Management of nasal septal perforation

Management of nasal septal perforationSeptal perforation repair, a multilayered reconstruction done in a hostile environment, is a challenge to surgeons.. The central concepts in septal

Management of nasal septal perforation

Septal perforation repair, a multilayered reconstruction done in

a hostile environment, is a challenge to surgeons A successful

repair requires a thorough search for the cause of perforation,

selection of an appropriate surgical candidate, and meticulous

surgical technique The central concepts in septal perforation

repair include wide elevation, tension-free suture lines, multi-

layer closure, and humidification In this article, the recent liter-

ature on the pathophysiology of, medical management of, and

advances in surgical technique for nasal septal perforation are

reviewed Curr Opin Otolaryngol Head Neck Surg 2000, 8:58–62 © 2000

Lippincott Williams & Wilkins, Inc.

Department of Otolaryngology, University of California, Davis, Sacramento,

California, USA

Correspondence to: Brad Strong, MD, University of California, Davis,

Department of Otolaryngology, 2521 Stockton Boulevard, Suite 7200,

Sacramento, CA 95817, USA; tel: 916-734-5573; fax: 916-456-7509; email:

ebstrong@ucdavis.edu

Current Opinion in Otolaryngology & Head and Neck Surgery 2000,

8:58–62

ISSN 1068–9508 © 2000 Lippincott Williams & Wilkins, Inc.

Septal perforation repair remains a challenge for the otolaryngologist It is often needed in a nose that has already undergone surgery and has limited tissue and a

compromised blood supply Patients may have self-induced traumatic perforations or an undetermined disease process that must be identified and treated before the perforation can be successfully managed These factors can lead to frustration on the part of the surgeon and even to reperforation after successful surgi- cal repair

The size of the perforation is important to the success of closure The height of the perforation correlates closely with the degree of difficulty of the repair Larger perfo-rations require greater tissue mobilization and can result

in greater tension on the closure The height at which closure rates decline substantially has not been clearly elucidated in the literature, but most authors place it between 2.0 and 3.0 cm [1••,2••,3] When perforations of all sizes are evaluated, historical closure rates range from 64% to 95% [2••]

We examine the pathophysiology of septal perforations, the medical management of perforations before surgery and in nonsurgical cases, and the surgical approach used when operative intervention is chosen We review

a variety of grafting materials and techniques and present comments from our personal experience

Pathophysiology

The central pathophysiologic phenomenon in septal perforation is turbulent airflow Disruption of normal laminar airflow results in the formation of crusts at the edges of the perforation This starts the cascade of inter- related symptoms that accompanies septal perforation

(Table 1) Dryness leads to crusting, which prompts bleeding, malodorous drainage, and obstruction Infection follows the stasis of secretions at the perfora-tion and contributes to pain Whistling is a direct result

of airflow through and around the perforation and completes the symptom profile Typically, patients with anterior perforations are more symptomatic than patients with posterior perforations

Cause and diagnosis

Septal perforation has numerous causes (Table 2), the most common of which is nasal trauma This can result from blunt or penetrating injury or from routine digital manipulation Unfortunately, iatrogenic injury

is also a

common cause of septal perforation Postoperative 58

Management of nasal septal perforation Coleman and Strong 59

Table 1 Symptoms of nasal septal perforation

Dryness

Symptomatic crusting

Epistaxis

Whistling

Malodorous drainage

Nasal obstruction

plasma reagin test, venereal disease research laboratory test, or fluorescent treponemal antibody absorption test (FTA-ABS) and a purified protein derivative

The inflammatory disorders most commonly associated with septal perforation are Wegener’s granulomatosis Paranasal pain and sarcoidosis [5] Both are granulomatous diseases,

and it may be difficult to distinguish between them clin- ically Generalized tests that may suggest a diagnosis of perforations are related to opposing tears in the

mucoperichondrial flaps, cauterization injuries, or

vascu-lar compromise from flap elevation [4] Accurate

diagno-sis of traumatic injuries depends on a thorough

history and review of previous surgical notes

Inhaled irritants can also lead to perforation Cocaine is

the irritant most often associated with perforation,

but over-the-counter decongestants and nasal steroids

have also been implicated Irritants lead to perforation

either

through a direct caustic effect or through

vascular compromise Again, a complete and honest

history can elucidate the diagnosis It is imperative

that use of the inhalants be discontinued before

surgery is considered

If persistent drug abuse is suspected, the surgeon

should consider drug testing before surgery

Bacterial infections are another cause of septal perfora-

tions Nasal pain and purulent nasal discharge are

charac-teristic findings Culture results can be

misleading because they can represent superinfection

or other flora in the nasal cavity Nonetheless, patients

with positive

cultures should receive appropriate

antibiotics Perforations can also result from fungal

infections, partic- ularly in immunocompromised

patients The diagnosis may be suggested by history

and culture but is confirmed by biopsy All biopsy

specimens should be sent while fresh; this allows the

pathologist to differentiate between

fungal infections and lymphomas Other infectious

causes of septal perforation include tuberculosis and

syphilis The appropriate serologic tests include rapid

Wegener’s granulomatosis or sarcoidosis include chest radiography, urinalysis, computed tomography

of the sinuses, and measurement of chemistry levels Specific serologic tests include cytoplasmic antineutrophil

anti-body (cANCA) for Wegener’s granulomatosis and angiotensin converting enzyme (ACE) for sarcoidosis The definitive diagnosis is made by pathologic analysis The hallmark of Wegener’s granulomatosis is vasculitis; sarcoidosis shows noncaseating granulomas

The final cause to be discussed is neoplasm Biopsy is

central to the diagnosis of neoplasm and, if clinical suspicion is high, biopsies should be repeated until a pathologic diagnosis can be made One neoplasm seen is

polymorphic reticulosis, also known as lethal

midline granuloma or idiopathic midline destructive disease This neoplastic process probably represents a

low-grade T-cell lymphoma Histologic examination shows focal necrosis as well as acute and chronic inflammation This may result in confusion with Wegener’s granulomatosis, but immunohistochemical staining confirms the correct diagnosis

In summary, a thorough history and physical examina- tion are central to determining the cause

of a perfora- tion When a diagnosis is questionable, appropriate labo- ratory and imaging studies are indicated The surgeon should culture and biopsy the perforation Biopsy speci- mens should be sent while fresh, and biopsy should be

repeated if a definitive diagnosis cannot be made Laboratory tests include complete blood count, chem-istry panel, FTA-ABS, cANCA, and ACE Imaging studies should include chest radiography and computed Table 2 Causes of nasal septal perforation

tomography of the sinuses A thorough search for the Trauma

Previous surgery

Cauterization Nose

picking Inhaled

irritants Cocaine

Snuff

Neoplasm

Inflammatory diseases

Sarcoidosis

Wegener’s granulomatosis

Other collagen vascular diseases

Infection

Bacterial

Fungal Syphilis

cause of the perforation

should be made before repair

is considered

Medical management

The keys to medical

management of septal

perforation

are hydration and

improvement of laminar airflow Hydration can prevent dryness and crusting Moist mucosal surfaces promote laminar airflow and limit the

cascade of symptoms mentioned above The best program for medical therapy includes several types of hydration Saline spray should be used as needed Propylene glucol, 200 ml, may be added to 800 ml of

Tuberculosis normal saline to increase the viscosity of the spray and

60 Nose and paranasal sinuses

enhance its effectiveness Water-based emollients with

or without antibiotics can also be applied to the

nasal vestibule as needed for more severe crusting

The second option for medical management is a silastic

“septal button.” The button is trimmed to fit the

perfo-ration and fills the defect, providing a mechanical

barrier Trimming and placement of the button is most

easily done while the patient is under sedation or

general anesthesia The button limits turbulent airflow

and decreases symptoms in some patients

Unfortunately, crusts may collect at the button’s edges,

leading to difficulties with nasal hygiene [6]

Medical therapy is appropriate for the long-term

manage-ment of numerous perforations and symptom profiles In

our own experience, small perforations located posteriorly

in the septum and very large perforations are less

sympto-matic Medium-sized perforations and those located

ante-riorly tend to be more symptomatic The surgeon must

objectively decide whether surgery should be offered to

the patient In almost all cases, a trial of medical

manage-ment is indicated Medical managemanage-ment often decreases

mucosal inflammation and makes tissues more receptive

to surgical intervention

Surgical management

Historically, buccal mucosal, skin, and dermal

grafts have been used to repair septal perforations

Although these grafts often resulted in closure of the

perforation,

they compromised mucociliary flow within the

nose The nonciliated grafts led to crusting and

perpetuated many of the symptoms experienced

before surgery Over the past 20 years, several key

principles of septal

perforation repair have been elucidated (Table 3)

Today, the emphasis is not simply on closing the

hole

but on using native tissue to create a multilayered

closure with minimal tension

Surgical approaches

Many approaches to septal repair have been described

The endonasal approach, done using a standard Killian

or hemitransfixion incision, provides good access

for smaller perforations However, it severely limits

expo- sure and mucosal elevation, making it less

appropriate

for larger perforations [11] The open rhinoplasty

approach gives the surgeon excellent exposure and

binocular visualization of the mucosal flaps and septum

[12] Lateral alotomy can be used by itself or in

combi-nation with the endonasal approach It makes manipula-tion of instruments easier and placement of sutures more accurate Midface degloving has been advocated for very large perforations to allow wide visualization and ease of instrument manipulation [13]

Mucosal elevation

As in any flap closure, the extent of mucosal elevation is greater than the distance to be closed This is a key prin-ciple in septal perforation repair The goal is tension-free closure of at least one mucosal flap The inferior elevation must extend across the floor of the nose and under the inferior turbinate The mucosa may even be elevated off of the turbinate itself The superior elevation should extend across the top of the septum, releasing the mucosa from the undersurface of the nasal vault (Fig 1) Once elevation is achieved, relaxing incisions should be placed at the base of each flap This leaves a bipedicled flap with anterior and posterior attachments and greatly increases superior–inferior mobility The releasing incisions may be placed bilaterally on the nasal floor (inferior flap) because these flaps do not coapt The releasing incision on the superior flap can be placed only unilaterally If septal cartilage is exposed bilaterally, a second perforation will result Care should be taken to avoid complete release of the mucosa from the upper lateral cartilages because this can lead to postoperative

“pinching” of the nasal dorsum [1•] Once the native tissue has been widely mobilized, a tension-free closure can be made on the side of the bilat-eral releasing incisions An attempt should be made to reduce the size of the perforation on the contralateral side This delicate suture placement can be facilitated by

the use of Castroviejo needle drivers (Xomed, Jacksonville, FL, USA)

For very large septal perforations, the concept of tissue expansion was recently introduced Using a tissue

Figure 1 Axial section through nasal cavity

Sutured septal flap

Interposition connective tissue graft

Table 3 Principles of surgical repair

Aggressive mucosal mobilization

Multilayer closure with interposition graft

Tension-free closure of at least one mucosal flap

Application of postoperative silastic sheeting Agressive postoperative humidification: saline irrigations and emollients

Advanced nasal mucosal Septal cartilage remnant flap from floor

Coronal cross-section of the nose showing aggressive flap elevation, tension- free closure of septal mucosa, and grafting material sandwiched by mucosal flaps.

Management of nasal septal perforation Coleman and Strong 61

expander on the floor of the nose, Romo et al [2••] have

generated up to 5 cm of additional mucosa to be

used with the inferior mucosal flap

Grafting materials

Complete closure of both mucoperichondrial flaps

is rarely achieved A graft placed between the

mucosal flaps serves as a second tissue layer and

prevents apposi- tion of opposing suture lines It also

provides a second

layer of defense if the primary closure should

break down Numerous materials have been used

for closure of septal perforations Temporalis muscle

fascia (deep temporal fascia) is the most common

The harvesting technique is well known to

otolaryngologists, and the incision can be hidden in

the hair or behind the auricle

Pedicled temporoparietal fascia (superficial

temporal fascia) flaps have also been described for

the repair of septal defects [7] Unfortunately, the

temporoparietal fascia flap requires a large scalp

incision, is difficult to raise, is at a site distant from

the septum, and can be difficult to suture into place

Near the temporalis fascia are the periosteum and

mastoid cortex These can also

be harvested through a postauricular incision The

periosteum provides a thin, malleable graft that

is similar in consistency to temporalis muscle fascia

The mastoid cortex provides a rigid graft but

requires substantially more harvest time and

equipment because the bone must be drilled free

and thinned before use

[3] The mastoid cortex graft also requires coverage with

a fascial graft before placement Thus, it has

limited popularity Other graft materials include

conchal carti- lage and tragal perichondrium Harvest

of these

materi-als has minimal donor site morbidity but provides

limited tissue

The nose often provides grafting materials Septal

carti-lage and bone supply thick grafts that are

easily harvested within the surgical field It is

preferable to wrap the bone or cartilage with fascia to

prevent expo- sure of the graft Disadvantages include

limited quality

and quantity of grafting material In our

experience, previous iatrogenic trauma often results

in insufficient donor material from the septum

Texas) for septal perforation repair This material is prepackaged in a variety of sizes and thicknesses It

is rehydrated during elevation of the mucosal flaps and has

enough rigidity to allow for accurate placement

It requires no donor site incision, is easy to shape, and can be sewn into position without difficulty Studies have shown that Alloderm provides an excellent matrix for

re-epithelialization of cutaneous and mucosal wounds [9,10] No cases of viral transmission or immunoreactiv- ity have been reported

Diligent postoperative care is as important as meticulous surgical technique After graft placement, silicone sheet-ing is placed bilaterally to protect the flaps This main-tains moisture at the graft site, prevents trauma to the flaps, and may help with mucosal migration The patient

is instructed to continue aggressive hydration with saline spray, antibiotic emollient, and humidification The silicone sheeting is carefully removed after 2 weeks

Conclusions

Over the years, septal perforation repair has been done using myriad techniques The recent literature reports success rates as high as 93% [2••] However, a realistic and honest approach should be taken with each patient, depending on the size of the defect

A thor- ough search for the cause of the perforation should be

done, and careful surgical judgment should then

be applied to each case We prefer the open rhinoplasty approach with generous exposure Bipedicled mucosal

flaps are approximated on one side, and perforation size is reduced on the contralateral side Temporalis muscle fascia has been our grafting material of choice,

but lack of donor site morbidity makes Alloderm an option that we use

References and recommended reading

Papers of particular interest, published within the annual period of review, have been highlighted as:

• Of special interest

•• Of outstanding interest

1 Kridel RWH, Foda H, Lunde KC: Septal perforation repair with acellular

•• human dermal allograft Arch Otolaryngol Head Neck Surg 1998, 124:73–78.

Vascularized free tissue transfer for the repair of septal

perforations was recently described The radial

forearm fascial flap provides a large, vascularized graft

[8] The disadvantages of this graft are related to

the

significant increase in surgical time, the donor

site defect, and the need for pedicle protection during

the healing phase The temporoparietal free fascial

graft has not been described but is another choice for

a thin fascial flap

Recently, Kridel et al [1••] introduced acellular human

dermal graft (Alloderm; LifeCell Corp., The Woodlands,

This is an excellent “how to” article with good illustrations and clear instructions.

2 Romo T 3d, Sclafani AP, Falk AN, Toffel PH: A graduated approach to the

•• repair of nasal septal perforations Plast Reconstr Surg 1999, 103:66–75 This very good summary article includes a description of tissue expansion for closure of large defects.

3 Nunez-Fernandez D, Vokurka J, Chrobok V: Bone and temporal fascia graft for the closure of septal perforation J Laryngol Otol 1998, 112:1167–1171.

4 Bent JP, Wood BP: Complications resulting from treatment of severe posterior epistaxis J Laryngol Otol 1999, 113:252–254.

5 Baum ED, Boudousquie AC, Li S, Mirza N: Sarcoidosis with nasal obstruc- tion and septal perforation ENT J 1998, 77:896–902.

6 Facer GW, Kern EB: Nasal septal perforations: use of the silastic button in

108 patients Rhinology 1979, 17:115–120.

62 Nose and paranasal sinuses

7 Delaere PR, Guelinckx PJ, Ostyn F: Vascularized temporoparietal fascial

flap for closure of a nasal septal perforation: report of a case

Acta

Otorhinolaryngol Belg 1990, 44:47–49.

8 Murrell GL, Karakla DW, Messa A: Free flap repair of septal perforation

Plast Reconstr Surg 1998, 102:818–821.

9 Wainwright DJ: Use of an acellular allograft dermal matrix (Alloderm) in the

management of full thickness burns Burns 1995, 21:243–248.

10 Shulman J: Clinical evaluation of acellular dermal allograft for increasing the

zone of attached gingiva Pract Periodont Aesthet Dent 1996, 8:201–208.

11 Fairbanks DN, Fairbanks GR: Nasal septal perforation: prevention and management Ann Plast Surg 1980, 5:452.

12 Kridel RWH, Appling D, Wright WK: Septal perforation closure utilizing the external septorhinoplasty approach Arch Otolaryngol Head Neck Surg

1986, 112:168–172.

13 Romo T, Jablonski RD, Shapiro AL, McCormish SA: Long term nasal mucosal tissue expansion use in repair of large nasoseptal perforation Arch Otolaryngol Head Neck Surg 1995, 121:327–331.