Technique for Closure of Nasal Septal Perforation
Edmund deAzevedo Pribitkin
INTRODUCTION
Conditions causing bilateral disruption of the opposing nasal septal mucoperichondrium frequently result in necrosis of the underlying septal cartilage resulting in the creation of a nasal septal perforation. Successful treatment of such perforations remains a surgical challenge, including closure of the perforation and restoration of normal nasal function. No single standardized technique exists for closure of all perforations, but successful repairs generally include mucoperichondrial advancement flaps and interpositional grafts of cartilage or connective tissue.
I combine either an endonasal or an open rhinoplasty approach with bilateral advancement flaps of the mucoperiosteum of the floor of the nose and an interpositional porcine intestinal submucosa graft (SurgiSIS ES Cook Surgical, Bloomington, Indiana) to achieve a 90% success rate in closing septal perforations.
HISTORY
Symptoms are generally related to the size and location of the perforation. Patients may complain of nasal congestion and obstruction, nasal crusting and drainage, recurrent epistaxis, a whistling sound on inspiration, and pain. Smaller, posterior perforations tend to be asymptomatic, whereas large, anterior perforations may result in loss of dorsal support resulting in a deformity of the external nose. As perforations increase in size, laminar airflow is increasingly disrupted, resulting in turbulence and a sensation of nasal obstruction. Increased turbulent flow causes drying of the nasal mucosa with a compensatory increase in the production of mucous and complaints of rhinorrhea. Eventually, crusting and bleeding result from an inability of the mucosa to heal overexposed cartilage at the edge of the perforation. Pain often accompanies crusting and bleeding as a result of a chronic, low-grade chondritis.
ETIOLOGY
The etiology of nasal septal perforations can be divided into four categories.
Traumatic Causes
Prior septal surgery is the most common cause of septal perforations. Perforation rates of 17% to 25% have been reported following submucous resection and 1% to 5% following septoplasty in which cartilage is preserved. When a tear in the mucoperichondrium occurs on one side, the intervening cartilage can usually get its blood supply from the opposite, intact membrane. However, when opposing mucoperichondrial flaps have been injured during surgery to remove intervening cartilage, a through-and-through perforation is likely to develop.
Immediate repair of any injured opposing flaps during surgery followed by placement of interposition grafts of cartilage, crushed cartilage, fascia, acellular human dermal allograft (AlloDerm LifeCell, Branchburg, NJ), or porcine intestinal submucosa (SurgiSIS ES Cook Surgical, Bloomington, Indiana) is recommended.
Immediate repair of any injured opposing flaps during surgery followed by placement of interposition grafts of cartilage, crushed cartilage, fascia, acellular human dermal allograft (AlloDerm LifeCell, Branchburg, NJ), or porcine intestinal submucosa (SurgiSIS ES Cook Surgical, Bloomington, Indiana) is recommended.
Other forms of iatrogenic trauma resulting in perforations include prior nasal cauterization or packing for epistaxis, nasogastric tube placement, nasal endotracheal intubation, and chronic use of a nasal cannula. Traumatic perforations may also arise from nose picking, blunt trauma with an untreated septal hematoma, nasal foreign bodies (especially batteries), and nasal fractures with exposed septal cartilage.
Inflammatory/Infectious
Inflammatory and infectious etiologies should always be considered and are often elicited during history taking. Infectious diseases include syphilis, human immunodeficiency virus infection, mucormycosis, and diphtheria. Granulomatous diseases causing perforations include sarcoidosis, Wegener granulomatosis, and tuberculosis. Septal perforations may be present in inflammatory conditions such as systemic lupus erythematosus, Crohn disease, dermatomyositis, and rheumatoid arthritis.
Neoplastic
Carcinomas, T-cell lymphomas, and cryoglobulinemias have been described as presenting with septal perforations. Many patients present with associated pain and tenderness. Biopsy of suspicious mucosal surfaces is indicated.
Inhaled Substances/Toxic Exposures
Inhaling cocaine may lead to septal perforation through the direct actions of adulterants whose toxic effects are heightened by the vasoconstrictive effects of the cocaine. This vasoconstriction decreases normal blood flow to injured areas of the septal mucoperichondrium. Chronic abuse may permanently damage the nasal mucosa and lead to chronic obstruction despite successful repair of perforations.
Physiologic changes in the mucosa may also be seen in perforations resulting from chronic use of oxymetazoline, phenylephrine, or menthol inhalers. Topical corticosteroids have also been implicated in the etiology of septal perforations, especially if applied incorrectly or used extensively following septal surgery.
Individuals who are continuously exposed to chemicals or aerosolized dust in the workplace may develop a septal perforation. Cited exposures include fumes from chromic and sulfuric acid, glass dust, mercurials, and phosphorus. Workers should wear a filter during exposure to irritants to prevent perforation and other toxic respiratory effects.
PHYSICAL EXAMINATION
Physical examination should focus on determining the dimensions and position of the perforation as well as the proportion of the septum involved by the defect. Nasal decongestion and removal of all crusts should enable complete visualization of the septum with rigid or flexible nasal endoscopy. The quality and quantity of the remaining intact mucosa should be assessed along with the amount of persistent cartilage and its relationship to the borders of the perforation. The amount of healthy available donor tissue from the floor of the nose and the mucoperichondrium surrounding the perforation must be determined. The extent of deviation of the remaining nasal septum and the presence of septal spurs must be evaluated.
Suspicious areas of mucosa must be biopsied. Nasal cultures for fungal and bacterial species may be necessary in the presence of an inflammatory process.
Evaluation of the external nose includes palpation to assess the integrity of the nasal dorsum and mechanisms of the tip support. The surgeon must assess the potential for a saddle nose deformity as well as the need for reduction of a dorsal hump to acquire additional mucoperichondrium to help close the perforation.
INDICATIONS
Nasal septal perforations that are symptomatic and have failed conservative medical therapy should be closed. Patients with a nasal septal perforation will generally benefit from a regimen of nasal douching with saline lavages and humidification of their home and work environments. Emollients such as Vaseline or muciprocin 2% may further reduce nasal crusting. Some authors have suggested the use of nasal topical estrogens to reduce mucosal squamous metaplasia and strengthen the vascular supply of the septal mucosa.
CONTRAINDICATIONS
Successful closure of a nasal septal perforation depends largely upon the size of the perforation and the availability of native nasal mucosa for repair. The lack of available, healthy nasal mucosa may make closure of large defects impossible without “borrowing” tissue from outside of the nose. The anterior-to-posterior length of
the perforation is not critical in closure because the greatest degree of tension of the wound is typically from the floor of the nose to the dorsum. However, a perforation that extends to the dorsum or the floor of the nose is almost impossible to repair unless there is some small cuff of membrane to which one can sew an inferiorly based advancement flap.
the perforation is not critical in closure because the greatest degree of tension of the wound is typically from the floor of the nose to the dorsum. However, a perforation that extends to the dorsum or the floor of the nose is almost impossible to repair unless there is some small cuff of membrane to which one can sew an inferiorly based advancement flap.
Patients with a chronic or recurrent disease process, those with persistent intranasal drug (cocaine) usage, and those without adequate donor site mucoperichondrium should be considered candidates for placement of a nasal septal obturator rather than attempting to repair the perforation. A nasal septal obturator can be placed as an office procedure under local anesthesia if there is a straight septum surrounding the perforation. Prostheses are made of a variety of materials including silastic, silicone, and acrylic. The prosthesis may virtually eliminate symptoms of epistaxis, whistling, and nasal obstruction, but crusting, unfortunately, continues and may even increase despite continued local irrigation.
PREOPERATIVE PLANNING
Serologic and Urine Testing
In patients without a definitive cause for the perforation or in patients with rheumatologic complaints, the clinician should place a Purified Protein Derivative (PPD) test for tuberculosis and should obtain the following serologic evaluations: erythrocyte sedimentation rate, rheumatoid factor, antineutrophil cytoplasmic autoantibodies (Wegener granulomatosis), angiotensin-converting enzyme (sarcoidosis), and fluorescent treponemal antibody absorption (syphilis).
A urine drug screen is performed on all patients with a suspected history of intranasal drug use.
Imaging
Computerized tomography (CT) of the paranasal sinuses is recommended for all patients to determine the presence or absence of concomitant paranasal sinusitis and to assist in preoperative planning. Acute exacerbations of chronic sinusitis can jeopardize the success of the SurgiSIS ES grafts. In my experience, approximately one out of ten patients will require functional endoscopic sinus surgery. Typically, this is performed 6 to 8 weeks prior to the repair of the septal perforation to permit complete healing. Imaging also permits more detailed measurements of the available mucoperichondrium in the donor site. Specifically, the width of the mucoperichondrium of the floor of the nose must be 1.5 times the height of the perforation on the coronal view CT to insure success (Fig. 4.1).
Stabilization of Systemic Illnesses
Successful control of diabetes, vasculitides, Wegener granulomatosis, sarcoid, syphilis, and chronic rhinosinusitis must precede surgical intervention. Cessation of intranasal drug use must be confirmed by urine drug screen.
Classification of Perforations and Determination of Operative Approach
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