Your septal perforation repair questions answered

A septal perforation is a through-and-through hole in the nasal septum, the central partition of the nose.

“There are several potential causes of septal perforation,” explains ENT surgeon Mr Annakan Navaratnam. “The main cause is previous nasal surgery, but it can also result from chronic nose picking, nasal trauma, or incorrect use of nasal sprays, and then the last group are cocaine users.”

Typically, this is due to the adulterants that cocaine is cut with, particularly the anti-worming medication levamisole, which is estimated to be present in “80% of cocaine” in the UK.

Here, we answer some of the most frequently asked questions on septal perforation and your treatment options for septal perforation.

What are the signs I have a septal perforation?

Nasal perforation is a condition that isn’t always noticeable right away but can lead to uncomfortable symptoms if not addressed.

“If there is a very small perforation, you can get a whistling sound when you breathe through the nose, especially when it is blocked or congested. Patients often have a general feeling of congestion because the laminar airflow through the nose is increasingly disrupted, resulting in turbulence.

“The septal perforation becomes crusted, bloody, and occasionally infected with bacteria that further damages the mucosa and cartilage.

“If the hole gets large enough, it can lead to the collapse of the nose, which we call a saddle deformity. Or, in some cases, especially if it’s due to cocaine use, it can also erode the skin between the nostrils.”

Will a septal perforation continue to get worse?

A tiny nasal perforation may heal on its own. However, as the size of a hole in the septum increases, it’s unlikely that it will heal, and in many cases, it’s more likely to worsen, particularly if left untreated. “The crusting, infection, and bleeding can further damage the mucosa and cartilage, with the septal perforation slowly becoming larger, leading to potential collapse and worsening symptoms.”

How do nasal sprays damage the septum?

“Partly this is because patients can become addicted to them, but also if they are spraying towards the middle part of their nose. If this causes repeated bleeding, which is cauterised with silver nitrate, then this can damage the nasal septum, leading to a perforation.”

What are my treatment options for septal perforation?

It is important to remember that some perforated septums cause no problems and can be safely left alone or managed successfully with non-surgical measures.

“The first step is to work out the underlying cause. If it is cocaine-related, we must ensure you have stopped using, but we also need to make sure there is nothing else present. You can have autoimmune conditions that are secondary to some of the adulterants used as cutting agents.

“If there’s been no use of cocaine or any other adulterants for 12 months at a minimum, then you can consider having it repaired. During this time, we advise using nasal washes to clean the nose to ensure it’s healthy.

“Some patients use plastic septal buttons or sheets that fill or cover the perforation. But these can cause their own irritation because there’s a foreign body inside your nose.

“The surgical option is septal perforation repair, a complex procedure. I use various techniques to repair the hole, mainly mucosal tissue from the lining of your nose, which you can manipulate into a flap to cover the perforation.”

How successful is septal perforation repair?

“The success of the repair will depend on how healthy the surrounding tissue is, where the hole is located and how large the perforation is. It’s a very intricate surgery and requires creativity regarding where you source the tissue to reconstruct the septum, depending on where the defect is located.

“Very small perforations are easily closed, but it becomes much more challenging when they are much larger, above two centimetres. I will always be candid with patients about the potential success rate. There may be a residual hole, or I can make the hole smaller and less symptomatic. And sometimes a second stage operation is required.”

More questions about your treatment options for septal perforation? Call +44 (0)203 627 2918 or email secretary@annakan.co.uk to arrange a consultation with rhinoplasty surgeon Mr Annakan Navaratnam  at one of his London nose clinics.