The nasal septum is the wall that divides the inside of the nose into two separate passages. This structure, which is composed of bone and cartilage, is lined with a delicate mucous membrane on both sides. A perforated septum occurs when a hole develops through this dividing wall, establishing an abnormal connection between the two nasal cavities. This structural defect can disrupt the natural flow of air, leading to a variety of symptoms that affect breathing and overall nasal comfort. Understanding the specific nature and causes of this condition is the first step toward effective management.
Defining the Condition
The nasal septum is a composite structure, with the forward portion primarily consisting of flexible quadrangular cartilage and the rear portion supported by perpendicular plates of bone. A perforation represents a full-thickness defect, meaning the hole passes completely through the delicate mucosal lining, the underlying cartilage or bone, and the mucosal lining on the opposite side. The size of these perforations can vary widely, ranging from a few millimeters to several centimeters in diameter.
Perforations most commonly develop in the anterior, cartilaginous part of the septum because this area is more fragile and receives less robust blood supply than the bony posterior section. A very small perforation may be entirely asymptomatic and only discovered incidentally during a medical examination. Conversely, a large perforation can compromise the structural support of the nose, potentially leading to a noticeable physical change in the external nose shape. The location and size of the defect significantly determine the severity of symptoms a person experiences.
Common Causes and Risk Factors
The formation of a septal perforation almost always results from a process that damages the blood supply to the septum, causing the deprived cartilage tissue to die and break down.
Trauma and Iatrogenic Causes
Physical trauma is the most frequent cause, often stemming from chronic, self-inflicted injuries like persistent nose picking, which leads to localized irritation and ulceration. Traumatic causes also include blunt force injuries to the nose or the improper removal of foreign bodies lodged in the nasal passage. A significant number of cases are classified as iatrogenic, meaning they result from a medical procedure, most commonly as a complication following a septoplasty, which is surgery to correct a deviated septum. Other medical interventions, such as repeated cauterization to stop recurrent, severe nosebleeds, can also compromise the septal tissue’s vascularity, leading to perforation. The incidence of this surgical complication is reported to be between 0.5% and 3.1% following septoplasty.
Chemical Irritation
Chemical irritation from inhaled substances represents another major risk factor due to their vasoconstrictive and toxic effects on the nasal lining. Intranasal use of illicit drugs, such as cocaine, causes severe local damage by constricting blood vessels and depriving the tissue of oxygen and nutrients. Similarly, chronic, excessive use of topical nasal decongestant sprays or certain inhaled chemical irritants in occupational settings can also contribute to the breakdown of the nasal mucosa and cartilage.
Systemic Conditions
Less common, but more serious, causes include chronic inflammatory and autoimmune conditions that directly attack the body’s tissues. Diseases like Granulomatosis with Polyangiitis can cause inflammation that destroys the septal cartilage. Infectious processes, such as syphilis or tuberculosis, also represent rare causes that can lead to septal perforation through tissue destruction. Identifying and addressing these systemic conditions is a crucial step in the overall management of the perforation.
Recognizable Signs and Symptoms
The presence of a hole in the septum alters the smooth, laminar flow of air through the nasal passages, leading to the most characteristic symptom. Small perforations often cause a distinctive, audible nasal whistling sound during inhalation or exhalation as air is forced through the narrowed opening. This turbulent airflow can also contribute to a subjective feeling of nasal obstruction, even though the nasal passage is technically open.
Disruption of the normal mucosal environment leads to a cycle of inflammation, dryness, and crust formation around the perforation’s edges. This chronic crusting is frequently the most bothersome symptom, causing discomfort and occasionally a foul smell if debris becomes trapped. The delicate, inflamed tissue surrounding the defect is also highly prone to recurrent epistaxis, or nosebleeds.
Some individuals may experience localized pain, pressure, or a persistent sensation of dryness within the nose. Symptoms tend to be more pronounced with perforations located closer to the front of the nose, as this area is exposed to the greatest air flow velocity. Conversely, perforations located further back in the bony septum are often less symptomatic because the air has already been humidified by the time it reaches that area.
Treatment and Management Options
The management of a perforated septum is primarily focused on relieving symptoms and preventing the perforation from enlarging.
Conservative Care
The first line of defense is conservative, non-surgical care aimed at maintaining a moist, clean nasal environment. This involves the regular use of nasal saline irrigation, which helps to wash away accumulated crusts and debris from the edges of the perforation. Applying topical emollients, such as petroleum-based or water-soluble gels, directly to the perforation margins helps to keep the mucosa lubricated and reduces both crusting and bleeding. Humidification, especially in dry environments, is also recommended to prevent the nasal lining from drying out. These simple measures can effectively manage symptoms for many individuals, particularly those with smaller perforations.
Septal Button
When conservative management fails to control symptoms, a non-surgical device known as a septal button or septal prosthesis may be recommended. This is a custom-fitted, two-piece device, often made of flexible silicone, that is inserted to plug the hole. The button functions by physically sealing the perforation, thereby restoring more normal, laminar airflow and immediately eliminating the characteristic nasal whistling. A septal button is a low-risk option that can significantly reduce crusting and nosebleeds, but it requires regular cleaning and may not be tolerated by all patients.
Surgical Repair
For perforations that are large, highly symptomatic, or causing structural changes to the nose, surgical repair may be considered. Surgery is generally complex and involves closing the hole by advancing local mucosal flaps and often grafting tissue from elsewhere in the body. The surgical technique commonly employs a graft material, such as temporalis fascia or cartilage, to create a structural scaffold over which the mucosal flaps are secured. This provides the necessary support and barrier to successfully close the defect. Success rates for surgical repair vary depending on the size of the perforation, with larger defects proving more challenging to close permanently.