Management of nasal septal perforation

Management of nasal septal perforation John R Coleman, Jr, MD, and E Bradley Strong, MD 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, multilayer closure, and humidification In this article, the recent literature 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 selfinduced 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 perforations 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 perforation 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 Symptoms of nasal septal perforation Dryness Symptomatic crusting Epistaxis Whistling Malodorous drainage Nasal obstruction Paranasal pain perforations are related to opposing tears in the mucoperichondrial flaps, cauterization injuries, or vascular compromise from flap elevation [4] Accurate diagnosis 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 perforations Nasal pain and purulent nasal discharge are characteristic 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 Table Causes of nasal septal perforation Trauma Previous surgery Cauterization Nose picking Inhaled irritants Cocaine Snuff Neoplasm Inflammatory diseases Sarcoidosis Wegener’s granulomatosis Other collagen vascular diseases Infection Bacterial 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 and sarcoidosis [5] Both are granulomatous diseases, and it may be difficult to distinguish between them clinically Generalized tests that may suggest a diagnosis of 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 antibody (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 Tcell 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, chemistry panel, FTA-ABS, cANCA, and ACE Imaging studies should include chest radiography and computed tomography of the sinuses A thorough search for the 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 Tuberculosis 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 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 perforation 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 management of numerous perforations and symptom profiles In our own experience, small perforations located posteriorly in the septum and very large perforations are less symptomatic Medium-sized perforations and those located anteriorly 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 management is indicated Medical management 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 combiTable Principles of surgical repair Aggressive mucosal mobilization Multilayer closure with interposition graft Tension-free closure of at least one mucosal flap nation with the endonasal approach It makes manipulation 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 principle 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 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 bilateral 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 Axial section through nasal cavity Sutured septal flap Interposition connective tissue graft Application of postoperative silastic sheeting Agressive postoperative humidification: saline irrigations and emollients Septal cartilage remnant Advanced nasal mucosal flap from floor Coronal cross-section of the nose showing aggressive flap elevation, tensionfree 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 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 materials has minimal donor site morbidity but provides limited tissue The nose often provides grafting materials Septal cartilage 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 Vascularized free tissue transfer for the repair of septal perforations was recently described Th e radia l 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 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 reepithelialization of cutaneous and mucosal wounds [9,10] No cases of viral transmission or immunoreactivity have been reported Diligent postoperative care is as important as meticulous surgical technique After graft placement, silicone sheeting is placed bilaterally to protect the flaps This maintains 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 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 Kridel RWH, Foda H, Lunde KC: Septal perforation repair with acellular human dermal allograft Arch Otolaryngol Head Neck Surg 1998, 124:73–78 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 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 Nunez-Fernandez D, Vokurka J, Chrobok V: Bone and temporal fascia graft for the cl osur e of septa l perfo rat ion J Laryngo l Otol 1998 , 112:1167–1171 Bent JP, Wood BP: Complications resulting from treatment of severe posterior epistaxis J Laryngol Otol 1999, 113:252–254 Baum ED, Boudousquie AC, Li S, Mirza N: Sarcoidosis with nasal obstruction and septal perforation ENT J 1998, 77:896–902 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 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 Murrell GL, Karakla DW, Messa A: Free flap repair of septal perforation Plast Reconstr Surg 1998, 102:818–821 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  ...common cause of septal perforation Postoperative 58 Management of nasal septal perforation Coleman and Strong 59 Table Symptoms of nasal septal perforation Dryness Symptomatic... tomography of the sinuses A thorough search for the Fungal Syphilis cause of the perforation should be made before repair is considered Medical management The keys to medical management of septal perforation. .. cross-section of the nose showing aggressive flap elevation, tensionfree closure of septal mucosa, and grafting material sandwiched by mucosal flaps Management of nasal septal perforation Coleman