Nasal septal perforation

What is a nasal septal perforation?

A nasal septal perforation is a hole that develops in your septum, the wall of cartilage, bone and lining tissue that divides the inside of your nose into two nostrils. Many people have no symptoms at all, but larger holes can affect your breathing and, occasionally, the shape of your nose.

Symptoms of a nasal septal perforation

Most people with a septal perforation have no symptoms whatsoever, and some only discover it by chance, for example while cleaning their nose, looking in a mirror, or during an unrelated examination. When symptoms do occur, you might notice:

• crusting and dryness inside your nose
• a feeling of blockage, even though your nose isn't physically blocked
• recurrent nosebleeds
• a whistling noise when you breathe, especially if the hole is small
• foul-smelling discharge from your nose
• a runny nose.

For many people, crusting and nosebleeds are the most troublesome symptoms. If the hole is very large, it can also change the shape of your nose over time, causing the bridge to dip inwards, sometimes called a 'saddle nose'.

Causes and risk factors

The most common cause of a septal perforation is trauma, accounting for around 4 in 10 cases. This includes a blow to the nose and nose picking, both very common, as well as repeated rubbing from medical tubes such as feeding tubes or oxygen tubing.

Foreign objects stuck in the nose can also cause damage, and button batteries are particularly dangerous, since they start corroding nasal tissue almost immediately.

Nasal surgery, especially septoplasty (surgery to straighten the septum), is another recognised cause, as is repeated cautery to treat nosebleeds. Overusing steroid nasal sprays or decongestant sprays can weaken the lining of your nose, and snorting cocaine or other drugs can damage it too, partly because these substances narrow the blood vessels that supply your septum with blood.

Rarely, a hole can be caused by an inflammatory or autoimmune condition, such as granulomatosis with polyangiitis, lupus, rheumatoid arthritis or sarcoidosis, or by an infection such as tuberculosis, syphilis or a fungal infection.

In very rare cases, a persistent sore that keeps growing can turn out to be a cancer. Because of this, your doctor may run tests to look for an underlying cause if there's no obvious explanation, such as an injury or recent surgery.

Types of nasal septal perforation

Doctors often describe perforations by where they sit in the septum. Those near the front of the nose tend to cause more symptoms, since this is where airflow is most turbulent, leading to more dryness, crusting and whistling. Perforations further back are more often silent and cause no problems at all.

Size matters too. Small holes, under half a centimeter across, and medium-sized holes, up to about 2 centimeters, generally respond well to treatment. Larger holes are more likely to cause noticeable symptoms and are harder to close successfully if surgery is needed.

How is a nasal septal perforation diagnosed?

Your doctor will ask about your symptoms, general health, any medicines you take, including over-the-counter and recreational drugs, and your nose-cleaning habits, since all of these can offer clues about the cause. They'll examine the inside of your nose using a light, and sometimes a flexible nasal endoscopy is used to get a fuller view.

Blood tests can check for signs of infection, inflammation or an autoimmune cause, and a urine sample may also help identify an autoimmune condition. Occasionally, a chest X-ray is taken, since some causes of septal perforation are also linked to the lungs, and CT or MRI scans are sometimes used to look more closely at your nose and sinuses.

If the edge of the hole looks irregular, a small sample of tissue (a biopsy) may be taken and examined under a microscope. This usually isn't needed if the edge looks smooth and healthy, or if the perforation followed a surgery you've already had.

How is a nasal septal perforation treated?

Non-surgical treatment

Many perforations don't need active treatment at all, especially if they're not causing symptoms. Where treatment does help, it usually focuses on keeping the inside of your nose moist and free from crusts. Daily nasal saline washes help clear crusts gently, and it's best to avoid picking at them yourself, since this can tear the fragile lining and cause bleeding.

Petroleum jelly or a water-based gel applied around the edges of the hole can help moisturise the area and trap irritants, though some doctors prefer water-based products in particular, since petroleum-based ones carry a small risk of being breathed into the lungs. Your doctor might also prescribe an antibacterial cream if nosebleeds are a particular problem.

If tests point to an underlying cause, such as an autoimmune condition or infection, you'll be referred to the right specialist, such as a rheumatologist, to treat that condition directly.

Septal button

A septal button is a small silicone device that bridges the hole from both sides, acting a bit like an artificial septum. It can be trimmed to fit, inserted under local anaesthetic during a clinic visit or sometimes under general anaesthetic, and can stay in place for years without problems.

It doesn't close the hole permanently, so you'll still need to keep your nose moist as before, and some people find having a foreign object in their nose uncomfortable or irritating.

Surgical repair

If your symptoms remain troublesome despite the treatments above, surgery to close the hole is an option.

Surgeons use tissue to bridge the gap: for smaller holes, tissue from inside your own nose is often enough, while larger holes usually need tissue taken from elsewhere in your body. The operation is done under general anaesthetic, typically takes 1 to 3 hours, and is usually done as a day case, so you can go home the same day.

Recovery from surgery

Afterwards, you'll usually need internal splints for about the first week, along with regular saline rinses for 2 to 3 weeks while everything heals.

You'll be asked to avoid nose blowing, nose picking and strenuous exercise during recovery, and to avoid lying on your back for around four weeks.

Most people can shower after a day, move around fairly normally after 2 days, drive again after about 2 weeks, and return to exercise after around 6 weeks, with full recovery taking 6 to 8 weeks. Most people need about 2 weeks off work.

Chances of success from surgery

How well surgery works depends largely on the size of the hole: smaller ones close far more reliably, while those larger than about 2 centimeters are notably harder to repair successfully.

Smoking reduces blood supply to your septum and lowers your chances of success, so quitting well before surgery matters, and certain conditions, such as diabetes, can also affect healing.

If drug use caused your perforation, most surgeons will want you to have stopped for a substantial period, often at least a year, before considering repair, since continued use risks the hole reopening. For certain autoimmune causes, surgery isn't usually recommended even when the condition is currently under control, because the risk of the repair failing is high. Even with successful surgery, the hole can occasionally reopen, and a further operation is sometimes needed.

When should I see a doctor?

See a GP or ask for a referral to an ear, nose and throat (ENT) specialist if you notice or suspect a hole in your septum, especially if you have crusting, nosebleeds, whistling or a blocked feeling that does not seem to fit a simple cold.

It's worth getting any suspected perforation checked properly rather than treating it yourself, since a small number of cases are linked to underlying conditions that need their own treatment.

See your doctor promptly if you notice a sore inside your nose that keeps growing and won't heal, or if you have unusual bleeding or pain.

Never try to explore, clean out or treat a suspected hole yourself with your finger or any tool. This can tear the tissue further and introduce infection, so it is best left to a healthcare professional.