A nasal septal perforation is a hole through the wall dividing your two nasal passages. Both linings and the cartilage or bone between them have been lost, leaving a direct opening from one side of the nose to the other.
People usually find out in one of two ways: a doctor mentions it in passing during an examination for something else, or they notice a whistle when they breathe.
The first question almost everyone asks me is whether it is dangerous. For the perforation itself, generally no. You can live with one indefinitely and many people do, some without symptoms at all. But the cause can matter a great deal, and that is the part that needs proper attention rather than reassurance.
The treatment options run from simple moisturising care, which is often enough on its own, through a removable silicone septal button, to formal surgical repair. Which of those is sensible depends on the size of the hole, where it sits, and why it happened. All three are covered below.
What are the symptoms of a septal perforation?
Air is meant to move through your nose in smooth, laminar flow. A hole in the septum disrupts that, creating turbulence at its edges. Nearly every symptom follows from this.
Whistling. Characteristic of small perforations, particularly those towards the front. Air accelerating through a small opening produces the noise. Larger holes tend not to whistle, because the airflow is not forced through a narrow gap.
Crusting. Turbulent air dries the exposed edges, the lining forms crust to protect itself, the crust falls away or is picked off, the raw edge dries again. This cycle is the most persistent and most irritating symptom, and it is what brings most people to clinic.
Bleeding. From those raw edges. Usually minor and recurrent rather than dramatic.
A blocked feeling, which surprises people, since there is now a bigger opening than before. It happens because the sensation of a clear nose depends on smooth airflow over the lining, not on the size of the hole. Turbulence reads as blockage.
Pain or pressure across the bridge, less commonly, and usually with larger perforations.
Perforations at the front cause the most symptoms. Ones further back are often silent, because airflow there is slower and better humidified already.
What causes a hole in the septum?
Previous septal surgery. The commonest cause. Around one percent of septoplasties result in a perforation, usually where the lining was torn on both sides at the same point during the operation.
Nose picking. Genuinely a leading cause, and not something to be embarrassed about mentioning. Repeated trauma to the same spot at the front of the septum, often combined with dryness.
Cocaine. It constricts the blood vessels supplying the septum. Repeated use starves the cartilage, which dies and disappears. Cocaine-related perforations tend to be large, to enlarge over time, and to carry a real risk of the bridge collapsing into a saddle nose.
Steroid nasal sprays aimed at the septum. This is avoidable and worth knowing. The spray should point outwards, towards the cheekbone on the same side, using the opposite hand. Directed straight up the middle it hits the same spot on the septum every day, causing crusting, bleeding and occasionally perforation.
Decongestant sprays used month after month. Oxymetazoline and xylometazoline are meant for a few days. Beyond about a week they cause rebound congestion, and prolonged use is associated with damage to the septal lining.
Vasculitis and inflammatory disease, particularly granulomatosis with polyangiitis. Also sarcoidosis and, rarely, lupus.
Infection, including tuberculosis and syphilis, uncommon but not extinct.
Trauma, including untreated septal haematoma after an injury, where a collection of blood strips the cartilage of its blood supply.
Nasal cautery performed on both sides at the same site.
Chemical and occupational exposure. Chrome plating is the classic industrial cause, and a working history is worth taking in anyone whose job involves inhaled dust or fumes.
Malignancy, rarely. A tumour of the nasal septum can erode through it. This is uncommon, but it is why an unhealthy-looking or ulcerated lining, persistent pain, or a lump in the neck should lead to urgent head and neck assessment rather than watchful waiting.
And in a proportion of people no cause is ever found, however thoroughly you look.
How is a septal perforation diagnosed?
By looking, mostly. I examine the inside of the nose, usually with a nasal endoscope, which shows the perforation directly along with the state of its edges and the surrounding lining. That single examination answers most of the questions that matter: how big the hole is, where it sits, whether the edges look healthy or suspicious, and what else is going on in the nose alongside it.
A scan is not routinely needed. The diagnosis is clinical, and in a straightforward case blood tests and a biopsy give far more useful information than imaging. A scan earns its place when there is associated sinus disease, when a tumour has to be excluded, or when planning complex reconstruction.
What examination cannot do is tell you why the hole is there. That needs the next step.
Why the cause has to be established
Because some of them are dangerous in ways the hole itself is not.
Granulomatosis with polyangiitis is a systemic vasculitis that also affects the kidneys and lungs. The nose is frequently where it shows up first. Missing it means missing a serious, treatable disease at the point where treatment works best.
So anybody presenting with a perforation without an obvious explanation should have blood tests, including ANCA, inflammatory markers and kidney function, and usually a biopsy of the perforation edge. The biopsy does two jobs: it looks for inflammatory disease, and it excludes a tumour. That second job is the reason I am unapologetic about taking one when the edge looks wrong.
If there is any suggestion of active inflammatory disease, that must be treated and controlled before any surgical repair, because operating on actively inflamed tissue fails and can make the perforation larger.
Ongoing cocaine use is the same principle. Repair will not hold while the cause continues.
How long can you live with a perforated septum?
Indefinitely. It is not a life-limiting condition and it does not become one.
The two things to watch are enlargement and bridge support. A perforation that is growing suggests the underlying cause is still active. And a very large perforation, particularly one extending upwards towards the bridge, can remove enough structural support for the nose to sink, producing a saddle nose deformity. That is a reason to have it monitored rather than ignored, and a reason to identify the cause early.
Does the size of the perforation matter?
Two things decide most of what follows: how big the hole is, and where it sits.
A common way to group them is small for under 0.5 cm, medium for 0.5 to 2 cm, and large for anything over 2 cm. There is no formal staging system, but the categories map onto what is realistic. Small and medium anterior perforations are the ones that close reliably. Large septal perforations, particularly those with little septum remaining above them, are a different operation with a different conversation attached.
So I measure the diameter, the position, and the height of healthy septum above the hole, because that lining is what any repair has to borrow from.
How is a septal perforation treated?
Conservative management first, and it is often enough.
Large-volume saline rinses several times a day. A greasy ointment such as Vaseline or a nasal gel applied to the edges to keep them moist. A humidifier in the bedroom. Stopping whatever caused it, whether that is a misdirected spray, picking, or cocaine.
A surprising number of people become largely asymptomatic on this alone. It is unglamorous and it works.
A septal button. A soft silicone device shaped like a collar stud, fitted through the hole to plug it and restore laminar airflow. It can often be placed in clinic under local anaesthetic. It stops the whistling immediately and reduces crusting substantially. Some people wear one for years very happily. Others find it collects crust around the rim and prefer not to. It can be removed if you dislike it, which makes it a low-risk thing to try before committing to surgery.
Surgical repair. The definitive option, and the honest position is that it is technically demanding and success depends heavily on size.
Small and moderate perforations at the front have good closure rates in experienced hands. Large perforations and those extending high towards the bridge are considerably harder, and closure rates fall. Perforations caused by ongoing cocaine use or uncontrolled vasculitis should not be repaired at all until the cause is controlled.
I would rather tell you honestly that a repair has a moderate chance of success than promise closure and deliver a recurrence.
What the operation actually involves
Many different repair techniques have been described, which tells you something useful: none of them works for every case.
What they share is three layers. Lining is brought across from each side to meet in the middle, and a graft of connective tissue is placed between the two so the repair has something to heal onto instead of two raw flaps facing each other. The lining is usually advanced from the floor and side wall of the nose as a flap. Where there is not enough available, a flap based on the inferior turbinate can be used instead. Graft material is your own tissue: septal cartilage or bone if any remains, cartilage or perichondrium from the ear, or temporalis fascia taken through a small incision in the hair above the ear.
The approach can be endonasal, working entirely through the nostrils, or open, through the same small incision across the columella used in open rhinoplasty. Open access is chosen where visibility and suture control matter more than avoiding a scar, which in practice means larger and higher perforations.
If the septum is also deviated, that is corrected at the same time. Nasal obstruction in someone with a perforation is often multifactorial, coming partly from a residual deviation or from turbinate hypertrophy, and closing the hole alone would leave that part of it untouched.
Recovery after septal perforation repair
Most repairs are day cases under general anaesthetic. An overnight stay is occasionally required if bleeding or your general health makes it sensible.
Soft silicone splints are stitched inside the nose to hold the repair flat while it heals, and they stay in longer than after a straightforward septoplasty before being removed in clinic. Until they come out the nose feels blocked and you breathe through your mouth. That part is genuinely unpleasant and entirely temporary.
No nose blowing at all in the early weeks, and avoid heavy lifting and strenuous exercise until around week six, as after septoplasty. Saline is used from early on to keep crusts off the healing lining. Most patients are back at a desk job inside two weeks.
Healing is slow to declare itself and the final results are not clear at the first review. If a repair is going to fail it usually does so in the first few months rather than years later, so the early appointments are the ones that matter.
What can go wrong
Being straight about complications matters more here than in most nasal procedures, because the main one is the problem you arrived with.
The perforation may not close, or may close and then re-open. Bleeding, infection, and adhesions between the septum and the side wall are the usual surgical risks. Smell is often dulled while everything is swollen and returns as that settles. With large perforations there is a further consideration: the repair borrows lining from high up on the septum, and in a nose where bridge support is already marginal that is not a free move. It is one more reason to take large perforations slowly rather than book them quickly.
None of this is a reason to avoid surgery when it is the right operation. It is a reason to have the conversation properly first.
How much does septal perforation repair cost?
Perforation repair is complex reconstructive surgery and the price depends on the size, the approach, and which graft material is needed, so I quote it individually after assessment rather than from a list. Consultation is £250, credited towards surgery if you go ahead. A septal button is a much smaller undertaking and correspondingly less expensive. My published fees for standard nasal surgery are on my pricing page, and you will always have a written quotation before committing to anything.
Where a perforation follows previous surgery or an inflammatory condition, some policies will cover repair. That depends on your insurer and the documented indication.
Frequently asked questions
Can a septal perforation heal on its own?
Very rarely. Once both linings are lost the edges epithelialise and the hole becomes permanent. Symptoms can settle even though the hole remains.
Is a hole in the septum dangerous?
The hole itself is not. The cause can be, which is why unexplained perforations need blood tests and often a biopsy.
How do I stop the crusting?
Frequent saline rinses, a moisturising ointment on the edges, and bedroom humidification. A septal button helps considerably in many people.
Can a nasal spray cause a perforation?
Steroid sprays repeatedly aimed at the septum can, which is why technique matters. Aim outwards towards the cheekbone, never up the middle.
Will my nose collapse?
Only with large perforations that remove significant structural support, particularly those extending towards the bridge. It is a reason for review rather than alarm.
Is septal button fitting painful?
Not usually. It is generally done under local anaesthetic in clinic and takes a few minutes.
How successful is surgical repair?
Good for small and moderate anterior perforations in experienced hands, and less reliable for large ones. Any surgeon should give you a size-specific answer rather than a general one.
Is septal perforation repair done under general anaesthetic?
A surgical repair is, and it is a longer procedure than most people expect. A septal button is different: it can usually be fitted under local anaesthetic in clinic in a few minutes.
Is there a size that is too big to repair?
No absolute cut-off exists and I am wary of surgeons who quote one. Above about 2 cm the odds fall and keep falling, and the very largest defeat most techniques. At that point the honest options include a well-fitted button, accepting the perforation with good medical management, or reconstruction in a unit with real experience of it. All three are legitimate.
Can I fly with a perforated septum?
Yes. Cabin dryness may worsen crusting, so use saline and ointment generously during the flight.
If you have been told you have a hole in your septum and nobody has explained why, that is worth pursuing. You can book a consultation, and I will examine it, measure it, and arrange the tests needed to establish the cause before discussing any repair.
Mr David Whitehead is a Consultant ENT and Facial Plastic Surgeon in London, on the GMC Specialist Register for Otolaryngology and certified by the Royal College of Surgeons Intercollegiate Board in Cosmetic Surgery. More about my training and credentials.