Nasal Septal Perforations

Picture can be found at this wonderful repository of ENT pictures, a site run by Bechara Y. Ghorayeb, MD an Houston otolaryngologist.

What you can see is the nostril on the right side being propped open with a nasal speculum. The hole is clearly visible because a light is being shone into the left nostril making the normal portion of the septum look bright red, much like when you hold a flashlight up to your finger. The hole is visible where the light shows through. I suspect this perforation is just under a centimeter in size.

If they remain small, you may never know that you have one, but if they get to be much more than a few milimeters (like the one in the picture) they can cause several symptoms:

1 – whistling when you breathe–they can act like a hole in a whistle

2 – crusting–holes tend to cause air flow in the nose to be turbulent which tends to have a drying effect leading to crusting of normal nasal mucus

3 – bleeding–excessive dryness can cause the mucus membrane lining of the nose to crack like dry skin on your hands. The difference is that the mucus membrane is tremendously thinner and the blood vessels much closer to the surface so that when the membrane cracks, the underlying blood vessels may open as well leading to epistaxis (nasal bleeding).

4 – nasal obstruction–any thing that disrupts the smooth movement of air flow through the nose will give you a sensation of nasal obstruction even if no actual obstruction exists. For example, when air passess over a perforation, it will start to swirl and become turbulent. This will then feel like there is a blockage when one isn’t in fact present.

5 – nasal collapse–a perforation can become large enough that it weakens the support of the nose along the bridge so that the outside of the nose appears to cave in. This is known as a saddle nose deformity.

There are many potential causes of septal perforations, but few occur for unknown reasons. If one is present, to help ensure that there is no threatening cause, it is appropriate to get a thorough work up with your physician. The following chart tries to categorize some of the various causes of perforations.

Treatment for septal perforations can consist of surgical repair. However, if the perforation is too big, reconstruction becomes difficult. This Houston area surgeon has a nice video showing the perforation in a cartoon fashion and briefly discusses the surgical closure. Another, less-invasive option, is to place a septal button. This is basically a soft rubber covering for the hole. It sits in the perforation and covers each side potentially eliminating all of the symptoms above without the need for extensive surgery.

Before embarking on a treatment course, it is important to have a thorough work up as to the cause if it is not easily identified to make sure that significant underlying health problems are not present.

–Richard D. Thrasher III, MD