Abstract
Importance
Repair of nasal septal perforations is challenging regardless of surgical technique due to their location and the health of surrounding tissue. There is currently no surgical procedure which is completely effective in the treatment of anteriorly located perforations.
Objective
To report a novel method of closing anterior septal perforations using an inferiorly based mucosal rotation flap and an acellular dermal interposition graft, as well as expand upon a previous series.
Design
The study includes patients who underwent surgical repair for septal perforations by the senior author between 2003 and 2015.
Setting
The study took place at MetroHealth Medical Center in Cleveland, Ohio.
Participants
Thirty-nine patients (15 male) with septal perforations of various size and etiology underwent endonasal repair using rotation flaps. The average age of patients was 42-years old (range 10–67 years).
Intervention for clinical trials or exposure for observational studies
Five patients had perforations such that we used inferiorly based flaps, while 35 cases utilized posteriorly based flaps. Acellular dermis was used in addition to a unilateral rotation flap.
Main outcomes and measures
The primary outcome desired was a complete closure of the septal perforation. The success, or lack thereof, was monitored after healing from surgery.
Results
Thirty-seven of the forty surgical procedures demonstrated complete closure of the perforation, a 92.5% success rate. Perforations were separated based upon size. Small perforations (< 1 cm) had a 93.3% success rate, medium (1–2 cm) 88.9%, and all seven large perforations (> 2 cm) were closed successfully. In addition, all five of the inferiorly based procedures resulted in complete closure of the perforation. Of the failed repairs, one required revision surgery to repair a recurring perforation, while the other two were asymptomatic following the procedure.
Conclusions and relevance
Endonasal repair using inferiorly based mucosal rotation flaps coupled with an acellular dermal interposition graft is a valid technique for the repair of septal perforations. Posterior rotation flaps are preferred due to major septal blood supply from branches of the sphenopalatine artery, but inferiorly based flaps are also viable options for repair for perforations located in the anterior septum.
1
Introduction
Nasal septal perforations are anatomic defects which allow airflow between the two nasal cavities due to a hole in the bony or cartilaginous septum. The most common symptoms of septal perforations include crusting, epistaxis, impairment of respiration, rhinorrhea, nasal whistling, and reported odor coming from the nose with aggressive symptoms occurring in patients with larger and more anterior perforations . The etiology of perforations is varied, but the majority arise due to iatrogenic injury following nasal or septal surgery. Other frequent causes include trauma, digital manipulation or nasal picking, neoplasm, and infection. Perforations have also developed in patients with nasal ulcers as well as following the inhalation of chemical irritants including cocaine .
Perforations are estimated to be found in 0.9% of the adult population . The portion of perforations which are symptomatic is unclear, but in the experience of the senior author, roughly 85% of cases noted in the office are symptomatic. Despite the prevalence, relatively few patients require surgery overall as symptoms can be treated through conservative approaches, most commonly with saline spray and topical gel or nasal emollients. Placement of nasal buttons has also proven to be effective, though complications can lead to widening of the initial perforation as well as irritation or crusting which may lead to patient discomfort . If conservative measures are not effective, there are many surgical techniques which seek to close the perforation . Surgical technique most commonly depends on the size and location of the perforation. Smaller perforations can often be repaired via an endoscopic approach while larger perforations may require an open septorhinoplasty. External procedures, though an open approach, afford binocular vision and allow for a wider operating field, particularly in the posterior and superior margins of the perforation . Endoscopic approaches, including the one detailed in this paper, create no external scarring and may permit closure of large perforations, but afford less visibility, hence requiring significant skill from the surgeon. There is currently no procedure which can be used to treat every perforation and even the most effective procedures have success rates in the low ninety percentile.
The objective of this work is to expand upon a previous series and describe a novel endoscopic approach utilizing an inferior mucosal rotation flap in combination with an acellular dermal interposition graft in order to provide a minimal tension closure of septal perforations.
2
Patients and methods
After obtaining approval of a MetroHealth Medical Center Institutional Review Board IRB15-00159, we reviewed 39 patients (15 male) who underwent septal perforation repair using the technique described between 2003 and 2015. 40 procedures were identified, and one patient was included as a revision procedure. The average age was 42 years old (range 10–67 years). Etiology was varied ( Table 1 ) with previous septal surgery being the most prevalent. The most common presenting symptoms reported were epistaxis, crusting, and rhinorrhea.
| Age (years) | Gender | Etiology | Size (cm) | Category | Technique | Result |
|---|---|---|---|---|---|---|
| 21 | Female | Septal surgery | 0.5 | S | Post | Successful |
| 30 | Female | Chemical exposure | 1.0 | M | Post | Successful |
| 32 | Female | Traumatic | 1.5 | M | Post | Successful |
| 34 | Female | Septal surgery | 3.0 | L | Post | Successful |
| 40 | Female | Septal surgery | 0.5 | S | Post | Successful |
| 42 | Female | Traumatic | 0.7 | S | Post | Successful |
| 44 | Female | Traumatic | 1.0 | M | Post | Successful |
| 47 | Female | Traumatic | 0.5 | S | Post | Successful |
| 48 | Female | Septal surgery | 1.0 | M | Post | Successful |
| 56 | Female | Cocaine | 1.5 | M | Post | Successful |
| 37 | Male | Traumatic | 0.3 | S | Post | Successful |
| 38 | Male | Septal surgery | 0.8 | S | Post | Successful |
| 43 | Male | Septal surgery | 0.4 | S | Post | Successful |
| 44 | Male | Traumatic | 1.0 | M | Post | Successful |
| 46 | Male | Septal surgery | 1.5 | M | Post | Successful |
| 26 | Male | Septal surgery | 1.0 | M | Post | 0.1 cm persistent perforation |
| 43 | Male | Septal surgery | 0.6 | S | Post | 0.1 cm persistent perforation |
| 47 | Male | Septal surgery | 1.5 | M | Post | 0.2 cm persistent perforation |
| 53 | Female | Traumatic | 1.5 | M | Post | Successful |
| 59 | Male | Septal surgery | 0.3 | S | Post | Successful |
| 10 | Female | Septal surgery | 2.0 | L | Post | Successful |
| 18 | Female | Septal surgery | 0.6–0.8 | S | Post | Successful |
| 41 | Female | Trauma | 1.5 | M | Inf | Successful |
| 22 | Male | Septal surgery | 2.0 | L | Post | Successful |
| 44 | Female | Trauma | 0.8 | S | Post | Successful |
| 63 | Male | Cocaine | 2.5 | L | Post | Successful |
| 51 | Female | Septal surgery | 2.0 | L | Post | Successful |
| 43 | Female | Cocaine | 1.7 | M | Post | Successful |
| 53 | Male | Septal surgery | 0.8 | S | Post | Successful |
| 41 | Female | Septal surgery | 0.3 | S | Post | Successful |
| 57 | Male | Septal surgery | 1.7 | M | Inf | Successful |
| 33 | Female | Cocaine | 1.0 | M | Post | Successful |
| 67 | Female | Trauma | 2.0 | L | Inf | Successful |
| 32 | Female | Trauma | 1.5 | M | Inf | Successful |
| 56 | Female | Trauma | 1.9 | M | Inf | Successful |
| 66 | Male | Septal surgery | 1.5 | M | Post | Successful |
| 56 | Male | Cocaine | 2.0 | L | Post | Successful |
| 31 | Male | Trauma | 0.2 | S | Post | Successful |
| 33 | Female | Cocaine | 0.5 | S | Post | Successful |
| 39 | Female | Trauma | 1.5 | M | Post | Successful |
Perforation size was determined based on the largest transverse diameter, measured using a 0-degree nasal endoscope and paper ruler or more accurately by distance tools on radiological images in cases where CT imaging was available. Perforations ranged in size from 0.2–3.0 cm. In total, 7 perforations were deemed to be large perforations (> 2.0 cm), 18 medium (1.0–2.0 cm), and 15 small (< 1.0 cm). The overall mean was found to be 1.2 cm. Comorbidities and known allergies were documented.
2.1
Technique
The technique for posteriorly based rotation flap repair has been previously detailed in prior work . In brief though; a septoplasty incision allows a sheet of acellular dermis to be slid beneath the mucosa and perforation on one side, while a posteriorly based rotation flap is incised on the opposite side ( Figs. 1, 2 A ). The hearty posterior septal branch of the sphenopalatine artery is the presumed blood supply for a posteriorly based flap.
