Nasal septal perforation and its management

By

Dr. T. Balasubramanian M.S. D.L.O.

Introduction: Septal perforation happens to the common disorder of nasal septum. In most patients septal perforations are incidental finding without any symptoms. Septal perforations may cause crusting, whistling sound during inspiration, epistaxis, nasal obstruction and pain. Whistling will be more when the perforation is small. These symptoms depend on the location of perforation, size, shape and conditon of the margins of the perforation. Surgical closure happens to be the best option, but a prudent decision will have to be made taking into consideration all the above said parameters as well as the competancy of the surgeon involved.

Classification of septal perforation:

Septal perforations can be classified according to the following parameters:

1. Cause2. Symptoms3. Location4. Size5. Shape6. Condition of margins7. Presence / absence of cartilage or bone around the defect

Causes of septal perforation:

1. Septal surgery (commonest cause) – Cartilage / bone around the perforation is usually missing

2. Repeated nose picking – Cartilage / bone around the perforation is usually present3. Repeated bilateral coagulation for epistaxis (in pts with hereditary teleangiectasis)4. Trauma5. Cocaine abuse6. Septal abscess – Cartilagenous portion of nasal septum is totally destroyed7. Granulomatous infections of nasal septum. In wegener's granulomatosis conservative

management is preferred over surgery8. Tumor surgeries of nose9. Exposure of caustics – Poor quality of mucosa surrounding the perforation should be borne

in mind before embarking on surgery

Symptoms:

1. Asymptomatic2. Severe crusting3. Epistaxis4. Whistling sound during inspiration – common in small perforations. Larger the perforation

lesser becomes the whistling5. Perforations involving the anterior portion of the septum is more symptomatic than those

involving the posterior portion6. Symptoms are severe in small perforations than larger ones

Location of perforation: Location of the perforation plays a vital role in the symptomatology. It

should also be considered before deciding the management modality. Anterior perforations cause more problems and are also amenable to surgical closure since it is easily accesible and can be managed endonasally. Posterior perforations are asymptomatic and are difficult to manage surgically because of poor access. Endonasal approach is virtually ruled out for repairing posterior perforations. The ideal route of surgical approach is mid facial degloving, as this would provide good visualisation and access to the perforated area.

Figure showing various areas of septal perforation. 1 – Large oval central perforation, 2 – small anterior cartilagenous perforation, 3 – anterior basal in the region of premaxilla and maxillary crest

Shape of perforation:

Slit like perforation cause fewer problems and are easy to close.Oval / oblong perforations are symptomatic and are difficult to close.

Condition of mucosal margins:This factor should also be taken into consideration before deciding on surgical closure. Infection, crusting and bleeding are signs of poor quality of mucosa around perforation. This mucosa is likely to tear when repair is being performed. It is always better to manage the patient conservatively till the mucosal infection subsides before embarking on surgical closure.

Presence of cartilage / bone around the defect:

The presence of cartilage / bone around the defect makes flap elevation easier, thereby helping the surgeon. Membranous perforation, may actually enlarge when attempts are made to elevate mucocutaneous flap around the perforation.

Coronal CT scan of a patient with septal perforation

Endoscopic view of septal perforation

In Killian era septal perforation due to septal surgeries was quite common. In fact 10 – 15 % of patients who underwent septal surgery in this era developed septal perforation. In modern septal surgeries this risk is eliminated to a large extent due to excellent illumination, better instruments and surgical technique (less than 1%).

Prevention of septal perforation:

Knowledge of preventing septal perforation is much more important than the skill acquired to repair it. Prevention is always better than cure.Guidelines which will minimize the risk of septal perforation:

1. Ensure good illumination, sufficient exposure and blood less field. This will go a long way in minimizing the risk of septal perforation

2. Elevation of septal mucosa should be performed in the proper plane. Proper instruments should be used. The movements should be gentle. Elevation should always be done in the

mucoperichondrial / mucoperiosteal plane. Blunt septal elevators should be used to elevate the mucoperichondrial flap / mucoperiosteal flap. The septal elevator should be moved in an upward and downward direction in a sweeping movement (akin to car windshield wipers). When mucoperichondrium is elevated the sharp end of the septal elevator should be used. Pressure should be applied only over the bone. Care must be taken to ensure that the instrument is in continuous contact with bone. Scar tissue should be cut using sharp scissors and cutting is usually done from inferior to superior direction for better visibility.

3. Safeguarding mucosal laceration: During surgery if mucosal laceration occurs it should first be isolated and safe guarded. Dissection should be continued either above or below the laceration thus releasing the mucosal tension around laceration. This enables the laceration to heal faster.

4. Tears involving the septal mucosa if any should be immediatly repaired. This is more so if the tear is more than 1cm. The septal mucosal tear should be closed immediatly using absorbable atruamatic sutures. Mucosa around the tear should be elevated to enable the edges of perforation to be closed without tension. When suturing the mucosal margins should be everted towards the nasal cavity.

Figure showing mucosal tear over nasal septum being isolated

Figure showing torn mucosa being sutured

5. Careful adjustment of the torn edges of the mucosa over nasal septum is one excellent way

of preventing septal perforation. This will be of immense help even if suturing is not resorted to. The mucosal edges of the perforation is held in place by appropriately positioned dressing on both sides of the nose. The edges should be meticulously adjusted with the blunt end of the septal elevator. Care should be taken to ensure that intra nasal dressing doesnot protrude between the edges of the perforation

6. Reconstruction of damaged septum by inserting plates of cartilage / bone in patients with extensive nasal septal laceration will prevent septal perforation. Compressed gelfoam can be used to hold these plates in position. Internal dressing (intranasal) can then be applied.

7. A mucosal tear when it appears close to the basal crest should be closed immediatly.

Figure showing mucosal tear over basal crest and the resultant suturing after reducing the height of the nasal septum to reduce the tension over sutured margins.

Treatment:

1. No treatment: May be difficult for a surgeon to digest, a significant number of septal perforations do well without repair. Sometimes a failed repair will make the patient worse.

2. Conservative management: Application of bland ointments / vaselin over the edges of perforation using a cotton applicator will cause symptomatic relief and prevent excessive crusting. Regular nasal douching using alkaline saline will prevent infection. If the mucosal edges around the perforation are infected then antibiotic steriod ointment can be applied.

3. Surgical closure: of the perforation is still the best option. The results are ofcourse dependent on the size of the perforation. Mucosal margins should be healthy for closure of perforation to be successful. Any attempt to close a septal perforation caused by repeated cauterization of septum may fail because of the poor quality of mucosa lining the edges of the perforation. Similarly it is surgically difficult to close an irregularly shaped perforation when compared to a regular oval shaped one. Anterior perforations can be closed easily when compared to posterior ones due to better access. Four methods of surgical closure have been accepted. They include: Direct closure, Rotation flap technique, Bridge flap technique and Bucco gingival flap technique.

Direct closure: This method is ideal in cases of immediate repair of septal mucosal laceration. This can be performed only when the size of the perforation is small, and there is also associated septal deviation. By correcting the deviation of nasal septum sufficient slack can be achieved to facilitate tension free primary closure of mucosa. For direct closure the nasal septal mucosa should be undermined. The undermined mucosa should be sufficient for tension free closure of the perforation.

Rotation flap technique: This method is very useful in closing anterior based perforation which is less than 2 cms. The margins should be of good quality, and there is adequate bone / cartilage around the perforation. Two pedicled mucosal flaps are created. One flap (upper septal flap) on one side and another one from the floor on the opposite side are created. The upper septal flap is based cranio posteriorly and is supplied by anterior and posterior ethmoidal arteries. The lower septal flap is pedicled caudo posteriorly and is supplied by the palatine artery.

Figure showing the incision for superior flap (Rotation flap technique)

Diagram showing inferior flap incision (Rotation flap technique) should be performed on the side opposite to that of the superior flap

Since these two flaps are cut from different areas of nasal cavity, the septum will not get denuded of

its mucosal covering.

Steps of this procedure include:Step 1: Creation of superior and inferior tunnels on opposite sidesStep 2: The inferior tunnel is extended along the floor up to the lateral nasal wallStep 3: Posterior pedicled flap is cut cranial to the perforation and is rotated into the defect from above.Step 4: An inferior based pedicle flap is cut inferior to the perforation on the opposite side and rotated into the defect from below.Step 5: These two flaps are sutured to each other across the perforation using atraumatic sutures

If possible a strip of autologous septal cartilage when inserted between these flaps will improve the results.

Bridge flap technique: This method is the most complicated but reliable in treating large anterior and posterior perforations. If done properly results are good and fairly predictable. This procedure is helpful in closing septal perforations of more than 3 cms. This method is more traumatic than rotation flap technique.

Procedure:

The septum is approached via four tunnel approach. The superior tunnels are extended up to the roof of the cartilagenous and the bony pyramid. The inferior tunnels on both sides are continued over the floor of the nasal cavity and the lateral wall of nasal cavity up to the arrachment of inferior turbinate. The incisive nerve will be damaged in this procedure.Longitudinal incisions are made in the nasal mucosa close to the nasal roof. These two flaps are advanced downwards towards the defect. Longitudinal incisions are made at the attachment of inferior turbinate and these flaps are advanced medially and superiorly towards the defect.

Diagram showing bilateral bridge flap technique

Bucco gingival flap technique: This technique is used to manage large anterior perforations. Bilateral oblong flaps are gut from the orogingival mucosa including its submucosa with their

attachment medially. These flaps are rotated through a small tunnel into the nasal cavity sealing the perforation. It is a complicated procedure will risk of upper lip deformity / stenosis of nasal vestibule.

Procedure:

1. Superior and inferior septal tunnels are created.2. Another incision is made in the posterior and inferior margins of perforation. Mucosa is

dissected while preserving the margins of the perforation.3. Labiogingival area is exposed using retractors. The area of flaps are marked after

identifying the parotid duct.4. The mucosa and submucosa are incised without damaging the periosteum. The lower arm

of the incision is made longer than that of the upper arm to facilitate rotation of flap. These flaps are dissected using curved scissors.

5. Small tunnels are created on either side of anterior nasal spine intraseptally.6. A curved hemostat is introduced into the para spinal tunnel through the nose and the flap is

pulled into the septal defect.7. The ends of the flaps are thinned and trimmed and is sutured over the defect.8. Unnecessary torsion of the flap should be avoided.9. Oral wound should be closed with catgut after undermining its margins to get some slack.

Careful attention should be paid to maintain upper lip symmetry.

Figure showing buccogingival flap being raised

Figure showing buccogingival flap rotated into the nasal cavity

A combination of more than one method may also be resorted to in managing difficult situations or in failure cases.

Use of free facial grafts and composite cartilage and skin grafts have been abandoned due to poor results.With the advent of nasal endoscope, it has become easy to visualize the whole nasal cavity while performing any of these reconstruction procedures. It is a valuable tool in the hands of a surgeon performing these surgical procedures.

Midfacial degloving approach:

This approach was first used by Portmann in 1927 to perform maxillectomy. Conley and Price in 1979 used this approach to remove benign nasal masses.Casson in 1974 performed the first septal perforation closure using this procedure.Maniglia in 1986 extensively used this approach for septal perforation closure.

This approach is very useful in repairing large septal defects as well as posterior septal defects. The advantage of this procedure is excellent exposure of surgical field without the need for any external incisions on the face. Cosmetically this procedure is acceptable.Surgical procedure involves:

1. Midfacial degloving surgical procedure with exposure of the whole nasal cavity2. Developement of posterior based mucosal flaps bilaterally3. Septoplasty if necessary need to be performed4. Intranasal closure of the perforation

The surgical field is liberally injected with 2% xylocaine with 1 in 1lakh units adrenaline. This will ensure a relatively bloodless field during surgery.

Intranasal incisions: These should be performed first. Bilateral intercartilagenous incisions are given. They are connected to each other at the septal angle thus forming a complete transfixation incision. The intercartilagenous incision should be extended inferiorly and laterally up to the level of the floor of the nose. This limb is also connected to the complete transfixation incision.

Gingivobuccal incision: is performed next. It extends between the first molars of both sides across the midline. This incision is joined to the already performed complete transfixation incision. This union is performed at the level of anterior nasal spine. The osseocartilagenous nose is degloved exposing the nasal architecture completely.

Closure of septal perforation: Nasal septum and its perforation is exposed. The mucosal lining over the nasal septum is elevated using 1% xylocaine with 1in 100000 adrenaline injections. Deviations involving the septum if any should be corrected at this juncture. The edges of the perforation are cut and undermined. Posterior based unipedicle flap is elevated on both sides. This flap is used to cover the perforation. Flaps should be sutured in place without tension.

Complications:

Complications of this procedure include:

1. Reperforation2. Vestibular stenosis3. Facial oedema during immediate post op phase4. Infraorbital nerve area anesthesia

Figure showing exposure of nasal vault in midfacial degloving approach

Use of synthetic prosthesis to close septal perforation:

Synthetic prosthesis like septal buttons, and obturator have been used with varying degrees of success to close septal perforations.

Indications for the use of these prosthesis:

1. Large and difficult to repair septal perforations2. Failed septal perforation repair3. Poor surgical candidates

Silastic is the most preferred material. These prosthesis can be inserted under local anesthesia and can be performed as an office procedure.

Before introducing the obturator the following procedures should ideally be followed:

1. The width and the height of the perforation should be accurately measured using a calibrator. Sometimes sagittal CT scan will have to be done in difficult to measure cases.

2. The nasal mucosa is anesthetised and decongested using 4% xylocaine solution.3. The commercially available prosthesis is cut to the precise shape and size of the perforation.4. To facilitate atraumatic insertion of the prosthesis, both the prosthesis and the nasal cavity

are greased by applying a bland ointment / vaseline. 5. A button is commonly inserted through the left nostril. The posterior end of the medial

flange is pushed through the perforation. It is delivered through the perforation by introducing an instrument into the right nasal cavity, and the prosthesis is rotated into place.

6. Care should be taken to ensure that the flanges dont come into contact with the floor / roof of the nasal cavity.

The insertion of septal prosthesis give good and predictable results.

Inferior turbinate flap technique:

This technique has been used to repair caudal septal perforations under 2 cms in size. Unilateral flaps are preferable. Normal sized healthy inferior turbinate should be used. Inferior turbinates which have been operated / inferior turbiantes in patients with atrophic rhinitis are not ideal flap candidates.

Septoplasty should be performed. If possible septal cartilage should be harvested. If septal cartilage is not available then conchal cartilage should be harvested to be used as interposition graft material. The dimensions of the cartilagenous graft should be larger than that of the dimensions of the septal perforation.The cartilage graft is placed over the perforation whose edges have already been freshened. This graft is stabilized using matress sutures which passes through the mucosa on both sides. This mattress sutures not only holds the graft in position, it also prevents hematoma formation.

Creation of inferior turbiante flap:

The inferior turbinate is liberally infiltrated with 1% xylocaine with 1 in 100000 concentration of adrenaline. Adequate sized inferior turbinate flap based on posterior pedicle is created and is sutured to the mucosal edges of the perforation. A small gelfoam pack is left behind the flap. The turbinate flap is cut 3 weeks after the surgical procedure.

Figure showing nasal septal perforation

Figure showing cartialge interposition to close the perforation

Figure showing inferior turbinate flap sutured to the edges of the perforation

Advantages of inferior turbinate flap:

1. This flap has a good vascularity2. It has a wide ring of rotation3. It provides both skeletal and epithelial support4. Since it is covered with respiratory mucosa it helps in the nasal septum achieving

physiological normalcy

Weerda slightly modified this technique by using only a small portion of the inferior turbinate tissue.