The nasal septum is the wall composed of cartilage and bone that divides the inside of the nose into two separate passages. This structure is covered by the mucosa, a delicate, moist lining that supplies blood to the underlying cartilage. A septal perforation is a full-thickness defect, or hole, that develops in this dividing wall, creating an abnormal communication between the right and left nasal cavities.
A perforation typically begins when the mucosal lining on both sides of the septum is injured in the same location, cutting off the blood supply to the cartilage. Since cartilage relies on the surrounding mucosa for nourishment, this exposure leads to tissue death, or necrosis, and eventually a hole. Understanding the underlying causes is the first step toward appropriate management.
Perforations Following Medical Interventions
Damage resulting directly from medical procedures, known as iatrogenic causes, represents a significant category of septal perforation origin. Septoplasty, the surgical procedure to correct a deviated septum, is a common iatrogenic factor, with the risk of perforation reported between 0.5% and 3.1%.
A perforation often occurs if the mucosal lining is torn on both sides of the septum during surgery, especially if the tears are directly opposite each other. This strips the cartilage of its blood supply, preventing proper healing. Other nasal surgeries, such as rhinoplasty, also carry a risk due to potential localized trauma to the septal tissue.
Procedures used to stop recurrent nosebleeds, such as aggressive or repeated nasal cauterization, can also destroy the mucosa and cartilage. Cauterization intentionally burns the blood vessels to seal them, but if performed too intensely on both sides of the septum, it can lead to tissue necrosis. Other medical causes include the pressure and irritation from prolonged use of nasal packing, nasal intubation, or nasogastric tubes.
Damage from Self-Inflicted Trauma and Substance Exposure
Causes originating from direct physical or chemical insult to the nasal tissues are major contributors to septal perforation. The inhalation of illicit substances, particularly powdered cocaine, is a well-documented cause. Cocaine is a powerful vasoconstrictor, severely narrowing blood vessels and restricting blood flow to the nasal lining.
This severe localized reduction in blood supply leads to ischemia and subsequent necrosis of the septal tissue. Adulterants used to “cut” the cocaine powder also contribute to the damage by introducing chemical irritants that further destroy the nasal lining.
Chronic nose picking, known as digital trauma, repeatedly prevents the delicate mucosa from healing. The constant mechanical irritation can erode the mucosal barrier, leading to ulceration that exposes the underlying cartilage. Acute blunt trauma to the nose, such as a facial fracture or direct blow, can also damage the septum and cause a septal hematoma, which may lead to necrosis and perforation if not treated.
Certain medications delivered via the nasal route can also contribute if overused. Over-the-counter decongestant nasal sprays containing vasoconstrictors, such as oxymetazoline, can mimic the effects of illicit drugs by reducing blood flow. Long-term or improper use of prescription nasal steroid sprays can also cause localized irritation and thinning of the septal lining, increasing the risk of perforation.
Systemic Disease and Chronic Inflammation
A significant number of perforations are caused by underlying systemic diseases or chronic environmental exposure, typically involving sustained, destructive inflammation. Autoimmune disorders and vasculitis conditions are prominent in this category.
Granulomatosis with Polyangiitis (GPA), formerly known as Wegener’s granulomatosis, is a condition where the body’s immune system attacks blood vessels and causes destructive inflammation of the tissue. This damage to the blood supply can lead to necrosis and perforation of the nasal septum. Sarcoidosis is another systemic inflammatory disease that can affect the nose and cause septal defects.
Rare but severe infectious diseases can also erode the septal cartilage. These include tertiary syphilis, which causes destructive lesions known as gummata. Tuberculosis and certain fungal infections are known to cause tissue destruction in the nose, especially in individuals with compromised immune systems.
Chronic occupational exposure to irritating fumes or dusts represents a different form of sustained injury. Industrial chemicals, such as chromic acid dust or chromium compounds, can cause chronic inflammation and tissue damage that may progress to a perforation. Finally, in a small percentage of cases, a thorough investigation may not reveal a specific cause, and the perforation is classified as idiopathic.