Septal perforation and deviation
Septal perforation and deviation: Excerpt from Professional Guide to Diseases (Eighth Edition)
Perforated septum, a hole in the nasal septum between the two air passages, usually occurs in the anterior cartilaginous septum but may occur in the bony septum. Deviated septum, a shift from the midline, is common in most adults. This condition may be severe enough to obstruct the passage of air through the nostrils. With surgical correction, the prognosis for either perforated or deviated septum is good. (See Septal perforation.)
Causes and incidence
Generally, perforated septum is caused by traumatic irritation, most commonly resulting from excessive nose picking; less frequently, it results from repeated cauterization for epistaxis or from penetrating septal injury. It may also result from perichondritis, an infection that gradually erodes the perichondrial layer and cartilage, finally forming an ulcer that perforates the septum. Other causes of septal perforation include syphilis, tuberculosis, untreated septal hematoma, inhalation of irritating chemicals, cocaine snorting, chronic nasal infections, nasal carcinoma, granuloma, and chronic sinusitis.
Deviated septum commonly develops during normal growth, as the septum shifts from one side to the other. Consequently, few adults have perfectly straight septa. Nasal trauma resulting from a fall, a blow to the nose, or surgery further exaggerates the deviation. Congenital deviated septum is rare.
Signs and symptoms
A small septal perforation is usually asymptomatic but may produce a whistle on inspiration. A large perforation causes rhinitis, epistaxis, nasal crusting, and watery discharge.
The patient with a deviated septum may develop a crooked nose, as the midline deflects to one side. The predominant symptom of severe deflection, however, is nasal obstruction. Other manifestations include a sensation of fullness in the face, shortness of breath, stertor (snoring or laborious breathing), nasal discharge, recurring epistaxis, infection, sinusitis, and headache.
Diagnosis
Although clinical features suggest septal perforation or deviation, confirmation requires inspection of the nasal mucosa with a bright light and a nasal speculum.
Treatment
Symptomatic treatment for perforated septum includes decongestants to reduce nasal congestion by local vasoconstriction, local application of lanolin or petroleum jelly to prevent ulceration and crusting, and antibiotics to combat infection. Surgery may be necessary to graft part of the perichondrial layer over the perforation. Also, a plastic or Silastic “button” prosthesis may be used to close the perforation.
Symptomatic treatment for deviated septum usually includes analgesics to relieve headache, decongestants to minimize secretions and, as necessary, vasoconstrictors, nasal packing, or cautery to control hemorrhage. Manipulation of the nasal septum at birth can correct congenital deviated septum.
Corrective surgical procedures include:
❑ reconstruction of the nasal septum by submucous resection to reposition the nasal septal cartilage and relieve nasal obstruction.
❑ rhinoplasty to correct nasal structure deformity by intranasal incisions.
❑ septoplasty to relieve nasal obstruction and enhance cosmetic appearance.
Special considerations
❑ In the patient with perforated septum, use a cotton applicator to apply petroleum jelly to the nasal mucosa to minimize crusting and ulceration.
❑ Warn the patient with perforation or severe deviation against blowing his nose. To relieve nasal congestion, instill saline nosedrops and suggest use of a humidifier. Give decongestants as ordered.
❑ To treat epistaxis, have the patient sit upright, provide an emesis basin, and instruct the patient to expectorate any blood. Compress the outer portion of the nose against the septum for 10 to 15 minutes, and apply ice packs. If bleeding persists, notify the physician.
❑ If corrective surgery is scheduled, prepare the patient to expect postoperative facial edema, periorbital bruising, and nasal packing, which remains in place for 12 to 24 hours. The patient must breathe through his mouth. After surgery for deviated septum, the patient may also have a splint on his nose.
❑ To reduce or prevent edema and promote drainage, place the patient in semi-Fowler’s position, and use a cool-mist vaporizer to liquefy secretions and facilitate normal breathing. To lessen facial edema and pain, place crushed ice in a rubber glove or a small ice bag, and apply the glove or ice bag intermittently over the eyes and nose for 24 hours.
❑ Because the patient is breathing through his mouth, provide frequent mouth care.
❑ Change the mustache dressing or drip pad as needed. Record the color, consistency, and amount of drainage. While nasal packing is in place, expect slight, bright red drainage, with clots. After packing is removed, watch for purulent discharge, an indication of infection.
❑ Watch for and report excessive swallowing, hematoma, or a falling or flapping septum (depressed, or soft and unstable septum). Intranasal examination is necessary to detect hematoma formation. Any of these complications requires surgical correction.
❑ Administer sedatives and analgesics as needed. Because of its anticoagulant properties, aspirin is contraindicated after surgery for septal deviation or perforation.
❑ Nose blowing may cause bruising and swelling even after nasal packing is removed. After surgery, the patient must limit physical activity for 2 or 3 days, and if he’s a smoker, he must stop smoking for at least 2 days.
❑ Instruct the patient to sneeze with his mouth open and to avoid bending over at the waist. (Advise him to stoop to pick up fallen objects.)
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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