Septal perforation

Background: A hole in the septum. This can cause symptoms of nasal obstruction due to the inability to “feel” the airflow through nose or extensive nasal crusting that obstructs airflow. Recurrent small volume epistaxis may also occur. In severe cases it can alter the external shape of the nose due to loss of nasal support, called a “saddle nose” deformity which can be difficult to correct. Common causes include:

• Nose picking
• Missed septal haematoma
• Chronic nasal decongestant use
• Cocaine use
• Iatrogenic e.g. following septoplasty
• Granulomatosis with polyangiitis
• Rarely, malignancies can present with an erosive septal lesion. If nasal pain or neck lymphadenopathy, this should raise concerns

How to manage:

Advise the patient should avoid putting anything into their nose e.g. cotton buds, fingers etc

Avoid cocaine use

Avoid nasal decongestant use

Topical nasal saline rinses may help clear the crusting that occurs. Use of e.g. a “Neilmed bottle” available from pharmacy allows a higher volume to be used, compared to sterimar.

Topical nasal moisturiser with Vaseline or naseptin may reduce crusting

Occasionally a septal button can be inserted to cover the hole if the above measures do not help. This is a silicone sheet that can be inserted under local anaesthetic. It does not fix the hole but simply covers it. Whether this can be used depends on the size and location of the septal perforation. Surgical repair is occasionally an option but historically had low success rates and so is not performed routinely.

Referral guidance:

Most cases of septal perforation should be referred to ENT on a routine basis

If saddle nose deformity, refer to ENT on a urgent basis

If the mucosa appears unhealthy, refer to ENT as urgent, suspicion of cancer to exclude malignancy