Closure Of Nasal Septal Perforation Via Endonasal

Otolaryngology–Head and Neck Surgery (2006) 135, 922-927

ORIGINAL RESEARCH

Closure of nasal septal perforation via endonasal approach Ignazio Tasca, MD, and Giacomo Ceroni Compadretti, MD, Imola, Italy

asal septal perforations are anatomic defects of nasal septum as a consequence of necrosis of the cartilage or bone tissues and their mucous covering. Perforations can be distinguished according to their etiopathogenetic factors, size, and location.1-3 A clear etiology must be established from a long, diverse list of potential causes, the most common of which is iatrogenic injury. Inappropriate and aggressive surgery, which aims at removing septal components, thus weakening the structure (eg, Killian operation), has a poor record. A tight nasal packing after surgery or for epistaxis, as well as repeated, deep chemical or electrical cauterization, especially if carried out bilaterally, often un-

dermines the septal structures and damages nasal mucosa trophism causing a perforation. The rhinologist often discovers a septal perforation during his examination as an incidental finding in a patient without symptoms. A number of septal perforations are asymptomatic if they are placed posteriorly within the nose where there is good humidification. The more anterior the perforation is, the more likely it is for the patient to seek evaluation and treatment for symptoms. The typical symptoms of septal perforation are crusting, bleeding, whistling, nasal obstruction, pain, and nasal discharge.1 An asymptomatic perforation rarely requires any treatment at all. Those patients with mild symptoms can usually be managed by medical therapy. Often just keeping the nose clean with nasal irrigations and moist with ointments may be satisfactory. If these treatments are unsuccessful or the patient is very symptomatic, surgery becomes a viable option. Silicone septal buttons may also be used in patients who, for other medical reasons, are not good surgical candidates. It should certainly be considered in patients with chronic or recurrent disease processes, as well as patients with continued cocaine usage or in case of large sized perforations.4 Numerous surgical techniques, both endonasal and external, have been developed to address the issue of septal perforation.5-8 We report our consolidated experience in nasal septum perforation surgery using the endonasal approach with the backward extraction–reposition technique.9,10 Patients underwent preoperative nasal endoscopy and rhinomanometry that allowed for a complete understanding of the disease and permitted the right surgical procedure to be planned. The same investigations have been used for the evaluation of the outcomes after a mean follow-up of 28 months. The role of rhinomanometry in rhinologic practice has been already widely explained by

From the Department of Otorhinolaryngology, Imola Hospital, Imola (BO), Italy. Reprint requests: Giacomo Ceroni Compadretti, MD, Department of

Otorhinolaryngology-Imola Hospital, Viale Oriani 1, 40024 Castel San Pietro Terme, Imola (BO), Italy. E-mail address: [email protected].

OBJECTIVE: We report our experience in nasal septum perforation surgery using the endonasal approach. The role of rhinomanometry and nasal endoscopy in the management of septal perforation repair is also discussed. STUDY DESIGN AND SETTING: We reviewed a sample of 30 patients with septal perforation. Patients underwent preoperative and postoperative nasal endoscopy and rhinomanometry. They were all treated using the Cottle technique with the backward extraction–reposition of nasal septum and inverted sliding flap suture technique. RESULTS: Closure rate for small-sized and middle-sized perforations was 94% and 75%, respectively. It was 86.6% if calculated for all patients. Preoperative nasal resistances was normal in patients with isolated septum perforation, and high in patients with associated septum deformity or hypertrophic turbinates. CONCLUSION: The Cottle technique is a viable procedure for the closure of small- and middle-sized perforations. Endoscopy and rhinomanometry help provide a correct and complete understanding of this nasal alteration. © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

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0194-5998/$32.00 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2006.04.017

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Closure of nasal septal perforation via . . .

numerous studies.11-13 This is the first study in international literature aimed at analyzing the outcomes of nasal septal perforation closure by means of rhinomanometry.

PATIENTS AND METHODS We reviewed a sample of 30 cases with complete records operated on for septal perforation at our ENT department between September 2000 and January 2004. Patients (19 males, 11 females) had a mean age of 42 years (range, 32 to 65 years). A thorough head and neck and generalized examination was carried out previously to rule out any other system involvement. On physical examination of the nose, a complete visualization of the septum was achieved after removing all crusts and after decongesting the turbinates. Diagnosis of septal perforation was confirmed by nasal endoscopy using a 0° telescope that allowed exploration of total nasal cavities to show any associated septal deformity or sinus diseases. The septum was palpated with a cotton-tip applicator to discern persistent septal structures between the mucosal flaps. Perforations were distinguished according to their size (small, ⬍1 cm; medium, 1 to 2 cm; large, ⬎2 cm) and location (antero-inferior, middle-inferior, antero-superior). A posterior active rhinomanometry was carried out in all patients by a Meditronic RMAC.01 rhinomanometer (Bologna, Italy) following the recommendations of the Committee Report on Standardization of Rhinomanometry14 and recording values of flow and resistance at 150

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Pa. Tests were carried out in standard conditions of temperature and humidity after a period of acclimatization of 15 minutes. Each test was carried out in basal conditions and after decongestion. All the patients were treated using the Cottle technique with the backward extraction–reposition of nasal septum and inverted sliding flap suture technique (Figs 1-3).9,10 Patients were re-examined after a mean follow-up of 28 months (range, 14 to 37 months) using nasal endoscopy. Anterior active rhinomanometry was carried out in cases with successful surgical treatment. An institutional review board is not available in our institution, but in keeping with the mandate of the Declaration of Helsinki, we obtained proper consent from the patients with signed permission allowing us to include their records in our study.

RESULTS Clinical history documented a previous nasal surgery in 20 cases, and a repeated use of tight nasal packing and cautery for recurrent epistaxis in five cases. Cocaine use was detected in one patient. No clear etiology was shown in the remaining four patients. The most recurrent patient complaints were nasal obstruction in 65% of cases and crusting in 43% of cases followed by nasal discharge (13%), whistling (8%), and bleeding (5%). Perforation was classified as small in 18 patients and medium in 12 patients. With regard to the localization,

Figure 1 (A) Right inferior tunnel extended to the insertion of inferior turbinate. (B) Incision of the floor of the right nasal cavity at the inferior turbinate insertion to move the flap cranially and close the perforation on the right side.

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Figure 2 Defects of cartilage and mucoperichondrial-mucoperiosteal coating are situated on two different levels by means of the backward extraction–reposition technique.

the perforation was located antero-inferiorly in 10 cases, middle-inferiorly in 12 cases, and antero-superiorly in 8 cases. Nasal endoscopy showed a concomitant nasal septum deformity in 9 cases and an inferior turbinate hypertrophy in 5 cases that were all amended during the same operation. No postoperative complications were documented. After a mean follow-up of 28 months, the closure rate for patients presenting small perforations was 94% (17 of 18 cases), whereas for patients with a middle perforation a complete closure was accomplished in 75% (9 of 12 cases). The closure rate calculated for all patients was 86.6% (26 of 30 cases). In the 4 cases of failure, the residual perforation was found to be smaller and more posterior and patients referred fewer symptoms. Preoperative nasal resistances in patients with isolated septum perforation were already within normal limits in basal condition. In the 9 patients with associated septum deformity, the inspiratory Nasal Airway Resistances (NARs) were high, and did not alter substantially after the decongestion test (Fig 4). In the group of 5 patients with associated hypertrophic inferior turbinates, NARs were high but they normalized after the decongestion test. At follow-up the anterior active rhinomanometry, carried out in 26 patients with complete perforation closure, showed normal resistances even in basal conditions (Table 1).

DISCUSSION Surgical repair of septal perforations represents a complex technical challenge for the surgeon. The main goal of sur-

gery is not only to repair the perforation, but also to restore normal function and physiology to the nose. Although many different surgical techniques have been proposed for the closure of septal perforations, no standard protocol has been accepted universally This multitude of different operations suggests that one procedure is not better than other procedures, but several factors play a role in the decision making of the surgical planning and in the success of the treatment. A fundamental prognostic indicator of successful surgery is the amount of septal structures remaining within the rest of the septum. A no less important determinant of success is quite simply the experience and skill of the surgeon. Another critical factor is good view of the operative field, and thus the contribution of the anesthesiologist is essential to achieve an effective hemostasis. Fairbanks,5 using the endonasal approach, reported a 95% success rate in 1- to 7-year follow-up for perforations ranging from 1 to 3 cm in size. Kridel et al7 popularized an external septorhinoplasty approach and reported a 77% complete closure rate for a group of 22 cases of septal perforation up to 4 cm. Among the different proposed approaches, Romo et al6 have described a midfacial degloving technique for perforations greater than 2 cm. Karlan et al15 used a sublabial incision, and Kuriloff16 described a modification of the open technique to further increase exposure. More recently, Friedman et al17 have proposed an inferior turbinate flap for selected cases of caudal septal perforations, whereas Hier et al18 have attempted an endoscopic approach to improve visualization without carrying out an excessive dissection. All these techniques are also variably associated with a number of different grafts, both autologous and heterologous, to obtain a safer closure.5,7,19,20 The hemitransfixion incision

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Figure 3 (A) Left anterior tunnel extended to the roof of the nasal cavity. (B) Incision at the roof allows the flap to be moved in caudal direction to close the perforation on the left side.

is the approach routinely used by the authors to expose the operating field.21 The flap made from the nasal floor is an axial flap (with predetermined circulation), based on the branches of the superior labial artery. Being a mucoperiosteal flap, it is suitable for the purpose because it is quite thick and strong. It can be enlarged according to need, and has a potential size of 2.5 ⫻ 4 cm in most patients. The backward extraction–reposition technique allows the defects of cartilage and mucoperichondrial-mucoperiosteal coating to be situated on two different levels: this is a further safety factor in the strength of the suture and flap trophism. Another greater margin of safety is provided by the inverted sliding flap technique. After making four large tunnels, an incision is made in the floor of the nasal cavity at the inferior turbinate insertion. In the contralateral nasal cavity an incision is made in the same direction at the roof. When the flaps have been prepared, they are made to slide asymmetrically (in a cranial direction, in one nasal cavity; and in a caudal direction, in the contralateral cavity). This asymmetric movement enables a non-opposing suture line and a good mucoperichondrial blood supply to the exposed portion of cartilage. In a previous study, Sarandeses-Garcia and Sulsenti,10 using the above-mentioned technique, accomplished an 87% success rate at 2-years follow-up in 1to 2-cm perforations. In the present trial, we obtained higher repair percentage for medium perforations, whereas the closure rate calculated for all patients was strictly comparable. The Cottle technique, with respect to open techniques, enables the operation to be carried out without further in-

cisions, and without sacrificing tissues or structures solely for reasons of exposure. We must take into account that any incision is bound to undergo some degree of contraction after surgery, so it is more convenient to carry out the lowest number of incisions in this type of surgery.9 Furthermore, many perforation repair techniques often require the use of interpositional autografts between the repaired flaps,5,7 and they are consequently accompanied by a donor site morbidity. Contrarily, this surgical procedure, by repositioning the remaining nasal septum, does not require further supporting implants and allows the perforation to be closed without associated morbidity. With regard to the role of endoscopy and rhinomanometry, these tests help for a correct and complete understanding of this nasal alteration, which is fundamental for choosing the right treatment and monitoring the healing processes. Nasal endoscopy is an indispensable test because it enables the assessment of the posterior regions of the nasal cavities that are difficult to reach by simple anterior rhinoscopy, especially when deformities of the anterior septum are present.22 The septal perforation is sometimes associated with other smaller septal defects, which are usually displaced posteriorly and can be shown only by endoscopy, thus allowing a correct balance of the residual septum. Endoscopy is also very useful for detecting any associated sinus diseases. Rhinomanometry, carried out by the posterior active method, provides useful information on the degree of nasal patency in basal and decongested conditions.23 In our study,

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Figure 4 Sigmoidal and sinusoidal tracings of a posterior active rhinomanometric test showing pathologic resistance values after decongestion due to obstructive nasal septal deformity.

we found that those patients presenting an isolated septal perforation had normal resistance values. Similarly, Naito et al24 evaluated nasal resistances in a group of asymptom-

atic patients affected by moderately-sized perforations and found no significant differences before or after closure on either inspiration or expiration. In our study, nasal resis-

Table 1 Functional analyses of cases by means of rhinomanometry* Rhinomanometry nasal resistances (Pa/cm3/sec) Basal

Posterior active (N) Pre-op (30) Straight septum (21) Deviated septum (9) Turbinate hypertrophy (5) Anterior active Post-op (26) Straight septum (19) Deviated septum (7) Turbinate hypertrophy (5)

Decongestion

Insp

Exp

Insp

Exp

0.15 ⫾ 0.03 0.94 ⫾ 0.02 0.42 ⫾ 0.05

0.16 ⫾ 0.02 0.85 ⫾ 0.04 0.31 ⫾ 0.03

0.08 ⫾ 0.03 0.81 ⫾ 0.03 0.17 ⫾ 0.02

0.07 ⫾ 0.01 0.72 ⫾ 0.01 0.13 ⫾ 0.04

0.16 ⫾ 0.04 0.17 ⫾ 0.02 0.15 ⫾ 0.04

0.13 ⫾ 0.01 0.18 ⫾ 0.03 0.14 ⫾ 0.02

0.09 ⫾ 0.03 0.11 ⫾ 0.01 0.09 ⫾ 0.03

0.07 ⫾ 0.02 0.12 ⫾ 0.02 0.08 ⫾ 0.02

*Data express the mean ⫾ standard deviation; Insp, inspiratory; Exp, expiratory.

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Closure of nasal septal perforation via . . .

tances remained within the normal range even in subjects complaining of nasal obstruction. In fact, this sensation, not justified from a physical point of view, is likely to be due to the fact that perforation changes the normal lamellar airflow into a turbulent airflow with a consequent sensation of nasal impairment.16,25 Tests carried out after decongestion showed the potentially associated disease of the soft tissues of the lateral wall. If there was a perforation with associated deformity of the residual septum, high resistances were found even after decongestion. In that case, normalization of the nasal resistances after surgery showed the success of the operation. This study assesses the role of rhinomanometry and nasal endoscopy in the management of septal perforation repair and indicates that they are effective tools for the documentation of some obstructive conditions often associated with septal perforation and for the monitoring of the healing processes. We wish to thank Prof. Giorgio Sulsenti for giving us permission to use photographs from his book.9

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