Septal Perforation Facts
A septal perforation, also referred to as a perforated septum, is a “hole” in the nasal septum and is considered a very complex problem. The nasal septum is the tissue that separates the nose into two distinct sides. The nasal septum is a partition in the nasal cavity, which allows proper flow of air through the nasal passageways. If the septum is perforated, the airflow can be turbulent or obstructed causing difficulty breathing, crusting, and other symptoms. It’s important to note that the perforation is located in the cartilaginous and/or bony portion of the septum. It is not just a single-layered hole—hence the complexity of the condition. It is actually a three-layered “through and through” hole, which makes correction of the problem tricky. The perforation violates all three tissue layers, including the right and left mucoperichondrium and the intervening septal cartilage or bone.
Causes of Septal Perforation
A hole or perforation of your nasal septum can occur as an unwanted result of previous nasal surgery, a chemical insult to the membranes, or from a nasal fracture or other nose injury. The long term use of certain steroid or other nose sprays has even been linked to this problem. The septum and its covering layers are delicate and can be easily injured.
The most common causes for septal perforations to occur are listed below:
- Previous nasal surgery procedures: Unfortunately, many perforations occur after septoplasty and rhinoplasty operations. Also, damage to the septum can follow sinus surgery and from cauterizing of the septum for nose bleeds. These cases are quite challenging when most of the normal septal cartilage has been removed.
- Cocaine Use: Even a one-time use of cocaine in the nose can cause a hole in the septum. Street cocaine is rarely pure and is often cut with abrasive and irritating substances, such as talc or borax, which, when combined with the cocaine eats right through the septal membrane and cartilage. Cocaine itself has extreme vasoconstrictive effects causing decreased blood supply. Chronic cocaine use is worse and can totally destroy the inside of the nose, leading to infections, extreme scarring and total nasal collapse. In the case of complete destruction of the septum and nasal collapse, these cases may not be repairable.
- Trauma: A new or previous nasal fracture due to an accident or sports injury can cause a perforation. Often, these perforations may go unnoticed until symptoms occur and the hole has enlarged.
- Infection: Perforations that are initially small can enlarge due to continued inflammation or infections.
- Prolonged use of nasal steroids or decongestants: Some steroid nasal sprays can be very irritating to the septal mucosa when used on a long-term basis and can lead to perforation.
- Excessive, long term nose picking
- Autoimmune conditions: Some systemic diseases can predispose to septal perforation including, renal disease, vasculitides, and collagen vascular disorders, such as lupus, rheumatoid arthritis, and polychondritis.
Symptoms of a Perforated Septum
When a septal perforation is present, a patient can have any number of uncomfortable and irritating symptoms that make daily life more challenging. This can be represented by one, or a combination, of the symptoms listed below that can be extremely time consuming, annoying and in some cases, so debilitating that it necessitates lifestyle changes.
- Nasal crusting: When the edges of the hole are open, crusts form and enlarge as one breathes, requiring daily nasal irrigations and frequent visits to the doctor remove crusting. Sometime the crusts will cause a foul odor that others around can easily discern. When crusts fill the nose, the patient’s sense of smell is decreased as well.
- Nasal bleeding: The raw edges of the perforation can bleed spontaneously at the most unwanted times. If frequent enough, blood loss may be significant. Bleeding, when it stops, forms scabs and crusts which then clog the nasal airway.
- Whistling: When the perforation is small the airflow through the nose can cause a whistling sound, which can be quite embarrassing and constant.
- Breathing difficulty: Sometimes a larger perforation disrupts the normal nasal cycle and airflow giving patients a feeling that their noses aren’t working well. Usually when the septal wall is repaired normal breathing returns as long as the internal scarring has not been excessive.
- Runny Nose: Rhinorrhea is the medical term that describes a nose that runs. When you have a perforated septum, the abnormal airflow can dry out the internal membranes. Your nose responds by generating secretions to try to keep it moist and so the nose drips or runs.
Surgical treatment, known as septal perforation repair, is indicated if symptoms are chronic and effect the patient’s quality of life. Surgery is also recommended if the patient has not responded well to nonsurgical treatments.
If a patient has a septal perforation but no symptoms, surgical repair may not be necessary. Some patients, with holes in their septum that are posteriorly located deep in the nose do not even know they have a perforation, don’t need to do anything.
But, as the perforation enlarges or if the perforation is located closer to the front of the nose, symptoms increase and become more bothersome. When the patient has not responded well to non-surgical approaches, surgery is often indicated.
Dr. Kridel believes patients do much better long-term with permanent repairs with surgery rather than constant irrigations or septal buttons, because a surgical solution is more apt to return normal nasal function and be hassle-free.
Learn more about the surgical process and Dr. Kridel’s unique approach
* All information subject to change. Images may contain models.