A septal perforation is a through-and-through defect in the nasal septum, the wall that separates the left and right nostrils. This condition affects nasal function and can lead to uncomfortable symptoms. A perforation occurs when all three layers—the mucosa on both sides and the intervening cartilage or bone—are damaged and lost in the same area.
Defining Septal Perforation and Common Causes
The nasal septum is composed of bone in the back, cartilage in the front, and a soft tissue lining called mucosa covering both sides. A perforation creates a direct connection between the two nasal cavities, disrupting the normal flow of air.
Common Causes
The most frequent cause of a septal perforation is trauma, often stemming from previous nasal surgeries like a septoplasty, or chronic physical damage such as habitual nose picking. Long-term or excessive use of certain nasal sprays, particularly vasoconstrictors or steroids, can also thin the mucosal lining and contribute to tissue breakdown.
The use of illicit drugs, such as inhaled cocaine, is another common reason for tissue loss, as it severely damages the area by narrowing blood vessels. Other causes include infections (e.g., syphilis or tuberculosis) and systemic autoimmune diseases like Granulomatosis with polyangiitis (GPA), which destroy septal tissue.
The Biological Reality of Natural Healing
The ability of a septal perforation to heal on its own is limited by the unique biology of the nasal septum. Unlike skin, the cartilage lacks a direct blood supply and relies entirely on the overlying mucosal lining for nourishment.
When a perforation occurs, the mucosal lining is breached on both sides, immediately cutting off the blood supply to the exposed cartilage edges. This lack of blood flow prevents the tissue from migrating across the defect to close it, making spontaneous closure rare.
In most cases, a septal perforation will not heal completely and may even enlarge over time due to constant airflow turbulence. Only extremely small, newly formed perforations (less than a few millimeters) might attempt to close via a mucosal bridge. However, the persistent drying effect inside the nose actively works against this limited healing potential, meaning spontaneous resolution is unlikely for the vast majority of perforations.
Identifying Symptoms and Consequences
The presence of a septal perforation disrupts the normal pattern of airflow, leading to several noticeable symptoms. A characteristic sign, especially with smaller perforations, is a whistling sound produced when breathing. This occurs because the hole acts like a nozzle, forcing air through a narrow opening at high velocity.
The altered airflow dynamics cause a persistent cycle of dryness and crusting inside the nasal passages. Air passing through the defect is not correctly warmed or humidified, causing the surrounding mucosa to dry out and form scabs. This chronic irritation often triggers recurrent nosebleeds (epistaxis).
Some individuals feel nasal congestion or obstruction, even though the passage is physically open. This sensation is caused by turbulent air currents bypassing the normal nasal valve area. For very large, untreated perforations, the structural support of the nose can be compromised, potentially leading to a visible collapse of the bridge, known as a saddle nose deformity.
Medical Intervention and Repair Options
Since natural healing is unlikely, medical intervention is necessary to manage or repair a septal perforation, especially if symptoms are present. Treatment is divided into non-surgical management and surgical repair.
Non-surgical options focus on alleviating symptoms and preventing enlargement. This management includes keeping the nasal environment moist through regular use of saline sprays, gels, or ointments to reduce crusting, dryness, and nosebleeds. Another solution is the placement of a septal button, a custom-fitted silicone prosthetic device used to physically plug the hole.
For definitive closure, surgical repair is the only option, though complexity depends on the perforation’s size and location. Surgeons utilize various techniques, often involving local tissue flaps where healthy mucosal tissue is mobilized to cover the defect on both sides. Supporting material, such as cartilage from another part of the body, may be used to provide structural integrity.