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8 groups of causes

Septal perforation: definition and causes

Surgery, picking, cocaine, sprays, inflammatory disease, work: the same hole can have very different origins. Knowing which matters above all for one reason: treat the cause before closing, or the hole reopens.

Written by the Septal Perforation team, patients, from the sources cited · Reviewed by doctors · Updated 2 November 2026 · Method and sources

In the population
0.9–2%
of adults have a septal perforation, often without knowing it.
2026 international consensus; about one perforation in five causes no symptoms.

In brief

1

The 2026 consensus sorts causes into eight groups; nasal surgery and intranasal drugs are the most common.

2

Finding the cause is not a formality: an active disease, ongoing drug use or a badly aimed spray will make the repair fail.

3

The surgeon's questions and an endoscopy are often enough; blood tests, drug screening or biopsy are only needed when the cause is unclear or suspicious.

On this page Definition The 8 groups Finding the cause Treat first Questions Sources

What happens

The septum is cartilage then bone, covered with mucosa on both faces. Once it is perforated the two nasal cavities connect: air swirls instead of following its path, the mucosa dries and crusts form at the rim of the hole.

Intact septum turbinates septum The two nasal cavities stay separate Perforated septum perforation Air crosses from one cavity to the other
Schematic coronal section. The septum is cartilage then bone, covered with mucosa on both faces. Once it is perforated the two nasal cavities connect: air swirls instead of following its path, the mucosa dries and crusts form at the rim of the hole. That cycle is what makes perforations grow.

The eight groups of causes

The 2026 international consensus groups the known causes into eight families. Several can add up in the same person: an operated septum, a long-term spray and picked crusts, for example. The first four have their own detailed page. Whatever the cause, the first sign of a small perforation at the front is often a whistling nose.

1Most commonNasal surgerySeptoplasty, rhinoplasty, cautery: two tears in the lining facing each other, where cartilage was removed. It is usually spotted in the weeks that follow, when the splints come out.Read the page →2CommonIntranasal drugsCocaine above all: it narrows the blood vessels and starves the cartilage, line after line. Cutting agents such as levamisole make the damage worse.Read the page →3PreventableMedicationsSteroid sprays aimed at the septum, decongestants used for more than a few days. How you spray matters as much as what you spray.Read the page →4Trauma, compulsive pickingA blow with an undrained haematoma, or repeated picking of crusts in the same spot, which the consensus recognises as trauma in its own right. After a blow, a swollen, painful septum needs to be seen urgently: a haematoma drained in time usually prevents a perforation.Read the page →
5To rule outInflammatory diseasesGranulomatosis with polyangiitis, sarcoidosis, other vasculitides: looked for with a blood test. Other signs point that way: fatigue, joint pain, cough, blood in the urine.
6InfectionsSyphilis, tuberculosis, some fungal infections: rare, but not to be missed when the appearance is unusual. A swab or sample identifies them, and they are treated before any closure.
7Occupational exposureChromium or nickel fumes and dust in some industrial jobs: chrome plating, electroplating, tanning. Occupational health can help reduce exposure, and the condition may be recognised as work-related.
8Tumours, unknown causeVery rarely a tumour. Fairly often, no cause is found despite a full work-up: this is called an idiopathic perforation. The work-up is still worthwhile: it rules out the causes that would make a repair fail.

How the ENT surgeon finds the cause

The work-up follows a logical order. The first two steps are enough in most cases; the others are only requested if something does not fit, as the consensus recommends. Bring your operation notes and a list of your medications, sprays included: they save time.

  1. 1Your answersOperations, sprays, drug use, job, picking, other symptoms: the step that tells the most.
  2. 2EndoscopySize, position, healed or raw edges, crusts, exposed cartilage, state of the rest of the nose.
  3. 3CT scanPart of the first assessment according to the consensus: it shows size, position and remaining support. It does not reveal the cause, but it helps plan the repair.
  4. 4Blood testOnly if something looks suspicious or the cause remains unknown: screening for vasculitis.
  5. 5Drug screeningIf drug use is possible, before any surgery, most often with a urine test.
  6. 6BiopsyRarely useful; kept for atypical appearances, to rule out a tumour or an inflammatory disease.
Step 1 · Prepare: the questions your ENT surgeon will ask
  1. Have you had nasal surgery, and when? Do you still have the operation note?
  2. Do you use a nasal spray, which one, for how long, and how do you aim it?
  3. Have you ever snorted a substance, even occasionally?
  4. Does your job expose you to industrial fumes or dust?
  5. Do you pick at crusts, including at night or without thinking?
  6. Do you have other symptoms: joint pain, fatigue, cough, blood in your urine, a rash?

The golden rule

Treat the cause before closing the hole

A closure relies on living, well-supplied lining that is moved across the hole. Anything that keeps damaging the septum will damage the repair too. That is why the search for the cause comes before surgery, never after.

In practice: a vasculitis is brought into remission with medical treatment; cocaine is stopped, for at least six months to a year according to the experts; a spray is stopped or aimed better; crusts are cared for rather than pulled off; an exposed job calls for proper protection, or a change of role. See daily care.

Once the cause is under control and the lining has settled, repair can be considered with a team that closes perforations regularly: techniques, real success rates and directory.

Frequently asked questions

Does a perforation mean I have used cocaine?

No. Cocaine is one cause among eight groups. A perforation after surgery, sprays or picking looks exactly the same; only the work-up can tell.

Can a perforation have no cause?

Yes. Fairly often, no cause is found despite a full work-up. The 2026 consensus includes a category for these so-called idiopathic perforations, which can be repaired like the others.

Can picking really perforate the septum?

The consensus recognises compulsive picking as trauma to the septum, and 91.6% of the experts agree it enlarges an existing perforation. Caring for crusts so you no longer need to pull them off is the first step.

Sources

Every figure on this page comes from one of these publications. The year is the year of publication.

  1. 2026International consensus statement on nasal septal perforationAlobid I. et al., Rhinology · eight-category classification, House groups, recommended work-up, prevalence of 0.9 to 2.05%
  2. 2023Septal PerforationStatPearls, NCBI Bookshelf (NIH) · traumatic, autoimmune, infectious, neoplastic and drug-related causes

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