Perforated Septum

A perforated septum is a hole in the nasal septum, the structure that separates the two sides of the nose. This condition can be seen on imaging studies like CT scans and may be discovered during evaluation for nasal symptoms such as congestion, nosebleeds, or whistling while breathing. It may also be found incidentally during sinus imaging. Understanding what it means on a radiology report can help patients and doctors decide on the next steps.

What Is the Nasal Septum?

The nasal septum is a wall made of cartilage and bone that divides the left and right nasal passages. A normal septum is straight and intact. A perforated septum means there’s an opening or defect in this wall, which can disrupt airflow and lead to symptoms.

Causes of a Perforated Septum

Imaging can suggest but not always confirm the exact cause of a septal perforation. Common causes include nasal trauma, past surgery (such as septoplasty or rhinoplasty), chronic nasal spray use, cocaine use, autoimmune diseases like granulomatosis with polyangiitis, and infections. When a radiologist sees a perforation on imaging, they may recommend clinical correlation and sometimes further testing depending on the pattern or surrounding findings.

How It Appears on CT Scan

A CT scan of the sinuses is typically the best imaging tool to identify a septal perforation. The hole appears as a break in the normally continuous line of the nasal septum. It may be described in terms of its size and location (anterior or posterior). The radiologist may also comment on nearby findings like sinus inflammation, crusting, or bone erosion. The perforation is most clearly visible in coronal and axial images.

MRI for Complex Cases

MRI of the face or sinuses is sometimes used when the clinical concern is more serious. MRI is helpful if there is suspicion of granulomatous disease, tumor, or extensive soft tissue inflammation. It shows more detail of the nasal lining and soft tissues, which CT cannot capture as clearly. If a radiologist sees an irregular or concerning area near a perforation, they may recommend MRI for better characterization.

Symptoms That May Be Linked

A radiology report may mention a perforated septum in patients with specific symptoms. These include nosebleeds, nasal crusting, a whistling noise while breathing, nasal congestion, and changes in nasal shape (such as a saddle-nose deformity). In other cases, the patient may be unaware of the perforation until it is found on imaging.

What to Do After Imaging

When a septal perforation is reported, the next step is usually evaluation by an ENT (ear, nose, and throat specialist). The ENT doctor may use a nasal scope to directly view the perforation. Depending on the suspected cause, they might order lab work or a biopsy. The imaging findings can help guide the workup.

Imaging Tips for Clinicians

Radiologists may review prior imaging studies to determine whether the perforation is new or stable over time. They should also check for signs of inflammation, bone erosion, or masses. Clear communication in the radiology report helps referring doctors know whether follow-up imaging or specialist referral is recommended. CT without contrast is usually sufficient unless there’s concern for soft tissue abnormalities.

When to Worry

A small, stable perforation without other findings is often not serious. However, some imaging findings may indicate a need for further evaluation. These include large or expanding perforations, surrounding bone erosion, soft tissue irregularities, or asymmetry. In these cases, further workup is needed to rule out serious conditions like autoimmune disease or cancer.

Treatment Based on Imaging

Not all septal perforations require treatment. If the perforation is small and the patient has no symptoms, monitoring may be enough. If symptoms are present, treatments can include saline sprays, emollients, and in some cases, a septal button to cover the hole. Surgery may be an option in select cases, particularly if the defect is small and located in an accessible area. Imaging helps guide these decisions by showing the size and extent of the defect.

Conclusion

A perforated septum seen on a radiology report is a hole in the nasal septum, usually identified on CT imaging. It can be caused by trauma, surgery, drug use, or underlying disease. Many cases are minor, but some may require further workup. Imaging findings provide valuable information that helps guide the diagnosis and treatment plan. If you see this term on your radiology report, it’s important to follow up with your doctor to determine whether further evaluation is needed.

Reference Links

https://radiopaedia.org/articles/nasal-septal-perforation-2

https://www.ncbi.nlm.nih.gov/books/NBK537208/

https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/484007