Septal Perforation 1

Take a history from this 35 year old fitness instructor with a septal perforation. He worked for several years as a club DJ.

History

  • Onset
  • Duration 
  • Associated symptoms – whistling, nasal obstruction, crusting, epistaxis, saddle deformity, hyposmia/anosmia, phantosmia, parosmia, headaches
  • Predisposing events – Nasal trauma, septoplasty/rhinoplasty, exposure to chemical irritants, septal haematoma/abscess, nasal cautery
  • Constitutional symptoms – weight loss, malaise, anorexia, night sweats
  • Past Medical History – granulomatosis with polyangiitis (GPA), syphilis, sarcoidosis, lupus, nasal foreign body, leprosy
  • Drug History – nasal steroids,bevacizumab (avastin), cocaine abuse
  • Social History – smoking, alcohol, occupation
  • Family History – cancer, above listed medical conditions
  • Systems review
  • Elicit the patient’s ideas, concerns and expectations 

 

Conclusion

  • Summarise consultation
  • Thank patient
  • Offer appropriate differential diagnosis

Differential diagnoses to consider*

Autoimmune

  • Granulomatosis with polyangiitis
  • Sarcoidosis

Infective

  • Syphilis 
  • Septal abscess

Malignancy

  • Primary nasal tumour

Drugs

  • Cocaine abuse
  • Bevacizumab

Trauma

  • Nasal trauma
  • Nose picking
  • Excessive nasal cautery
  • Septal haematoma

*Table not exhaustive

 

Management

 

You will be asked to suggest an appropriate management plan based on your presumed diagnosis. Ensure that you offer a complete ENT examination including nasendoscopy prior to further investigations.

 

Further investigations will depend on the history and your examination findings. As a baseline, offer to check full blood count, urea and electrolytes and ESR. Some examples are below:-

Suspected diagnosis

The following investigations/management strategies may be indicated however you must offer based on the clinical scenario you are given

GPA

ANCA, chest x-ray, urine dip

Sarcoidosis

Angiotensin converting enzyme (ACE)

Syphilis

Venereal Disease Research Laboratory – VDRL

Nasal tumour

Biopsy

 

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