Insights, Options, and Realities for Nasal Health

Join Dr. Undavia in this episode of We Nose Noses on septal perforations, uncovering the intricacies of causes, treatments, and recovery. From hydration hacks to surgical nuances, this exclusive guide offers a holistic understanding to empower your nasal wellness journey.

What you’ll learn

  • The different causes of septal perforations, from medication use to systemic diseases, and understand the associated symptoms.
  • Non-surgical approaches to septal perforation such as hydration techniques and nasal buttons, along with their benefits and limitations.
  • Surgical repair methods, including tissue grafting and closure techniques, and learn about post-operative care and recovery expectations.

Listen now for all your facial plastic surgery and ENT questions and get insights from the experts. For professional ENT support, schedule a consultation today at our Marlton, New Jersey location or call 609-710-NOES (6673).

Listen to the audio version below.

Audio Transcript:

Dr. Undavia
Hey guys, it’s Dr. Undavia from NJENT and Facial Plastic Surgery, and I wanted to talk to you today about septal perforations. So what do you do if you found out that you have a septal perforation? First, just a quick recap why you might have a septal perforation. Sometimes medications can cause a septal perforation. Septal perforation is just a hole in the septum, in your nose. And you can have it from medications, you can have it from previous surgery, you can have it from drug use in your nose, and you can have it from systemic connective tissue diseases that can cause it like lupus or Wagner’s, other rheumatologic problems. The most common causes for it are having a previous septoplasty and intranasal drug use.

So, and really quickly, the symptoms that you might get from a septal perforation are whistling in your nose, nose bleeds, a lot of crusting, you might just feel like you can’t breathe through your nose well, sinus infections, and sometimes they hurt. They’re just tendered at the touch of your nose. But what do you do? Somebody tells you that you have a septal perforation. What are your options? So the first thing, the most important thing that we can do is really just hydrate the nose. It’s super important to keep your nose wet on the inside with saline, not just water. It has to be a saline, a balanced solution. And the saline helps to prevent a lot of crusting. It helps to just soothe some of that exposed skin or mucosa on the inside of your nose. Sometimes I have patients put a little starch in the saline rinse, and it just helps soothe the nose even more. Occasionally we use like a Vaseline or even an antibiotic in a Vaseline like Vasitracin. That can help prevent a lot of the crusting. We definitely have our patients stop nasal medication. So a lot of our patients are on flow nays because they think it’s going to help their breathing. It actually makes the septal perforation worse. There’s other medications like azolastine or ipotropium. Those also can dry out the nose, make your septal perforation worse. So really we stop all medications and we have patients use a lot of saline in the nose.

But if that’s not enough and you want to do something more or you’re really getting other symptoms like nosebleeds and crusting. The two other options that we have for septal perforations are one, more of like an office-based procedure. It’s placing a little button in the nose, and then two is a surgical fix.

So first I’ll just talk about the button in the nose. The button in the nose is good because it’s quick, it’s reversible, we can take it out if we don’t like it. And you kind of just need to put the button, like a new fresh button in every now and then, whether it’s one year. It’s every couple of years. It kind of depends on how big the button is, how much crusting you get around the button. Patients don’t necessarily like the button a lot because it does develop a lot of crusting around the button and it basically, you can feel it a little bit. So patients aren’t thrilled about it, but for a patient who might not be a surgical candidate because the septal perforation is big, too big, or because they have other medical problems that prohibit a general anesthetic, a button is not a bad option.

But it’s not always our first option. It’s just a distant backup. Especially if an ENT physician doesn’t know how to fix a septal perforation, they might offer you a button. But in general, for most septal perforations, we can fix them.

That brings us to our second option, which is fixing it. Surgery is really meant to close the hole and to take any crooked parts out of the septum so that the air doesn’t bounce around in the nose. The hole in the nose causes turbulent airflow and that’s why you get the crusting, the whistling, infections and bleeding actually. So when we close the hole, it prevents the air from bouncing back and forth. Now, how we close the hole depends per patient, but we have a few general methods.

We like to use lining from inside the nose to close the hole. And the reason for that is that lining is meant to be in the nose. So it has goblet cells inside there, which produce mucus. So you really want your nose to be able to produce mucus. If it can’t, then it gets dry and you get crusting again. So we like to try and use lining from inside the nose. The way I like to do it is the way I was trained to do it. You take lining from the floor of the nose, and you move it up and you take lining from the roof of the nose and you move it down. At the same time, you might need to put a little graft in between that lining, especially if there’s a gap. If there’s not enough lining to close a hole, we use the lining from inside the hairline here, or we use a tissue graph called Alloderm to put in between the flap that we’ve made.

At the same time, sometimes we put a graft right here to help make sure that you don’t have trouble breathing after the surgery because sometimes pulling the lining can pull down this part of the nose right here. So we try and put that graft in to bring it back out again. But there are surgical options for most septal perforations. I’ve closed septal perforations that are almost three centimeters. I’ve even had septal perforations that are bigger where we’ve closed it at a stage procedure where we closed maybe half or two-thirds and then we go back at a stage time like six months later and we close the rest of it.

It really depends on the size, the shape, and the location of the septal perforation. Not all septal perforations have to be fixed, by the way. If the septal perforation is in the back of the nose, most patients don’t really have that many symptoms. We actually sometimes create controlled septal perforations as a part of a surgical fix for other problems. So if it’s in the front of the nose, it gives you more symptoms. If it’s in the back of the nose, not so many symptoms and we leave it alone.

Now, septal perforation repair is kind of like a rhinoplasty. So it has similar recovery, like a similar recovery profile. And we have another video telling you what that’s like. But in general, you feel like you have a bad cold. This isn’t a terribly painful procedure at all. Occasionally, when we use the hair graft or, sorry, the scalp graft or ear cartilage, you can be more aware of these two surgical sites than you are of your nose. You still do get a lot of swelling afterwards and you’re pretty stuffy, not from packing, but just from swelling.

Sometimes we put something called a silastic sheet on the inside of the nose and what that does is that just protects the area that we’ve closed while your nose is recovering. Once the sutures are dissolved then we take that out and you go on your merry way. Typically I see patients, well our septal perforations come from all over so it depends on where you’re coming from but if you’re local-ish, we can see you at weeks one, three, five, and eight, and then every three months. If you’re not from around here, I have you follow up with your ENT from where you are, just to check on the closure site. I do wanna talk about the fact that septal perforation is difficult, so I don’t promise anybody a closure. We do have above a 90% closure rate, but even septal perforations that are half a centimeter have given me trouble because sometimes the lining just doesn’t want to hold the sutures. So it can be, I will talk to you about what your recovery is like and what your probability of closure is during our visit, but I can’t guarantee closure for most of our patients. Having said that, 90% of our patients do have closure and they feel great afterwards.

So those are your basic options. The main options are, again, hydration with saline, sometimes vaseline, a septal button, and then surgery. Surgery and hydrate, hydration is a must, surgery is the obvious first choice, and then a button is a distant second. So I hope you learned something from this. If you have any other questions, email us at info@njent.com or follow us on our Instagram and Facebook pages.

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