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BackgroundNasal septal perforations (NSP) can have a heterogeneous appearance on endoscopic examination with varying degrees of crusting, inflammatory change, and associated septal deviation. The clinical applicability of these findings as contributors to patient symptoms may be enhanced by use of a standardized assessment.MethodsVideo nasal endoscopy recordings were obtained from 40 patients with NSP. Five raters with varied levels of training ranging from a senior resident to an experienced septal perforation surgeon independently reviewed the videos for the following exam findings: crusting, scarring, granulation tissue, septal deviation, and edema. Scoring for each item was reported on a 3‐point (0–2) scale, and each reviewer repeated scoring at a 14‐day interval. Interrater and intrarater agreement were calculated using Fleiss kappa for each item and the total scores. Additionally, endoscopy scores were correlated with patient‐reported NOSE‐Perf symptom scores.ResultsInterrater agreement for the overall instrument was in the “fair‐to‐moderate” range with the following interrater agreement for each item: crusting (0.458–0.575), scarring (0.286–0.308), granulation (0.403–0.406), deviation (0.487–0.494), and edema (0.253–0.406). Intrarater agreement was generally “substantial” for individual items as well as the overall instrument (0.688). The NSP endoscopy scores were moderately correlated with NOSE‐Perf scores (r = 0.44, p = 0.008).ConclusionsAn endoscopic evaluation of NSP comprising five exam findings has acceptable interrater and intrarater reliability and correlates with patient‐reported outcomes. NSP endoscopy may be applied to future clinical studies for characterization of NSP and assessment of treatment outcomes.Level of Evidence3 Laryngoscope, 134:3049–3053, 2024