The nasal septum is the wall of cartilage and bone that divides the nose into two separate nasal cavities. This structure is covered on both sides by a thin, moist lining called mucosa, which is rich in blood vessels. A nasal septal perforation is a defect, or hole, that develops in this dividing wall. This opening connects the two nasal passages directly, disrupting the normal flow of air within the nose. Perforations vary widely in size and location; while some people have no symptoms, others experience significant discomfort and nasal issues.
Recognizing the Signs
The presence of a hole in the septum can drastically alter the aerodynamics of the nose, leading to a range of noticeable symptoms. One of the most distinctive signs of a septal perforation is a high-pitched whistling sound that occurs during breathing, particularly with smaller perforations. This sound results from turbulent airflow as air rushes through the small, narrow opening.
A common complaint is the persistent feeling of nasal obstruction, even when the passages are clear. The altered airflow causes excessive drying of the surrounding mucosa, triggering chronic crusting and scabbing around the edges of the perforation. These dry crusts can lead to recurrent epistaxis, or nosebleeds, when they are dislodged or when the irritated mucosal lining breaks down.
The severity of symptoms often relates directly to the size and position of the defect. Perforations situated in the anterior portion of the nose, closer to the nostrils, are more symptomatic because they are exposed to the most turbulent and drying air currents. Larger perforations, typically exceeding two centimeters, may cause more pronounced symptoms like significant nasal dryness and a noticeable collapse of the nasal bridge, known as a saddle nose deformity.
Why Septal Perforations Occur
A septal perforation forms when the blood supply to the septal cartilage is compromised, causing the tissue to die. The cartilage itself relies entirely on the surrounding mucosal lining for nourishment. Any event that damages both layers of the mucoperichondrial lining can interrupt this blood flow, leading to cartilage breakdown and the formation of a hole.
One common cause is trauma, which can be external (like a blunt force injury) or self-inflicted (like aggressive nose picking). A specific type of trauma is a septal hematoma, a collection of blood between the cartilage and the mucosa. If untreated, this pressure cuts off the blood supply, resulting in tissue death and perforation. Surgical procedures like septoplasty, performed to correct a deviated septum, are also a known cause due to potential complications or healing issues.
The corrosive effects of inhaled substances represent another significant etiology. Intranasal drug abuse, particularly with cocaine, causes intense vasoconstriction, severely narrowing the blood vessels and starving the septal tissue of oxygen and nutrients. Chronic overuse of certain topical nasal sprays, such as decongestants or corticosteroids, can similarly irritate and thin the mucosa over time, making it vulnerable to perforation.
Less frequent causes involve systemic issues. These include inflammatory and autoimmune diseases, such as Granulomatosis with polyangiitis (GPA), which attack the blood vessels and tissues of the nose. Certain chronic infections, like syphilis or tuberculosis, can also lead to septal destruction. Identifying the underlying cause is necessary, especially with systemic diseases, to prevent future perforations or enlargement.
Options for Repair
Management of a septal perforation is determined by the severity of the patient’s symptoms, not just the size of the hole. For individuals with small or asymptomatic perforations, doctors recommend a conservative approach focused on symptom relief and mucosal health. This regimen includes regular use of nasal saline irrigation, humidifiers, and moisturizing ointments applied to the perforation edges. These measures help reduce crusting and dryness, which drive bleeding and discomfort.
If conservative measures fail, a mechanical device called a septal button or silicone plug may be used as a non-surgical option. This prosthesis is designed to sit flush against both sides of the septum and mechanically close the opening. Septal buttons are typically made of soft silicone and can be custom-fitted. They offer symptomatic improvement by eliminating the whistling sound and reducing the turbulent airflow that causes crusting.
Surgical closure is considered the definitive treatment for symptomatic perforations, though it is often complex. The goal of surgery is to cover the hole completely with healthy tissue that has a reliable blood supply. This often involves creating and rotating local tissue flaps, such as mucosal advancement flaps, to cover the defect.
To support the new tissue, surgeons place a supportive graft material, such as fascia or cartilage, between the flaps to bridge the gap in the septum. The success of surgical repair is related to the size of the perforation, with smaller defects having higher closure rates. Larger perforations require more intricate techniques and are often reserved for specialized surgeons who utilize extensive flaps to ensure a tension-free closure.