Indications
Symptomatizing nasoseptal perforation not responding to conservative treatment.
The size of perforation should be small to moderate.
The inferior turbinate should be hypertrophic or normal but not atrophic or previously excised.
Fibrosis of the septal mucosa or adherent mucosa (bipedicled or advancement flaps are difficult or impossible to elevate). In these cases this technique can be applied, as it does not imply elevation of much mucoperichondrium.
9.2 Surgical Steps
The repair is performed under general anesthesia using a closed endonasal endoscopic approach.
The mucoperichondrium on both sides and the inferior turbinate on the one side are infiltrated using 1/200,000 adrenaline with 1% lidocaine. A caudal septal incision (hemitransfixion) is made on the one side and subperichondrial dissection starts from anterior to posterior until the septal perforation is reached.
The edge of the perforation is entered and the dissection continues above and below the perforation.
At this point an endoscope (0 degree, 4 mm) is used. The edge of the perforation is incised superiorly, posteriorly, and inferiorly using a number 12 scalpel blade, and a tunnel is created by dissecting between the mucoperichondrium of both sides and between the mucoperichondrium and the septal cartilage on the one side ( ▶ Fig. 9.1).
A partial inferior turbinectomy is performed. The inferior turbinate graft is then flattened, taking care not to disturb its continuity ( ▶ Fig. 9.2).
Vicryl 4/0 sutures are used to fix the graft in place within the tunnel. The first stitch is made posteriorly by taking one bite about 5 mm posterior to the posterior edge of the perforation and the other bite into the graft. The graft is then approximated to the perforation and tucked into place as the stitch is tightened ( ▶ Fig. 9.3).
The graft is positioned between the mucoperichondrium of both sides and between the mucoperichondrium and the cartilage of the one side. The graft is fixed by more stitches positioned superiorly, inferiorly, and anteriorly ( ▶ Fig. 9.4, ▶ Fig. 9.5).
The anterior septal incision is then closed, and Silastic splints are applied to protect the graft and prevent adhesions. They are removed after 1 week ( ▶ Fig. 9.6).
This technique has the following advantages:
The use of respiratory mucosa is physiologic, avoiding dryness that is the disadvantage when labial mucosa or skin grafts are being used.
The ease of harvesting the graft and accessibility of the donor site.
The graft is vascular and strong with easy handling, and leaving a part of turbinate bone adds to the support of the repaired area.
There is limited mucoperichondrium elevation with no flap needed that means an easier procedure with no fear of further tear of the mucoperichondrium and mucoperiosteum or alteration of blood supply while elevating the flaps. This is of value especially if the septal mucosa is damaged because of excessive fibrosis or previous surgery.
The use of this technique avoids tension on suture lines, which is the case when advancement or rotation flaps are being used.
No need for a second-stage surgery to separate the flap from the donor site and no possibility of nasal obstruction secondary to bulky flaps.
Fig. 9.1 Dissection between mucoperichondrium of both sides (small circles). Middle turbinates (stars). Inferior turbinates (arrowhead). Remnant of sepal cartilage (arrow).
Fig. 9.2 Inferior turbinate graft is prepared and flattened with remnant of bone (arrow).
Fig. 9.3 A diagram showing the first stitch taken in the posterior margin of the perforation and the graft. As the suture is tightened, the graft is tucked in place.
Fig. 9.4 A diagram showing the graft in place.
Fig. 9.5 The graft (arrow) is in place with sutures. Septum above and below (stars). Inferior turbinate (triangle). Middle turbinate (diamond).
Fig. 9.6 One-week follow-up of the free graft.
Leaving a raw area on the one side is not a drawback as the septal mucosa was found to creep and cover the raw area within 3 to 5 weeks. 1, 2, 3
Previously, similar technique using inferior turbinate composite graft was described in which the margin of the perforation was elevated using 20 G needle bent into appropriate angle for about 3 to 4 mm circumferentially. The latter technique was also performed in an endonasal endoscopic approach. The inferior turbinate graft was harvested such that two layers of turbinate mucosa and part of turbinate bone are included. This way of using the graft and the absence of septal incision are the differences between this technique and the one described previously. The same authors described another technique for larger perforations. A hemitransfixion incision was used and bipedicled flaps created and sutured with interposition of inferior turbinate graft. 4
The same endonasal endoscopic approach and the steps described previously were applied using inferior turbinate graft with the addition of temporalis fascia to cover the raw surface of the inferior turbinate. This includes hemitransfixion incision and trimming the margin of perforation with a sickle knife in a preliminary study. 5
Cassano described a technique using a combined endoscopic endonasal approach and a hemitransfixion incision. On the one side the advancement or rotation flap was created to close the defect. On the other side the mucoperichondrium was elevated and an inferior turbinate graft was applied. 6
The mucosal regeneration technique was described using auricular conchal cartilage with perichondrium as a graft. While using open rhinoplasty approach, mucoperichondrium was elevated; the graft was shaped to fit the cartilage and bone defect and sutured to the remaining cartilage and bone without creation of advancement or rotational flaps. The mucosal defect was closed by secondary healing (over the graft was left for regeneration and reepithelization by the surrounding septal mucosa). This approach is similar to cartilage tympanoplasty waiting for remnant of the tympanic membrane to heal over the graft. 7, 8 Although the mucosal regeneration technique was described using an open rhinoplasty approach, it would be possible to perform it endoscopically.
Conchal cartilage in combination with temporalis fascia is also described as a suitable graft in literature. Using this technique, the edge of the perforation is elevated by endonasal endoscopic approach and the graft is placed and fixed by bioabsorbable staples. 9
Auricular conchal cartilage was also used as an interposition graft. The mucoperichondrium and mucoperiosteum were widely elevated up to the choana, nasal dome, and nasal floor. A vertical posterior and/or horizontal inferior relaxation incision can be added. The graft is kept in place by absorbable sutures to the residual septum. 10
Autogenous septal graft (cartilage or bone) from behind the perforation was used as a graft. A pedicled local mucoperichondrial flap was created in the one side and the other side of the defect was left to heal secondarily. 11
The residual septal cartilage or bone coated by quadriceps fascia was used for repair of septal perforation. In the same study middle turbinate free graft was also used in addition in larger perforation. Using endoscopic-assisted intranasal approach, the incision and dissection of the mucoperichondrium and mucoperiosteum is more or less the same as the steps described previously but with removal of crest of maxillary bone. No stitches were used. 12
A technique using acellular dermis as a graft without the creation of local advancement or rotation flaps was described. A piece of medium-thickness acellular dermis was used to cover the defect by undermining the graft under the elevated mucoperichondrium. Bilateral Silastic splints were placed to hold the mucoperichondrium and the graft in place with one transseptal suture. No sutures were used to fix the graft and the defect was left for mucosalization by the surrounding mucoperichondrium. 13
Acellular human dermal allograft was also used to repair septal perforation by endonasal endoscopic approach. A hemitransfixion incision is used to raise the mucoperichondrium on the one side and a rotational flap was created on the other side. The allograft was inserted between the cartilage and mucoperichondrium in underlay fashion on the opposite side. 14
9.3 Case Example
A 45-year-old man with history of septal surgery 2 year ago was forwarded to our department. The patient presented nasal crusts with nasal obstruction and recurrent epistaxis. These symptoms did not improve on conservative treatment.
Nasal endoscopic examination demonstrated medium-sized septal perforation. No signs of past turbinal surgery were found and endoscopic approach with free graft was taken. Left hemitransfixion incision was made with dissection of the mucoperichondrium. Partial inferior turbinectomy was undertaken and the graft was fashioned. The inferior turbinate graft was flattened and tucked in place as described previously. The first stitch was made posteriorly by taking one bite about 5 mm posterior to the posterior edge of the perforation and the other bite into the graft. Silastic splints were left in place for 1 week. Daily nasal douches and ointments were recommended. It was noticed that raw surface of the graft is covered by mucosa within 8 weeks ( ▶ Fig. 9.7). Complete closure of the perforation was achieved with no further symptoms ( ▶ Fig. 9.8).
Fig. 9.7 Raw surface of the graft is covered by mucosa within 8 weeks.
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