A perforated septum, sometimes called a nasal septum hole or septal perforation, occurs when a gap forms in the thin wall of cartilage and bone that separates the two nasal passages. When a hole develops in the nasal septum, it can disrupt breathing, cause crusting or bleeding, and in some cases alter the external shape of the nose. The condition ranges from small, asymptomatic defects to large perforations that cause significant functional and cosmetic problems.
At Centre for Surgery in Baker Street, London, we provide expert diagnosis and advanced treatment for conditions affecting the nasal septum, including perforated nasal cartilage and complex nasal reconstruction. Our consultants are highly experienced in both aesthetic and functional nasal surgery and take a personalised approach to every case, from minor symptomatic management to major reconstructive procedures.
What is a Perforated Septum?
The nasal septum is a central wall made up of cartilage at the front and bone further back, lined on each side by a thin mucous membrane. This structure divides the nasal cavity into left and right sides, directing airflow and providing structural support to the nose. A septal perforation develops when both sides of this lining and the underlying cartilage are damaged simultaneously, forming a direct opening between the two nostrils.
The size of a nasal wall defect can range from a few millimetres — often producing a characteristic whistling sound during breathing — to several centimetres, which may result in significant nasal collapse and a visible change in the shape of the nose from the outside. Smaller perforations are often located anteriorly, towards the front of the septum, while larger ones may extend further back towards the bony portion.
Causes of a Perforated Septum
There are numerous possible causes of a nasal septum perforation, and establishing the underlying cause is an important part of selecting the most appropriate treatment.
Nasal trauma is one of the most common causes. A blow to the nose that disrupts the blood supply to the cartilage, or a septal haematoma — a collection of blood between the lining and the cartilage — that is not promptly drained can lead to cartilage death and subsequent perforation.
Previous nasal surgery, including septoplasty or rhinoplasty, can occasionally result in perforation when the lining is torn on both sides simultaneously during the procedure, removing the blood supply from a segment of cartilage. This is a recognised but uncommon complication of nasal surgery.
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Overuse of topical nasal sprays — particularly vasoconstrictors such as oxymetazoline — can impair blood flow to the septum over time, leading to ischaemic damage and eventually perforation. Intranasal drug use, most notably cocaine, is a well-recognised cause due to its direct vasoconstrictive and tissue-toxic effects.
Inflammatory and autoimmune conditions including granulomatosis with polyangiitis (formerly Wegener’s granulomatosis), sarcoidosis, lupus, and relapsing polychondritis can cause septal destruction as part of their systemic effects. Certain infections, including tuberculosis, syphilis, and fungal infections, may also cause perforation in some cases. Chronic exposure to irritating chemical fumes or dusts in certain occupational settings is an additional recognised risk factor.
Symptoms of a Perforated Septum
The symptoms of a perforated septum depend significantly on the size and location of the perforation. Small perforations located near the front of the septum often cause a high-pitched whistling sound when air passes through during breathing — this is sometimes the first sign that alerts patients to the problem. Nosebleeds are another common symptom, as the edges of the perforation are vulnerable to crusting and cracking, leading to bleeding particularly in dry environments or on waking in the morning.
Nasal crusting is a persistent complaint for many patients, as the turbulent airflow created by the perforation leads to drying and mucous accumulation around the edges of the defect. A sensation of nasal blockage, dryness, or congestion is also frequently reported, despite no structural obstruction being present. Some patients notice a reduced sense of smell as a result of the disrupted airflow patterns.
Larger nasal septum holes may cause more pronounced symptoms including discomfort, a persistent sense of something being wrong within the nose, and in advanced cases, changes in the external shape of the nose. When sufficient cartilage has been lost, the bridge of the nose may begin to sink inward — a condition known as a saddle nose deformity — which can become a significant cosmetic concern as well as a functional one.
Non-Surgical Treatment for a Perforated Septum
Not all septal perforations require surgical repair. When symptoms are mild and the underlying cause has been addressed, conservative management may be sufficient to keep the patient comfortable. Regular saline sprays or rinses help to maintain moisture within the nose, reduce crusting, and keep the edges of the perforation clean. Applying a thin layer of ointment or gel around the inside of the nose can also help protect the vulnerable tissue and reduce dryness. Using a humidifier in sleeping areas is often recommended, particularly during the winter months when indoor air tends to be drier.
A nasal septal button — a small silicone prosthesis designed to fit within and seal the perforation — is a non-surgical option for patients whose perforation is a suitable shape and size for this device. When properly fitted, a septal button can relieve whistling, significantly reduce crusting and bleeding, and restore a more normal pattern of nasal airflow almost immediately. It requires periodic removal and cleaning, and is not suitable for all perforations, but for the right patient it represents an effective and reversible management option.
Surgical Treatments for a Perforated Septum
Septal Perforation Repair
Surgical repair of a septal perforation aims to close the defect by reestablishing a continuous mucosal lining across the septum. The procedure involves delicately lifting the mucosal lining away from the edges of the perforation and carefully advancing or rotating local tissue flaps to cover both sides of the defect. A cartilage graft is often placed between the two layers to provide structural support and a scaffold for healing.
The surgical approach varies depending on the size and position of the perforation. Smaller, anteriorly located perforations can sometimes be repaired through the nostrils using a closed technique. Larger or more posterior perforations typically require an open rhinoplasty approach, where a small incision across the columella provides wider access to the internal structures of the nose. The success rate of perforation repair is influenced by the size of the defect, the quality of the remaining tissue, and whether any underlying inflammatory condition has been fully treated before surgery is attempted.
Septoplasty
Septoplasty is a surgical technique designed to straighten and stabilise the septum. In the context of a perforated septum, it may be performed concurrently with perforation repair to address any coexisting deviation or structural irregularity that could impair the outcome of the repair. When performed together with perforation repair, it ensures the septum heals evenly and that nasal breathing is fully restored across both sides of the nose.
Septorhinoplasty
When a nasal perforation has caused visible collapse or deformity of the bridge — particularly in cases of saddle nose deformity where the nasal dorsum has sunk due to loss of septal cartilage support — a septorhinoplasty may be recommended. This combined procedure addresses both the internal functional aspects of the septum and the external cosmetic concerns, using cartilage grafts to restore nasal height, projection, and structural integrity.
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Why Choose Centre for Surgery
At Centre for Surgery, we are leaders in nasal and facial plastic surgery, providing expert treatment for septal perforation and related nasal conditions using the most advanced reconstructive techniques available. Our consultants combine extensive surgical experience with a precise understanding of nasal anatomy, ensuring that every patient receives a treatment plan tailored to their specific perforation, symptoms, and goals. We offer a full continuum of care from initial assessment and conservative management through to complex surgical repair and long-term follow-up.
For expert advice or to book a consultation, contact Centre for Surgery, 95-97 Baker Street, London W1U 6RN.
Call 0207 993 4849 or email contact@centreforsurgery.com.
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