In a patient experiencing crusting inside the nose, recurrent bleeding, a whistling sound, and discomfort while breathing, the problem is not always only deviation. A septal perforation repair case example shows that not only the size of the hole in the nasal septum, but also the quality of the tissue, previous surgeries, and the patient’s expectations determine the treatment decision. Therefore, perforation repair is a delicate process that requires personalized surgical planning rather than a standard closure procedure.
The example below has been evaluated through a representative case in which clinical characteristics have been changed to protect patient privacy. Not every septal perforation is treated in the same way; while regular care is sufficient in some patients, surgical repair may significantly improve quality of life in others.
What is septal perforation and why is it important?
The septum is the partition that divides the nasal cavity into right and left sides; its front part consists of cartilage and its back part consists of bone. Septal perforation is a full-thickness opening that forms in this partition. The opening changes the airflow inside the nose. Air that is normally humidified and directed may cause turbulence around the edges of the perforation, increasing the cycle of dryness, crusting, and bleeding.
Perforations may develop because of previous nose surgeries, trauma, frequent intranasal interventions, uncontrolled use of certain nasal sprays, chronic irritation, infections, or, more rarely, rheumatological diseases. Especially in people who have previously undergone septoplasty or rhinoplasty, the condition of the existing cartilage support and the intranasal lining tissue should be carefully examined.
Not every perforation causes symptoms. A small perforation with healthy edges may be detected incidentally. On the other hand, when there is an enlarging opening, frequent bleeding, extensive crusting, a sensation of bad odor, breathing difficulty, or structural weakening of the nose, a more comprehensive evaluation is required.
Septal perforation repair case example
In our representative case, a 38-year-old patient presented with complaints of dryness, crusting, and intermittent nosebleeds that began after nose surgery performed approximately four years earlier. The patient stated that the burning sensation inside the nose increased especially in air-conditioned environments and during air travel, and that a faint whistling sound was heard while breathing. Previously, only moisturizing treatments had been applied at different centers, but the complaints had not permanently improved.
During examination, a perforation measuring approximately 1.4 centimeters was observed in the anterior part of the septum. However, surgical planning was not based only on this measurement. There was crusting and thinning at the edges of the perforation; in addition, the amount of usable cartilage in the septum was limited because of the previous surgery. Mild loss of support in the external nasal framework and narrow areas contributing to the breathing difficulty described by the patient were also detected.
At this point, the main question is not whether the hole can be closed, but whether it can be closed with which tissues, under what degree of tension, and while preserving nasal function. For a successful repair, the mucosal covering on both sides must have sufficient mobility, regional blood supply must be preserved, and the support tissue to be placed between the layers when necessary must be selected correctly.
Why is the preoperative evaluation performed in detail?
Before surgery, the diameter and location of the perforation, the thickness of the surrounding tissues, and signs of active crusting or infection are evaluated. When necessary, the entire inside of the nose is examined with endoscopic examination and imaging methods. The aim is not only to see the perforation, but also to identify accompanying deviation, turbinate enlargement, sinus disease, or anatomical changes related to previous surgery.
The medications used by the patient, nasal spray habits, smoking, and history of systemic disease also affect the plan. Especially if there is ongoing inflammatory disease, active infection, or a habit that irritates the inside of the nose, these should first be brought under control. Surgery performed under suitable conditions provides more predictable healing.
In this case, the patient was clearly informed that closing the perforation had the potential to reduce the complaints; however, healing in previously operated tissues could be more variable compared with primary cases. The aim is to establish realistic expectations. Complete closure of the perforation is an important goal, but increased intranasal comfort and reduction of the crusting-bleeding cycle are also valuable outcomes of treatment.
Surgical planning and repair approach
In this case, controlled access to the nasal framework and septum was planned using an open approach. The open approach is not mandatory for every patient; however, when the location of the perforation, accompanying deformity, previous surgical scars, and the need for support are present, it may provide the surgeon with a wider field of view.
The critical stage of repair is the careful preparation of healthy mucosal tissues around the perforation. These tissues are brought together over the perforation without tension as much as possible. When necessary, a graft obtained from the patient’s own tissue is placed between the two mucosal layers. Graft selection may vary according to the suitability of tissues such as existing septal cartilage, ear cartilage, fascia, and other corrections planned during the same operation.
It is not correct to speak of a single technique here. Small, posteriorly located perforations with healthy tissue and anteriorly located, large perforations with thin edges or perforations that have previously undergone repair attempts are not at the same level of difficulty. One factor determining surgical success is selecting the technique suitable for the patient; another is working with sufficient precision to preserve the blood supply of the tissues.
In the representative case, while the perforation was being closed, the narrow areas supporting the intranasal airway were also addressed during the same operation. The advantage of this approach is that it allows both perforation-related complaints and accompanying mechanical breathing problems to be evaluated together. On the other hand, as the scope of the procedure increases, the duration of the operation, healing requirements, and sensitivity of follow-up may also increase. This balance should be discussed in detail with the patient before surgery.
What should the patient expect during the recovery period?
During the first days after septal perforation repair, nasal obstruction, mild drainage, and a feeling of pressure may occur. Silicone supports or protective materials used inside the nose help the repaired tissues remain stable. How long these remain in place varies according to the technique applied.
During the first weeks, the most important goal is to keep crusting inside the nose under control and protect the repair line from trauma. Irrigation and moisturizing applications recommended by the physician should be performed regularly, nose picking should be avoided, and follow-up examinations should not be missed. Individual recommendations are also provided regarding strenuous exercise, activities carrying a risk of impact, and forceful movements that may increase nasal pressure in the early period.
In this case, early follow-up examinations showed that the repair line remained viable, crusting gradually decreased, and the patient’s bleeding complaints improved. In the following months of the healing process, the burning sensation inside the nose and whistling sound also disappeared in parallel with the improvement in airflow. Nevertheless, follow-up after perforation surgery is not limited only to the first weeks. Maturation of the tissues and stabilization of the intranasal moisture balance take time.
Is surgery necessary for every perforation?
No. In small, stable perforations that do not cause symptoms, conservative treatment and regular follow-up may be preferred instead of surgery. Saline applications, appropriate moisturizing, and care aimed at reducing crusting may provide sufficient relief in some patients. The decision for surgery is made by evaluating the severity of the complaints, the characteristics of the perforation, the risk of progression, and the patient’s general health condition together.
On the other hand, making a decision based only on the size of the perforation may be misleading. A small but anteriorly located perforation may cause severe whistling and crusting. A larger perforation may cause fewer complaints if the surrounding tissue is suitable and proper care conditions are maintained. Therefore, the correct approach is to evaluate examination findings together with the patient’s daily-life experience.
In Prof. Dr. Gediz Murat Serin’s approach, especially in noses that have previously undergone surgery or in which functional and aesthetic problems coexist, planning is based on individual anatomy and tissue reserve. The surgical goal is not only to close the anatomical opening, but to achieve a balanced result that preserves intranasal health and breathing comfort in the long term.
If septal perforation complaints affect daily life, the most useful first step is to evaluate the cause of the perforation and the condition of the intranasal tissues in detail. Proper patient selection, meticulous surgical planning, and regular follow-up form the strongest components of this delicate treatment.
