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Septal perforation: symptoms and measurement

A septal perforation is an opening right through the nasal septum, connecting the two nasal cavities; repairing it is complex because it has to be closed on both sides with living, well-vascularised mucosa. Symptoms, size, position, growth and tests, based on the 2026 international consensus.

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

On this page Symptoms Size Position Growth Tests Warning signs Questions Empty nose

Symptoms

8 in 10
perforations cause symptoms
Crusting and drynessOften the main complaint
BleedingRepeated, at the rim of the perforation
WhistlingWhen breathing, mostly with a small perforation
Paradoxical blockageFeeling of blockage, burning, pain
Reduced smellMild to moderate loss
Daily lifeSleep, work and mood, sometimes disabling

How it is measured

Nasal endoscopy (front-to-back diameter) and a sinus CT scan, which shows position, size and remaining cartilage. Size classification adopted by the consensus:

1Nasal endoscopy
length and height, in millimetres
2Sinus CT scan
position, size, remaining cartilage
Small
< 1 cm
Medium
1 to 2 cm
Large
2 to 3 cm
Subtotal
≥ 3 cm
1.5 cm
Height counts for moreFrom 1.5 cm high, a perforation is classed as large, even if narrow: height is what makes closure difficult.

Where the hole is, and why it matters

Position matters as much as size. Air entering the nose hits the front of the septum first: that is where most perforations form, and where they cause the most trouble.

Side view of the septum
cartilage bone front 123
  1. 1At the frontThe most common, in the cartilage. Cold, dry air hits the edges directly: dryness, crusting, bleeding, and whistling when the hole is small.
  2. 2At the backIn the bony part, it can be less symptomatic: air arrives already warmed and humidified, and it is sometimes found by chance. This is the idea behind perfoplasty, which enlarges the hole backwards to calm the turbulence.
  3. 3High up, towards the bridgeIt can weaken the support of the nose. A nose that starts to sag (saddle nose) needs prompt medical advice.

Will it get bigger?

Nobody can predict it in advance. Many perforations stay stable for years; others enlarge, especially when the cause is still active or the edges stay dry and raw.

What makes them grow

crusts pulled offpickingdrynessa poorly fitted septal buttoncocainedecongestant or steroid spraysuntreated inflammatory disease

How to tell

have the perforation measured at every check-up, with the same method (endoscopy, in millimetres, length and height), and keep the reports. Without written measurements, there is nothing to compare.

The tests to ask for

  1. 1Always
    Nasal endoscopyIdeally recorded, with the perforation’s dimensions in millimetres (length and height) and its position.
  2. 2Always
    A sinus CT scanIt shows how much septum is left and the state of the sinuses, two things that guide the choice of closure technique.
  3. 3If needed
    Blood testsIf the cause is not obvious: inflammatory markers, ANCA (to look for granulomatosis with polyangiitis), serology.
  4. 4If needed
    A biopsyOnly if the edges look abnormal or a disease is suspected; it is not routine.

Report promptly

Signs that call for a search for a general disease

A perforation with no nasal surgery and no obvious cause can reveal an inflammatory disease, such as granulomatosis with polyangiitis (formerly Wegener’s) or sarcoidosis. These diseases are treatable, but must be controlled before any surgery. See your doctor promptly if you also have:

  • !Very heavy, bloody crusting that keeps coming back
  • !Sinusitis, ear infections or hearing loss
  • !A lasting cough, blood in your sputum or breathlessness
  • !Blood in your urine
  • !Fever, severe fatigue or weight loss
  • !A nose that starts to sag

Take to your appointment

Questions to ask your ENT

  1. What are the exact dimensions of my perforation, and where is it?
  2. What is the likely cause, and do we need tests to check it?
  3. Is it stable? Can you measure it at every check-up?
  4. Which local care do you recommend, and what should I avoid?
  5. Can it be repaired, and which surgeon who closes them regularly can you refer me to?

Perforation and empty nose

When the turbinates were affected too

Many perforations come from surgery that also reduced the turbinates, the structures that warm and humidify the air. When too much is missing, the nose becomes paradoxically too open: you breathe deeply without feeling that you are breathing, with dryness, burning and disturbed sleep. That is empty nose syndrome, distinct from a perforation but often present in the same patients.

The distinction matters when deciding: closing the perforation does not rebuild missing turbinates, and some symptoms can persist after a successful closure. It matters for the technique too: if your turbinates have already been reduced, have that history noted in your file and ask the surgeon which technique they propose in this context, as some harvest from the turbinates or the inferior meatus.

One practical point, often missed: the devices some empty-nose patients place in the nostril to redirect airflow, cotton or a prosthesis, are dangerous when a perforation is present. The material can lodge in the hole or damage its edges, and enlarge it.

Keep reading

Back to the full guide Definition and causes Common myths