A perforated nasal septum is a condition caused by a number of iatrogenic, traumatic, infectious events. It is a clinical diagnosis, however, the etiology may be more challenging to determine.
Perforated nasal septum (PNS) can occur due to different reasons like infection, trauma, and inhalation of substances. The majority of patients presenting with septum perforation experience no symptoms . Perforations can either be anterior or posterior and anterior ones are more likely to be symptomatic than the posterior defects  . Furthermore, the size of the perforation also plays a role in the presentation . Frequent complaints include wheezing, epistaxis, nasal obstruction, olfactory dysfunction, and pain. Scabs and crusting can be seen. In the case of a small perforation, or uninterrupted hydration of the septum, symptoms are likely to be less severe. Patients may experience whistling sounds during respiration.
Ultimately PNS results from disruption of perfusion of the septal area, leading to ischemia and tissue necrosis. Iatrogenic causes are common and can be due to various surgical procedures, indwelling nasogastric tubes and nasal packing  . Traumatic events such as excessive nose picking, injury by foreign bodies and nasal fractures have been described .
PNS has been associated with the chronic use of inhaled substances, such as cocaine and nasal decongestants, which over time lead to perforation due to local vasoconstriction . The long-term use of steroids has also been linked to PNS, and the concomitant intake of both steroids and decongestants compounds the risk  . Females are more affected by this . Occupational exposure to some industrial chemicals such as cement dust, platinum salts, arsenic, and mercury leads to PNS.
Syphilis, human immunodeficiency virus (HIV) infection and tuberculosis are among the many bacterial, fungal and viral diseases that can affect the airway and predispose to PNS . In some parts of the world, leprosy is still prevalent and is an acknowledged etiology of PNS. There are systemic inflammatory conditions that contribute to the occurrence of PNS, and these are systemic lupus erythematosus (SLE), Wegener's granulomatosis and sarcoidosis . Malignancies are another factor in the development of a perforation, notably squamous cell carcinoma .
Diagnosis of a perforated nasal septum is by visualization of the defect on physical examination. Rhinoscopic exploration is needed to determine the extent of the lesion. Further investigation is warranted in order to reveal the underlying disease process. This is achieved by first obtaining a thorough patient history . Other laboratory and imaging studies may be carried out, and the choice of test is guided by clinical suspicion based on all the symptoms that a patient may present with . The following are examples of such tests: