Perforation of Nasal Septum: Etiology and Diagnosis

Summary

Introduction: The nasal septum perforation is an occasional finding of rhinoscopy and most patients are asymptomatic. However, there are several possible etiologies of this condition, making necessary a thorough investigation.

Objective: To review the literature the main causes of septal perforation and describe the diagnostic tests currently used. Method: A systematic literature review of journals indexed identifiable until December 2008.

Final Comments: The main causes are the traumatic / iatrogenic nasal drug use, exposure to toxic gases, inflammatory and infectious diseases and neoplasms. The diagnosis is based on detailed medical history, focusing on occupation and origin of the patient, observation of the characteristics of mucosal injury on biopsy and collection of additional tests such as ANCA, guided by the main suspect.

Resumo

Introdução: A perfuração do septo nasal é um achado ocasional da rinoscopia anterior e a maioria dos pacientes são assintomáticos. Contudo, são várias as etiologias possíveis dessa afecção, fazendo-se necessária uma investigação criteriosa.

Objetivo: Revisar na literatura as principais causas da perfuração septal e descrever os exames diagnósticos atualmente utilizados.

Método: Revisão sistemática da literatura de periódicos indexados identificáveis até dezembro de 2008.

Comentários Finais: Entre as principais causas, encontram-se as traumáticas/iatrogênicas, o uso de drogas nasais, a exposição a gazes tóxicos, as doenças inflamatórias e infecciosas e as neoplasias. O diagnóstico se baseia na anamnese detalhada, com enfoque na ocupação e procedência do paciente, na observação das características mucosas da lesão, na biópsia e na coleta de exames complementares, como o ANCA, guiada pelas suspeitas principais.

Keywords

nasal septum - diagnosis - granuloma

Palavras-chave

septo nasal - diagnóstico - granuloma

Introduction

The perforation of the nasal septum are occasional findings in ENT examination. Most patients are asymptomatic[1] [2] [3] [4], and estimated that approximately two thirds of people infected show no nasal complaints[1] [4]. The absence of symptoms is directly related to the size and location of the perforation of the nasal septum[5].

Often, patients come to the ENT complaining of wheezing and nasal crusting and discover they possess a septal perforation. The more subtle symptoms, such as discrete whistles caused by air turbulence, are related to small perforations. The perforations of larger sizes are related to the appearance of scabs, bleeding, runny nose, sensation of nasal obstruction, olfaction, nasal pain, headache and cacosmia[6] [7] [8] [9]. If moisture is preserved nasal, septal perforation is usually asymptomatic. The more anterior, more frequent presence of symptoms[3] [10] [11].

There are several causes of septal perforation (SP). The most common cause is iatrogenic laceration of mucoperichondrium bilaterally during a septoplasty or hematoma formation post-surgical nutrition compromises the quadrangular septal cartilage. Also among the various causes of granulomatous diseases (leishmaniasis, leprosy, Wegener, rhinoscleroma, syphilis, among others), trauma, for example, chemical cauterization for epistaxis, use of narcotics, mainly cocaine, a potent vasoconstrictor as well as drugs used for the treatment of conditions such as nasal corticosteroids and nasal vasoconstrictors.

In this article, we highlight the main causes of nasal septum perforation and review the diagnostic methods currently used. Importantly, recent articles deal mainly with the surgical management of the closure of septal perforations, and less common in the literature a broader approach on the etiology and diagnosis.

Etiology

Perforations occur in the septal cartilage injury caused by the loss of integrity of the coating mucoperichondrium, with interruption of blood supply and consequent necrosis. Such injuries can be iatrogenic, traumatic, inflammatory, neoplastic, infectious or inhaling irritants[5]. The following table shows the main causes of septal perforation ([Table 1]).

Table 1. Etiology of septal perforation.

Traumatic /Iatrogenic	Septal Surgery
	Chemical Cautery
	Nasal packing
	Nasogastric probe
	Prolonged Nasal Intubation
	Nasal Fracture
	Foreign Body
	Digital Manipulation
Nasal Drugs Abuse	Decongestant Nasal
	Nasal corticosteroids
	Cocaine
Occupational Exposure	Chromium Fumes and Sulfuric Acid
	Swarf
	Powder Glass
Inflammatory	Wegener's granulomatosis
	Sarcoidosis
	Systemic Lupus Erythematosus
	Rheumatoid Arthritis
	Crohn's Disease
	Dermatomyositis
	Sarcoidosis
Infectious	Syphilis
	HIV
	Fungal Infections
	Leprosy
	Tuberculosis
	Leishmaniasis
	Rhinoscleroma
Neoplasms	Carcinoma
	Lymphomas
Idiopathic / Indefinite	?

Iatrogenic and traumatic causes are the most prevalent and occur after surgery septoplasty, septal cauterization, radiotherapy and prolonged nasal tamponade[1] [3] [5] [10] [12] [13]. Prolonged use of nasogastric tube is also described as possible causes of septal perforation[5]. The presence of perforation in the postoperative results from the opposing mucoperichondrium lacerations, injury and loss of cauterizing the blood supply by raising the flap mucopericondral[14]. Of the patients undergoing nasal surgery, men are the most affected. It explains that higher prevalence in males the greatest number of septoplasty in men[13] [15].

The septal perforation after septoplasty are found between 1% and 8% of patients in research. Some authors cite that the number of holes increases when it adopts the technique of Killian, characterized by submucosal resection without addressing the caudal septum. Already in Cottle's technique, which covers the caudal septum, the most common complications are further displacement and postoperative instability[16] [17] [18] [19].

The most common traumatic causes are nasal fractures, rhinoliths, foreign bodies, septal hematomas and digital manipulation repeated[1] [5] [7].

Chronic use of inhalants as irritating nasal decongestants and cocaine can lead to cartilage necrosis by local vasoconstriction, with resultant ischemia, and also by the caustic component present in some of his compositions[10]. The use of nasal corticosteroids for the long term is also described as a causative agent of perforations (5.20), particularly in females[21]. And the combination of corticosteroids and nasal decongestant seems to increase the occurrence of perforations[22].

Besides the aforementioned irritants, are described in the literature several substances related to PS: chemical and industrial dusts (vapors of chromium, copper, salt, sulfuric acid and hydrochloric acid, cement dust, iron filings, tar, glass powder, soda sodium, calcium oxide, calcium cyanide, arsenic, mercury, phosphorus and benzene) and aerosols used in agriculture.

The bacterial and fungal rhinosinusitis are infectious causes of this disease. They also come within this group, syphilis, HIV, tuberculosis, rhinoscleroma, rinoesporidiose, paracoccidioidomycosis and septal abscesses. Still among the infectious causes are cutaneous leishmaniasis and leprosy, which still show high prevalence in Brazil, with an increasing number of cases reported in all regions[7] [23] [24].

Wegener's granulomatosis and sarcoidosis are inflammatory diseases most commonly associated with septal perforation[25]. Other vascular changes and collagen, the case of systemic lupus erythematosus, also cause degeneration of the nasal septum.

Neoplasms should never be forgotten in the differential diagnosis of septal perforation. The most commonly associated are squamous cell carcinoma, cryoglobulinemia and T-cell lymphomas[5] [26].

Diagnosis

The presence of septal perforation is easily diagnosed by the otolaryngologist during his medical history and physical examination and its etiology is rarely defined. Greater diagnostic clarification is due to follow the following steps: questions about nasal symptoms, history of prior use of medication and social habits, rhinoscopy, nasal endoscopy, detection of septal perforation as the appearance, size and location.

First, the diagnosis depends on obtaining a thorough history, noting the surgery, nasal previous treatments and previous use of inhaled irritants, such as cocaine[10] [Table 2].

Table 2. Diagnostic approach.

Anamnesis	Include origin, occupation, drug use, nasal surgeries and treatments, constitutional symptoms (weight loss, fever, cough, arthralgia, hematuria, skin areas without sensation) - Inquiry about possible etiologies
Physical Examination /	Spot size, dimension,
Nasal Endoscopic	location of PS evaluate edges of PS and characteristics of the adjacent mucosa.
Suspicious area biopsy	It is usually performed in the posterior edge of the PS and, if possible, include in the sample and mucosa healthy suspicion.
Assess the need	Described in [Table 3]
Other exams

When symptomatic, the patient presented with typical complaints of wheezing, crusting, nasal obstruction, rhinorrhea, nasal dryness, nasal pain and epistaxis. These complaints are mainly explained by the turbulent nasal airflow. The loss of laminar flow leads to nasal crusting at the edges of perforation, which in turn results in the other signs and symptoms mentioned. The dry nose leads to crusting, epistaxis responsible for the subsequent odor and nasal obstruction. Wheezing is a direct consequence of air flow by drilling[10].

On physical examination, it is important to assess the presence of whitish spots on the skin with loss of sensation and nerve thickening, indicating a diagnosis of leprosy.

On ENT examination, most often during rhinoscopy can be viewed septal perforation.

The septal perforations can be classified by size into small (up to1 cm), medium (1 to 2cm) and large (greater than 2cm). The measurement of size is important not only for legal issue, but mainly for choosing the best therapeutic option[10]. This measurement can be done in several ways, all very simple realization. The first is that literature deals with the measurement rule by side which is taking place rhinoscopy. Another technique involves placement of suture to posterior margin of the perforation and with a hemostat, mark the point on the anterior margin, after performing measure with a ruler. Finally, it can be used barium paste at the edges of perforation and, through a lateral view, define the size of perforation.

The size of the drilling, survey Pedroza evaluating 68 patients, we observed that 12% had small perforations, 57% medium and 31% were large[13].

After easy to diagnose structural biggest problem is after, when seeking the causes of perforation.

Rhinoscopy showed a hyperemic mucosa and abundant purulent discharge assumes an infectious cause for perforation, bacterial or fungal. A fungal infection primarily affects immunocompromised individuals. It is confirmed fungal infection by a compatible history and biopsy of infected tissue. It is recommended that the fresh tissue is sent to the laboratory and without previous contact with gauze, measures that facilitate the characterization of fungal infection[10].

Complementary examinations in the investigation of the etiology of septal perforation are shown in [Table 3].

Table 3. Investigations.

Biopsy	Staining
	Culture
	Immunohistochemistry
Serum	CBC
	VHS
	FAN
	ANCA
	FR
	Calcium
	Dosing of ACE
Serology	Leishmaniasis
	Paracoccidioidomycosis
	Histoplasmosis
	Aspergillosis
	VDRL / FTAAbs
Intradermal reaction	Montenegro
	PPD
Urine I
Thorax RX
Sputum - Search of AFB	3 samples
Nasal Swab	Search of AFB

As seen, due to several possible causes of septal perforation laboratory evaluations may be very broad. It is for the otolaryngologist by clinical history and physical examination to discern which tests are most appropriate for each case.

The biopsy is of utmost importance for the etiology of septal perforation and should be done in the initial investigation. In addition to rule out or confirm the presence of cancers such as squamous cell carcinoma[27], makes the differential diagnosis of various diseases. In the case of inflammatory diseases, for example, the presence of vasculitis complements the diagnosis of Wegener's granulomatosis, while the finding of noncaseating granulomas indicate a picture of sarcoidosis[10]. If the suspicion of malignancy persists, biopsy should be repeated until diagnosis.

Final Comments

The etiology of septal perforation should be sought in all patients. A complete history was followed by anterior rhinoscopy, nasofibrocospia exams and appropriate for each case, especially for biopsy of the lesion, are the main means to correct the diagnosis and subsequent therapeutic management.

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