International consensus statement on nasal septal perforation

Nasal septal perforation (NSP) is a multifactorial condition characterised by a full-thickness defect in the nasal septum, with clinical presentation ranging from asymptomatic cases to significant nasal obstruction, crusting, epistaxis, and impaired quality of life. A major challenge in NSP management is the absence of standardised diagnostic and therapeutic protocols, contributing to inconsistent outcomes. This study aimed to develop an international consensus on the assessment, classification, and management of NSP to standardise linical decision-making and improve patient care.

A modified Delphi process was conducted over three iterative rounds involving 25 panellists from 15 countries across four continents. Structured questionnaires addressing NSP diagnosis and management were developed, distributed, and refined. Statements covered eight categories: assessment; physiopathology and causes; position; dimensions; non-surgical treatment; surgical treatment, follow-up and results; and quality of life. Consensus was defined as ≥70% agreement, with no more than 10% disagreement.

Consensus was reached for 98.2% of the proposed statements. Fifty-six agreements included validated symptom assessment tools, imaging protocols, classification systems based on size and location, preferred medical and surgical treatments, perioperative care standards, and outcome evaluation methods. Areas without full consensus included the clinical relevance of superior-inferior perforation location, prognostic significance of mucosal oedema, the optimal abstinence period from intranasal drug use, and the necessity of early postoperative debridement.

These expert consensus statements emphasise validated assessment tools, structured classification systems, and treatment approaches, providing a comprehensive framework to unify NSP management, guide future research, and improve patient outcomes.