Symptomatic Nasal Septal Perforation Research Articles

Temporoparietal Fascia Graft and Polydioxanone Plate Repair of Nasal Septal Perforation.

Surgical repair of septal perforations has been historically cumbersome. Recently described techniques utilizing interposition grafting with polydioxanone (PDS) plates wrapped in a temporoparietal fascia (TPF) graft have reported successful closure in 90% to 100% of cases. Our objective is to expand the investigation into the use of interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft for nasal septal perforation repair. Retrospective review of the medical record was performed for all septal perforation repairs using the TPF-PDS plate interposition graft technique from August 1, 2017 to March 1, 2021 at the University of Iowa. Minimum post-operative follow-up was 1 month. Our series included 31 patients with symptomatic nasal septal perforations. Thirteen patients underwent open while 18 patients underwent endonasal graft placement. The mean perforation size was 1.49 cm2. The mean post-operative follow-up was 11.5 months. Repair of symptomatic nasal septal perforations using an interposition graft of polydioxanone plate wrapped in temporoparietal fascia demonstrated an overall success rate of 90%.

Outcome of Endoscopic Repair of Nasal Septal Perforation.

The anterior ethmoidal artery (AEA) flap has been demonstrated to be a reliable option for endoscopic repair of symptomatic nasal septal perforations. The purpose of this study is to study the outcome of this technique. A retrospective case series of all consecutive patients who underwent repair of nasal septal perforation utilizing the AEA flap among 2 institutions from August 2020 to July of 2022 was conducted. Demographics and comorbidities were collected preoperatively and postoperatively. The main outcome of this study was to identify the risk factors for surgical failure. Forty-one patients were included. Mean perforation size was 2.2 cm (range 0.5-4.5 cm). Mean age was 42.5 years (range 14-65 years), 53.6% were female, 39% were active smokers, mean body-mass-index (BMI) was 31.9 (range 19.1-45.5), 20% with history of CRS and 31.7% had diabetes mellitus (DM). Etiologies of the perforation included idiopathic (n = 12), iatrogenic (n = 13), intranasal drug use (n = 7), trauma (n = 6), and secondary to tumor resection (n = 3). Overall success rate for complete closure was 73.2%. Active smoking, history of intranasal drug use, and DM were significantly associated with surgical failure (72.7%vs 26.7%, P = .007; 36.4%vs 10%, P = .047; and 63.6%vs 20%, P = .008 respectively). The endoscopic AEA flap is a reliable technique for closure of nasal septal perforation. It may not work when the etiology is intranasal drug use. Close attention to diabetes and smoking status is also needed.

Closure of Nasal Septal Perforation

Symptomatic nasal septal perforations can lead to a substantial restriction in the quality of life of patients and present a distinct surgical challenge for the otolaryngologist/head and neck surgeon. Symptomatic patients complain about nasal crusting, recurrent nosebleeds and nasal obstruction. The so called 4 bridge-flap technique including the interposition of autologous ear cartilage presents an established surgical method for closure of a septal perforation. In the present article, the surgical procedure is described in detail.

Septal Perfoplasty for Management of Symptomatic Nasal Septal Perforation: An Alternative to Surgical Closure

Importance: Symptomatic septal perforations are often difficult to manage and can have a significant impact on patient quality of life. Available surgical techniques for repair have demonstrated a varying rate of success, presenting a need for reliable interventions targeting symptom control. Objectives: To describe the modified surgical technique here termed septal perfoplasty. To demonstrate that creation of favorable septal perforation characteristics is effective in managing symptoms and improving patient quality of life. Design, Setting, and Participants: A retrospective review of the medical record was performed of patients who underwent the procedure of interest between July 1, 2006 and October 1, 2019 at Vanderbilt University Medical Center. All patients with symptomatic septal perforation who underwent septal perfoplasty within the timeframe reviewed were included. Septal perfoplasty was standardly performed in combination with turbinate reduction in all cases. This was combined with other indicated procedures for chronic sinusitis, repair of vestibular stenosis or nasal deformity. Main Outcomes and Measures: Creation of a well-mucosalized septal perforation, combined with patient-reported acceptable symptom control, was the primary outcome. Secondary outcomes include time to resolution, duration of follow-up, postsurgical complications, and need for further intervention. Results: Twenty patients (70% female; mean [range] age, 45.8 [15-72] years) underwent septal perfoplasty over the course of 13 years. The most common etiology of perforation was trauma (40%), presenting symptom was crusting (95%), and size of perforation repaired was large (60%). Mean follow-up was 37.6 months (range, 1-153 months). Overall, favorable perforation characteristics were created in 95% of cases by the first postoperative appointment. Acceptable symptomatic control was achieved in 18 out of 20 patients (90%), with a median time to improvement of 66 days. Eight patients required additional surgery to address chronic sinusitis or vestibular stenosis. Two patients experienced postoperative infections, treated conservatively with antibiotics. Conclusion and Relevance: Septal perfoplasty is a safe, simple, and effective method for management of symptomatic nasal septal perforation, which provides an alternative to more complicated interventions with comparable rates of symptomatic resolution. This procedure should particularly be considered for patients in which difficult repair is anticipated.

Outcomes of Nasal Septal Perforation Repair Using Combined Temporoparietal Fascia Graft and Polydioxanone Plate Construct.

Numerous techniques are used for septal perforation repair, yet success rates remain variable. Few studies have evaluated the effectiveness of interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft for septal perforation repair. To investigate and describe the use of interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft for septal perforation repair and the expansion of this technique to patients with more challenging comorbidities, including granulomatosis with polyangiitis. A retrospective medical record review was performed of patients who underwent septal perforation repair using interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft from January 1, 2015, to July 1, 2018, at Vanderbilt University Medical Center and from January 1, 2017, to July 1, 2018, at the University of Iowa. All patients underwent septal perforation repair with interposition grafts of polydioxanone plates and a temporoparietal fascia graft. Assessing closure of septal perforation was the primary outcome. Secondary outcomes were resolution of presenting symptoms of septal perforation, area of perforation, length of postoperative stent and silastic sheeting placement, postoperative complications and resolution, and duration of follow-up. Preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores were assessed. A total of 17 patients (12 women and 5 men; mean [SD] age, 45 [15] years) were included. The causes of perforations were iatrogenic (9 [53%]), rheumatologic (2 [12%]), and unknown or idiopathic (6 [35%]). Patients most commonly presented with nasal crusting (12 [71%]), whistling (9 [53%]), nasal obstruction (9 [53%]), and epistaxis (5 [29%]). Mean (SD) perforation size was 0.99 (1.04) cm2. Mean (SD) postoperative follow-up was 6.1 (4.1) months. A total of 15 patients (88%) had complete resolution of presenting symptoms at last follow-up. All perforations were closed with overlying mucosa at the most recent follow-up examination. Nine of 17 patients completed both preoperative and postoperative NOSE. There was a significant difference between the mean (SD) preoperative and postoperative NOSE scores (62.78 [27.74] vs 17.78 [15.83]; P = .004). Repair of symptomatic nasal septal perforations using a temporoparietal fascia graft combined with a polydioxanone plate was associated with positive outcomes. Repair of septal perforations caused by rheumatologic disease, including granulomatosis with polyangiitis, can be considered for repair using this technique. Resolution of symptoms appeared to be clinically more meaningful in evaluation of septal perforation repair than rate of perforation closure, and the NOSE scale has the potential to serve as an objective corroboration to patient-reported postoperative outcomes. 4.

Asymptomatic vs symptomatic septal perforations: a computational fluid dynamics examination

A nasal septal perforation (NSP) can lead to frustrating symptoms for some patients while remaining completely asymptomatic for others, without a clear mechanism differentiating them. We applied individual computed tomography (CT)-based computational fluid dynamics (CFD) to examine the nasal aerodynamics differences between 5 asymptomatic and 15 symptomatic NSP patients. Patients' symptoms were confirmed through interviews, 22-item Sino-Nasal Outcome Test score (asymptomatic, 25 ± 18.8; symptomatic, 53.7 ± 18.2), nasal obstruction symptom evaluation score (asymptomatic, 28.0 ± 32.1; symptomatic, 62.2 ± 32.2), and review of medical history. No statistical differences were found in perforation location, size (asymptomatic, 1.94 ± 1.88 cm2 ; symptomatic, 1.36 ± 1.44 cm2 ), nasal resistance (asymptomatic, 0.059 ± 0.012 Pa·s/mL; symptomatic, 0.063 ± 0.022 Pa·s/mL), and computed flow rate shunting across the perforation (asymptomatic, 52.9 ± 30.9 mL/s; symptomatic, 27.4 ± 23.6 mL/s; p > 0.05). However, symptomatic patients had significantly higher wall shear stress (WSS) and heat flux, especially along the posterior perforation margin (WSS, 0.54 ± 0.12 vs 1.15 ± 0.49 Pa, p < 0.001; heat flux, 0.21 ± 0.05 vs 0.37 ± 0.14 W/cm2 , p < 0.01). A WSS cutoff at 0.72 Pa can separate asymptomatic vs symptomatic NSP with 87% sensitivity and 100% specificity. Flow visualization showed flow peaks toward the posterior margin that may be responsible for the high WSS and heat flux among symptomatic NSPs. This study is the first CFD examination of asymptomatic and symptomatic NSP with regional aerodynamics and stress abnormalities, beyond size or location, being implicated as the mechanism behind the symptomology of NSP. This finding could serve as an objective basis for future personalized treatment decisions and optimization.

Sino-Nasal Outcome Test-22 quality-of-life patterns in patients presenting with nasal septal perforation.

To assess the impact of nasal septal perforation (NSP) on quality of life. Retrospective cohort study. Rhinology clinics from two hospitals in Liverpool, United Kingdom. Patients diagnosed with NSP. Patients (n = 26) diagnosed with NSP completed the Sino-Nasal Outcome Test-22 (SNOT-22). The collated data were compared with SNOT-22 scores from a cohort of healthy volunteers (n = 34) and a cohort of patients (n = 30) diagnosed with chronic rhinosinusitis (CRS). The mean total SNOT-22 score of NSP and CRS cohorts was higher than that observed in healthy volunteers. The mean total SNOT-22 score in the CRS cohort (57.2, standard deviation SD 10.3) was the higher than NSP (50.2, SD 23.5), although this difference did not achieve statistical significance. The mean score for the rhinologic-specific domains (rhinologic symptoms, extranasal rhinologic symptoms), ear/facial symptoms and psychological dysfunction domain was higher in the CRS cohort compared to NSP, although statistical significance was only observed in the extranasal rhinologic symptoms domain (11.2, SD 2.4 vs 6.4, SD 4.1). Conversely, the mean sleep dysfunction domain score for NSP (12.7, SD 7.5) was higher than CRS (10.0, SD 4.9, respectively) although this was not statistically significant. This study has assessed the clinimetric and psychometric properties of patients suffering from symptomatic NSP. Future reports should consider inclusion of SNOT-22 data but with the addition of perforation-specific symptoms (nasal crusting, epistaxis, whistling noise).

Unilateral Inner Mucoperichondrium Flap From Upper Lateral Cartilage and Inferior Mucosal Advancement Flap Technique for Repair of Septal Perforations.

Many surgical technique have been described for repair of nasal septal perforations with different success rates. This study aimed to describe authors' surgical technique and discuss its results as well as those reported in the literature. Nineteen patients with nasal septal perforation were operated on between March 2009 and February 2015 at Istanbul University, Istanbul Medical Faculty. The technique described in this article, closure of the perforation with unilateral upper lateral cartilage inner mucoperichondrial flap and inferior meatal advancement flap is an alternative surgical technique. Nineteen patients with symptomatic nasal septal perforation were operated with this technique. All surgical procedures were performed by the same surgeon. Neither intraoperative nor postoperative major complications were observed in any patients. Preoperative and postoperative symptom scores for nasal obstruction, epistaxis, nasal discharge, crusting, whistling, snoring, and olfactory loss as well as overall discomfort levels were compared using a visual analog scale. Complete closure of the perforation was achieved in 18 patients (95%). Small and large perforations may be reliably closed with this technique. Also, this technique can be easily applied via closed or external approach.

Bacterial flora and the epidemiology of staphylococcus aureus in the nose among patients with symptomatic nasal septal perforations

Conclusions Patients with symptomatic perforations of the nasal septum had a high prevalence of S. aureus in the nasal mucosa. Pulsed field gel electrophoresis (PFGE) analysis revealed a high genetic heterogeneity of S. aureus among both patients and controls. This indicates that presence of different strains of S. aureus can maintain a chronic inflammation in symptomatic nasal septal perforations. Objective The purpose of this study was to investigate the microbial flora around nasal septal perforations in patients having severe symptoms regarding bleeding, obstruction, and crustation associated with their perforation. Methods Twenty-five patients with untreated symptomatic nasal septal perforations were included. For culture, swabs around the perforations were collected. Bacteria were identified with standard laboratory techniques including a MALDI-TOF mass spectrometer. Epidemiological analysis was done using PFGE protocols. Bacteriological data were compared with data from a healthy control group. Results Staphylococcus aureus was present in the mucosa surrounding the nasal perforation significantly more often (p < 0.0001) in the patients (88%) compared to a control group (13%). Corynebacterium spp. and Propionibacterium spp. were significantly more frequently identified in the control group. The PFGE analysis of S. aureus strains revealed a high genetic heterogeneity and no specific S. aureus genotypes were associated with septal perforation.

Prelaminated fascia lata free flap for large nasal septal defect reconstruction

Nasal septal defects can be challenging to repair, given their location, size, and the unique, tri-layered structure of the septum, which includes a thin piece of cartilage positioned between mucosal layers. The report herein presents a case of a 47 year-old woman with a large symptomatic nasal septal perforation, despite saline irrigations and ointment. Placement of a septal button or a traditional surgical approach was not considered because of the extremely large nature of the perforation. We describe the use of a tri-layered fascia lata flap prelaminated with buccal mucosa grafts to successfully repair this complicated defect. Subsequent follow-up visits showed complete repair of the defect and patent nasal passages, without the need for any debulking procedures. Based on these results, we conclude that a prelaminated fascia lata flap is a good reconstructive option for large, complex nasal septal defects, bringing thin, healthy mucosalized tissue to the defect and minimizing future surgical procedures.

Experiences with a New Surgical Technique for Closure of Large Perforations of the Nasal Septum in 55 Patients

The surgical closure of nasal septal perforation is still an unsolved clinical problem. In this study the experiences with a novel surgical technique for closure of large perforations of the nasal septum are presented. A total of 55 patients with symptomatic nasal septal perforation measuring 23 ± 3 mm (range, 11-38 mm) at the widest point were enrolled in the study. The closure of the nasal septal perforation was performed with a new and simple surgical technique using a nasal mucosal flap consisting of the defect-corresponding mucosa of the floor of the nose, inferior nasal meatus, and inferior turbinate. A symptomatic improvement of nasal symptoms was noted in all treated patients. In only 3 of 55 cases was the perforation closing incomplete. Our experience with this flap shows its reliability and safety in repairing large nasal septal perforations, with many advantages compared with other techniques for septal perforation repair.

Repair of nasal septal perforation using inferior turbinate graft

Nasal septal perforation can cause troublesome symptoms. Surgical repair is indicated in symptomatic patients. Many approaches and techniques have been described, each with its advantages and indications. The study included six patients with symptomatic nasal septal perforations sized 1-2.5 cm horizontally by 0.5-1.5 vertically. Patient symptoms included nasal crusts (all patients), nasal obstruction (five), cacosmia (three) and recurrent epistaxis (three). Patients underwent endonasal endoscopic repair using an inferior turbinate free graft applied between the mucoperichondrium of both septum sides. Follow up ranged from six months to two years. Five patients (83 per cent) had complete perforation closure and one had partial closure. All patients were symptom-free post-operatively. This endoscopic endonasal approach, using an inferior turbinate free graft, is effective in closing small and medium-sized nasal septal perforations.

Outcome of surgical closure of nasal septal perforation

To assess success rates and symptom control after surgical treatment of nasal septal perforation. A prospective study was undertaken of 28 consecutive patients with symptomatic nasal septal perforation treated surgically by one surgeon between 2005 and 2007. All patients underwent an open rhinoplasty approach with bilateral superior and inferior nasal mucosal advancement flaps and acellular porcine collagen placed in between. Symptom severity was assessed pre- and post-operatively using a validated visual analogue score. The nasal valve angle was assessed pre- and post-operatively by two independent assessors. Patients comprised 12 women and 16 men, with a mean age of 45 years (range: 21-76). The mean follow up was 16 months (range: 6-24). The mean vertical and horizontal diameters of the perforations were 22 mm (range: 10-35) and 27 mm (range: 10-37), respectively. Twenty-seven (96 per cent) patients had complete closure of nasal septal perforation. There were statistically significant differences between the pre- and post-operative mean visual analogue scale scores for epistaxis (p < 0.001), crusting (p < 0.001), whistling (p < 0.001) and nasal obstruction (p < 0.001). Epistaxis, crusting and whistling resolved in all patients, and 92 per cent reported improvement in nasal blockage. Closure of nasal septal perforation using an open rhinoplasty approach with nasal mucosal advancement flaps and a porcine collagen sandwich is a pertinent and reliable technique for the management of nasal septal perforation.

Repair of nasal septal perforation using a simple unilateral inferior meatal mucosal flap

Nasal septal perforation may cause recurrent epistaxis, nasal obstruction, discharge, crusting, dryness, pain and whistling. Many surgical approaches for the repair of septal perforations have been reported in the literature, however most of the available closure techniques are technically difficult, require experienced surgeons and have a high rate of re-perforations. A new and simple surgical technique for the treatment of nasal septal perforations is described in the present study. A total of 13 patients with symptomatic nasal septal perforation measuring 17+/-3mm (range 5-26 mm) at the widest point were enrolled in the present study. All patients were treated with a unilateral inferior meatal mucosal flap and had their septal defects closed. Complete symptomatic resolution was documented among all of these patients. This technique provides a new method with many advantages compared to other techniques for closure of septal perforations. Our first experiences with this flap show its reliability in repairing septal perforations.

Upper Lateral Cartilage Inner Mucoperichondrial Flap Technique for the Repair of Nasal Septal Perforation

Treatment of nasal septal perforations which decrease quality of life is a surgical challenge with variable success rates. Numerous surgical methods have been proposed for closure of perforations. The technique described in this article, i.e. closure of the perforation with an upper lateral cartilage mucoperichondrial flap through an external septorhinoplasty approach, is an alternative surgical technique. Twenty-four patients with symptomatic nasal septal perforation were operated on using this technique and followed up for a mean duration of 28 months. Preoperative and postoperative symptom scores for crusting, nasal obstruction, bleeding, discharge, whistling, headache, nasal pain, snoring and olfactory loss as well as overall discomfort levels were compared using a visual analogue scale. Complete closure of the perforation was achieved in 19 patients.

Improved nasal septal prosthetic button

Nasal septal button prostheses are useful alternatives to surgical management of symptomatic nasal septal perforations. The new modified button appears to be superior to the conventional button in several ways. It can be trimmed or ordered with larger or asymmetric disks if needed. The two new features of this button are (1) its flexible hub, giving it plasticity and adaptability; and (2) the tapered dome or umbrella-shaped, flexible disks, which allow for greater conformity to the septum.

Improved nasal septal prosthetic button.

Nasal septal button prostheses are useful alternatives to surgical management of symptomatic nasal septal perforations. The new modified button appears to be superior to the conventional button in several ways. It can be trimmed or ordered with larger or asymmetric disks if needed. The two new features of this button are (1) its flexible hub, giving it plasticity and adaptability; and (2) the tapered dome or umbrella-shaped, flexible disks, which allow for greater conformity to the septum.

Prosthetic Closure of Nasal Septal Perforations

One hundred seventy-one patients had closure of symptomatic nasal septal perforations by insertion of a Silastic nasal septal prosthesis between June 1972 and August 1981. Follow-up revealed that successful closure of the defect was accomplished in 73% of cases, with reduction in crusting and epistaxis and improvement in nasal respiration in many cases. Prefabricated prostheses have been effective in treating smaller perforations. The treatment of four patients with unusually large septal perforations by custom-carved prostheses sized using computerized axial tomographic scanning is described.

Closure of nasal septal perforation with composite flaps.

A procedure for closure of symptomatic nasal septal perforations is described. The procedure combines the advantages of the good vascular supply of a rotation flap with the strength of a composite graft.

Repair of nasal septal perforation with a silicone button.

AbstractA symptomatic nasal septal perforation is an annoyance to both the patient and the treating physician. Patients complain of a whistling sound on respiration, persistent nasal crusting, occasional odor, and recurrent bouts of epistaxis. Most of the described surgical methods to attempt to close them, are not very successful; they may require more than one surgical procedure, entailing the associated hospitalization, morbidity, etc., and, at best, dubious outcome.The technique I have used for the past few years was first proposed to me by Vernon Gray M.D.;1 it offers a simple atraumatic office procedure which, has proven to be successful in eliminating the symptoms resulting from a nasal septal perforation. Naturally, the physician should try to determine the underlying cause of the perforation and when practical, treat it. Most cases, however, are due to previous septal surgery or trauma