Perforated Septum: Symptoms, Types, Causes and Treatment

A perforated septum—a hole or defect in the nasal septum—can be an unexpected and sometimes distressing diagnosis. While many people are unaware they have this condition, others may experience a range of symptoms that impact their quality of life. Understanding the symptoms, types, causes, and available treatments is crucial for effective management and patient comfort. This comprehensive article explores all aspects of perforated septum, synthesizing insights from the latest clinical research.

Symptoms of Perforated Septum

When it comes to a perforated septum, symptoms can be as subtle as a faint whistle when you breathe or as severe as persistent nosebleeds and nasal discomfort. Not everyone with a septal perforation will notice symptoms—some cases are discovered incidentally during routine exams. For those who do experience symptoms, they can vary widely in nature and intensity.

Symptom	Description	Severity	Sources
Crusting	Formation of dry, thick nasal crusts	Mild-Severe	1 3 9
Bleeding	Frequent or recurrent nosebleeds	Mild-Severe	1 3 9
Stuffy Nose	Sensation of nasal blockage or congestion	Mild-Mod	1 2 3 9
Whistling	Audible sound during breathing, especially inspiration	Mild	3 9
Nasal Discharge	Persistent runny nose	Mild-Mod	3 6 9
Parosmia	Altered or reduced sense of smell	Mild	3
Neuralgia	Facial or nasal pain	Moderate	3
Saddle Nose	Collapse of nasal bridge (in large, chronic cases)	Severe	3 9

Table 1: Key Symptoms

Symptom Breakdown

Common and Subtle Presentations

• Crusting and Bleeding: The most frequently reported symptoms are the formation of crusts within the nose and intermittent to frequent nosebleeds. These occur due to the exposure of raw cartilage and bone along the perforation edge, which loses its normal mucosal protective covering 1 3.
• Stuffy Nose and Obstruction: Many patients describe a sensation of nasal stuffiness or blockage. This is usually due to disturbed airflow and reduced humidification inside the nasal cavity 2 3 9.
• Whistling Sound: Small perforations, especially those located toward the front (anterior) part of the septum, can cause a distinctive whistling noise during breathing 3 9.
• Nasal Discharge and Infection: Some individuals experience a persistent runny nose or recurrent infections as a result of impaired mucociliary clearance 3 6 9.

Less Common and Severe Manifestations

• Parosmia and Neuralgia: Some patients report changes in their sense of smell (parosmia) or even neuralgic pain in the nasal or facial region 3.
• Saddle Nose Deformity: In cases of large, long-standing perforations, especially those left untreated, structural support for the nasal bridge may be compromised, leading to visible collapse known as a “saddle nose” 3 9.

Symptom Assessment Tools

Validated clinical tools like the NOSE-Perf scale have been developed to systematically assess and track the severity of these symptoms, aiding both diagnosis and treatment planning 2 4.

Types of Perforated Septum

Just as symptoms can differ, so too can the nature of the perforation itself. Septal perforations are usually classified by their size, location, and underlying tissue involvement. These factors influence both symptoms and treatment choices.

Type	Defining Feature	Common Symptoms	Sources
Anterior	Front part of septum	More symptomatic: crusting, bleeding, whistling	3 6 9
Posterior	Back part of septum	Often asymptomatic or mild symptoms	3 9
Small	<1 cm diameter	Whistling, mild symptoms	3 9 12
Large	>1-2 cm diameter	Severe obstruction, saddle nose	3 9 12
Cartilaginous	Involves cartilage only	Varies	3 6 12
Osteocartilaginous	Involves cartilage and bone	More complex symptoms	6 12

Table 2: Types of Septal Perforation

Classification Details

By Location

• Anterior Perforations: These are located toward the front of the nasal septum and are generally more symptomatic because they disrupt the initial airflow and humidification. They tend to cause crusting, bleeding, and a whistling noise 3 6 9.
• Posterior Perforations: Situated toward the back, these are often less symptomatic. The airflow in this region is more humidified, and the turbinates help protect against drying and crusting 3 9.

By Size

• Small Perforations: Typically less than 1 cm in diameter, these may cause minimal symptoms, such as a whistling sound, or remain unnoticed 3 9 12.
• Large Perforations: Those measuring over 1–2 cm can cause significant airflow disturbances, leading to more severe symptoms and structural changes, such as saddle nose deformity 3 9 12.

By Depth and Tissue Involvement

• Cartilaginous Perforations: Affect only the cartilage of the septum. These are generally easier to manage surgically 3 6 12.
• Osteocartilaginous Perforations: Involve both cartilage and bone, making them more complex to repair and often associated with more pronounced symptoms 6 12.

Causes of Perforated Septum

Understanding what causes a septal perforation is essential—not only for treatment but also for prevention. The underlying cause can range from previous surgery to rare diseases, and sometimes multiple factors contribute.

Cause Category	Example/Description	Frequency	Sources
Iatrogenic	Surgery (septoplasty, rhinoplasty), nasal intubation	Most common	3 6 9 12
Trauma	Physical injury (accident, nose picking)	Common	6 9 10
Drug Exposure	Cocaine abuse, nasal decongestants, intranasal steroids	Common	8 9 10
Occupational	Toxic fumes/metals (e.g., welders, chromium)	Less common	7 9 10
Infections	Tuberculosis, syphilis, leprosy	Rare (developed countries)	10
Inflammatory	Granulomatosis with polyangiitis (Wegener’s), sarcoidosis	Rare	10
Neoplastic	Tumors (benign or malignant)	Rare	10
Idiopathic	No identifiable cause	Uncommon	3 9

Table 3: Major Causes of Septal Perforation

Detailed Exploration of Causes

Iatrogenic and Traumatic Causes

• Surgical Causes: The most frequent cause is previous nasal surgery (septoplasty or rhinoplasty), where mucosal injury on both sides of the septum can lead to perforation, especially if mucosal flaps are inadvertently damaged 3 6 9 12.
• Trauma: Physical trauma—either accidental (such as a blow to the nose) or self-inflicted (nose picking)—can also result in perforation 6 9 10.

Drug-Related and Medication-Induced

• Cocaine Abuse: Chronic intranasal cocaine use is notorious for causing septal perforations due to its vasoconstrictive and tissue-destructive properties 9 10.
• Nasal Decongestants and Steroids: Prolonged use of topical nasal sprays, especially steroids, has been increasingly recognized as a risk factor, particularly in young women and during the first year of use 8 9 10.
• Other Drugs: Overuse of other nasal medications can also contribute 9 10.

Occupational and Environmental Exposures

• Industrial Chemicals and Metals: Chronic exposure to certain occupational hazards such as hexavalent chromium (notably in welders) can damage nasal tissues and cause perforation 7 9 10.
• Toxic Gases: Long-term exposure to harmful gases in industrial settings is another risk factor 10.

Infectious and Inflammatory Diseases

• Infections: Rare in developed countries, but diseases like tuberculosis, syphilis, and leprosy can erode the septum 10.
• Autoimmune and Granulomatous Conditions: Disorders such as granulomatosis with polyangiitis (Wegener’s) and sarcoidosis can also cause septal destruction 10.

Neoplastic and Idiopathic

• Tumors: Malignant or benign nasal tumors are rare causes 10.
• Idiopathic: Occasionally, no cause is identified despite thorough investigation 3 9.

Importance of Diagnosis

A careful patient history, examination, and sometimes lab tests (such as ANCA for autoimmune disease) are crucial to identify the underlying cause and rule out serious conditions 10.

Treatment of Perforated Septum

Treatment options for septal perforation depend on the size, location, symptoms, and underlying cause. Management ranges from conservative therapies aimed at symptom control to complex surgical repairs for definitive closure.

Treatment Type	Description/Examples	Indication	Sources
Conservative	Saline irrigation, ointments, emollients, nasal hygiene	Mild or asymptomatic cases	1 3 9
Prosthesis	Septal button (silicone/plastic device)	Non-surgical candidates or temporary relief	9 11
Surgical Repair	Mucosal flaps, grafts, crossover techniques	Symptomatic or large perforations	3 11 12 13
Endoscopic Approach	Minimally invasive flap/graft techniques	Selected cases	3 13
Open Approach	External rhinoplasty, midfacial degloving	Complex/large defects	11 13
Medical Treatment	Topical steroids, antibiotics (for infection)	Adjunctive or supportive care	3 9

Table 4: Treatment Options for Septal Perforation

Deeper Dive into Treatment Approaches

Conservative Management

• Nasal Hygiene: The first line for mild or asymptomatic cases includes saline irrigations, topical antibiotic or lubricant ointments, and regular nasal cleaning to reduce crusting and bleeding 1 3 9.
• Topical Steroids: Can help reduce inflammation and promote mucosal healing, though care must be taken to avoid overuse, which can itself be a risk factor 3 9.
• Prosthetic Devices: For those not suitable for surgery or seeking temporary relief, a septal button or plug can help restore nasal airflow and reduce symptoms 9 11.

Surgical Treatments

• Mucosal Flap Techniques: Various surgical techniques use local tissue (mucosal flaps) to cover the perforation. The endoscopic crossover flap uses bilaterally raised mucosal flaps to achieve closure with good outcomes in selected patients 3 11 13.
• Interposition Grafts: Often, a graft (from the patient’s own tissue or synthetic materials) is placed between the flaps to improve healing and success rates. Materials include temporalis fascia, cartilage, or dermal grafts 11 13.
• Approach Selection: Endoscopic (closed) approaches are preferred for small-to-moderate perforations, while open techniques or combined approaches are reserved for large or complex defects 11 12 13.
• Postoperative Care: Nasal packing, splints, regular saline irrigations, and close follow-up are essential for surgical success 3 9.

Outcomes and Considerations

• Success Rates: Surgical closure rates vary depending on technique and patient factors, but interposition grafts generally lead to higher success compared to flaps alone 11 13.
• Patient Selection: Not all perforations require surgery. The decision depends on symptom severity, perforation characteristics, and patient preference 3 9 12.

Conclusion

A perforated septum can range from a silent anatomical curiosity to a source of significant discomfort and nasal dysfunction. Understanding its symptoms, classification, causes, and treatment options empowers patients and clinicians alike to make informed choices for optimal care.

Key Takeaways:

• Symptoms vary widely; many patients are asymptomatic, while others experience crusting, bleeding, obstruction, and even nasal deformity.
• Types of perforations are classified by location, size, and tissue involvement, each with different clinical implications.
• Causes are diverse, with prior nasal surgery, trauma, drug use, and occupational exposures being most common.
• Treatment is individualized: conservative management is often sufficient for mild cases, while surgical repair is reserved for symptomatic or large perforations.
• Advances in surgical techniques, combined with validated symptom assessment tools, are improving patient outcomes and satisfaction.

If you suspect a perforated septum or are experiencing persistent nasal symptoms, consult with an otolaryngologist for proper diagnosis and personalized management.