The incidence of nasal septal perforation is estimated at 1%. ¹ In fact, the otolaryngologist has to identify the cause, which in most cases is either iatrogenic or idiopathic, to decide the need for surgery and select the most suitable surgical technique of those currently available, for the case under consideration.

Nasal septal perforations are complete defects of the mucosal and cartilaginous tissues of the nasal septum. These defects in the cartilaginous areas of the septum, with direct communication between the two nasal cavities, lead to impairment of the airflow, which is often accompanied by a wide variety of symptoms. Septal perforation may also be detected during routine medical examinations. Anterior and wide septal perforations are more symptomatic, whereas posterior perforations tend to be less symptomatic, due to humidification from the turbinates. While some of the perforations remain unnoticed by patients, in many cases of septal perforations patients suffer from recurrent epistaxis, nasal obstruction sensation, discharge, crusting, dryness, foreign-body sensation, headache, pain, and whistling. Nasal septal perforations differ widely in cause or origin. Symptoms in patients with nasal septal perforations are attributable to a physiologic disturbance in nasal airflow. Instead of the normal, parabolically shaped lamellar flow, the perforation creates turbulent flow, with a resultant decrease in the normal humidification process, resulting in crusting and desiccation of the affected area. Aggressive cauterization of nasal mucosa in epistaxis, self-induced trauma, external trauma, neoplasms (carcinoma, T-cell lymphomas), infectious diseases (e.g., syphilis, diphtheria, and tuberculosis), inflammatory diseases (sarcoidosis, Wegener’s granulomatosis, systemic lupus erythematosus), inhalatory drug abuse, and iatrogenic perforations secondary to nasal septal surgery are possible etiologic factors. ^{2,​ 3}

Management of nasal septal perforations initially requires medical treatment. Patients with significant intranasal crusting can be treated with nasal irrigation and a topical emollient. Dryness can be treated with topical nasal estrogenic spray. ⁴

Symptomatic nasal septal perforations often require surgical treatment. Nasal irrigation and topical ointments do not improve the symptoms of the patients significantly. The use of septal obturator as a silicon grommet prosthesis is often not able to reduce the patient’s symptoms and causes additional problems of foreign bodies in the nose. Resurfacing the defect with respiratory mucosa of nasal origin is the method of choice for closure of septal perforations. Surgical repair of the nasal septal perforation is indeed a difficult challenge for every rhinologist because of the high rate of reperforations. Many surgical approaches for repair of septal perforations have been reported in the literature ⁵ however, the available closure techniques are technically difficult and require experienced surgeons.

This chapter aims to describe and present our experiences with a new and simple surgical technique of endoscope-assisted endonasal approach for the repair of septal perforations.

The blood supply of the middle turbinate occurs by lateral branches of sphenopalatina artery and anterior ethmoidal artery.

10.2 Indications

Our technique suggested 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 areas.

In our opinion, only techniques with nasal mucosal flaps achieve a normal nasal physiology because they use the normal respiratory epithelium for closure. ⁶ Our flaps, despite being monopedicled and often with wide dimensions, never showed a vascular suffering.

Numerous flap designs have been described in the literature. The main factor contributing to a high closure rate was the choice of a flap design, which suited the nasal septal perforation. This choice was dependent on perforation location (anterior or posterior); perforation size (the perforation size is inversely proportional to the amount of viable mucosal available to be used as a flap); ability to preserve the flap’s vascular supply; and availability of viable intranasal tissue to be used as a flap.

A new flap with many advantages in comparison to the other surgical techniques is described in the present study. With this technique, the normal respiratory mucosa of the nose is used for the reconstruction of the anatomy and physiology of the nose. The mucosa of the turbinate shows a good vascularization, which promotes the healing process. An individual adaptation of the size of this mucosal bone flap to the size of the perforation is possible.

10.3 Surgical Steps

1. 
   

   Under general anesthesia, the nasal septum and middle turbinate were injected with 1% lidocaine with 1:100,000 epinephrine solution to reduce intraoperative bleeding.

   
   
2. 
   

   The nose was decongested using xylometazoline HCL (Otrivin) on cotton nasal pledgets. All patients received both intra- and postoperative antibiotics. After 5 minutes decongestion, both the nasal cavities were examined and septal perforation size was measured ( ▶ Fig. 10.1). Each surgical step was performed under endoscopic view.

   
   
3. 
   

   The mucosa around the perforation was then incised circumferentially approximately 3 mm from its edge. Posterior margin of the perforation was easily elevated with a blade by using the tip of 20 G needle whereas angulated instruments were needed for the elevation of mucosal flaps at the anterior, superior, and inferior margins of the perforation ( ▶ Fig. 10.2). The most appropriate middle turbinate was chosen for the surgical procedure, according to its size, location, and CT scan.

   
   
4. 
   

   Chosen turbinate was then lateralized and dissected from the midline started from superior to inferior and anterior to posterior, and turbinate opened like leaf ( ▶ Fig. 10.3).

   
   
5. 
   

   The conchal bone was removed circumferentially approximately 5 mm from its edge. This relaxing excision permits the that includes superiorly conchal bone. The length of the flap was adapted to the size of the septal defect. It is more appropriate to harvest the graft slightly larger than the perforation size. The prepared conchal mucosal flap’s anterior, posterior, and inferior parts were positioned between mucoperichondrial flap and septal cartilage in inferior, posterior, and anterior parts. The flap was then sutured to the septal mucosa of the anterior, posterior, and inferior margins of the perforation, with a reabsorbable suture (5–0 polyglycolic acid) ( ▶ Fig. 10.4). Silastic splints were subsequently placed bilaterally. The nasal splints were removed after 10 days postoperatively in the clinic. Saline nasal drops and antibiotic cream were prescribed to keep the nose moist and clean during the postoperative 30 days period. Endoscopic control of the surgical site was made in this period. After 2 months, flap pedicles in all patients were cut by a scissors under local anesthesia. Bipolar cauterization was used to control bleeding. ▶ Table 10.1 presents some points of difficulty and technical solutions.

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