Diagnosis of Septal Perforation
Diagnosing a septal perforation involves more than confirming that an opening is present. Assessment also considers its size, position, surrounding tissue, nasal structure and the likely reason it developed.
Some patients need only a focused clinical assessment. Others may require additional investigation when the cause is uncertain or examination raises another concern.
Size, position, tissue quality and the wider nasal cavity can all influence diagnosis and treatment planning.
Diagnosis Has Two Different Jobs
The first question is straightforward: “Is there a septal perforation?”
The second can be more important: “Why did the perforation develop, and is anything still affecting the nasal tissue?”
In some patients, the cause is already clear — for example, where a perforation developed following previous nasal surgery. In other patients, there may be no obvious explanation and further assessment can be appropriate.
Understand the Perforation
The clinician assesses whether an opening is present and considers its dimensions, position, surrounding mucosa and impact on nasal structure.
- Is a perforation present?
- Where is it located?
- What are its dimensions?
- Is the surrounding tissue healthy?
- Is nasal support preserved?
Establish the Clinical Context
Previous surgery, trauma, medication, intranasal exposure or systemic illness may help explain why the perforation developed.
- Previous nasal operations
- Previous nasal injury
- Medication or spray history
- Intranasal exposure
- Relevant wider medical symptoms
How Septal Perforation Is Assessed
The exact sequence varies between patients, but diagnosis usually begins with history and nasal examination before any additional investigations are considered.
Clinical History
Symptoms, previous surgery, trauma, medication and other relevant medical information.
Learn more ↓ 02 ExaminationNasal Assessment
Direct inspection can often confirm that a septal opening is present.
Learn more ↓ 03 Detailed ViewNasal Endoscopy
Endoscopy allows examination of the septum and wider nasal cavity.
Learn more ↓ 04 CharacterisationMeasurement & Tissue
Size, position, crusting, mucosal quality and structural support are considered.
Learn more ↓ 05 If IndicatedFurther Investigation
Selected blood tests, imaging or biopsy may be considered when clinically appropriate.
Learn more ↓The History Often Provides the First Important Clue
Before deciding whether investigations are needed, the clinician needs to understand what happened before the perforation developed and what symptoms are present now.
Previous nasal operations are particularly important, but trauma, medication, intranasal exposure and relevant systemic symptoms can also influence the diagnostic approach.
Septoplasty, rhinoplasty, sinus surgery and previous septal procedures may be relevant.
Significant injury, fracture or repeated local trauma may provide useful context.
The clinician may ask which sprays or nasal medicines have been used and how they were used.
An accurate exposure history can be important for assessing tissue health and treatment suitability.
Relevant respiratory, inflammatory or other systemic symptoms may change the investigation strategy.
Direct Examination Can Often Confirm the Perforation
A septal perforation is an anatomical opening, so diagnosis can often be made by directly examining the inside of the nose.
An ENT examination may use appropriate lighting and a nasal speculum to inspect the septum.
Examination is not limited to seeing the hole. The surrounding lining, crusting, bleeding, inflammation and the external shape and support of the nose may also be assessed.
The Clinician May Assess
What Is Nasal Endoscopy?
Nasal endoscopy uses a narrow endoscope to provide a more detailed view inside the nasal cavity.
It can help the ENT specialist assess the perforation, surrounding tissue and other parts of the nasal cavity that may not be fully visible with simple anterior examination.
Endoscopy can also help identify other nasal conditions that may be contributing to symptoms, such as inflammation, polyps, crusting, discharge or structural narrowing.
Measurement Is Only One Part of the Assessment
The size of the perforation is important, but treatment decisions should not be based on one diameter alone.
Horizontal & Vertical Size
Both dimensions can be useful when describing the defect and considering potential treatment options.
Where the Opening Sits
An anterior perforation may behave differently from one positioned further back in the nasal cavity.
Surrounding Tissue Health
Healthy mobile mucosa differs from tissue that is inflamed, scarred, crusted or previously operated on.
Remaining Septal Support
The clinician may assess how much supporting septal framework remains and whether the external nose is stable.
Available Nasal Tissue
Previous operations can alter cartilage, scarring and the tissue available for future reconstruction.
Clinical Impact
The importance of the perforation also depends on what symptoms it is actually causing for the patient.
Size Does Not Equal Severity
A larger perforation is not automatically more symptomatic than a smaller one.
Airflow, position, crusting, mucosal health, septal support and other nasal conditions can all influence how troublesome the defect feels.
Measurements are useful for describing anatomy and planning treatment, but the patient and their symptoms remain central to decision-making.
Does Every Patient Need Blood Tests, Scans or a Biopsy?
No. The investigation should match the individual clinical circumstances.
Blood Tests
Blood testing may be considered if the history or examination suggests inflammatory, autoimmune, infectious or another systemic cause.
Not routinely necessary for every perforation.Imaging
CT or other imaging may occasionally be useful where wider sinonasal disease, structural problems or another clinical concern needs assessment.
Imaging is guided by the clinical question.Biopsy
Tissue sampling can be considered where the cause is uncertain or examination identifies abnormal tissue that requires pathological assessment.
Biopsy is not a routine requirement for everyone.The Investigation Pathway Can Be Very Different Between Two Patients
Clear Post-Surgical History
A patient develops a perforation after previous septal surgery, with otherwise reassuring examination and no wider concerning symptoms.
No Clear Cause
A patient has no previous nasal surgery or clear traumatic explanation and the clinical history raises additional questions.
Why Might a Septal Biopsy Be Considered?
A biopsy allows tissue to be examined under a microscope. It can sometimes help investigate inflammatory disease, infection, neoplasia or other abnormal tissue processes.
The decision is clinical. A patient with an obvious post-surgical cause and otherwise reassuring findings may not need one.
A Biopsy Removes Tissue
Because tissue is taken from the edge of the perforation, biopsy can increase the size of the defect slightly.
The potential diagnostic benefit should therefore justify the procedure.
Diagnosis Does Not Mean Ordering Every Possible Test
Investigation should answer a genuine clinical question rather than create unnecessary testing.
Blood Tests
Testing depends on whether the clinical history gives a reason to investigate a systemic cause.
CT Scan
Imaging is selected when it is likely to provide useful information beyond physical examination.
Biopsy
Tissue sampling is generally reserved for situations where it is clinically justified.
Surgery
Confirming a perforation does not itself mean surgical repair is necessary.
Other Nasal Conditions May Be Found at the Same Time
A patient may have a septal perforation and another nasal problem simultaneously.
Examination should therefore consider the whole nasal airway rather than treating the opening as the explanation for every symptom.
Information That Can Help at Your Consultation
You do not need to arrive with every detail, but previous clinical information can sometimes make the assessment easier.
Previous Operation Details
Approximate dates and types of previous nasal surgery are useful where known.
Previous Clinic Letters
Relevant ENT correspondence or previous assessments may provide useful context.
Current Medication
Include prescribed nasal sprays and other relevant medicines.
Previous Investigations
Existing blood tests, scans or biopsy results may avoid unnecessary duplication.
Symptom History
Consider when symptoms began and whether they have remained stable or changed.
Questions You Want Answered
Diagnosis, symptom control, treatment options and surgery can all be discussed.
What Should a Septal Perforation Assessment Establish?
The goal is to create a useful clinical picture rather than simply attach a measurement to the perforation.
Confirmation of the septal perforation.
Size, position and tissue characteristics.
Likely cause and whether further testing is needed.
How much of the patient’s experience comes from the perforation.
Observation, symptom management, prosthesis, repair or further investigation.
The Septal Perforation Information Pathway
Background
Understand septal anatomy and altered airflow.
Read background → 02 CauseCauses
Understand why septal perforations develop.
Explore causes → 03 Patient ExperienceSymptoms
Understand crusting, bleeding and altered airflow.
Explore symptoms → 04 PreviousComplications
Understand possible progression and structural concerns.
Explore complications →Diagnosis
Understand clinical assessment and targeted investigation.
Current pageThe Next Question Is Not Simply “Can It Be Closed?”
Treatment depends on symptoms, perforation characteristics, surrounding tissue, underlying cause, previous surgery and the patient’s own goals.
Options can range from conservative symptom management to septal prostheses and surgical reconstruction in selected patients.
Mr Hassan Elhassan
Consultant ENT, Rhinology & Nasal Surgeon
A specialist assessment considers the perforation, the surrounding nasal structures and the clinical circumstances in which it developed. The aim is to understand both the anatomy and the patient’s symptoms before discussing appropriate treatment options.
The diagnostic information on this page describes general clinical principles. The tests or examinations appropriate for an individual patient depend on their history and clinical findings.
Next: Septal Perforation Treatment Options
Explore conservative management, septal prostheses, surgical repair and approaches for more complex or previously operated perforations.