What is a Perforated Septum?

Also known as septal perforation, a Perforated Septum is a hole in the septum, the cartilage which runs between the nostrils, dividing the nose into two chambers.

The septum is made from cartilage, bone, and soft tissue called mucosa, which lubricates and protects the inside of the nose from pathogens in the air. If a hole or tear develops in the septum, it weakens this structure and can cause a number of functional and aesthetic concerns.

While some people may have a Perforated Septum without experiencing any symptoms, for others, it can be a debilitating condition affecting confidence and quality of life. While the aesthetic effects on the nose may cause self-consciousness and a reluctance to participate in certain activities, breathing difficulties may affect comfort, sleep, and wider health and wellbeing.

If you are concerned about the impact of having a Perforated Septum, the best course of action is to speak with a Consultant ENT Surgeon with experience of treating septal perforation who can assess your condition and discuss treatment options.

Why Do We Have Two Nostrils?

We have two nostrils for a few interconnected anatomical and physiological reasons.

Having a septal perforation may counteract these natural benefits, affecting the function of the nose, resulting in negative impacts to health and quality of life.

What are the Symptoms of a Perforated Septum?

There are several Perforated Septum symptoms that it is important to be aware of if you believe you may be experiencing septal perforation. These are also the signs your surgeon will discuss with you as part of your assessment.

Typical perforated nasal septum symptoms include:

• Nasal obstruction
• Sleep disorders, such as snoring or sleep apnoea
• Dryness and crusting inside the nose
• Regular nosebleeds
• Persistently runny nose
• Dip in the bridge of the nose (known as Saddle Nose Deformity)
• Whistling sound when breathing through the nose

In some cases, you may be able to feel the septal perforation with your finger. However, it isn’t advisable to try feeling the perforation or to keep interfering with it, as this increases the risk of worsening the hole and introducing infection, which may result in additional complications.

What Causes a Perforated Septum?

There are several causes of perforated nasal septum. While in many cases, patients may be aware of what has led to their septal perforation, in other instances, the reason may not be immediately apparent.

The many causes of a perforated nasal septum typically stem from injuries and conditions that damage the blood vessels within the nose, particularly around the septum. This trauma restricts blood flow to the septum, resulting in the deterioration of the tissue, causing a hole to develop.

Septal perforation causes include:

Autoimmune Conditions

Autoimmune diseases are a group of conditions that involve atypical responses from an individual’s immune system, resulting in the body attacking healthy tissues and organs. This often causes chronic inflammation, which affects the blood vessels surrounding the septum, disrupting blood flow and causing the breakdown of the tissues.

• Granulomatosis with polyangiitis – As well as inflammation, this condition involves small masses forming in the blood vessels, resulting in additional damage
• Lupus – A septal perforation may result as a complication of advanced or unmanaged lupus
• Rheumatoid arthritis – Although rare, rheumatoid arthritis can cause inflammation within the nose, disrupting blood flow and leading to a Perforated Septum

Autoimmune diseases can be congenital (present from birth) or develop later in life. A Perforated Septum is usually a severe symptom of any autoimmune disease and may indicate your condition is not being managed effectively.

Drug Misuse

Drug misuse is one of the most common causes of septal perforation. Due to media coverage, a Perforated Septum caused by drug use is most often associated with illegal drugs, usually cocaine. However, excessive use of steroid nasal sprays and other medications applied directly into the nasal passages to treat sinus infections, allergies, and nasal irritation may also lead to nasal septum perforation.

If you have a Perforated Septum caused by drug misuse, your surgeon will need to be confident that you haven’t used the drug or medication for an extended period of time, and that you have strategies in place to ensure you don’t relapse. Performing Perforated Septum surgery without these guarantees may result in further damage to the septum, which is then more challenging to resolve.

Occupational Hazards

People who work in environments involving high levels of certain irritants are at a higher risk of developing a Perforated Septum, especially if the relevant safety procedures are not followed.

Irritants and chemicals, which are known to be a risk factor for septal perforation, include:

• Chrome plating
• Wood dust
• Nickel dust
• Cadmium
• Mercury fulminate
• Arsenic
• Cement dust

If you are regularly working with any of these substances, ensure your workplace is following the correct health and safety protocols to protect respiratory health and prevent nasal septal perforation.

Infections

Chronic or recurrent nasal and sinus infections (sinusitis), as well as wider spread infections such as Tuberculosis and Syphilis, can lead to septal perforation.

In the case of both Tuberculosis and Syphilis, nasal septal perforation is a rare and serious symptom which may not always be immediately connected to the infection. It is essential to take a thorough medical history in cases of septal perforation to ensure all options are considered.

While chronic sinusitis and nasal infections can lead to ongoing inflammation, resulting in a Perforated Septum, it is also essential to consider the effects of long-term medication use and the impact this may have had.

Injury

A broken nose or ongoing damage to the septum caused by nose picking can lead to a septal perforation. If the septum is already deviated and, therefore, weakened, additional injury is more likely to result in a perforation. Underlying conditions and previous trauma to the nose should always be considered when diagnosing a Perforated Septum to ensure that other septum concerns, such as misalignment, are also addressed.

Previous Surgery

Septal perforation is a complication that may arise from previous nose surgery, particularly functional procedures that address the septum, such as Septoplasty or Septorhinoplasty. This can be due to a poorly performed surgery or additional recovery concerns, including an abscess or a blood clot forming.

When an experienced Consultant Surgeon performs nose surgery, the risk of nasal septum perforation occurring is greatly reduced. In part, this demonstrates the importance of finding an experienced and qualified surgeon to perform any procedure, and also to avoid travelling abroad for surgery.

If your surgeon thinks that you may be at a higher risk of developing a septal perforation after any nose surgery, they will discuss this with you in depth during your initial consultation to ensure you are fully informed.

How to Treat a Perforated Septum

Perforated Septum treatment depends on the severity of the symptoms, the size of the perforation, and the impact on your nose’s structure and your quality of life.

Non-Surgical Perforated Septum Treatment

For mild cases of septal perforation, your consultant may suggest non-surgical treatments which can manage your symptoms and improve your comfort. In very mild cases, septal perforation may heal on its own, and non-surgical treatment may aid in this process. However, in most cases, to resolve septal perforation completely, further intervention is required.

Topical Medication

For patients experiencing crusting and dry skin due to a Perforated Septum, emollient lotions and ointments can be applied inside the nose to keep the skin moist and prevent the perforation from worsening.

In cases where the perforation has become infected, you may be prescribed an antibiotic cream to treat this, before switching to a non-medicated alternative.

Saline Rinses

Also known as nasal irrigation, saline rinses can be used to keep the tissues within the nose moist and lubricated, preventing the perforation from worsening.

It is important to emphasise that saline rinse products do not contain steroids or any other ingredients associated with Perforated Septum causes. Your consultant will recommend specific products which are safe to use.

Humidifier

In cases where applying topical medication or saline rinses directly into the nasal passages is not possible, or may exacerbate a perforated septum, your surgeon may recommend using a humidifier at home. This increases the moisture in the air and helps maintain the nose’s lubrication, without risking disturbance or irritation of the internal nasal tissues.

Perforated Septum Surgery

For patients whose perforated nasal septum symptoms are too severe to be managed with non-surgical treatments, or who wish to find a permanent solution, Perforated Septum surgery is often the most effective option.

Perforated Septum Surgery can be performed as a standalone procedure or may be combined with other surgical options, depending on the severity of the condition and the desired outcomes of the patient. If your Perforated Septum Surgery is a secondary procedure, it is essential that your surgeon has the full details of your initial procedure so they can address your concerns thoroughly.

Standalone Perforated Septum Surgery techniques include:

Silicone Prosthesis

Sometimes described as a prosthetic button, this involves a small piece of silicone being inserted into one or both sides of the perforation to fill the gap. This can either be a pre-made prosthetic or may be custom-made for your nose size and shape.

Typically, these prosthetics can be removed for cleaning purposes, but permanent options are also available. Your surgeon will discuss the available options with you and help you to decide which will be suitable for your concerns and lifestyle.

Cartilage Graft

In some cases, your surgeon may take a graft of cartilage from your ears or ribs, which is used to fill the perforation. With the correct aftercare, this provides a permanent solution. Due to the personal variations in septal perforation, the success rate of this procedure is around 85% and in large septal perforation cases, this may be lower.

Your surgeon will assess whether you are suitable for this treatment option during your consultation.

Silicone prosthetics and cartilage grafts may be performed as part of other nose surgeries to optimise the overall results:

Septoplasty

Septoplasty surgery addresses only concerns affecting the nasal septum, such as a deviated septum. Although in significant cases, this may result in the nose looking straighter from the outside, for most patients, the appearance of the nose won’t be affected.

Either a silicone prosthetic or a cartilage graft can be carried out alongside Septoplasty in the right circumstances. This results in improved nose function and addresses breathing difficulties, without dramatically changing the shape or size of the nose.

Septorhinoplasty

For patients who are looking for a comprehensive procedure addressing functional and aesthetic concerns, Septorhinoplasty is often the most suitable option. Septorhinoplasty involves operating on the internal and external nasal structures to improve breathing and function, as well as altering the size, shape and position of the nose.

Due to the nature of Septorhinoplasty surgery, a cartilage graft is often the more suitable Perforated Septum treatment to be performed alongside. Septorhinoplasty is also ideal for patients experiencing a Saddle Nose Deformity, where the bridge of the nose has collapsed due to the breakdown of the septum.

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