Septal Perforation - Surgical Aspects Treatment & Management

Symptoms caused by septal perforations may be managed with saline nasal irrigations or regular humidification to reduce crusting. Patients who complain of pain and dryness at the perforation site often experience an improvement with antibiotic ointment or a petroleum-based ointment applied intranasally a few times a day. Although nasal hygiene and lubrication may provide some symptomatic relief, progressive enlargement of the septal perforation is a continued risk with medical therapy alone.^[22]

The nasal septal prosthesis (ie, button) is the most conservative approach (see the image below). It may serve as a temporary or long-term solution, especially in patients who may have a comorbid condition that precludes them from undergoing surgical treatment. The prosthesis has been available since the 1970s and may be placed in the office setting.

Prostheses are available in a variety of materials (eg, acrylic, plastic, silicone). The basic design is that of 2 flat disks connected to a central solid hub. In general, placement requires that the septum, anterior and posterior to the perforation, is relatively straight. Sometimes, a simple septoplasty may be necessary to straighten the septum surrounding the perforation before the prosthesis is placed. Insertion is not always easy. New devices have been made with flexible disks and hubs to improve accommodation of any irregularities of the neighboring septum.

Insertion begins with topical nasal decongestion and anesthesia. The perforation can be measured by placing a piece of white paper on 1 side and marking the perforation from the other side. Disks may be trimmed but must remain larger than the perforation. The button is lubricated well, passed into 1 side, and grasped with a clamp and pulled through the contralateral side. Ensure the flanges fit against the upper lateral cartilage–septum junction, and avoid pressure against the septal floor. Two-piece buttons (each with a flange, 1 with a male end and the other with a female end) can be used for small perforations.

For irregularly-shaped perforations, Federspil et al have reported on the use of custom-made septal buttons, formed by the surgeon using silicon and an intranasal cast as a template.^[2] He reports success in symptom relief and patient satisfaction using this technique.

CT has been used as a tool to accurately tailor custom silicone buttons. This technique is specifically helpful for large (> 3cm) perforations. A durable prosthesis must to fit precisely into large perforations because of a lack of surrounding soft tissue on which to hinge it.

Repair techniques can be classified broadly into several groups, from the most conservative to the most radical. These techniques include prosthetic devices, local mucosal flaps, 2-stage procedures, and free-flap repair. In current practice, most reconstructions entail the use of bilateral mucosal flaps with an interposition graft of connective tissue. Some specific techniques are outlined below, followed by detailed explanation of how septal perforations are dealt with at select institutions.

Preoperative evaluation is crucial for providing the best procedure for the patient at the proper time. A small posterior perforation may not cause any symptoms and likely does not require correction. Comorbidity (eg, uncontrolled diabetes, heavy tobacco use) may decrease the likelihood of successful surgical repair secondary to vascular compromise. Systemic causes, malignancy, or any other ongoing process must be excluded prior to repair. CT of the paranasal sinuses may be indicated to evaluate for the presence of concomitant paranasal sinus disease.

The surgeon must stabilize the nasal mucosa and decrease inflammation before repair is contemplated. Success of the repair depends on the condition of surrounding tissues, cartilage, and blood supply. Proper nasal hygiene plays a vital role in success and requires patient cooperation. This care includes lavage with frequent saline nasal irrigations or water picks; application of emollients; weekly nasal toilet, including suctioning and debriding of crust; use of nasal steroids; and antibiotic treatment for infection.

Local Flaps

Many patients with symptomatic perforations seek surgical repair to avoid the long-term care necessary with the prosthesis. Various flaps of local endonasal mucosa have been described in the literature. Knowledge of the vascular supply is paramount for success. Mucosal flaps may be taken from nearby healthy septum or from the inferior turbinate and pedicled posteriorly. Posteriorly based mucoperichondrial flaps have been described. A bilateral, hinged technique leaves 1 side pedicled superiorly and the other side pedicled inferiorly, creating donor defects at nonopposing sites.

Tardy proposes a sublabial mucosal flap.^[3] Advantages to this procedure include a large amount of available mucosal tissue, minimal patient discomfort, and relative technical ease of the procedure. The ipsilateral mucoperichondrium is elevated 0.5-0.8 cm around the perforation to achieve fresh bleeding edges, which are controlled with epinephrine-soaked pledgets. The upper lip is then exposed, and the ipsilateral buccal mucosa is raised and pedicled medially just lateral to the frenulum and 15-20% larger than the defect. A midline sublabial-nasal fistula is created, and the flap is then tunneled beneath the mucoperichondrial flap.

In 1980, Fairbanks described bipedicled mucosal advancement flaps with an underlying connective tissue autograft (ie, temporalis fascia, fascia lata, external oblique fascia) for support.^{[4, 5]} Twenty patients were followed for 7 years. The success rate, which was measured as the relief of symptoms and complete closure of the perforation, was 95%. Defects as large as 3 cm were closed. Large (> 4-cm) perforations were deemed inoperable due to inadequate local mucosa to cover the defect.

In 1986, Bridger described a 2-procedure plan. For perforations smaller than 2 cm, a posterior inverting septal flap composed of mucoperiosteum from the bony septum is used and the now-exposed bone is left to granulate.^[6] This procedure was successful in 7 of 8 patients. For defects larger than 2 cm, a 2-stage nasolabial skin flap is used, similar to that used in head and neck cancer surgery for anterior floor-of-mouth defects. The flap is introduced into the nasal passage through a facial incision. The second stage involves dividing the pedicle. The procedure was successful in 2 patients.

Kridel has popularized the external septorhinoplastic approach.^[7] This method allows direct access to the usually undisturbed dorsal septum, it allows for improved exposure to the superoposterior portion of the perforation, and it affords binocular vision and frees both of the surgeon's hands. Septal mucoperichondrial advancement flaps are combined with a supporting graft, usually mastoid periosteum, cartilage, or ethmoid bone. In 22 patients from 1981-1983, Kridel reported a 77% complete closure rate, including defects as large as 4 cm, and symptomatic improvement in all 22 patients.

His recent reports utilizing an acellular human allograft as the supporting graft showed upwards of 90% closure in perforations up to 3 cm. In patients in whom the defect was too large to be closed primarily, Kridel noted remucosalization in most patients, resulting in complete closure or significant reduction in the perforation after 3 months.^[20]

Freidman et al described an inferior turbinate flap pedicled anteriorly.^[8] This technique is particularly advantageous for caudal septal perforations that are difficult to close by using local advancement flaps. Abundant vascular tissue can be harvested and rotated to cover large defects. Moreover, this is relatively simple endoscopic alternative for difficult septal perforations. A bullous middle turbinate pedicle flap, recently described by Kazkayasi, decreases nasal obstruction prior to pedicle transaction and shows promising results.^[19] However, patient follow up and case numbers are limited at this time.

Daneshi et al utilizes a titanium membrane with an open rhinoplasty approach for repair. Bilateral mucoperichondrium is elevated around the defect. Nasal floor mucoperiosteum is elevated up to the inferior turbinate and any dorsal hump is removed to provide extra mucosa. A titanium membrane is placed at the septal defect and the mucoperichondrium is closed primarily. If primary closure is not possible, the flaps are reapproximated with quilting sutures in order to allow mucosalization of the membrane. Perforations up to 3 cm were closed with this technique, and, after 1 year, 8 out of 10 patients had complete mucosalization. All 10 patients reported decrease in symptoms at 1 year following surgery even if complete mucosalization had not occurred.^[18]

For more extensive perforations, the use of facial artery musculomucosal (FAMM) pedicled flaps has been described. The flap is raised along the intraoral course of the facial artery (demarcated with Doppler imaging) to the gingivobuccal sulcus region. A full-thickness skin graft harvested from the posterior auricular region lines the distal raw of the musculomucosal flap. The flap is then tunneled into the nasal cavity and sutured into the defect. Heller and others reported their experience with 6 patients by using FAMM flap reconstruction for septal perforations larger than 2 cm. Complete symptom resolution and full closure of the septal perforation was noted in 100% of patients who were followed up for a mean of 17 months.

Authors' Selected Technique

A 3-tier comprehensive approach is used with the patient under general anesthesia. The images below show schematic representations of a graduated approach to the repair of nasal septal perforations. Anterior perforations smaller than 0.5 cm are closed by means of a transnasal approach by using opposing septal mucosal flaps similar to the aforementioned techniques. Perforations larger than 0.5 cm and smaller than 2 cm are routinely corrected with a transnasal approach by using the extended external rhinoplasty technique. This alteration in the standard approach for external rhinoplasty eliminates the need to dissect between the medial crura and membranous septal flaps, enabling direct visualization of the caudal nasal septum.

A 2-stage procedure is performed for perforations larger than 2 cm or when additional endonasal mucosa is needed for closure. First, tissue expanders are placed bilaterally under the nasal floor mucosa. Next, the expanders are removed by means of a midface degloving approach, and the perforation is closed by rotating the bilateral, posteriorly pedicled flaps.

Defects 0.5-2 cm

First, the nose is packed with Merocel sponges (Xomed, Jacksonville, Fla) soaked with 3 mL of 0.25% phenylephrine solution. Then, the nasal and paranasal soft tissues are injected with 1% lidocaine with 1:100,000 epinephrine. A transcolumellar incision is made at the columella-philtrum junction and carried inferiorly under the feet of the medial crura. It is carried posteriorly to meet the caudal septum. Elevation of the entire columella improves maneuverability and eliminates the lower lateral cartilages from impeding exposure. A full transfixion incision is performed through the membranous septum over the anterior septal angle. Columella and medial crural flaps are elevated superiorly by using a single hook to expose the caudal septum.

By using a no. 15 scalpel or round otologic knife, the perforation is incised along its circumference and bilateral posterior tunnels are developed. Any deviated septal cartilage or bone is straightened or removed. Next, with a Cottle elevator, the mucoperichondrium is elevated superiorly to the septal–upper lateral cartilage junction, anteriorly to the caudal septum and inferiorly to the maxillary crest. A transverse mucosal incision is now made from the nasal spine across the anterior nasal sill onto the lateral pyriform aperture to the level of the inferior turbinate insertion.

A curved Cottle elevator is now used to elevate the nasal floor and inferior meatus mucoperichondrium posteriorly to the junction of the hard and soft palate. Dissection continues laterally to the insertion of the bony inferior turbinate stalk and medially to the maxillary crest. Densely adherent fibers are incised with fine scissors or a scalpel in an anterior-to-posterior direction. After the inferior turbinate is infractured, a full-thickness incision is carried through the inferior meatal mucosa, just inferior to the turbinate insertion. At the posterior portion of the incision, a back-cut is made toward the nasal floor to facilitate medialization of the posteriorly based floor and inferior meatal flaps.

Intranasal mucosa is now freed from the upper lateral cartilages and nasal floor and up to the inferior turbinate. Posteriorly based mucosal flaps are medialized, with the inferior edge of the perforation advanced to the superior edge. Mucosal edges are then closed posterior to anterior using interrupted 5-0 Vicryl sutures. To reduce tension on the superior flap, a unilateral incision may be needed in the mucosa near the junction of the septum and upper lateral cartilage to create a bipedicled flap and allow for inferior displacement of the superior flap.

An AlloDerm (LifeCell, Branchburg, NJ) decellularized dermal matrix graft is used as an interposition graft between the opposing mucosal flaps. AlloDerm has several advantages, including the elimination of donor site morbidity, an unlimited size, and convenience. The material comes packaged in a freeze-dried form, which, on rehydration, becomes soft, pliable, and suturable. The graft is sutured to the septal cartilage superior to the perforation on one side with 5-0 Vicryl sutures and draped to completely cover the defect. Mucoperichondrial flaps are placed into position, and the exposed nasal floor is covered with a previously harvested full-thickness postauricular skin graft. The graft is secured to the nasal sill and medialized mucosal flap with interrupted 5-0 Vicryl sutures. Placing these skin grafts over the exposed bone of the nasal sill helps prevent vestibular stenosis.

The intercartilaginous and transfixion incisions are closed with 4-0 chromic sutures, and the columellar incision is closed with 6-0 nylon sutures. Bilateral silastic sheeting is secured to the flaps with a single 4-0 nylon mattress suture. Finally, both sides are packed with Telfa pads over Merocel sponges.

Large defects

A 2-stage procedure is performed when closure requires additional endonasal mucosa, usually with perforations larger than 2 cm. In the first stage, small tissue expanders are placed beneath the bilateral nasal floor mucosa, with the peripheral ports placed onto the premaxillary fossae. An incision is made in the mucosa of the anterior nasal sill and carried laterally onto the pyriform aperture. The nasal floor and inferior meatal mucosa are raised using a curved Cottle elevator.

A 1 X 3-cm tissue expander (PMT AccuSpan, Chanhassen, Minn) is inset into the nasal-floor pocket. Maximal gain of 5 cm in flap length can be expected when an expander of this size is used. Premaxillary soft tissues are elevated through the pyriform mucosal incision. Peripheral ports are placed onto the maxilla and connected to the expander, paying particular attention to not kink or bend the tubing. Next, 0.2 mL of sterile saline dyed with methylene blue is instilled into the peripheral port to enlarge the expander. The mucosal incision is closed with interrupted 4-0 chromic sutures, and no nasal pack is used.

Two weeks later, 0.5- to 1-mL aliquots of sterile saline are intraorally injected into the peripheral port. Transcutaneous injections may be performed but typically require an infraorbital nerve block with local anesthesia. Expansion typically requires 6-8 weekly injections to reach a final volume of 4-7 mL.

The second stage entails a midface degloving approach to fully expose the endonasal vault and septal perforation. Bilateral tissue expanders are removed, and posteriorly based expanded mucosal flaps are raised and medialized. The perforation is closed (as described earlier) over an AlloDerm graft.

Bilateral intercartilaginous incisions are connected to a complete transfixion incision. Intercartilaginous incisions are extended laterally and inferiorly into the nasal floor and sill region, where they are connected to the transfixion incision. Next, a complete gingivobuccal sulcus incision is made between the right and left first upper molars by using cautery. The osseocartilaginous nose is then degloved over the upper lateral cartilages and nasal bones. By using sharp scissors, the gingivobuccal and intranasal incisions are connected from 1 pyriform aperture across the nasal spine to the contralateral side.

The maxillary face is stripped with a periosteal elevator, identifying the pyriform aperture and infraorbital nerves. Tip structures and the upper lip are retracted superiorly, and the last remaining tissue connections lateral to the pyriform aperture and upper lateral cartilages are divided with cutting cautery. Midface degloving is now complete, isolating the nasal fossae at the level of the pyriform apertures, nasal valve, and septal angle. The nasal tip, upper lip, and midface are retracted superiorly and secured with 0.5-in Penrose drains.

The nasal floor and inferior meatal mucoperiosteum are elevated in a manner similar to that previously described, with additional removal of tissue expanders and peripheral ports. Posteriorly based expanded intranasal flaps are medialized to close the perforation (as described above).

Midface soft tissues are reapproximated, and intranasal incisions are closed with 4-0 and 5-0 chromic sutures. A 3-0 chromic suture is used in a running fashion for the intraoral incision. The previously described nasal pack is placed.

All packing and external splints are removed on the seventh postoperative day, but the internal nasal silicone stent is removed at the fourth to sixth postoperative week. Patients receive maintenance therapy with nasal saline irrigations to decrease crusting and to maintain a moist environment for healing.

Septal prosthesis

Follow-up requires routine nasal irrigation and nasal toilet every few months for an indefinite period. Forewarn patients that constant nasal toilet is required.

Surgery

Patients are examined postoperatively every week for nasal toilet until crusting subsides.

Septal prosthesis

Failures may be related to poor fit, patient intolerance, or poor hygiene. They occur usually within the first few months. Any mobility of the button may lead to enlargement of the perforation.

Surgery

Potential postoperative complications include repeat perforation, vestibular stenosis, nasal deformity, and oronasal fistula.

Septal prosthesis

In 22 patients from 2 institutions (ie, New York Eye and Ear Infirmary, University of California Medical Center), septal prosthesis were placed in conjunction with septoplasty. Successful maintenance has been achieved for as long as 21 years in 21 patients. One patient required removal of the prosthesis secondary to complaints of pressure against the junction of the upper lateral cartilage and septum. Two patients underwent reinsertion of new prostheses because the original prostheses were too small and were expelled during sneezing.

Surgery

Thirty-six patients have undergone repair by using 1 of the 2 approaches: (1) Fourteen patients underwent extended external rhinoplasty, with total closure noted in 13 patients (93%). One patient had a small inferior septal perforation; at 1 year after surgery, this patient underwent second closure for symptomatic whistling. (2) Twenty-two patients underwent midfacial degloving, and 18 (82%) were had total closure at 1 year. Four patients had repeat perforation at the posterior superior margin. However, to date, none has required revision. Other than repeat perforation, no clinically significant complications including vestibular stenosis, nasal deformity, and oronasal fistula, were encountered.

In 1997, Murrell et al described the first reported use of a radial forearm fascial free flap for repair of a septal perforation in a 24-year-old man.^[9] The authors used an external septorhinoplastic approach with a left lateral alotomy. The radial artery was anastomosed to the facial artery, and paired venae comitantes were anastomosed to 2 branches of the facial vein. An advantage of this technique is an abundance of thin, pliable, highly vascular tissue that carries its own blood supply. It may be used with or without a cutaneous component. Disadvantages of this technique include the technical expertise needed to perform the procedure and donor-site morbidity.

New variations on already described techniques are likely. No single technique has been standardized, but all successful repairs share similar basic principles. Advances in other rhinological procedures may modify current techniques for septal perforation closure .  Tami et al recently reported the use of bioresorbable staples for mucoperichondrial flap coaptation in septoplasty. Although this has not been specifically reported in the closure of mucoperichondrial flaps during septal perforation, it may be preferred to the quilting stitch by some surgeons.^[21] Each surgeon should perform the technique with which he or she is most comfortable and which yields the optimal success rate with the fewest complications.