Party Lines and Other Mucosal Crimes: Nasal Septal Perforation: A Review of Common and Uncommon Causes

Nasal septal perforation refers to the abnormal communication of the nasal cavities via a defect in the nasal septum. Clinical symptoms, if present, include bleeding, crusting, a sensation of nasal obstruction, and whistling noises during inhalation. The mucoperichondrium of the nasal cavity contains most of the nasal septal vasculature and sandwiches the relatively avascular septal cartilage. An insult to the mucoperichondrium on both sides of the septal cartilage in approximately the same area results in ischemic necrosis of the septal cartilage, which leads to nasal septal perforation. Nasal septal perforation is a common end to an expansive list of etiologies that occur due to ischemic necrosis or direct erosion of the osteocartilaginous nasal septum from a tumor or infection. Imaging alone is typically insufficient to establish the exact underlying etiology. However, there are imaging features that may narrow the differential diagnosis or suggest less common causes, particularly malignancy. Radiologists can also identify lesions that place the nasal septum at risk, such as for a nasal septal hematoma or an abscess. Preoperative imaging allows for the evaluation of the size of the defect, as well as other areas of osseous and cartilaginous destruction in the palate, sinus walls, or orbits, that may need surgical reconstruction.Learning Objective: Describe nasal septal anatomy, pathophysiology of nasal septal perforation, and the differential diagnosis for causes of nasal septal perforation.