A 23-year-old woman comes to the physician because of a 4-week history of a whistling noise during respiration. She underwent a difficult rhinoplasty a few months ago. The noise is getting louder and is annoying. Which of the following is the most likely diagnosis?

Question

A 23-year-old woman comes to the physician because of a 4-week history of a whistling noise during respiration.  She underwent a difficult rhinoplasty a few months ago.  The noise is getting louder and is annoying.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Complications are common following rhinoplasty, and up to one in four rhinoplasties may need revision. Common complications include patient dissatisfaction, nasal obstruction and epistaxis. Those that involve the nasal septum are less common but more serious. The septum is made up of cartilage and has poor blood supply contrasting sharply with the rich anastomosing blood supply of the nasal sidewall. The underlying cartilage relies completely on the overlying mucosa for nourishment by diffusion. Because of the poor regenerating capacity of the septal cartilage, trauma or surgery on the septum may result in septal perforation. The typical postoperative presentation is a whistling noise heard during respiration. Following nasal surgery, septal perforation is typically the result of a septal hematoma though a septal abscess may also be the cause. Additional conditions that can cause septal perforation are self-inflicted trauma (nose picking), syphilis, tuberculosis, intranasal cocaine use, sarcoidosis and granulomatosis with polyangiitis (Wegener's). (Choice B) Nasal polyps are usually seen in patients with asthma and allergic disorders but may also occur in patients with other inflammatory conditions of the nasal mucosa. They may cause chronic nasal obstruction and should be surgically removed in symptomatic patients. (Choice C) Foreign bodies are common in children. On presentation, patients will have nasal obstruction and may have a foul odor, halitosis and nasal bleeding. Following surgery, a retained foreign body such as nasal packing most classically would cause toxic shock syndrome. (Choice D) Allergic rhinitis commonly presents with rhinorrhea, nasal pruritus, cough and occasionally dyspnea. On examination, the nasal mucosa is edematous and pale, and polyps may be present. (Choice E) Nasal furunculosis results from staphylococcal folliculitis following nose picking or nasal hair plucking. It is potentially life threatening as it can spread to the cavernous sinus. Patients complain of pain, tenderness and erythema in the nasal vestibule. Educational objective: If a patient develops a whistling noise during respiration following rhinoplasty, one should suspect nasal septal perforation likely resulting from a septal hematoma.

A 23-Year-Old Woman Comes to the Physician Because of a 4-Week