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What Is A Nasal Septal Perforation?

The nasal septum is the wall that divides your nose into left and right nasal airway passages. The nasal septum is made up of cartilage and thin bone which is covered on both sides by a thin layer of soft tissue. You can feel the nasal septum as the middle structure when you pinch the tip of your nose. A nasal septal perforation is a hole through the nasal septum. The hole may range in size depending on the cause of the perforation. The following illustrates the causes, symptoms, and ultimate treatments for a nasal septal perforation repair when necessary.

Nasal Septal Perforation Repair Graphic


What Are The Symptoms Of A Septal Perforation?

Septal perforations cause disruption in how air moves through the nasal passages, making airflow more turbulent and less smooth. The air passes from one side to the other of the nose instead of straight back into the airway. As a result, having a septal perforation may cause you to experience some if not all of the following symptoms:

  • Bleeding: The turbulent airflow causes the inner lining of the nose to become dry. As a result, the lining may form scabs and crusts that when dislodged can cause bleeding. The bleeding is usually temporary but may require minor procedures to prevent further episodes of bleeding.
  • Crusting: The exposed edges of the hole in the septum prevent the delicate lining of the septum from staying moist as well as preventing humidification of the air that is inhaled. As a result, crusts and scabs form along the septal perforation and may form in other parts of the nose. This crusting can progress and cause difficulty breathing. Scabs and crusts may also cause the remaining nasal septum to become infected, requiring antibiotic treatments. Nasal crusting is usually prevented with humidifiers and nasal irrigation. However, if crusting is significant it may require a physician to remove.
  • Nasal Obstruction: Large nasal perforations may give the sensation of not being able to breathe properly. This is because the sensors in the nose that detect air movement may be missing. You may be breathing properly, but it feels like you are obstructed. Large crusts may also block one or both sides of the nose.
  • Whistling: Small perforations, especially near the nostrils, may be bothersome as they can cause a whistling noise from the nose. This is because air can move between either side of the perforation at a higher speed than other parts of the nose. As a result, a high pitched whistling noise forms.
  • Nasal Collapse: A large septal perforation can decrease support of the outside of the nose and cause the nose to collapse. This “saddling” is dramatic externally and will usually block the upper nasal airway.


Causes Of A Septal Perforation

Nasal septal perforations are caused by disruption of blood flow to the nasal septum. Because the nasal septum has a delicate blood supply, any factor that decreases this blood flow may result in a septal perforation. Some of the most common causes of septal perforations include:

  • Surgery: Nasal surgery can cause significant disruption of the blood flow to the septum as the tissues inside the nose are manipulated decreasing blood flow. A tear in the nasal septum mucosa on both sides will prevent blood flow to the cartilage and a hole may be formed. The risk of septal perforation increases if there is a previous history of nasal surgery.

Sinus CSF Leak


  • Cocaine: Long-term cocaine use is a significant risk factor for developing a nasal septal perforation. Cocaine causes the blood vessels inside the nose to shrink. The more cocaine used over a period of time, the more the vessels shrink. If the vessels decrease in size enough, it may cause a hole to form.
  • Infection: Infection may result in what is called tissue necrosis, a term used to refer to tissue death. Such infections may result in a collection of pus in the septum. As the pus collects, it may compromise the vascular blood flow to the septum.
  • Medical Conditions: Some medical conditions may cause nasal septal perforations. More specifically, autoimmune conditions such as Wegener’s disease and Sarcoidosis may result in diseased blood vessels, especially in the nose. It is an important consideration for your doctor to make sure that an undiagnosed illness is not recognized. Individuals with septal perforations without an obvious cause should have an autoimmune workup.
  • Self-manipulation: Excessive scratching inside the nose can create a hole in the septum. Using instruments in the nose like Q-tips or bobby pins can traumatize the soft tissue and disrupt the nasal septum blood supply.
  • Trauma: Trauma to the nose may result in blood collection in the septum, known as a hematoma. As the hematoma expands it disrupts the blood flow which can lead to a septal perforation.
  • Nasal Medications: Long-term use of nasal sprays such as steroids or over the counter nasal sprays may also decrease the size of the blood vessels along the septum leading to perforation.

Because of the complex and potentially interconnected causes of a nasal septal perforation, it is important to speak with a specialist.

How Can Dr. Mourad Help With Septal Perforations?

Dr. Mourad is an Otolaryngologist and Facial Plastic Surgeon with extensive experience in all sizes of septal perforation repair. After a thorough history and examination, you will learn how big your perforation is and what options for closure exist. We will check your medical benefits to let you know what to expect so there are no surprises. If you think we can help please give our office a call.

Meet Moustafa Mourad, MD, FACS

Moustafa Mourad, MD, FACS is board-certified in head and neck surgery and highly-trained in cosmetic plastic surgery and facial reconstruction. Dr. Mourad is also a Fellow of the American College of Surgeons. He treats many conditions, both cosmetic and complex, that affect the head, neck... Learn More »

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