The nasal septum plays a critical role in both the function, as well as the aesthetics, of the human nose. Structurally, the septum forms the foundation of the nasal pyramid and acts as the central support element of the nose, providing support for the cartilaginous and soft-tissue components of the nose and nasal cavity. Functionally, the nasal septum, and its relation with the upper lateral cartilages, forms a critical portion of the internal nasal valve. Disorders of the nasal septum can therefore cause both structural and functional morbidity to the patient.
Nasal septal perforations can be a source of great morbidity to a patient. Structurally, nasal septal perforations may weaken the foundational support of the nasal pyramid so as to cause significant aesthetic deformities. Functionally, septal perforations alter the airflow through the nasal cavity, which in turn may lead to crusting, epistaxis, and pain.
With these morbidities in mind, it is imperative that the rhinoplastic surgeon be thoroughly comfortable with the management of nasal septal perforations. In this chapter, we review the relevant anatomy, etiology, pathophysiology, and management of nasal septal perforations. A review of the different surgical techniques will be discussed as well the appropriate indications for each approach.
Relevant Anatomy
The nasal septum divides the nose into two separate nasal cavities. Each nasal cavity is bounded by the nasal septum, lateral nasal wall, and nasal floor. The nasal septum is composed of a bony and cartilagenous framework covered by a layer of mucoperichondrium and mucoperiosteum. The bony components of the septum include the nasal crest of the palatine bone, the nasal crest of the maxilla and premaxilla, the vomer, the perpendicular plate of the ethmoid, the nasal crest of the frontal bone, and the spine of the paired nasal bones. The anterior septum is composed of the quadrilateral cartilage, with its caudal most projection extending beyond the nasal spine.
The lateral nasal wall is composed of the laminae papyracea of the lacrimal bone, portions of the ethmoid bone, and the inferior and middle nasal conchae or turbinates. The inferior, middle, and superior turbinates are composed of a thin bone for structural support and covered by an adherent mucoperiosteum. Stratified squamous epithelium is found on the anterior tip of the inferior turbinate, whereas pseudostratified ciliated columnar respiratory epithelium covers all other surfaces.
Knowledge of the blood supply to the septum and lateral nasal wall is important for designing mucosal flaps for septal perforation repair. Blood supply and innervation of the nasal septum travel within the mucoperiosteal and mucoperichondrial linings. The arterial blood supply derives from the ophthalmic branch of the internal carotid artery and the maxillary and facial branches of the external carotid artery. The upper nasal septum is supplied by anastomoses of the anterior and posterior ethmoid arteries, which originate from the ophthalmic branch. The external carotid artery contributes via a major branch of the sphenopalatine artery that supplies the posterior and inferior septum. The columella and caudal septum receive blood supply from the septal branch of the superior labial artery. The septal mucosa itself contains complex arteriovenous anastomoses and venous sinusoids that can become engorged or constricted via neural or extrinsic pathways.
The blood supply to the lateral nasal wall is supplied posteroinferiorly by the sphenopalatine artery via the posterior lateral nasal artery and by the anterior and posterior ethmoid arteries superiorly. The posterior lateral nasal artery runs inferiorly on the perpendicular plate of the palatine bone and courses downward at approximately 1 cm anterior to the posterior end of the middle turbinate and approximately 1.5 cm anterior to the posterior end of the superior turbinate. The posterior lateral nasal artery occasionally gives off branches to the superior turbinate and is the predominant supplier of blood to the middle and inferior turbinates.
The arterial supply to the inferior turbinate runs in a direction parallel to the turbinate and nasal floor. Thus, in cases where relaxing incisions are needed to gain length on a mucoperichondrial flap, these incisions should be made immediately below the inferior turbinate bone so as to avoid arterial disruption.
Incidence and Etiology
The incidence of nasal septal perforations in adults is 0.9%. In a retrospective review of 74 patients with nasal septal perforations and ulcers, Diamantopoulos and Jones found that 80% of perforations were seen anteriorly, 11% were located posteriorly or superiorly, and 9% were classified as total or subtotal. Although the size of the perforations varied, the majority (39%) had a perforation size of 1 to 2 cm in diameter with an almost equal distribution of perforations less than 1 cm and greater than 2 cm. Crusting, minor bleeding, and erythema were the most common findings on initial presentation.
The etiology of nasal septal perforations is quite varied ( Table 37-1 ). The most common cause of perforation is the result of previous septal surgery. Other causes include nose picking, cocaine use, vasculitis, malignancy, and idiopathic. Proper workup of a patient with a nasal septal perforation should include a thorough history with specific attention to questions that address the wide differential diagnosis.
| Traumatic | Inflammatory/Infectious | Neoplastic | Other |
|---|---|---|---|
| Nasal surgery | Sarcoidosis | Carcinoma | Lime dust |
| Intranasal steroid sprays | Wegener granulomatosis | T-cell Lymphomas | Cryoglobulinemia |
| Nose ring piercing | Leishmaniasis | Renal failure | |
| Cauterization for epistaxis | Systemic lupus erythematosus | Industrial exposure | |
| Nose picking | Tuberculosis | Nasogastric tube placement | |
| Syphilis | Dermatomyositis | ||
| Nasal cannula oxgen | AIDS | ||
| Nasal foreign body | Diphtheria | ||
| Illicit drugs | Rheumatoid arthritis | ||
| Crohn disease |
The history should be followed by a complete nasal endoscopy with documentation of the size and location of the perforation as well as any other findings such as crusting, bleeding, or granulation tissue. The septum should also be inspected to assess the degree of remaining cartilage. This can be assessed by gentle palpation with a cotton swab. In terms of laboratory studies, if the patient does not have a history to suggest a traumatic etiology, then a c-ANCA, antinuclear antibodies, rheumatoid factor, and erythrocyte sedimentation rate tests are sufficient. If any of these are positive, then a rheumatology referral may be warranted.
The previously accepted dogma that all septal perforations should be biopsied has recently come into question. Several studies have shown that septal biopsies have very little diagnostic value. Frequently, septal perforation biopsies are nondiagnostic even in the case of known vasculitis or malignant disease. It is therefore suggested that in patients with a clinically unremarkable septal perforation, even in the absence of a diagnostic history, biopsy of the edges does not add to the management of the patient and should not be performed. Biopsy should be reserved for patients in whom a clinical suspicion of malignancy exists and repeated biopsies may be needed to confirm the diagnosis.
Morbidity of Nasal Septal Perforation
Patients with nasal septal perforations commonly have a dry and obstructed nose. They also may complain of crusting, bleeding, and a whistling noise during breathing. Pathophysiologically, the airflow jet is directed toward the posterior aspect of the perforation. This leads to an increase in airflow turbulence, which in turn causes desiccation, bleeding, and crusting. These complaints are usually associated with anterior, rather than posterior, perforations. The reason for this finding is that by the time the nasal airflow reaches the posterior nasal cavity, it is sufficiently conditioned at that point. Likewise, smaller perforations are less likely to cause symptoms as would large ones.
Lindemann et al. studied the effects of closure of septal perforations on intranasal humidity and temperature. In a prospective study of 10 patients, surgical closure of the perforation was shown to have a statistically significant increase in nasal airway humidity and temperature. Moreover, clinical symptoms of recurrent epistaxis and nasal dryness were shown to improve after repair. The study provides further evidence to support the proposed mechanism that intranasal dryness secondary to turbulent airflow with septal perforations is responsible for the morbidity of this condition.
Management of Nasal Septal Perforations
The first step in the management of nasal septal perforations is to determine whether the perforation needs to be closed. Often, small perforations are asymptomatic and can be left alone. Also, patients with nasal septal perforations may have chronic rhinosinusitis and their symptoms may be attributable to this condition rather than to the perforation. In these circumstances, appropriate medical therapy may provide more benefit than closure of the perforation.
If the patient’s symptoms are minor with minimal crusting, then the use of saline sprays or topical petroleum jelly may be sufficient. With more severe crusting, saline irrigation or similar sinus rinses may be needed.
For the patient who does require closure of the septal perforation, two options exist: mechanical obturation and surgical closure.
Nonsurgical Approaches
The mainstay of nonsurgical treatment of septal perforations is the silicone button. Since the 1970s, the use of both prefabricated and custom prostheses has shown some benefit. Recently, Blind et al. studied the impact of custom-made silicone buttons on the quality of life of patients with septal perforations. Their results demonstrated that the use of the silicone obturator led to a decrease in epistaxis, crusting, whistling, dryness, and obstruction in a majority of patients. Moreover, the majority of patients who used the obturator had improved quality of life scores as evidenced with use of a validated questionnaire. The glaring finding in the study was that only 38% of the patients still used their obturator after the follow-up period. The most common reasons given for not using the obturator included difficulty with positioning button, pain, and enlargement of the perforation, rendering the obturator obsolete.
Surgical Approaches
As Kridel has stated, the goals of septal perforation repair are closure of the perforation and restoration of normal nasal physiology. To achieve these goals, the surgical approach must be tailored for each specific perforation. The size and location of the nasal septal perforation will thus dictate whether to approach repair via a closed or open technique, whether to use an interpositional graft, or which vascular flap to use for repair.
The majority of septal perforations that require surgical closure fall into two main categories: small- to medium-sized anterior perforations and large central perforations. Small posterior perforations are usually asymptomatic and rarely require surgical intervention. The following is a review of several techniques used to repair both types of perforations. The review has been written to provide the reader with an overview of the different approaches and we recommend referring to the original reports for further details on each specific technique.
Small- to Medium-Sized Anterior Perforations
Repair of nasal septal perforations can be achieved by creating well-vascularized transpositions flaps to close the septal defects. Several authors have described their varying techniques and success with these procedures.
De Witt has described the use of a composite flap of mucoperichondrium and a “button” of cartilage at the posterior septum. The flap is created with the base at the flap centered at the posterior edge of the perforation. This composite flap is then rotated into the perforation site as a door hinge. Neighboring mucoperichondrium is then elevated to close the donor site. The author stated success with this method on two patients.
In a similar fashion, Shikowitz describes using a mucoperiosteal flap harvested from the bony septum, which is rotated anteriorly to repair the septal defect. In addition, acellular dermis and occasional autogenous cartilage is used to support the flap. Ninety percent of patients had successful repair of their perforations, with all patients having resolution of their symptoms.
Friedman et al. described their approach and experience with the inferior turbinate flap that was previously described by Vuyk and Versluis. Their indication for use of this flap is for small- to medium-sized perforations. Using nasal endoscopes, the inferior turbinate is incised from a posterior to anterior direction with the pedicle of the flap at the anterior portion of the turbinate. The flap is then rotated anteriorly and sutured to the rimmed perforation. Any exposed bone of the donor site is removed. The pedicle is then taken down 3 weeks later under local anesthesia. Seven of 10 patients had successful closure of their perforation, and one patient required radiofrequency ablation of a bulky flap.
The inferior turbinate flap provides a well-vascularized local flap for repair of small- to medium-sized nasal septal defects. However, disadvantages of this technique are that it requires at least two staged procedures and may lead to nasal obstruction from a bulky flap even after the pedicle is taken down.
Repair of small- to medium-sized anterior perforations can also be achieved by extracting and repositioning the quadrangular cartilage, a technique that was initially described by Sulsenti. In this procedure, the quadrangular cartilage is extracted and then replaced with the perforated end first. This places the perforation in a more posterior location, which no longer matches the perforation in the mucoperichondrium. Local mucoperichondrial flaps are then used to allow a tension-free closure at the perforation site. In a recent series, 87% had successful closure of the perforation at a minimum of 2 years from the time of surgery. However, successful closure was obtained in only 60% of the patients with a greater than 1-cm perforation.
Several authors have described using oral mucosal flaps to repair nasal septal perforations. Both sublabial and buccal flaps have been used with varying degrees of success. In general, the flap is harvested and tunneled into the nasal cavity at the gingivolabial sulcus. Meyer describes a three-staged procedure in which a buccal flap is secured to a conchal cartilage graft. The pedicle is then taken down at a later date. Kogan et al. describe their technique of using a medially based sublabial flap without the use of an interpositional graft. The flap is secured into place with absorbable sutures and the donor site is closed, obviating the need for a second procedure to transect the pedicle. They report a 71% success rate based on their experience with seven patients.
Large Perforations
For the repair of large nasal septal perforations, the creation of a large, well-vascularized flap that is not overly bulky is a challenge. Several surgeons have described techniques to accomplish this goal.
Paloma et al. report the use of a pericranial flap to reconstruct large septal perforations. Via a bicoronal incision, a pericranial flap consisting of periosteum and subgaleal fascia is raised and rotated caudally 180 degrees over the supraorbital rim. The flap is tunneled under the glabella inserted into the nasal cavity after detachment of the upper lateral cartilages. The flap is based on the deep branches of the supraorbital and supratrochlear vessels. The advantage of this approach is that it provides a well-vascularized flap of autogenous tissue with an adequate size to repair large septal defects.
Reports of using a free flap for subtotal septal defects have been documented. The free flap is anastomosed to the facial artery and vein and tunneled under the upper lip. The flap is inset via an open rhinoplasty approach. This technique is reserved for large perforations in which local tissue for repair is unavailable.
Pedroza et al. reviewed their experience of 100 septal perforation repairs. Their technique shares many of the same principles as several other authors in the literature. The authors use a “postcartilaginous” incision via a closed approach, unless the perforation is greater than 2 cm, in which case the procedure is performed via an open rhinoplasty approach. Bilateral mucoperichondrial flaps are raised at the septum, nasal floors, toward the attachment of the inferior turbinates, and superiorly toward the junction of the upper lateral cartilages and septum. A temporalis fascia graft is harvested and used as an interpositional graft between the mucoperichondrium layers. If tension is found at closure, relaxing longitudinal incisions are made at the floor and superiorly if needed. Their overall success rate of closure was 97%, with 100% closure with perforations less than 2 cm. The follow-up period ranged from 1 to 10 years.
Which Interpositional Graft to Use?
In a study by Mola et al., New Zealand rabbits had varying materials placed in their nasal septum. Histologic analyses were performed at 3 months. Gore-Tex (Implantech Associates, Ventura, CA) was found to cause the most severe inflammatory reactions, followed by Dacron and acellular dermis (Alloderm; Lifecell, Branchburg, NJ). Autogenic cartilage demonstrated the least immune response.
The use of porcine small intestinal submucosa (SurgiSIS; Cook Biotech Inc., West Lafayette, IN) for the repair of septal perforations has also been shown to be effective. With the use of SurgiSIS positioned between two mucoperichondrial flaps, the authors reported a 100% success rate of closure in 10 patients. In an adjunctive study on rabbits, the placement of SurgiSIS interpositioned between mucoperichondrial flaps demonstrated evidence of cartilage regrowth.
Personal Surgical Technique
Tissue Graft Selection
Closure of a septal perforation requires the reconstruction of the three layers of the missing septum: bilateral mucosal layers and a connective tissue layer to replace missing cartilage. Interposition grafts have traditionally been composed of either temporalis fascia or pericranium. More recently the use of human acellular dermal grafts (Alloderm) have become increasingly popular due to the fact that they avoid the time and morbidity of harvest as well as the generally thicker nature of the material that eases its use as an interpositional graft.
Graft selection is based on at least two competing concepts. The use of pericranium and temporalis fascia has a theoretically improved success rate over autologous cartilage, due to the rapid neovascularization of these thinner tissues, as well as the lower metabolic activity of these grafts. Alternatively, however, much of the success of closure of the septal perforation relies on complete closure of the perforations. Due to the consistent fact that most closures fail at the point of the suture line, the structural scaffolding of human acellular dermis allows remote mucosalization from the edge of the mucosal flaps. This is important in clinical situations where small, unilateral defects due to incomplete closure or wound breakdown persist after repair. The strength of the acellular dermal graft serves as scaffolding for mucosa to heal upon. In the senior author’s experience, these small unilateral and occasionally bilateral defects in the mucosa will fill in from the mucosal wound edge much as remucosalization occurs over exposed bone and cartilage after septoplasty.
When autografts are harvested, the harvest should include a generous amount of temporalis fascia or pericranium that will allow overlay at least 1.5 cm beyond the cartilaginous defect. The harvests of these grafts have been well described and are techniques that most otolaryngologists, facial plastic surgeons, and plastic surgeons are familiar with (i.e., in the harvest of grafts for tympanoplasty).
Operative Approach
While endonasal approaches have been popularized in the past, they are rarely appropriate for most septal perforations except those that are small, low, and anterior, due to the limit of exposure for larger perforations and patients with small nostrils.
The success rate is also affected by size of the perforation, with larger perforations requiring broader undermining of surrounding mucosa to recruit into the defect. This requires extensive exposure necessitating an external approach. Septal perforation repair is one of the most technically difficult procedures to obtain consistent success due to the delicate nature of the tissues, oblique angle of visibility that occurs through most of the surgery, many pitfalls for enlarging the perforation, and production of rents in the mucosal flap as the surgery proceeds. Patient selection is also very important as perforations over 1.5 cm in vertical height, especially in small noses, often do not have sufficient nasal mucosa to allow complete closure. In addition, if the septal perforation is due to cocaine abuse, the vascularity of the tissue involved may be permanently compromised. Preoperative screening may be necessary to ensure the surgeon that the patient has discontinued cocaine, as ongoing use will likely condemn the perforation repair to failure.
At the time of surgery, the patient is placed in the supine position. General endotracheal intubation with a RAE (Ring-Adair-Elwyn) tube is performed and the throat is packed with saline-moistened gauze. The nose is injected with 1% lidocaine with 1 : 100,000 epinephrine, as is standard in an external rhinoplasty approach, with infiltration of all septal and nasal mucosa. The patient is then prepped and draped in the usual sterile fashion, and careful intranasal examination is performed to confirm the office examination. Any existing synechiae are identified, and the extent of the cartilaginous septal defect, which may be masked by mucosa, is inspected using a 0-degree endoscope and contralateral palpation of the septum.
Marginal incisions are then performed with a No. 15 blade, as well as a transcolumellar incision in an inverted-V fashion using a No. 11 blade. The soft tissue envelope is then undermined and a wide local exposure is begun by sharply disarticulating the intercrural ligaments and exposing the anterior and caudal septum. Meticulous dissection is required throughout the procedure so as not to perforate the septal flaps. Careful entry into the full submucoperichondrial plane on both sides of the septum is performed sharply with careful attention not to weaken the anterior and caudal septum with multiple knife cuts. A Cottle elevator is then used to create a tunnel underneath the upper lateral cartilages on both sides of the septum. The upper lateral cartilages are then sharply dissected along the dorsum. This may be performed with a No. 15 blade on to the Cottle elevator or with sharp straight Iris scissors. Next, elevation of the mucosal flaps is begun toward the perforation with elevation of the mucoperichondrium surrounding the perforation. The rim of the perforation is incised with a No. 15 blade along its posterior, superior, and inferior edge, and careful blunt dissection is then performed from the remaining septal cartilage toward the perforation to avoid enlargement of the septal defect.
The mucosa of the floor of the nose is then elevated in a submucoperiostial plane. This is performed by first creating a small incision along the ridge of the inferior piriform aperture. Blind dissection is then performed in a subperiostial plane with the Cottle elevator extending up underneath the inferior turbinates and posteriorly. Once this is broadly elevated on both sides, decussation of fibers is performed sharply at the point where the maxillary crest and cartilaginous septal intersection is carefully divided, with careful attention again not to perforate the septal flaps. Backcuts are made underneath the inferior turbinate for the full length of the turbinate with a No. 15 or Beaver blade. Connection of this incision to the subperiosteal plane of the mucuperiosteal flap is then made to increase their mobility and advance them as a bipedicled flap into the defect. Once there has been complete release of the mucoperiosteal flaps, the cartilaginous defect is addressed with the use of either autograft or allograft. The graft is placed with adequate overlap. It is then sutured first anteriorly with two septal mattress sutures using 5-0 chromic suture to anchor the graft. It is then unfurled over the septal cartilaginous defect and sutured posteriorly as well. Septal flaps are then advanced superiorly toward the superior edge of the defect ( Figure 37-1 ). The advancement of the flaps is not strictly in a vertical direction as membranous septum is recruited for its laxity in many cases, such that an anterior-to-posterior direction advancement also occurs ( Figure 37-2 ).
