Nasal Septal Perforation: Causes, Symptoms and Surgical Repair

4 days ago

3 min read

Key takeaways

A septal perforation is a hole through the nasal septum, the wall of cartilage and bone that separates the two nostrils.
Common causes are previous nasal surgery, nose picking and trauma, long-term nasal spray misuse, cocaine use, infections, inflammatory diseases and, rarely, tumours.
Symptoms depend on size and position: crusting, nosebleeds, a whistling sound, congestion, discharge and pain; large front perforations can make the bridge collapse.
Many perforations can be repaired with mucosal flaps and cartilage grafts; small, asymptomatic ones may simply be managed with moisturising care.

What is a septal perforation?

The nasal septum divides the nose into two passages and supports the bridge and tip. A perforation is a full-thickness hole through the septum's lining and cartilage (or bone). Because the lining on both sides is damaged, the edges dry out, form crusts and bleed. Air passing through the hole becomes turbulent, which is why many patients hear a whistle when breathing.

Causes

Previous nasal surgery, particularly septoplasty or rhinoplasty, when both sides of the lining are torn in the same place
Nose picking, piercing, foreign bodies and repeated minor trauma
Long-term use of nasal sprays, including decongestants and incorrectly aimed steroid sprays
Cocaine and other intranasal drug use, which constrict blood vessels and destroy tissue
Infections and chronic inflammation
Autoimmune and inflammatory diseases such as granulomatosis with polyangiitis or sarcoidosis
Tumours (rare), which is why unexplained perforations are sometimes biopsied

Symptoms

Some perforations cause no symptoms at all; others are very bothersome. Symptoms vary with the location, cause and size:

Crusting inside the nose
Recurrent nosebleeds
A whistling sound when breathing
Nasal congestion and a feeling of obstruction
Pain or discomfort
Nasal discharge and post-nasal drip
Inflammation of the septal cartilage
In large perforations at the front of the septum, loss of dorsal support and collapse of the bridge (saddle nose); see saddle nose repair

Diagnosis

Front perforations are easily seen by gently opening the nostril with an instrument during examination. Perforations further back are assessed with nasal endoscopy. Both examinations are painless and quick. The surgeon measures the size and position of the hole, checks the surrounding tissue and looks for underlying causes; blood tests or a biopsy may be recommended.

Treatment

Conservative management

Small perforations without symptoms may only need moisturising care: saline sprays, nasal ointments and humidification to prevent crusting. A silicone septal button can be fitted to close the hole mechanically for patients who are not candidates for surgery.

Surgical repair

Surgery aims to close the hole with the patient's own well-vascularised tissue:

Mucosal advancement or rotation flaps are raised from inside the nose on both sides and moved over the defect.
An interposition graft (septal, ear or rib cartilage, or connective tissue) is placed between the two flap layers for strength.
Repair is often done through an open approach, especially for larger perforations, and can be combined with rhinoplasty when the bridge has collapsed or when aesthetic correction is desired.

Success depends on size, position, tissue quality and the elimination of the cause; smoking and continued drug use significantly reduce success. See case study 11: revision septorhinoplasty with perforation closure.

Recovery

Thin silicone splints protect the repair for one to three weeks. Saline irrigation and ointment keep the lining moist while it heals. Avoid nose blowing, heavy lifting and smoking during healing.

Frequently asked questions

Can a septal perforation heal on its own?

No. The hole does not close by itself, although symptoms can be controlled with moisturising care.

Is septal perforation repair painful?

Discomfort is moderate and well controlled with painkillers; congestion from splints is the main complaint.

Can a perforation cause nasal collapse?

Yes, large front perforations can weaken dorsal support and cause a saddle-nose deformity.

Can septal perforation repair be combined with rhinoplasty?

Yes, and it is often advantageous because the same approach allows both repair and structural reconstruction.

Next step

Contact Prof. Dr. Suleyman Tas Clinic for an endoscopic assessment and a personalised repair plan with Prof. Dr. Suleyman Tas.

About the author

Prof. Dr. Suleyman Tas is a European Board-certified plastic, reconstructive and aesthetic surgeon based in Istanbul with over 20 years of experience, author of Rhinoplasty in Practice (CRC Press) and founder of the Closed Atraumatic Rhinoplasty Course. Read verified patient reviews or book a consultation.

This article is for general information and does not replace an individual medical consultation.