The nasal septum is the thin vertical wall that separates the right nasal airway from the left nasal airway. A septal perforation is a hole through the septum. A septal perforation may sometimes cause no symptoms, but often will cause nasal crusting, bleeding, whistling, a sense of nasal blockage, and if the perforation is very large, a dip in the nasal profile (saddle-nose deformity).
What can cause a septal perforation?
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Trauma: a septal perforation can be caused following an injury to the nose, or by repetitive nose picking.
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Cocaine: recreational use of cocaine causes inflammation and reduced blood supply to the nasal septum. Regular use can cause the septum to break down completely, leading to a perforation.
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Surgery: rarely, poor healing after surgery on the nose and septum can lead to a perforation.
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Inflammatory disease: the commonest medical cause of a septal perforation is granulomatosis with polyangiitis (GPA), which is a form of vasculitis.
How can septal perforations be treated?
Septal perforations that cause no symptoms do not usually require any treatment. If a perforation causes mild symptoms such as crusting, it can be treated with regular nasal irrigation (washing with salty water).
However if a perforation is causing severe symptoms that do not respond to medical treatment, there are two main options:
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Insertion of a septal button. These are specially designed pieces of silicone that are custom-sized and fixed inside the nasal cavity in such a way that blocks the perforation. This makes the air-flow through the nose more uniform and prevents whistling and crusting. The insertion is relatively straightforward and can often be performed under local anaesthetic.
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Surgical perforation repair. This procedure aims to repair the perforation using the patient's own tissue. The procedure is relatively complex, and the chances of success are higher the smaller the perforation. The procedure should be individualised to the patient.