A patient has crusting, bleeding and whistling from a 2 cm anterior septal perforation after previous surgery. Autoimmune and drug-related causes have been excluded. Symptoms persist despite humidification and emollients. What is the best next principle?
After cause assessment and conservative treatment, mechanical obturation or multilayer surgical repair can be considered. Size, location, mucosal quality, previous surgery, symptoms and willingness to accept failure determine the choice.
A. Enlarge the perforation routinely: Enlargement may reduce whistling in exceptional situations but worsens structural loss and is not routine treatment.
B. Discuss a septal button versus specialist surgical repair according to anatomy and preference: After cause assessment and conservative treatment, mechanical obturation or multilayer surgical repair can be considered. Size, location, mucosal quality, previous surgery, symptoms and willingness to accept failure determine the choice.
C. Perform blind cautery around the entire margin: Cautery can enlarge the defect and worsen crusting.
D. Prescribe repeated antibiotics indefinitely: Colonisation may occur, but antibiotics do not restore humidification or close a stable perforation.
E. Offer cosmetic rhinoplasty without addressing the perforation: External surgery alone does not treat the symptomatic septal defect and may compromise reconstruction.
If cocaine use or granulomatosis with polyangiitis were suspected, disease control and cessation would precede reconstructive surgery.
Independent Clinora educational preparation material; not official JCIE content, an accredited programme, clinical advice, or a substitute for local policy and specialist judgement.
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