Septal Perforation (Perforated Septum): Causes and Treatment

A septal perforation is a hole through the nasal septum — the wall of cartilage and bone dividing the two sides of the nose. The two sides connect where they should not, and air passes through the hole instead of over it.

Two things about it are counterintuitive, and both matter.

Small perforations often cause worse symptoms than large ones. A hole under a centimetre disturbs airflow at exactly the point where it produces whistling, drying and crusting. A large hole can be surprisingly quiet, because air passes through without the same turbulence.

A perforation with no obvious cause is a medical finding before it is a nasal one. Most follow surgery, injury or drug use and the cause is clear. Where it is not, the possibilities include systemic vasculitis, and that needs a blood test rather than a surgical opinion.

This guide covers what a perforated septum is, why it produces the symptoms it does, every significant cause, and what can honestly be achieved with a septal button or surgical repair. Where the septum is deviated rather than perforated, see deviated septum.

What Is a Septal Perforation?

The septum has three layers: cartilage or bone in the middle, with mucosal lining on each side. The lining supplies the cartilage with blood, and the cartilage has no independent supply of its own.

That arrangement explains almost every perforation. Damage the lining on both sides at the same point, and the cartilage between them dies — it has lost its blood supply from both directions. The dead cartilage is absorbed, and a hole remains.

This is why perforations are so strongly associated with surgery on both sides of the septum, with recreational drug use, and with anything else that injures both mucosal surfaces at once.

Why It Causes Symptoms

Air normally travels through the nose in a smooth, laminar stream, warming and humidifying as it goes. A hole disrupts that. Air crosses from one side to the other, breaks into turbulent eddies, and dries the lining at the edges of the perforation.

Dry lining crusts. Crusts are shed and bleed. The exposed edge dries again. That cycle sustains itself, and it explains why perforations tend to enlarge slowly over years rather than heal.

The whistling has the same origin — air forced through a small aperture at speed, exactly as with a whistle. Enlarge the hole and the whistle usually stops, which is why some people report the noise disappearing while other symptoms worsen.

Septal Perforation Symptoms

• Whistling on breathing — the most recognisable symptom, and typical of small perforations. Often the first thing noticed.
• Crusting inside the nose, persistent and recurring however often it is cleared.
• Recurrent nosebleeds, usually minor but frequent, from the dried edges.
• Nasal blockage — partly from crust, partly because turbulent airflow feels obstructed even when the airway is open.
• Dryness and discomfort, sometimes a persistent ache or pressure over the bridge.
• Foul-smelling discharge where crust becomes infected.
• Reduced sense of smell in some cases.
• A visible change in the nose — where a large perforation undermines support, the bridge can drop into a saddle nose deformity. This is uncommon but it is the reason large perforations are taken seriously.

Does size matter?

Yes, but not as people expect.

Small perforations, under 1cm, whistle most and are the easiest to repair surgically.

Medium, 1 to 2cm, tend to crust and bleed more than they whistle.

Large septal perforation, over 2cm, causes the most crusting, bleeding and dryness, rarely whistles, and is considerably harder to close — there is less surrounding tissue to bring across. Very large perforations also carry the risk of losing structural support.

Position matters too. Perforations towards the front of the nose cause more symptoms than those further back, because that is where airflow is fastest and where the lining is least able to cope with drying.

What Causes a Septal Perforation?

Previous nasal surgery

The commonest cause overall. Septoplasty, septorhinoplasty and turbinate surgery all carry a small risk, and the mechanism is always the same — tears in the lining on both sides at the same point. Careful repair of any tear at the time of surgery is what prevents it.

Recreational drug use

Intranasal stimulant use causes intense vasoconstriction, starving the septal lining and cartilage of blood. Repeated use produces perforation, and in advanced cases destruction extending beyond the septum — drug-induced midline destructive lesion.

Worth being straightforward about for one practical reason: surgical repair has a high failure rate if use continues, because grafted tissue placed into a nose still subject to vasoconstriction does not survive. Surgeons generally require a documented period of abstinence beforehand. That is a structural requirement, not a moral judgement.

Nose picking

A genuine and under-acknowledged cause, particularly in younger people. Repeated trauma to the same spot — usually Little’s area at the front of the septum, where the blood supply converges — ulcerates the lining. Once a small perforation forms, the crusting it causes prompts more picking, and the cycle sustains itself.

There is nothing embarrassing about this and it is worth mentioning at consultation, because stopping is the single most effective treatment.

Trauma

Nasal fracture, penetrating injury, or an untreated septal haematoma where blood collecting between the cartilage and its lining kills the cartilage. That last one is preventable if drained within days, which is why a nasal injury with complete one-sided blockage should be assessed urgently. See broken nose surgery.

Inflammatory and systemic disease

Granulomatosis with polyangiitis (formerly Wegener’s) is the important one. An autoimmune vasculitis that frequently presents in the nose before anywhere else, and which also affects the kidneys and lungs. Sarcoidosis, lupus and relapsing polychondritis can all do the same.

See a doctor promptly if a perforation has appeared without an obvious cause, particularly alongside blood in the urine, persistent cough or breathlessness, red painful ears, joint pain, unexplained fever or weight loss. Diagnosis usually begins with a blood test — ANCA antibodies, inflammatory markers, kidney function — which your GP can arrange.

Other causes

Nasal cautery for nosebleeds, especially if performed on both sides at once. Prolonged nasal packing. Chromium, nickel and other industrial dust exposure. Radiotherapy. Rarely, sinonasal malignancy — which is why an atypical or rapidly enlarging perforation is biopsied.

What about steroid nasal sprays?

Steroid sprays are frequently blamed and are an uncommon cause. Where it does happen, the mechanism is usually mechanical rather than pharmacological — the spray aimed straight at the septum, day after day, causing local irritation and ulceration.

The fix is technique, not stopping treatment: angle the spray outward, toward the ear on the same side, using the opposite hand. If you have been spraying straight up your nose, that is worth correcting regardless.

How It Is Diagnosed

Often visible on simple examination with a light, if the perforation is towards the front. Nasal endoscopy gives the full picture — exact size, position, whether the edges are healthy or actively inflamed, and how much septum remains.

Blood tests are performed wherever the cause is not clearly surgical or traumatic: ANCA, inflammatory markers, kidney function, and syphilis serology. Biopsy of the edge is taken where vasculitis or malignancy is suspected, or where the appearance is atypical.

Where an inflammatory cause is found, that takes priority. Repairing a perforation in a nose being actively destroyed by untreated disease will fail.

Treatment

Conservative management

For many people this is enough, and it should be tried first.

Regular saline irrigation and nasal moisturising gels or ointments keep the edges hydrated, which breaks the drying-crusting-bleeding cycle. Petroleum-based products are avoided in favour of water-based preparations. Humidifying the bedroom helps. Stopping whatever caused it — picking, recreational drug use, poor spray technique — is essential and often sufficient to stabilise things.

This will not close the hole. It frequently makes it asymptomatic, and an asymptomatic perforation needs nothing further.

Septal button

A soft silicone prosthesis shaped like two discs joined by a central stud, fitted through the nostril to plug the perforation from both sides. Placed under local anaesthetic in clinic, usually in a few minutes.

It stops whistling immediately, restores something close to normal airflow, and reduces crusting substantially. It is an excellent option where surgery is not appropriate, where the perforation is large, or where someone wants relief without an operation.

Its limitations are honest ones: it is a foreign body in the nose. Some people cannot tolerate it. It requires cleaning, and it can crust around the edges, dislodge or need replacing. It does not heal anything.

Surgical repair

Closure uses local mucosal flaps — tissue mobilised from within the nose and advanced across the hole from above and below — with an interposition graft placed between the two layers to provide a scaffold. Graft material is typically temporalis fascia, cartilage, or perichondrium.

Nearly always performed through an open approach for adequate access, under TIVA, taking two to four hours.

On success rates, the honest position: published closure rates vary widely and depend heavily on size, position, cause and whether the cause has been removed. Small anterior perforations in non-smokers with a clear cause do well. Large perforations, posterior ones, and those in continuing recreational drug users do considerably less well. Anyone quoting you a single reassuring percentage without knowing which category you are in is guessing.

Repair is generally not attempted where the perforation exceeds a certain size relative to the remaining septum, where the cause is still active, or where previous attempts have failed and there is insufficient tissue left.

Recovery

Splints are usually left for one to two weeks to protect the repair. Congestion and crusting throughout that period, and it feels worse before better. Desk work within a week to ten days. Nose-blowing, heavy lifting and strenuous exercise are restricted for several weeks, since raising pressure inside the nose can disrupt the repair. Saline irrigation continues for months.

NHS and Cost

Septal perforation causes functional problems rather than cosmetic ones, so NHS assessment and treatment are available through GP referral to ENT. Septal buttons are provided on the NHS. Surgical repair is available but is specialist work, and waiting times vary considerably by area.

Private cost depends on whether a button is fitted in clinic or surgical repair is required, on the size and complexity of the perforation, on the graft material needed, and on the anaesthetic. Your exact cost is confirmed in writing after in-person consultation and endoscopy. Finance is available through Chrysalis Finance, subject to status — see our finance options.

Septal Perforation FAQs

Nasal Assessment at Centre for Surgery

Assessment of a septal perforation covers four things: its size and position, the state of the edges, what caused it, and whether that cause is still active.

That third question determines everything. Where the cause is clear and has been removed, repair can be discussed. Where it is not clear, investigation comes first — a perforation is sometimes the first sign of a systemic condition, and finding that matters more than closing the hole.

We will tell you plainly where conservative management is likely to be enough, where a septal button is the more realistic option than surgery, and where repair carries a meaningful risk of failure. Our ENT surgeon and rhinologist leads nasal airway assessment, including patients whose original surgery was performed elsewhere.

All surgery is performed by GMC-registered surgeons at our own day-surgery facility at 95–97 Baker Street, Marylebone. We are regulated by the Care Quality Commission and rated Good overall. We recommend a two-week cooling-off period before any surgery is booked.

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Related Reading

• Deviated septum
• Septoplasty (deviated septum surgery)
• Saddle nose deformity
• Nasal synechiae (adhesions)
• Nasal turbinates
• Nasal valve collapse
• Nasal polyps
• Broken nose surgery
• Revision rhinoplasty
• Septorhinoplasty