Nasal Septal Perforations_our Surgical Technique

Otolaryngology–Head and Neck Surgery (2007) 136, 369-372

ORIGINAL RESEARCH

Nasal septal perforations: Our surgical technique Livio Presutti, Matteo Alicandri Ciufelli, Daniele Marchioni, Domenico Villari, Alessio Marchetti, and Francesco Mattioli, Modena, Italy OBJECTIVE: The aim of this paper was to describe our surgical technique for the treatment of nasal septal perforations. STUDY AND DESIGN: We studied 31 patients with nasal septal perforation treated with an endoscope-assisted technique, based on a bilateral dissection of monopedicled mucosal flaps from the nasal fossa floor, sutured at the edge of the perforation previously unstuck, without any graft interposed between the two mucosal layers. RESULTS: In our experience with 31 patients, the use of this technique led to the persistent closing (with follow-up for at least one year) of 96.3% of the perforations smaller than 3 cm. CONCLUSIONS: Our technique has the advantage of an endonasal approach, without any external incision, and the use of monopedicled flaps from the nasal fossa floor without any graft interposition, avoiding any other surgical procedure and morbidity in the donor site of the graft. The use of nasal endoscopy permits superior precision in all surgical steps. SIGNIFICANCE: The high success rate in perforations smaller than 3 cm seems to confirm the effectiveness of this technique. © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Management of septal perforation initially requires medical therapy: patient with significant intranasal crusting can be treated with nasal irrigation and a topical emollient. The dryness can be treated with topical nasal estrogenic spray.1 A silicon grommet prosthesis (septal obturator) can be used when medical therapy is inadequate. Often, medical and prosthetic therapies are not able to reduce symptoms. In these cases, surgical therapy is deemed necessary. The surgical repair of nasal septal perforation is indeed a challenge for every nasal surgeon, in particular due to the high reperforation rate. Surgical therapy consists of the closure of the perforation, or the enlargement and repair of the edges.2 Many approaches and techniques to perform perforation closure have been reported in the literature. Our technique is based on an endoscope-assisted endonasal approach, with the dissection of bilateral monopedicled mucosal flaps from the nasal fossa floor, without any graft interposition. The results on 31 patients show a closure rate of 96.3% of perforations smaller than 3 cm (the highest success rate reported in literature for that diameter).

INTRODUCTION

MATERIALS AND METHODS

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From 1991 to 2004, 31 patients with symptomatic nasal septal perforation were treated, 19 males and 12 females, with a mean age of 44.5 (⫹/⫺10.5) years. In 26 cases, the maximum diameter of the perforation was between 2 and 3 cm; in four cases, it was bigger than 3 cm; in one case, it was smaller than 2 cm. The perforations involved the medium-anterior portion of the septum. The presenting symptoms were as follows (Table 1): recurrent epistaxis (in 23 cases), crusting (in 28 cases),

asal septal perforation is a complete interruption of mucosal and cartilaginous tissues of the nasal septum. Presenting symptoms are of a wide variety such as recurrent epistaxis, crusting and dryness, nasal obstruction sensation, foreign body sensation, headache, whistling and nasal pain with a similar variety of possible etiologies such as postoperative complication after septoplasty, aggressive cauterizations, inhalatory drug abuse, self-induced intranasal trauma or external trauma.

Corresponding author: Dr Matteo Alicandri Ciufelli ENT department, Policlinico di Modena, Università degli Studi di Modena e Reggio Emilia, Via del Pozzo 71 40100. Modena, Tel: 00393470585750.

E-mail: [email protected].

0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2006.09.026

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Table 1 Symptoms Symptoms Crusting Epistaxis Nasal obstruction Foreign body sensation Headache Rhinorrhea

Number of cases (%) 28 23 23 7 4 3

(90.3%) (74.2%) (74.2%) (22.6%) (12.9%) (9.7%)

difficulty in breathing through the nose (in 23 cases), headache (in 4 cases), foreign body sensation (in 7 cases), and rhinorrhea (in 3 cases). Regarding its etiology, we observed the following in our patients: septoplasty outcome (in 21 cases), aggressive cauterizations (in 4 cases), idiopathic (in 3 cases), self-induced intranasal chronic trauma (in 2 cases), and nasal trauma (in 1 case). Every patient underwent an accurate endoscopic examination in the pre-operative period to measure and value the dimensions, shape, and margins of the perforation. Our intervention is based on an endoscopeassisted endonasal approach, without any external incision. Description of the technique. Each surgical step is performed under endoscopic view, for superior precision in the dissection of flaps, suturing, and for excellent exposure of the operative field. The endoscope is held by a second operator in most phases, while the first operator holds the suction, knife or decollement instruments. Surgical approach begins with an anterior caudal septal incision; the cut is extended laterally, to the floor of the nasal fossa, and then posteriorly under the inferior turbinate proximal to the cohana. This releasing excision permits the creation of a monopedicled posteriorly-based flap (Figs 1A and 2). The dissection is made under the periostial layer of the nasal fossa floor and then continued under the pericondral layer of the septum, and extended all around the perforation (Fig 1B). Once completely elevated, the flap is transposed medially, and is then pulled cranially to cover the perforation. The nasal fossa floor is left uncovered. The flap is then sutured to the mucosa of the upper margin of the perforation, with a reabsorbable suture (Fig 1C). The same approach is followed on the other side, without interposition of any cartilage or connective graft (Fig 1D). The nasal package is mild (made with a Lyofoam sponge), and is removed after three days. IRB approval was not requested because the use of monopedicled flaps without any graft interposition, like the use of a “close” technique, was already mentioned in the literature.

Figure 1 (A) and (B): The dissection of the nasal fossa floor flap. (C) The suture at the edge of the perforation. (D) The same approach is made on the other side, without any graft interposition.

was left uncovered after the operation was almost completely epithelized in most patients. There were no local or systemic post-operative complications. Some patients referred a nasal obstruction in the first post-operative period, and reverted in a few weeks. To follow are the results (Table 2): – Of the 27 perforations smaller than 3 cm, 26 were closed (96.3%: the highest rate reported in literature for that diameter). In only one case we were unable to achieve complete closure of the perforation during the first operation; however, at revision stage, made after one year with the same technique, this perforation was finally closed.

RESULTS On each patient, we did a follow-up after 30 days, 6 months, and one year. At 30-day control, the nasal fossa floor that

Figure 2 The incision of the mucosa in the nasal fossa floor to create the posteriorly-based flap.

Presutti et al

Nasal septal perforations: our surgical technique

Table 2 Results in our case series Number of cases

Closed at the first operation

27 4

26 (96.3%) 2 (50%)

SP smaller than 3 cm SP larger than 3 cm SP, success for perforations

– Of the four perforations larger than 3 cm, two were closed (50%). Of the two perforations that were not closed after the surgery, one patient had a revision surgery performed with the same technique, resulting in a subsequent successful closure of the perforation; while in the other case, the patient refused the revision surgery. Despite the fact that 3 out of 31 patients had reperforation (documented in all cases at the 30-day control), this occurred with reduced dimensions, and the patients reported a considerable symptomatic improvement.

DISCUSSION As mentioned previously, surgical therapy of symptomatic nasal septal perforation often gives unsatisfactory results because of the high rate of reperforation. Many approaches have been used for surgical therapy. The open rhinoplasty approach with an external columellar incision is often preferred3-5 for the wide exposition of the septum and the perforation. For the same reasons, some authors also use the midfacial degloving6 in larger perforations. The endonasal approach is preferred among a minority of other authors.7,8 The use of nasal endoscopy has been previously reported by four authors.9-12 Our experience suggests that the endonasal approach is adequate for surgical exposition of septal perforations, flap dissection, and suturing. The absence of external scars and morbidity on the donor site are advantages of this technique. The use of nasal endoscopy allows superior precision in all surgical steps by ensuring excellent exposure of the operative field. Nasal mucosa flaps are the most commonly used flaps: they can be mono- or bi-pedicled (a bipedicled flap is preferable because of increased vascular supply).13 Inferior turbinate flaps can also be used.2,22 The use of forearm free flaps16 or oral mucosal flaps17 have been described, but in our opinion, only techniques with nasal mucosal flaps achieve a normal nasal physiology because they use the normal respiratory epithelium for closure.13 Our flaps, despite being monopedicled and often with wide dimensions, never showed a vascular suffering. Connective tissue grafts are commonly interposed between the repaired septal flaps. The most frequently used autografts are the temporal muscle fascia and the pericranium. Temporoparietal and deep temporal fascia sandwich

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graft;18,19 extraction-reposition of the quadrangular cartilage;16 conchal cartilage with pericondrium21 and mastoid periosteum22,6 or both in a sandwich technique23 have been used. To decrease risk in the donor site, a human acellular dermal allograft can be used.3 Porcine small intestine mucosa24 and bioactive glass (BAG)14 have also been described. Nevertheless, according to our results, in perforations smaller than 3 cm, the interposition of a graft between the two mucosal layers is, in our opinion, useless. Post-operative nasal package (left in situ for 3 days) can help the adequate adhesion of the mucosal layers: in our case series of 31 patients, no complications between two mucosal layers (like dehiscence or abscess) was reported. As previously stated, the closure rate in perforations smaller than 3 cm was 96.3% (26/27) after one year of follow-up. In the perforations larger than 3 cm, results have not been equally satisfactory: in four patients considered, complete closure had been achieved after the first operation in only two cases (50%). In one patient, the perforation was closed at revision and another declined to undergo any further operations. Despite the fact that in 3 out of 31 patients we had a reperforation (documented in all cases at the 30-day control), this occurred with reduced dimensions, and the patients reported considerable symptomatic improvement. The same technique was used in the revisions. The epithelization of the nasal floor that was left uncovered does not represent a problem because it is complete after 30-40 gg.

CONCLUSIONS A wide variety of surgical techniques have been described for the therapy of nasal septal perforations. Our technique has the advantages of an endonasal approach, without any external incision, the use of monopedicled flaps from the nasal fossa floor without any graft interposition in between, avoiding any other surgical procedure and morbidity in the donor site of the graft. The use of nasal endoscopy is useful for superior precision in the surgical steps, giving a wide exposure of the operative field. The technique is also fast and easy to perform, and can be used for surgical revisions. Nasal mucosal flaps are able to achieve a normal nasal physiology because they use the normal respiratory epithelium for closure. The high rate of success for perforations smaller than 3 cm seems to confirm the effectiveness of this technique.15,20,25

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