regardless the size of the perforation, Dr. Hamilton, believes that septal buttons should only be used as a temporary measure. In Dr. Hamilton’s experience most patients do not tolerate septal buttons indefinitely. Mucus accumulation around the septal button, implant rotation and uncontrolled pistoning of the implant inside the nose often leads to chronic irritation causing patients to request a permanent surgical option. Patients do best, long-term, with permanent repair as this returns the nose to normal function. Dr. Hamilton’s method of surgical repair is over 99% successful in relieving symptoms, closing the perforation, and stabilizing the nose.

surgery nasal septum

Figure 16a, 16b: Normal humidity is restored to the nasal mucosal tissues after septal repair is completed. The airflow is uniform and parallel with no recirculation or swirling air currents. With nasal septal perforation repair by Dr. Hamilton’s method the functional septum is restored. The chronic crusting, foul odor, nosebleeds and infections stop.

Review

Definition: Septal perforations are holes in the nasal septum, caused by an injury to the septal mucosa.

Symptoms: Whistling, epistaxis (nosebleeds), foul odors, crusting, bacterial infections, obstruction, recurrent sinusitis, and nasal collapse are the most common symptoms associated with septal perforation.

Treatment: Treatment is based on the size of the septal perforation. Generally all perforations, regardless of their size, should be treated aggressively to prevent complications. Medical, minimally invasive, and surgical options are selected based on the size of the perforation at initial diagnosis. Dr. Hamilton’s preference is to intervene before symptoms lead to complications.

Recommendations: Dr. Hamilton recommends surgical intervention to permanently repair all septal perforations. Dr. Hamilton’s success rate is currently over 99%. Please contact us today to schedule a consultation to discuss your options for treatment and repair of your septal perforation.