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Nasal septal perforation

Nasal septal perforation is typically discovered on routine physical examination during evaluation of nasal symptoms including discharge, congestion, epistaxis, or characteristic nasal whistling sounds.
Look For First
  • Defect or hole in the nasal septum visible on anterior rhinoscopy or endoscopy
  • Location of perforation: anterior cartilaginous area (most common) versus posterior bony area (suggesting syphilis)
  • Size of defect and communication between bilateral nasal cavities
Key Image Findings
  • On CT: focal discontinuity in the nasal septal bone or cartilage with loss of normal septal contour, typically located anterior to the vomer in most cases
  • On MRI: T2 hyperintense defect within the septum with potential surrounding mucosal thickening or crusting, and intermediate signal from any exposed bone
  • Endoscopic appearance: visible hole or defect in the septum allowing visualization through to the opposite nasal cavity, often with crusted or granulating edges
  • Anterior perforations most commonly follow septoplasty or excessive cautery; posterior/bony perforations suggest granulomatous disease or syphilis
  • The perforation disrupts normal laminar airflow causing secondary symptoms and potential for mucus crusting within the defect
Differential Diagnosis
  • Septal hematoma following trauma: appears as fluid collection within the septum without full-thickness perforation; requires urgent drainage to prevent necrosis
  • Septal deviation: intact septum with asymmetric positioning, no actual defect or communication
  • Granulomatosis with polyangiitis: causes perforation but associated with systemic vasculitis findings; consider ANCA serology
  • Syphilis-related perforation: characteristically affects the bony posterior septum (palate/vomer) unlike common anterior iatrogenic perforations
  • Leprosy or tuberculosis: may cause septal perforation but accompanied by other mucosal involvement and constitutional symptoms
  • Malignant tumors (lymphoma, malignant granuloma): present with perforation but show mass effect and aggressive imaging features
Discussion

The vast majority of septal perforations are iatrogenic, occurring after septal surgery (especially Killian submucous resection) or from repeated cautery during epistaxis treatment.

Cocaine abuse (chronic use >3 months) and topical decongestants or corticosteroids can cause perforation through mucosal and perichondrial necrosis.

Loss of normal laminar airflow across a perforation paradoxically causes nasal congestion rather than relief, a counterintuitive clinical finding to remember.

Small anterior perforations may produce characteristic 'nasal whistling' as air turbulence occurs through the small defect.

The location of perforation provides diagnostic clues: anterior cartilaginous (most common, iatrogenic or trauma), posterior bony (syphilis, granulomatosis with polyangiitis).

Diagnosis is typically clinical via physical examination; imaging is primarily useful when etiology is unclear or malignancy is suspected.

Reporting Pearls

Report the location (anterior cartilaginous vs. posterior bony), size, and margins of the perforation clearly: for example, 'A 1.2 cm anterior septal cartilaginous perforation is present with intact margins' or note if the defect shows aggressive features, surrounding enhancement, or mass that would suggest an underlying malignant or inflammatory etiology requiring further clinical correlation.

Pitfalls
  • Mistaking a septal deviation for a perforation: deviation involves buckling or displacement of intact septum, not a through-and-through defect
  • Failing to recognize posterior bony perforations as a clue to syphilis or granulomatosis with polyangiitis rather than simple iatrogenic etiology
  • Overlooking aggressive imaging features (mass, enhancement, bone erosion) that suggest malignancy or infection rather than benign iatrogenic perforation
  • Assuming all septal perforations are symptomatic: asymptomatic perforations discovered incidentally do not always require intervention
Source: Reference source

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