Septal perforation
A septal perforation is a hole through the nasal septum — the cartilaginous and bony partition that divides the nasal cavity into right and left sides. The septum is composed of a cartilaginous framework covered on each side by a mucosal lining (mucoperichondrium). When both layers are disrupted at the same point, a through-and-through defect forms. Perforations range from a few millimetres in diameter to near-complete absence of the septum.
Septal perforations are uncommon but clinically significant. Their consequences depend on size and location — small anterior perforations are typically symptomatic and troublesome, while large posterior perforations are often asymptomatic. Management depends on the cause, the symptoms, and the size and characteristics of the defect.
Causes of Septal Perforation
The most common causes of acquired septal perforation include:
Symptoms
The symptoms of septal perforation depend primarily on the size and location of the defect. Small anterior perforations are typically the most symptomatic — they create turbulent airflow at the anterior nasal valve and cause crusting of the exposed edges. Large posterior perforations may be entirely asymptomatic and discovered incidentally on nasal endoscopy.
Common symptoms include:
- Crusting — dried secretions form on the edges of the perforation, causing nasal blockage and discomfort
- Epistaxis (nosebleeds) — crusts dislodge and cause bleeding from the raw perforation edges
- Whistling — turbulent airflow through a small perforation produces an audible whistle on breathing
- Nasal obstruction — disrupted airflow and crusting can cause significant perceived blockage despite a patent nasal passage
- Nasal discharge — blood-tinged or purulent, associated with crusting and secondary infection
- Saddle nose deformity — in large or progressive perforations where structural support is lost, the dorsum may collapse, producing the characteristic saddle-shaped nasal bridge
Assessment and Investigation
Assessment includes anterior rhinoscopy and nasal endoscopy to define the size, location, and edges of the perforation and to assess the remaining mucosal integrity. The nasal dorsum is examined for evidence of structural compromise. A thorough history is taken to identify the likely cause — particularly to identify any systemic inflammatory disease that may require concurrent treatment.
Where a systemic cause is suspected, blood tests including ANCA, ANA, ACE, and inflammatory markers are performed. Biopsy of the perforation edge may be required if granulomatous or neoplastic disease is on the differential.
It is important to identify and address any underlying cause before considering surgical repair — repairing a perforation in a patient with active granulomatosis with polyangiitis or ongoing cocaine use, for example, is likely to fail.
Management Options
Conservative management — moisturisation and crusting control
For patients with small, stable perforations whose primary symptom is crusting and minor bleeding, conservative management is appropriate. Regular saline nasal irrigation reduces crusting. Topical emollients — petroleum jelly, medical-grade nasal lubricants — applied to the perforation edges reduce drying and crusting. This does not close the perforation but significantly reduces symptoms in many patients.
Septal button (prosthetic obturator)
A septal button is a soft silicone prosthesis that sits in the perforation and occludes it. It is available in various sizes and can be fitted in the clinic. A well-fitting button eliminates the whistle, reduces crusting, and can substantially improve symptoms without surgery. Buttons are a good option for patients who are not surgical candidates, who have perforations too large for reliable surgical repair, or who wish to avoid surgery. They require regular cleaning and can dislodge. Tolerance varies.
Surgical repair
Surgical repair of a septal perforation is technically demanding and is considered one of the more difficult procedures in rhinology. Reported success rates in the literature range from 50% to 100% depending on technique, perforation size, and patient selection. There is no universally agreed gold standard approach — numerous flap techniques have been described, each with advantages and limitations.
Patient selection is the most important determinant of outcome. Surgery is most appropriate for symptomatic patients with adequate surrounding mucosal tissue, no active inflammatory disease, and no ongoing trauma or drug use. The underlying cause must be established and addressed before repair is attempted.
Anterior Ethmoidal Artery (AEA) Flap with Collagen Matrix — Dr Roth’s Preferred Technique
Dr Roth uses the anterior ethmoidal artery (AEA) pedicled flap with collagen matrix inlay as his primary technique for surgical repair of septal perforations. This approach was described by Castelnuovo et al. and has been reported by Cavada, Orgain, Alvarado, Sacks, and Harvey (American Journal of Rhinology & Allergy, 2019) — a series from the rhinology units at UNSW and Macquarie University, Sydney — to achieve 100% closure at both 21 and 90 days across perforations ranging from 0.3 to 3.5 cm.
The AEA flap is a pedicled mucosal flap based on the anterior ethmoidal artery’s septal branches, raised from the lateral nasal wall and floor. Its key advantages are robust vascularity from a named arterial pedicle and a wide angle of rotation that allows it to reach perforations across a range of sizes and anterior locations — including perforations close to the columella that would be difficult to reach with other flap designs. The ipsilateral side of the perforation is covered by the rotated flap; the contralateral side heals spontaneously or, preferably, is augmented with a free mucosal graft from the inferior turbinate tail to accelerate remucosalisation.
The procedure is performed endoscopically under general anaesthesia. The endoscopic approach eliminates external scarring, provides excellent visualisation of the perforation margins, and allows precise flap elevation and inset. Postoperative saline irrigation is commenced on day one. Most patients are reviewed at three to six weeks for silicone sheet removal and then again at three months.
The principal limitation of the AEA flap is that perforations exceeding 50% of the total septal area may not have sufficient ipsilateral mucosal tissue available for an adequately sized flap without undue tension. For very large defects, partial closure or symptom reduction rather than complete anatomical closure may be the realistic surgical goal, and this is discussed honestly at consultation.
Dr Roth’s Clinical Perspective
Septal perforations are one of the more challenging problems in nasal surgery. The first priority is always to establish the cause — a perforation without an obvious mechanical explanation warrants investigation for systemic inflammatory disease, and surgery into an active process will fail. Addressing the cause is not optional.
For many patients with small, stable perforations, the honest recommendation is conservative management — saline irrigation, topical emollients, and where necessary a septal button. The septal button is genuinely underused. It provides meaningful symptomatic relief for a significant proportion of patients and avoids operative risk entirely. I discuss it at every consultation for this problem.
Where surgical repair is appropriate, I use the anterior ethmoidal artery flap with collagen matrix inlay. The AEA flap has robust vascularity and a wide angle of rotation — it reaches anterior perforations reliably and handles larger defects better than many other described techniques. The key principle is that the flap must be sized generously so it lies without tension; closure under tension is a common reason for breakdown. The collagen matrix provides a scaffold on the contralateral side and a free mucosal graft accelerates remucosalisation significantly. Even so, this is not a simple procedure and patient selection remains the most important factor in a good outcome.
— Dr Jason Roth, MBBS, FRACS (ORL-HNS), IBCFPRS
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Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
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