The nasal septum is the wall composed of cartilage and bone that divides the nasal cavity into two separate passages. This structure is covered by a layer of soft tissue called mucosa, which helps keep the nasal passages moist. A septal perforation is a full-thickness defect, or hole, that develops through this dividing wall. While the idea of a hole in the nose may sound alarming, many perforations are small and do not cause significant problems. The condition becomes a medical concern when the defect disrupts the normal function of the nose, leading to uncomfortable symptoms.
Defining the Condition and Associated Symptoms
A septal perforation disrupts the natural, laminar flow of air through the nose, leading to turbulent airflow. This altered movement of air across the lining of the nose causes the primary symptoms that motivate people to seek treatment. Small perforations often create an audible whistling sound as air rushes through the narrow opening during inhalation and exhalation.
Larger perforations often lead to troublesome symptoms, including chronic crusting and recurrent nosebleeds (epistaxis). The turbulent air dries out the surrounding nasal mucosa, causing irritation and forming painful, bloody scabs. The persistent dryness and crusting can also lead to a subjective feeling of nasal obstruction, even though the passage is physically open. Diagnosis is typically made during a clinical examination using a nasal speculum or, more accurately, with a nasal endoscopy, which allows visualization of the defect’s size and location.
Common Causes of Septal Perforation
The formation of a septal perforation is related to a compromise of the blood supply to the septal mucosa and underlying cartilage. The most frequent cause is iatrogenic, meaning it results from a medical procedure, particularly following nasal surgery such as a septoplasty. Damage to the mucosal lining during these procedures can expose the underlying cartilage, which then loses its blood supply and breaks down. Repeated cauterization of the septum to stop chronic nosebleeds can also damage the tissue enough to cause a perforation.
Mechanical trauma is another major category, with repeated digital manipulation—commonly known as nose picking—being a frequent culprit. This constant pressure and scraping can lead to ulceration and eventual breakdown of the septal wall. Furthermore, the chronic inhalation of chemical irritants, notably illicit drugs like cocaine or methamphetamine, can cause severe vascular constriction. This narrowing of blood vessels restricts blood flow to the septum, causing the tissue to die and the perforation to form.
Less common but more serious causes include certain systemic conditions that attack the body’s own tissues. Autoimmune diseases, such as Granulomatosis with Polyangiitis (formerly known as Wegener’s granulomatosis), can cause inflammation that destroys the nasal cartilage. Identifying the precise cause is important, as systemic diseases require dedicated medical treatment before any physical repair is considered.
Non-Surgical Management Strategies
For many patients, especially those with small or minimally symptomatic perforations, non-surgical management offers effective relief. The primary goal is to manage the dryness and crusting caused by the disturbed airflow. Environmental control, such as using a humidifier, helps to increase the moisture content in the air breathed into the nose, which soothes the nasal lining.
Patients are often instructed to use saline irrigation or specialized moisturizing nasal gels and ointments regularly. These treatments help to lubricate the nasal passages and prevent the formation of hard, dry crusts that can lead to pain and bleeding. A non-surgical approach involves the placement of a prosthetic device called a septal button or obturator. This is a custom-sized silicone device inserted to physically cover the hole, acting as a temporary internal patch. The button immediately restores more normal airflow, often eliminating the whistling sound and reducing crusting, though it requires routine cleaning and may cause some localized irritation.
Surgical Repair Options
Surgical closure is reserved for perforations that are highly symptomatic or those that fail to respond to conservative management. The objective of surgical repair is to completely close the defect, which often requires a multi-layered technique. This procedure involves mobilizing mucosal flaps—sections of healthy tissue taken from adjacent areas inside the nose. These flaps are rotated or advanced to cover the hole on both sides of the septum.
A tissue scaffold, known as an interposition graft, is usually placed between the two mucosal flaps to provide structural support for healing. Common autologous materials used for this graft include cartilage from the patient’s own septum or ear, or fascia harvested from the temporalis muscle. This layered closure provides the necessary bulk and blood supply to ensure the perforation remains closed. The success of the surgery is highly dependent on the size and location of the defect, with smaller perforations generally having a higher rate of successful closure.