Septal button insertion—The screw technique

Abstract

Nasal septal perforation can be asymptomatic or can present with symptoms, such as epistaxis, crusting, secondary infection, whistling, or nasal obstruction.1 Septal perforations can be caused by various etiological factors, including trauma, infection, irritant (chemical), neoplasm, or inflammatory conditions.2 In symptomatic patients it is common to occlude the perforation by insertion of prosthesis. Various types of prostheses have been made for this purpose. The most common is the Xomed one-piece septal button (Medtronic ENT, Jacksonville, FL). Inserting the prosthesis can be difficult, and different techniques have been described for ease of insertion. Most often button insertion is done under general anaesthesia due to patient discomfort. We describe a technique that makes the insertion of the button easy, and thus can be done under local anaesthesia. Step 1: Local + topical anaesthesia. Lidocaine infiltration along with spray is used. Step 2: A circular slit starting from the outer edge of one of the flanges of the Xomed one-piece septal button is made. The slit goes in towards the hub covering ≥300° of the circle of the flange (Fig. 1). Step 3: After getting the button through one nostril, the split end of the flange is pulled through the perforation into the other nasal cavity using a hemostat/Tilley's forceps. By rotating the button, all of the flange will be in the other nostril, and thus the button will be positioned accurately (Fig. 2). Placement of the button through a perforation demonstrated on cardboard. Button inserted by the technique described. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.] The septal perforation may be treated by conservative measures, such as nasal douching, emollients, and humidification. Definitive treatment involves closure of the perforation either surgically or using prosthesis. Surgical techniques described include nasal septal rotation flaps, inferior turbinate pedicle flaps, nasal labial flaps, sublabial flaps, temporalis fascia, and mastoid periosteum.3 Surgical closure is difficult in larger perforations and has the risk of failure. Prosthesis is an effective alternative. Prosthetic closure can be achieved using prefabricated buttons or personalized obturators.4 When the services of a specialist in dental prosthetics are not available, it is easier to use a prefabricated silicone button. The main problem with the silicone button is the insertion of flange through the septal perforation, especially when the perforation size is relatively small. Some authors recommend trimming the edges of the silicone button, but that may result in traumatizing the perforation edge.2 Kelly et al. suggested sewing the flange in a purse string fashion, and then applying traction so that the disc assumes a concertina shape, thus making it small enough to pass through the perforation.5 Al-Khabori suggested trimming the edges and making a radial slit in one of the flanges to facilitate insertion of the septal button.2 However, with the radial cut we found it difficult to deliver the flange across the perforation. All of the above methods are associated with significant discomfort to the patient and some amount of maneuvering to correctly position the septal button. We instead tried the above-mentioned technique, which was initially described for inserting permavents (long-term tympanostomy tubes) for middle ear effusions.6 In our experience, this method is simpler, easier, and quicker for inserting the septal button. The modified screw technique to insert the Xomed one-piece septal button can be effectively done as an office procedure and under local anaesthetic in an ear, nose, and throat out-patient clinic for most patients, as long as the diameter of septal perforation is equal or more than the hub of the septal button.