Symptomatic small- to medium-sized perforation
20.2 Surgical Anatomy and Operative Implications
Nasal septal perforations (NSPs) are anatomical defects of nasal septum caused by the necrosis of the cartilage and/or bone tissues and their mucous covering. Perforations are classically distinguished according to their etiopathogenic factors, size, and location. 1, 2, 3 Size and location must be considered because they determine the choice of the reconstructive procedure and consequently the closure rate success. For this purpose, some basics of anatomy should be considered by the surgeon to discriminate the amount and the type of tissue defect, whereas the knowledge of septal vascularization is essential for the planning of the endonasal flaps.
The nasal septum divides the nose into two cavities. The bony components of the septum include the nasal crest of the palatine bone, nasal crest of the maxilla and premaxilla, vomer, perpendicular plate of the ethmoid, nasal crest of the frontal bone, and spine of the paired nasal bones. The anterior septum is composed of the quadrilateral cartilage and joins the free edges of the aforementioned bones. The anterior superior margin of the quadrangular cartilage joins, at its extreme cephalic, with the caudal end of the median suture of nasal bones contributing, together with the ethmoid perpendicular plate and the upper lateral cartilages, gives the support of the nasal vault. The anterior superior angle of the septal cartilage, defined as septal angle, constitutes an important surgical point. The septal angle is located immediately above the lower lateral cartilages in the supratip area. The loss of cartilaginous support in this area can cause the collapse of the mid-nasal vault. The caudal margin goes from lobule to the nasal spine, contracting relationships with the membranous septum. The caudal edge presents an intermediate angle and a posterior angle just above the nasal spine.
The osteocartilaginous skeleton is covered by periosteum and perichondrium, which are highly vascularized. The arterial blood supply consists of terminals from the external and internal carotid systems. 4 The sphenopalatine artery, terminal branch of the internal maxillary artery (external carotid artery), gives rise to outer branches such as the artery of the middle turbinate and the artery of the inferior turbinate, and also internal branches such as the septal artery that gives rise to the artery of the upper turbinate and septal arteries.
All these arteries anastomose with the ethmoid arteries. The underseptal artery, branch of the facial artery, runs along the nasal vestibule region and the lower anterior septal cartilage. The anterior ethmoid artery, branch of the ophthalmic artery (internal carotid), gives rise to two branches: an internal nasal and external nasal branches, which supply the frontal sinuses and ethmoid cells. The internal and external posterior ethmoidal arteries have anastomose with the anterior ethmoidal artery at the level of the turbinates and with the sphenopalatine artery in the upper part of the septum.
20.3 Patient Selection
Surgical repair of septal perforations represents a complex technical challenge for the surgeon. The principal aims of the surgery are to repair the mucous and also to reestablish the function and physiology of the nose. 5 Many different surgical techniques have been proposed for the closure of septal perforations, but there is no standard protocol universally accepted. 6, 7, 8, 9, 10 This multitude of different techniques suggests that there is no better procedure than another, but several factors play a role in both decision making of surgical planning and treatment success. 11 A fundamental prognostic indicator of successful surgery is the amount of septal structures remaining within the rest of the septum. An important surgical success factor is the surgeon’s experience and skill. Another critical factor is the adequate view of the operative field, and thus the collaboration of the anesthesiologist is essential to achieve an effective haemostasis. All the techniques are also variably associated with a number of different grafts, both autologous and heterologous, to obtain a safer closure. 12, 13 More recently, some authors have developed the endoscopic approach to improve visualization without performing an excessive dissection. 14, 15, 16, 17, 18
In case of small- to medium-sized perforation, the endonasal approach is the treatment of choice. The backward extraction-reposition technique allows the defects of cartilage and mucoperichondral-mucoperiosteal coating to be situated on two different levels, making safer the strength of the suture of the flap. 19 A further safe point is also provided by the inverted sliding flap suture ( ▶ Fig. 20.1). This asymmetric movement of flaps enables a nonopposing suture line and a better mucoperichondral blood supply to the repositioned graft. 20 The endonasal approach, compared with open techniques, enables a small incision, without sacrificing tissues or structures for improving the exposition. We must consider that any incision is bounded to undergo some degree of contraction after surgery, so it is more convenient to perform the lowest number of incisions, above all in this type of surgery. Furthermore, many perforation repair procedures often require the use of interpositional autografts between the repaired flaps and they are consequently accompanied by donor site morbidity. Contrarily, this technique, by repositioning the remaining nasal septum, does not require further supporting implants and that way allows the perforation to be closed without associated morbidity.
Fig. 20.1 Schematic representation of the backward extraction-reposition technique of the quadrangular cartilage with inverted sliding flap suture.
20.4 Surgical Steps
The septum is achieved by the endonasal approach through the classic hemitransfixion incision. The caudal margin of the septal cartilage should be completely exposed using suction dissector with careful movements.
Once the caudal margin is exposed, the surgeon begins creating the anterior tunnels along the subperichondral avascular plane. Dissection must be performed carefully around the perforation without opening it.
Subperiosteal inferior tunnels are then created along the floor of the nasal cavities after exposing the nasal spine, the anterior-inferior septal angle, and the medial portion of the inferior margin of the pyriform aperture.
Next, the four tunnels are joined and the septal space is exposed, allowing a general view of the whole septum and its bony framework.
Only at this moment the perforation is opened by a mucosal incision to separate the two nasal cavities. With the aid of a nasal speculum, the entire septum can be visualized from vault to floor.
After performing the subtriangular chondrotomy and posterior osteotomy, the residual septum is extracted leaving only a small 3-mm strip of cartilage close to the keystone area.
Next, 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, it is necessary to slide asymmetrically in a cranial direction in one nasal cavity, and in a caudal direction, in the contralateral cavity.
The closure of the mucosal perforation is achieved by using a 4–0 Polysorb braided absorbable suture. The flap made from the nasal floor is an axial flap, 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 it has a potential size of 2.5 × 4 cm in most patients.
Once the mucosal perforation is closed in both sides, a soft nasal packing is placed into the nasal cavities and pushed posteriorly toward the nasopharynx and up to the attic.
On a back table, the septum is reconstructed to fill the defect and create a regular graft to be repositioned.
Cartilage graft fixation is accomplished by a three-point suture using a 2–0 Safil polyglicolic acid braided absorbable suture with 60-mm straight needle.
The nasal packing is maintained for 2 days to ensure that the flap adheres and to prevent septal hematoma and displacement of the inserted fragments. Fluoroplastic nasal splints are also positioned into the nasal cavities. They remain to guide healings and then removed after 15 days.
In the large perforations associated with external deformities of the nose, the provision of intranasal tissue to close the perforation can be obtained with methods of downward displacement of the pyramid: the push-down and the let-down. The push-down is used to correct the bony and cartilaginous hump. 21 It requires to perform the basal and transverse osteotomy. When the osteocartilaginous deformity occurs on a prominent pyramid above all in the cartilaginous vault, let-down technique can be implemented. Compared to the push-down that drops the nasal pyramid in the nasal cavity, the let-down lowers the pyramid relative to the plane of the face without determining volume inside the nasal cavity. It provides for a double basal osteotomy for the removal of a bony triangle, symmetric or asymmetric according to the needs, and the transverse osteotomy that allows the lowering of the pyramid downward (Video 20.1).
20.5 Complications and Technical Solutions
▶ Table 20.1 discusses points of difficulty and technical solutions.
Possible enlargement of the mucosal perforation during the dissection
Incision of the mucosa around the perforation only at the end of the dissection
Nasal dorsal collapse and keystone area destabilization
Preserve a 0.3-mm dorsal cartilaginous without cutting the upper lateral cartilages
Make a careful graft fixation
Closure of the mucosal perforation without tension
Move wide flaps by making a large dissection toward the insertion of the inferior turbinate and up to the nasal vault
20.6 Case Examples
20.6.1 Case 1
A 32-year-old man presented complaining of whistling and nasal obstruction for many years. The patient tried medical therapy without success. He reported clinical history of nasal chemical or electrical cauterization for epistaxis during childhood. In anterior rhinoscopy, he presented a small-sized perforation of the anterior nasal septum ( ▶ Fig. 20.2). After septum extraction, a further undiagnosed cartilaginous defect appeared posteriorly ( ▶ Fig. 20.3). The patient was successfully operated by the backward extraction-reposition of nasal septum technique. At 1-year follow-up the nasal septum was definitely restored, the patient reported an adequate nasal respiration, and he was satisfied with the results ( ▶ Fig. 20.4).
Fig. 20.2 Rhinoscopic view of the left nasal cavity showing a small-sized and circularly shaped perforation of anterior nasal septum.