Nasal Septal Button Placement 

Perforations of the nasal septum (see images below) are more often asymptomatic but can lead to a host of distressing symptoms. Larger anterior lesions are more likely to affect nasal laminar air flow and be symptomatic.^[1] Posterior perforations tend to be less troublesome because of humidification of the nasal mucosa and turbinates. Crusting and epistaxis are the most frequently noted symptoms, but difficulty breathing, pain, rhinorrhea, and postnasal discharge are also common.^{[2, 3]} Small anterior lesions may cause a whistling sound with inspiration.^[4]

Approximately 40% of perforations are caused by nasal surgery. External and intranasal trauma, cocaine use, cautery, and chemical inhalants are less frequent etiologies. Infection, lupus erythematosus, Wegener granulomatosis, sarcoidosis, and Osler-Weber-Rendu disease should also be considered.^[3]

The initial management of septal perforations is to correct the underlying causative process and encourage natural healing of the lesion. Conservative treatment usually consists of emollients and humidification.^[4] For patients with persistent symptoms, surgical closure or placement of a septal prosthesis are available options.^{[5, 6]} The techniques and success rates of different closure techniques vary considerably in the literature.^{[5, 7]}

Septal buttons have been commonly used since the 1970s and may be placed in an office setting under local anesthesia. Buttons have been made from acrylic and plastic in the past but are now primarily made of soft silicone (Silastic; see image below).^[8] Prefabricated buttons are typically 2-piece units with a flexible hub and pliable discs which allow them to adapt to the curvatures and irregularities of the septum.^[8] These can be placed as temporary or long-term treatment and do not preclude future surgical closure. Septal buttons are also an option for those in whom surgery may be contraindicated because of age, comorbidities, or underlying pathology.

Most patients experience improvement or resolution of epistaxis, difficulty breathing, pain, and whistling after placement of nasal septal buttons. However, less than half experience improvement in rhinorrhea and postnasal drainage,^[3] and improvement in crusting is variable.^{[4, 3]} Patient intolerance was usually due to local irritation, nasal obstruction, or accumulation of inspissated secretions. Patients who requested removal usually did so within 6 months.^[2]

Several recent studies have examined outcomes when using computed tomography (CT) to custom-fit septal buttons. These techniques are particularly useful for large (>3 cm) perforations in which adjacent soft tissue to secure the button in place is limited. A precise fit is necessary to avoid movement of the button, which can enlarge the perforation and allow the button to be dislodged.^{[3, 9]} Button loss after 5 years was often due to button breakdown, but this exceeds the normal wearout period for Silastic.^[3] Additionally, CT-fabricated buttons may improve symptoms to a greater degree than traditional obturators.^[9]

• Septal button insertion is an elective procedure for symptomatic nasal perforations.^[2]

• Septal deviations are relative contraindications to button placement, since they may cause poor fit against the septum. Absence of the nasal spine also makes for a difficult fit.
• Additional contraindications include patients with active infections of the nasal cavity, patients who actively use intranasal drugs, or patients who have perforations that are raw or actively bleeding. These patients require workup of an autoimmune, infectious, and malignant process.

• Anesthetize the nasal mucosa with 1% lidocaine and 1:1000 epinephrine solution on gauze or surgical patties. Alternatively, lidocaine, tetracaine, or cocaine sprays may be used, although cocaine has fallen out of favor because of adverse effects and required regulatory control (see Anesthesia, Topical).
• Some patients, particularly those with very tender nasal passages, may require light sedation.
• For more information, see Anesthesia, Nose.

• Topical anesthesia
• Fiberoptic headlight illumination
• Nasal speculum
• Gloves
• Silastic button
• Scissors
• Silk suture, 2-0
• Hemostat
• Piece of paper, 4 X 4 cm
• Marking pen

• Patients should be sitting comfortably in the office chair if this procedure is being performed in an office setting.

• Measure the septal defect along with the upper and lower limit of the septum by inserting a piece of paper in one nostril and laying it long the septum. The size of the perforation can be marked from the other nostril using a marking pen.
• Trim the flanges of the button to lie equidistant between the perforation and the upper and lower limits of the septum. Smooth the edges of the flanges. See images below. Endoscopic view of a nasal septal button from the right nasal airway. Black dots outline septal perforation. Red dots outline septal button. Endoscopic view of a nasal septal button from the left nasal airway. Black dots outline the septal perforation. Red dots outline the septal button.

Technique 1

• Use the pursestring technique on a 2-0 silk suture (Mersilk, Ethicon, Scotland) to collapse one disk of the silastic obturator 3 mm from the circumference of the disk, with approximately 8-mm spaces between each puncture site. Tie the suture, which results in the disk assuming a concertina shape.
• Loop the silk suture around the concertina and tie a second knot, which further collapses the disk.
• Grasp the undeformed disk of the silastic obturator with artery forceps and introduce it into one naris with the knotted end of the silk suture placed anteriorly.
• Advance the collapsed disk through the septal perforation with fiberoptic headlight illumination.
• Once in situ, cut the silk suture with scissors and remove the suture. This results in the silastic disk returning to its original shape.
• If any further manipulation of the obturator is necessary, it can be carried out at this point.
• Postoperative care is with regular steam inhalations for the first 2 postoperative weeks.^[10]

Technique 2

• Make a slit in one of the flanges from the outer edge to the hub.
• Insert the septal button in one nostril with the slit side toward the septum.
• Deliver the tip of one of the slit edges through the perforation with a Jobson-Horne probe.
• Hold the introduced edge from the other side with a hemostat. With the help of another hemostat, rotate the introduced edge in a corkscrew fashion until all of the flange is in the other nostril. Rotate the flange further so that the slit end faces the nasopharynx.^[11]

Technique 3

• Introduce the well-lubricated button into the narrower nasal passage until the anterior-most free margin of the disk, intended to be passed through the perforation, presents itself in the middle of the perforation.
• Grasp the free margin with a curved hemostat and pull it through the septum toward the contralateral, wider side.
• Rotating the button along its central axis allows it to optimally adapt to the contours and surfaces of the septum.^[8]

Postplacement care

• The patient should apply normal saline irrigation 3 times daily and nasal cream twice daily.
• Regular steam inhalations are recommended for 2 weeks.

• All tissue margins of the perforation must be adequately covered to minimize crusting and bleeding.^[2]
• If the flanges are left too large, they can touch the area where the lower lateral cartilages are inserted into the septum. This can cause pain and discomfort.^[11]

• A few cases of displacement of the prosthesis posteriorly into the nasopharynx have been reported. The prostheses remained there and were retrieved uneventfully.^[2]