The nasal septum is the wall composed of cartilage and bone that divides the nasal cavity into two separate air passages. This structure is covered by a thin layer of mucous membrane, which provides its blood supply and keeps the inner nose moist. The septum regulates airflow, ensuring the air we breathe is filtered, warmed, and humidified before reaching the lungs. A septal perforation is a full-thickness defect, or an abnormal hole, that develops through all layers of this dividing wall. This defect can range widely in size and location, leading to various symptoms and disruption to normal nasal function.
Physical Damage and Post-Surgical Complications
Physical disruption is a frequent cause of a hole forming in the nasal septum, often resulting from direct injury or repetitive mechanical stress. Self-inflicted trauma, such as chronic nose picking, is a common culprit because it repeatedly damages the delicate lining on the front of the septum. This consistent irritation can cause localized ulceration and infection, ultimately leading to the death and breakdown of the underlying septal cartilage.
Accidental external trauma, like a forceful blow to the face or nose, can also initiate the process. A severe injury may cause a septal hematoma, a collection of blood that pools between the cartilage and the overlying mucous membrane. If this hematoma is not promptly drained, the pressure blocks the blood flow to the cartilage, causing the tissue to die from lack of oxygen and nutrients, leading to a perforation. Foreign objects lodged in the nasal passages, such as small toys or button batteries, can also cause rapid and severe tissue destruction.
Perforations can also occur as a complication following nasal surgical procedures, known as iatrogenic causes. Surgeries like septoplasty (to correct a deviated septum) or rhinoplasty (to change the nose’s shape) carry an inherent risk. The most common surgical mechanism involves the accidental disruption of the blood-rich mucoperichondrial flaps that cover the cartilage. If the flaps on both sides are torn or poorly reapproximated, the exposed cartilage loses its blood supply, leading to necrosis and the formation of a hole. Additionally, repeated or overly aggressive cauterization performed to stop recurrent nosebleeds can also damage the septum enough to cause a perforation.
Chemical Exposure and Medication Side Effects
The introduction of caustic chemicals or substances that constrict blood vessels into the nasal cavity represents another category of septal perforation causes. Cocaine use is a recognized cause because the drug is a powerful vasoconstrictor, severely narrowing the blood vessels in the nasal lining. This vasoconstriction dramatically reduces the blood supply to the septum’s cartilage, causing the tissue to die. Furthermore, the chemical composition of cocaine and the various “cutting” agents used to dilute it are directly irritating and corrosive, leading to chemical inflammation and tissue necrosis at the site of contact.
The misuse of certain over-the-counter and prescription nasal medications can also contribute to this damage. Prolonged or excessive use of topical decongestant sprays can cause a rebound effect that leads to chronic inflammation and dryness. This persistent irritation thins the mucosal lining, making the underlying cartilage vulnerable to damage. Similarly, the improper application or overuse of certain steroid nasal sprays can lead to localized irritation and ulceration that progresses to a full-thickness defect.
Occupational exposure to certain industrial chemicals can also erode the nasal lining over time, leading to perforation. Workers exposed to high concentrations of dust, lime, cement, or specific caustic compounds are at risk. Chromium compounds, such as chromic acid used in processes like chrome plating, are a notable example. Inhaling these irritants causes chronic inflammation and ulceration of the septum, which can advance to a perforation if exposure continues.
Systemic Disease and Inflammatory Conditions
Septal perforations can sometimes be the first sign of an underlying systemic medical condition that affects the body’s tissues and blood vessels. These conditions cause damage either through chronic inflammation or by compromising the blood flow necessary to keep the septal cartilage alive. Autoimmune conditions known as vasculitides are a cause, where the body’s immune system mistakenly attacks its own blood vessels.
Granulomatosis with Polyangiitis (GPA), formerly known as Wegener’s granulomatosis, is the most common form of vasculitis known to cause these perforations. This disease causes inflammation that damages small and medium-sized blood vessels, often targeting the nose, sinuses, and lungs. The resulting lack of blood flow and chronic inflammatory process causes the tissue to break down, leading to the defect. Other autoimmune diseases, such as systemic lupus erythematosus or rheumatoid arthritis, have also been linked to septal perforation through similar inflammatory mechanisms.
Specific types of chronic infections that are slow-growing and destructive can also lead to tissue loss in the septum. Although rare in the general population, diseases like tertiary syphilis and tuberculosis can involve the nasal structures. These infections cause a localized, destructive inflammatory response that consumes the cartilage and bone. Fungal infections, particularly in individuals with compromised immune systems, also have the potential to cause tissue necrosis and perforation.
Identifying Symptoms and Seeking Diagnosis
The presence of a septal perforation causes a noticeable change in the way air flows through the nose, leading to a specific set of physical symptoms. One frequently reported issue is a distinct whistling sound that occurs when breathing, especially with smaller perforations where turbulent air passes through a narrow opening. The disruption of normal airflow also leads to dryness and the formation of hard, dry crusts around the edges of the hole.
Patients often experience recurrent nosebleeds, known as epistaxis, as the dry air irritates the exposed edges of the perforation. A feeling of chronic nasal blockage or obstruction may also be present, even if the nasal passages are physically open, because the turbulent airflow feels abnormal. If the perforation is large or involves a significant portion of the cartilage, the structural support of the nose can be lost, potentially leading to a visible collapse of the nasal bridge, known as a saddle nose deformity.
If a perforation is suspected, seeking a professional diagnosis is the next step. A healthcare provider will take a detailed medical history, focusing on past nasal trauma, surgeries, medication use, and any history of systemic diseases. The definitive diagnosis is typically made through a physical examination, often utilizing nasal endoscopy. This procedure involves inserting a thin, lighted instrument to allow the doctor to visualize the size, location, and condition of the perforation and surrounding tissue. If an autoimmune condition or infection is suspected, blood tests or a biopsy of the perforation’s edge may be ordered.