Septal perforation: causes and endoscopic repair

Op. Dr. Erdal Erkoç · Last updated: October 15, 2026

A septal perforation is a hole in the septum, the middle wall that separates the two nasal cavities. It can cause nasal obstruction, crusting, bleeding, dryness and a whistling sound when breathing. Some small holes cause no symptoms at all. When a perforation causes symptoms, non-surgical measures such as saline sprays and gels, nasal moisturizers and silicone septal buttons can help. Closing the hole requires surgery. In suitable patients, Op. Dr. Erdal Erkoç closes the hole endoscopically, without opening the nose, using a mucosal flap that keeps its own blood supply.

In brief

Topic	Details
Reason for surgery	Septal perforation that causes symptoms
Common causes	Previous nasal surgery, trauma, cocaine, autoimmune diseases
Surgical techniques	Local flaps, grafts, regional flaps, open repair; closed endoscopic repair in suitable patients
Recovery	Return to work usually in 1-2 weeks; full healing takes weeks to months
Success rate	Reported range 50-90%; depends on the size of the hole, the technique and the surgeon’s experience
Non-surgical options	Saline sprays and gels, nasal moisturizers, silicone septal buttons

What causes a septal perforation?

The hole usually opens after the nasal lining has been damaged. Common causes include:

• Previous nasal surgery (especially septoplasty or rhinoplasty)
• Trauma (nose picking, accidents)
• Infections
• Cocaine use
• Autoimmune diseases (such as Wegener’s granulomatosis or lupus)
• Long-term use of nasal sprays or steroids
• Chronic inflammation
• Rarely, cancers or other systemic diseases

What symptoms does it cause?

Some people have no symptoms. When symptoms do occur, they depend on the size and location of the hole and may include:

• Nasal obstruction
• Whistling sound when breathing
• Nosebleeds, including recurrent bleeding
• Crusting and dryness
• Bad smell
• Recurrent infections
• Pain or discomfort inside the nose
• Collapse of the nose’s shape in large perforations

Some small holes stay silent for years. In most cases, however, disturbed airflow and chronic inflammation of the lining make symptoms worse over time. Early diagnosis and treatment can prevent the hole from growing.

How is it diagnosed?

The size, location and cause of the hole are determined during the examination. Nasal endoscopy is the basis of the assessment. In some patients, blood tests and imaging are needed to rule out systemic inflammatory diseases or other factors that contribute to the problem.

What can be done without surgery?

If surgery is not suitable or the patient does not want it:

• Saline sprays or gels keep the nose moist and reduce crusting.
• Nasal moisturizers, such as petroleum jelly or antibiotic ointments, are applied inside the nose.
• Silicone septal buttons plug the hole and block airflow through it, which relieves symptoms. This is a temporary solution.

When is surgery needed?

Surgery is usually considered when:

• Symptoms do not go away
• The hole is getting larger
• Non-surgical methods have not been enough
• There is an aesthetic concern

The aim of surgery is to restore the integrity of the septum and to correct nasal function and the patient’s comfort. The choice of technique depends on the size of the hole, tissue quality, previous operations and whether there are other shape problems in the nose.

What are the surgical methods?

In modern techniques, the mucosal flaps are carefully lifted and the hole is closed with surrounding tissue, connective tissue grafts, cartilage grafts or, when needed, biological materials. A successful repair requires the blood supply of the mucosa to be preserved and the septal framework to be carefully rebuilt.

1. Local tissue flaps

The surrounding nasal lining is used to close the hole. This method works better for small and medium-sized perforations.

2. Interposition grafts

A graft (cartilage, fascia or synthetic material) is placed between the flaps to provide support and help healing. Cartilage can be taken from the nasal septum (if enough is available), from the ear (conchal cartilage) or from a rib.

3. Regional flaps

For larger perforations, tissue from a nearby area, such as the inside of the cheek, can be moved through a tunnel to the site of the hole.

4. Open (external) approach

If enough view cannot be obtained from inside the nose, an open rhinoplasty approach may be needed.

How is endoscopic repair performed?

Op. Dr. Erdal Erkoç closes perforations of about 1 cm, carefully selected, with a mucosal flap based on the anterior ethmoidal artery. The operation is performed through a completely closed endoscopic approach, with no skin incision and without opening the nose.

Steps:

1. The edges of the hole and the surrounding lining are assessed with an endoscope.
2. Scar tissue is released while healthy, well-supplied mucosa is preserved. The tissues regain their mobility.
3. The flap is lifted while its vascular pedicle is protected, then rotated to cover the hole without excessive tension.
4. Depending on the features of the hole, additional support grafts are used if needed to strengthen the repair.

Every stage is performed under high-definition endoscopic vision. This protects the healthy structures around the hole and keeps trauma to neighboring nasal structures to a minimum. Because there is no external incision, the surgical trauma is also reduced.

Why is this flap preferred?

Healing depends on blood flow to the tissue during recovery. Free grafts have to wait for new blood vessels to grow into them. A mucosal flap that is moved on its own vascular pedicle stays supplied with blood from the moment it is placed. This reduces tissue death (necrosis) and crusting after surgery, helps the mucosa join, and increases the chance that the hole closes permanently. It also reduces tension at the repair site.

Who is a suitable candidate?

Patient selection is one of the most important factors in success. In suitable patients with a perforation of about 1 cm, this method, performed with careful technique, can achieve very high closure rates. Small holes generally have a much higher chance of complete healing than large ones. Previous operations, tissue quality and individual anatomy always affect the outcome. Whether this method suits you is decided during a detailed examination before surgery.

Why is this surgery difficult?

Closing a septal perforation is considered one of the most technically demanding operations in nasal surgery. In a narrow space, the surgeon has to rebuild two separate mucosal surfaces while protecting their delicate blood supply. Scar tissue from earlier operations limits tissue movement and lowers the quality of the mucosa available for repair. Excessive tension, poor blood supply, ongoing inflammation or trauma after surgery can cause the wound to open and the hole to form again.

For this reason, the operation should be performed by surgeons experienced in advanced endoscopic nasal surgery and complex septal reconstruction. Surgeons need to know the blood vessel anatomy inside the nose, flap design, wound healing and revision surgery. Op. Dr. Erdal Erkoç plans each patient’s treatment individually, aiming for both nasal function and structural stability, using his experience in functional rhinoplasty and septal reconstruction.

What are the risks?

• The hole does not close completely
• The hole opens again (recurrence)
• Infection, or the graft does not take
• Nasal obstruction
• Prolonged crusting or bleeding
• Change in the appearance of the nose (rare)

Even a very well-performed operation cannot completely rule out the hole opening again, because healing depends on many biological and patient-related factors. Poor blood supply, excessive crusting, infection, repeated nasal trauma, insufficient moisture and impaired wound healing can all contribute to failure. Earlier nasal surgery, chronic inflammation, autoimmune disease and poor tissue quality make repair harder. The reported success rate is between 50% and 90%, depending on the size of the hole, the technique and the surgeon’s experience.

Why do smoking, alcohol and drug use matter?

Healing depends on blood circulation in the small vessels after surgery. Smoking narrows blood vessels, reduces the oxygen reaching the tissue, slows the renewal of the mucosa and impairs collagen formation. Vaping and e-cigarettes are not a safe alternative: nicotine and the other inhaled chemicals also impair circulation and damage the regenerating lining. Excessive alcohol and drug use increase inflammation, weaken immunity and reduce adherence to aftercare. Continuing any of these after surgery greatly increases the chance that the repair fails and the hole opens again. Avoiding these substances completely is a basic requirement for healing.

How does recovery go?

• Day surgery or a short hospital stay
• A septal splint (silicone) or packing may be placed for support
• Return to work usually in 1-2 weeks
• Full healing can take weeks to months, depending on the size of the hole and the type of graft
• Regular check-ups are essential

Aftercare determines the result as much as the operation itself. To reduce crusting and support the renewal of the mucosa, saline rinses and moisturizing treatments are continued regularly as recommended by the surgeon. During healing, avoid blows to the nose, forceful nose blowing, heavy physical effort and touching the healing septum. Planned endoscopic check-ups catch crusting, local inflammation or healing problems before they grow. Most patients’ symptoms gradually decrease during healing. When the recommendations are followed, the chances of permanent closure and the return of normal nasal function increase considerably.

Written and reviewed by Op. Dr. Erdal Erkoç, ENT surgeon · Last reviewed: 15 October 2026