International consensus statement on nasal septal perforation: the essentials
In 2026, 25 specialists from 15 countries agreed for the first time on how to assess, classify and treat a perforation of the septum. Here are their statements in plain English, each linked to the page of this site that covers it in detail.
Written by the Septal Perforation team, patients, from the sources cited · Reviewed by doctors · Updated 2 November 2026 · Method and sources
In brief
The 2026 consensus is the first shared framework for septal perforation: 25 experts, three voting rounds, 56 statements adopted.
It asks for symptoms to be measured with validated tools, the hole to be classified by size and position, and medical treatment to come first, with exceptions.
It also sets rules for surgery and follow-up: lining on both sides, splints, no intranasal drugs before closure, and results judged at six months at the earliest.
How it was built
Until now, every team assessed and operated on perforations in its own way, which made results impossible to compare. An international panel therefore voted on each statement, anonymously and over several rounds (the Delphi method): a statement was only kept with at least 70% agreement. Several panel members appear in our directory.
The recommendations in six steps
The consensus follows a patient's journey, from the first appointment to the check-up after surgery. Click a step to go to its detail.
Assess: symptoms, examination, tests
First rule, adopted at 100%: determine whether the perforation causes symptoms. About one in five causes none and does not necessarily need treatment. To measure how much it bothers you, the consensus uses two tools: the NOSE-perf questionnaire, scored out of 48, where an improvement of 4.85 points after surgery is considered a real difference, and a visual scale from 0 to 10.
Visual severity scale used by the consensus, from 0 to 10. Our self-assessment gives you a score to show your ENT surgeon.
Understand: how a hole forms, and where it comes from
The consensus adopts Lanier's four-stage model: the lining is damaged on the surface, loses its blood supply, ulcerates, and then the septum perforates. Crusting and drying keep the cycle going. Picking is not a compulsory stage, but 91.6% of the experts recognise it as a factor that enlarges an existing perforation.
Perforations after surgery follow a different path: they result directly from tears facing each other in both linings, where cartilage was removed. Causes are grouped into eight categories, detailed on the page Causes: surgery, trauma and picking, drugs, medications, inflammatory diseases, infections, tumours, occupational exposure, plus perforations with no cause found.
This three-group classification, proposed by House and highlighted by the consensus, helps predict how difficult the repair will be.
Classify: size and position
The experts recommend measuring the perforation with a small surgical ruler under an endoscope and, on CT, its front-to-back length and its height. They adopt the Davis classification, the most widely used:
Size by greatest length. A height of 1.5 cm or more also makes a perforation large: beyond that, advancement flaps fail more often.
Position matters as much as size. A perforation is called anterior when its back edge lies in front of a line drawn from the incisive canal, behind the front teeth, to the root of the nose. Anterior perforations are generally more troublesome, and the distinction guides the choice of technique.
Should top and bottom be distinguished too? The experts see value for the surgeon, but no consensus on its importance for symptoms. Sizes and positions are covered in detail on Understand.
Treat without surgery first, with exceptions
Medical treatment should be offered before surgery, even though it does not close the hole: its aim is to relieve dryness, crusting and bleeding. The experts acknowledge that many patients end up preferring an operation.
- 1Saline rinsesSoften and clear crusts several times a day.
- 2Ointments and gelsProtect the edges; an antibiotic ointment only if there is an associated infection.
- 3Humidified airA humidifier at night reduces drying.
- 4Hands offDo not pick or pull off crusts: that is what enlarges the hole.
The three cases for offering surgery straight away
Younger patients, exposed cartilage at the edge of the hole, and whistling. In these situations, waiting for local care to fail makes no sense. See Whistling nose.
The septal button, a silicone plug, is not a first-line treatment: it is reserved for patients who cannot or do not want to have surgery. See The septal button and Daily care.
Operate: what the experts agree on
Surgery is the definitive treatment. Published series often report over 90% closure, but anonymous surveys of surgeons give 31 to 84%: the consensus attributes this to the complexity of the procedure and to publication bias. Hence the importance of looking at real rates and choosing an experienced team.
The techniques mentioned are described one by one in Closure techniques. The consensus also mentions techniques that relieve symptoms without closing, such as perfoplasty and posterior septectomy.
Judge the result: at six months, on two levels
The result cannot be judged before six months. A hole still open before then is a failure; a hole that reopens after closure was confirmed at six months is a "reperforation". Above all, the consensus separates two kinds of success: closure, which the surgeon sees, and relief, which the patient feels.
The four possible outcomes at six months according to the consensus. To track quality of life: NOSE-perf, the visual scale and, as a complement, the SNOT-22 questionnaire for emotional impact. See After the operation.
Still debated
Where the experts did not agree
Top or bottom. Distinguishing a high from a low perforation matters to the surgeon, but no cut-off or relevance to symptoms reached consensus.
How long off drugs. 52% of the experts ask for at least 12 months, 36% for 6 to 12 months.
Splints and aftercare. Splint duration ranges from a few days to a month; whether early cleaning is needed is still debated.
Swelling. Swollen lining matters when planning surgery, but its value in predicting the result is not established.
Frequently asked questions
Who wrote it?
A panel of rhinologists and nasal surgeons led by Professor Isam Alobid (Barcelona), with Professor Richard Harvey (Sydney) and Professor Claire Hopkins (London) as senior authors. Several members repair perforations and appear in our directory.
Does my ENT surgeon have to follow it?
No, it is not a law. It is an expert reference that lets you ask precise questions: your symptom score, the size and position of the hole, the planned technique, and when the result will be judged.
Where can I read the original?
In the journal Rhinology, under the title "International consensus statement on nasal septal perforation", DOI 10.4193/Rhin26.027. This page summarises the essentials.
Sources
Every figure on this page comes from one of these publications. The year is the year of publication.
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