A perforated septum is a hole through the septum, the wall of cartilage and bone that divides the left and right sides of the nose. It can follow nasal surgery, injury, repeated picking, drug use, some nasal sprays or inflammatory conditions. Small perforations may cause no symptoms, while larger ones can cause whistling, crusting, nosebleeds and, occasionally, collapse of the bridge. Treatment ranges from simple moisturising care to a silicone button or surgical repair.
How the septum works
The septum supports the lower two-thirds of the nose and helps direct airflow. Its cartilage has no blood supply of its own and relies on the thin lining (mucosa) covering both sides. If that lining is damaged on both sides at the same point, the cartilage beneath can die and a hole forms. Because the front of the septum carries much of the nose’s structural support, a perforation here is more likely to cause symptoms and changes in shape than one further back.
Common causes
- Previous surgery: septoplasty, rhinoplasty or cautery for nosebleeds can occasionally lead to a perforation.
- Trauma: a broken nose, or an untreated septal haematoma (a collection of blood between the lining and the cartilage).
- Nose picking: repeated minor injury to the front of the septum.
- Cocaine use: the drug constricts blood vessels and is a well-recognised cause of septal damage.
- Nasal sprays: long-term or incorrect use of some steroid or decongestant sprays, particularly when aimed at the septum.
- Medical conditions: certain autoimmune and inflammatory diseases, and some infections.
In some people no clear cause is found, which is why an assessment is important.
Symptoms to look out for
Many small perforations are found by chance. When symptoms occur they include a whistling sound when breathing through the nose, crusting and dryness, a sensation of blockage, recurrent nosebleeds and an unpleasant smell. Larger perforations near the front can weaken support, causing the lower bridge to sink and giving a saddle-nose appearance. The edges of the hole are fragile, and crusting often forms there, which can make the nose feel blocked even though the hole itself lets air through.
Diagnosis and when to see a GP
See your GP if you notice whistling, persistent crusting, frequent nosebleeds or any change in the shape of your nose. You are likely to be referred to an ear, nose and throat (ENT) specialist, who can examine the inside of the nose with a small camera and measure the hole. Blood tests or a biopsy of the edge may be arranged to look for an underlying inflammatory condition, especially if there is no history of surgery or injury. After a nasal injury, a painful, rapidly increasing blockage of both nostrils needs same-day assessment, as a septal haematoma should be drained promptly to prevent perforation.
Non-surgical treatment
The first step is to remove or stop the cause wherever possible. Regular saline rinses and a nasal ointment or moisturiser applied to the edges can reduce crusting and bleeding, and a humidifier may help at night. For persistent symptoms, a soft silicone septal button can be fitted to close the hole. Buttons can relieve whistling and crusting for many people, but they need cleaning and some find them uncomfortable.
Surgical repair
Surgical closure of a perforation is specialised work, usually undertaken by ENT or facial plastic surgeons with a particular interest in the septum. It involves moving flaps of lining from inside the nose to cover the hole, often with a graft sandwiched between them. Success depends on the size and position of the hole, the health of the surrounding tissue and whether the cause has been removed. Very large perforations may not be suitable for closure.
Perforation and rhinoplasty
If the septum has lost support and the bridge has collapsed, rebuilding the shape of the nose may be considered once the underlying cause is controlled and the lining is healthy. This can require cartilage from the ear or rib. Mr Nassab will ask about previous surgery, injury and drug or spray use, examine the nose, and advise on onward ENT referral where closure of the perforation itself is needed. Surgery with active cocaine use carries a high risk of failure and further damage. Rhinoplasty costs from £8,950 and complex reconstruction is quoted at consultation. The £150 consultation fee is separate.
Frequently Asked Questions
Can a perforated septum heal on its own?
No. Once a hole has formed it does not close by itself, although symptoms can often be controlled with moisturising care or a septal button.
Is a perforated septum dangerous?
It is not usually dangerous, but it can cause bleeding, crusting and changes in nose shape, and occasionally points to an underlying condition that needs treatment.
Why does my nose whistle?
Whistling is a classic sign of a small perforation towards the front of the septum. An ENT examination can confirm it.
Can a perforation be repaired during rhinoplasty?
Sometimes, but closure is specialised and depends on the hole’s size and cause. Mr Nassab will advise whether referral to an ENT surgeon is the best route.
