The nasal septum is the internal wall separating your right and left nasal passages. Composed of both flexible cartilage in the front and solid bone further back, this structure is covered by a delicate mucous membrane. Its primary functions are to provide structural support to the nose and to help regulate the smooth flow of air as you breathe. A septal perforation is a hole that develops through this dividing wall, creating an opening between the two sides of the nasal cavity.
The size of a perforation can vary significantly, from a small pinhole to a very large opening. This hole disrupts the normal pattern of airflow within the nose, which can lead to complications. While some individuals with a septal perforation may not experience any noticeable issues, others can face significant discomfort and functional problems depending on the hole’s size and location.
Causes of a Perforated Septum
A hole in the nasal septum can develop for numerous reasons, with physical trauma being one of the most frequent causes. This includes direct injuries, such as a blow to the nose, or self-induced trauma from chronic nose picking, which can erode the delicate lining and underlying cartilage. Complications from previous nasal surgeries, like a septoplasty to correct a deviated septum or a rhinoplasty, can also result in a perforation if the blood supply to the tissue is compromised during healing.
Certain substances inhaled through the nose are another major contributor. The long-term use of vasoconstrictive drugs, most notably cocaine, is widely known to cause perforations by severely restricting blood flow to the septum, leading to tissue death. The improper or prolonged use of medicated nasal sprays, such as steroids or over-the-counter decongestants, can damage the septal lining and lead to the formation of a hole.
Less commonly, systemic diseases are the underlying cause. Autoimmune conditions like granulomatosis with polyangiitis (GPA) or sarcoidosis can trigger inflammation that attacks and breaks down the septal cartilage. In rare instances, chronic infections such as syphilis or tuberculosis may lead to a perforation. Cancers within the nasal cavity can also present as a hole in the septum.
Recognizing the Symptoms
The symptoms of a septal perforation are directly related to the disruption of normal nasal airflow and the size of the hole. One of the most distinct symptoms, particularly with smaller perforations, is a whistling sound during breathing. This noise is created as air passes through the small opening at high velocity.
For many, the most troubling symptoms are persistent nasal crusting and bleeding, also known as epistaxis. The edges of the perforation are exposed to constant airflow, causing them to become dry and form crusts. When these crusts are dislodged, bleeding often occurs. This cycle of crusting and bleeding can cause significant irritation.
A feeling of nasal blockage or obstruction is also common. This sensation can be caused by the buildup of crusts or by the turbulent, inefficient airflow resulting from the hole. In some cases, individuals may experience pain within the nose. With very large perforations that compromise the structural integrity of the nose, a visible deformity called a “saddle nose” can occur, where the bridge of the nose collapses.
The Diagnostic Process
Confirming the presence of a septal perforation begins with a thorough physical examination by an Otolaryngologist (ENT) specialist. The physician will use a bright light and a nasal speculum to get an initial view of the internal nasal structures. In many cases, a perforation, especially a larger one, can be identified during this initial inspection.
For a more definitive diagnosis, a nasal endoscopy is the standard procedure. This involves guiding a thin, rigid or flexible tube equipped with a light and a camera, called an endoscope, into the nasal passages. This instrument provides a magnified, detailed view of the entire nasal cavity, allowing the doctor to assess the perforation’s size, location, and the health of the surrounding mucosal tissue.
If the physician suspects that an underlying systemic condition might be the cause, further tests may be ordered. These can include blood tests to screen for autoimmune markers or infections. In some situations, a small tissue sample, or biopsy, may be taken from the edge of the perforation to be examined for signs of specific diseases or cancer.
Management and Repair Options
Treatment for a septal perforation is tailored to the patient’s symptoms. For individuals who wish to avoid surgery or have minimal symptoms, non-surgical management focuses on alleviating discomfort. This approach involves diligent nasal hygiene, using saline sprays or rinses to keep the nasal passages moist, reduce crusting, and clear away debris. The use of a humidifier at home can also help prevent the nasal lining from drying out.
To further protect the area, emollients or ointments, such as petroleum jelly or antibiotic ointments, can be applied directly to the edges of the perforation. This creates a barrier that locks in moisture and promotes the healing of irritated tissue. Another non-surgical option is a septal button, a soft, non-reactive silicone prosthesis designed to plug the hole. The button is custom-fitted and inserted into the perforation, which can stop whistling and reduce crusting, though it does not permanently close the hole.
For those seeking a permanent solution, surgical repair is the definitive treatment. The goal of surgery is to close the perforation completely by using the patient’s own tissue. The most common techniques involve creating flaps of the nasal lining (mucosa) from areas around the perforation and moving them over to cover the hole. These flaps bring their own blood supply, which is necessary for successful healing.
In cases of larger perforations, an additional support layer may be needed between the mucosal flaps. Surgeons often use grafts of tissue taken from another part of the body, such as fascia from the temple region or cartilage from the ear, to provide a scaffold for the repair. The success of the surgery often depends on the perforation’s size and location, as smaller holes are generally easier to close.