Septal perforation: what to do, in what order
The most common mistake is skipping steps: operating on inflamed mucosa, or choosing a surgeon before knowing what needs repairing. Here are the five steps experts recommend, from measurement to choosing a high-volume surgeon.
Written by the Septal Perforation team, patients, from the sources cited · Reviewed by doctors · Updated 1 November 2026 · Method and sources
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1
Get it measured and documented
Recorded endoscopy and a sinus CT. Insist on dimensions in the report: without a precise measurement, no surgeon can give you an honest prognosis. Ask for a copy of your records, including the CT images (DICOM) and the operative report from any previous surgery.
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2
Find and treat the cause
Blood tests and an autoimmune work-up if the cause is not obvious; complete stop of irritant sprays and any snorted drug. A perforation with an active cause will reopen.
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3
Local care and controlling the inflammation
Several months of daily care (see daily care) so the edges heal over with healthy mucosa. No good surgeon operates on inflamed, flaring mucosa: it is the most avoidable cause of failure.
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4
Decide: close, plug or soothe
If symptoms persist despite care, three routes: surgical closure, a septal button, or “perfoplasty” (smoothing the edges without closing). The cotton test, done by the ENT in clinic, helps predict whether closure will actually bring relief. A button is not the “risk-free” route: a permanent foreign body, it exposes you to infection and can enlarge the perforation (the risks in detail).
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5
Choose a true specialist, with high volume
This is the most important factor you can control. Most ENTs, including good rhinologists, very rarely operate on a perforation, one a year, sometimes fewer, whereas an expert centre closes dozens. A failed repair enlarges the hole and reduces the odds next time: do not hand this operation to someone “willing to give it a try”. Check the directory and ask about annual volume.
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