The answer is that under specific conditions, particularly related to the type of medication and improper application technique, certain nasal sprays can indeed contribute to a “hole in the nose,” medically known as a nasal septal perforation. A septal perforation is a full-thickness defect in the nasal septum, the wall of cartilage and bone that separates the two nasal passages.
How Nasal Sprays Damage the Septum
The nasal septum is covered on both sides by a delicate, highly vascular tissue layer called the mucoperichondrium. This tissue is responsible for delivering blood and nutrients to the underlying quadrangular cartilage. Damage to this mucosal layer is the first step toward a perforation.
The mechanism often begins with chronic irritation or direct injury to this delicate lining. Once the mucosa is injured on both sides of the septum in the same location, the blood supply to the central cartilage is severely compromised. This loss of blood flow is known as ischemia.
If the ischemia persists, the cartilage tissue begins to die, a process called necrosis. The dead tissue eventually breaks down, resulting in a permanent hole. Improperly aiming the spray nozzle directly at the septum’s midline can repeatedly traumatize this area, initiating the cycle of mucosal ulceration and tissue death.
Identifying the Specific High-Risk Medications
Two main classes of nasal sprays are most often associated with an increased risk of septal perforation. Intranasal corticosteroids, such as fluticasone or mometasone, are the primary culprit, though the risk is low when used correctly. The local effect of the steroid can cause thinning and irritation of the septal mucosa over time.
The major contributor with steroid sprays is typically poor application technique, which concentrates the medication on the fragile anterior septum rather than distributing it to the lateral walls where it is most effective. This localized exposure causes mucosal drying and inflammation, which can lead to ulceration.
Topical decongestants, including over-the-counter sprays containing oxymetazoline or phenylephrine, present a different, yet significant, risk with overuse. These medications work by causing severe vasoconstriction, which shrinks the blood vessels to reduce swelling. When used for more than the recommended three to five days, this intense and prolonged constriction can lead to persistent ischemia of the septal mucosa. This lack of oxygen and nutrients causes necrosis and eventual perforation.
Techniques for Safe Nasal Spray Use
Safe and effective use relies heavily on a precise application technique to deliver the medicine away from the septum. Before using a metered-dose spray, gently shake and prime the bottle by spraying a few times into the air if it has not been used recently. This ensures a consistent, full dose is ready for delivery.
The most important step is to point the nozzle away from the midline of the nose. When inserting the spray tip into the right nostril, aim the nozzle toward the right ear or the outer corner of the right eye. The same technique is applied to the left nostril, aiming toward the left ear.
This method directs the medication toward the turbinates and the lateral nasal wall, where the medicine is intended to work, while avoiding direct high-pressure contact with the septum. Additionally, users should inhale gently as they spray to prevent the medicine from immediately dripping out or running down the back of the throat. Following the prescribed duration of use is also paramount, especially for topical decongestants, which should never be used for extended periods.
Signs of Perforation and Medical Intervention
A septal perforation can sometimes be asymptomatic, especially if it is small. When symptoms do occur, they are often related to the disruption of normal airflow and can include a distinct whistling sound when breathing through the nose. Other common symptoms include recurring nosebleeds (epistaxis), chronic crusting around the perforation’s edge, and a sensation of nasal obstruction even when the nasal passages are open. If any of these symptoms appear during or after using a nasal spray, it is advisable to stop the medication and seek an evaluation from a healthcare provider, ideally an Ear, Nose, and Throat (ENT) specialist.
Treatment depends on the size of the hole and the severity of the symptoms. Conservative management involves regular nasal irrigation with saline solutions and applying moisturizing gels or ointments to keep the area moist and reduce crusting. For large or highly symptomatic perforations, medical intervention may include the placement of a silicone septal button, a prosthetic device that covers the defect.
Surgical repair to close the hole with tissue grafts is another option for individuals who do not respond to conservative measures.