Treatment Of Nasal Septal Perforations Research Articles

Pediatric nasal septal perforation

Objective1.) Describe demographic and clinical characteristics of pediatric nasal septal perforations (NSP), 2.) Analyze efficacy of treatment modalities in symptom management and resolution of pediatric NSP, 3.) Describe the surgical technique of external rhinoplasty with vascularized nasal septal flaps in the treatment of nasal septal perforations. MethodsIRB-approved retrospective chart review of pediatric patients ages 0–18 years with nasal septal perforations treated at a tertiary care pediatric otolaryngology practice.Demographic and clinical characteristics including gender, age, race, and presenting symptoms, and location, size, and etiology of perforation were collected. Outcomes including persistence of perforation and symptoms at 1 year and most recent visit were recorded. A total of 20 patients were included. Statistical analysis used Fisher's t-test for categorical variables and Wilcoxon rank-sum for continuous variables. ResultsMedian age was 167.5 months (1.5–221.0). The most common etiology was iatrogenic (40%), followed by button battery (20%). Thirty percent of patients underwent surgical repair. Fifty percent of patients who underwent surgical repair achieved closure of their perforation at most recent follow up. ConclusionPediatric NSP is a challenging issue with limited literature to date. Iatrogenic causes (40%) and button batteries (20%) were the most common etiologies of nasal septal perforation in our study. We introduce an advancement in our center's surgical technique with a case illustration with repair via external rhinoplasty and bilateral vascularized nasal septal flaps. Future larger studies may further elucidate characteristics and treatment modalities associated with successful closure.

Surgical treatment of nasal septal perforations: SIR (Italian Society of Rhinology) experts opinion

Background and aimThe aim of our study has been to investigate the perception of aspects related to nasal perforation among experts in Rhinology and ENT surgeons. Our aim was reporting the situations in different Countries to improve the knowledge of colleagues interested in this topic. MethodsA panel of experts prepared a 20-question questionnaire regarding nasal perforations and their surgical repair, that were emailed to all the members of SIR (Società Italiana di Rnologia – Italian Society of Rhinology). ResultsData obtained from their answers showed that Cottle technique (64%) is the most common technique to perform septoplasty worldwide. 37% of the sample reported an occurrence of nasal septal perforation in less than 1% of patients and 75% attributed this occurrence to the skill of the surgeon, to infections, to drug use and to septal deformity. Trauma, pressure and Wegener's granulomatosis were also mentioned. The most common closure technique is the mucosal flap (75%), followed by the cartilage grafts (11%). Much less common were oral flaps, septal buttons and others. The majority agreed not to suggest septal perforation surgery in minimal (less than 3–4mm) perforations (73.5%), or limiting it to symptomatic patients (43.5%). The contraindications to repair surgery were reported to be: Wegener's granulomatosis, drug abuse, non-symptomatic perforation, its dimension and age of the patient. Septal deviation, atrophic rhinitis, smoke epistaxis and systemic diseases were also claimed. Failure in repair surgery has been observed to occur in less than 30% of cases. Discussion and conclusionsGiven the great difficulty to make random studies about controversial topics and obtain statistically significant data related to that, expert opinion shall be of great value (expert opinion, level of evidence 5)

Surgical treatment of nasal septal perforations: SIR (Italian Society of Rhinology) experts opinion

Background and aimThe aim of our study has been to investigate the perception of aspects related to nasal perforation among experts in Rhinology and ENT surgeons. Our aim was reporting the situations in different Countries to improve the knowledge of colleagues interested in this topic. MethodsA panel of experts prepared a 20-question questionnaire regarding nasal perforations and their surgical repair, that were emailed to all the members of SIR (Società Italiana di Rnologia – Italian Society of Rhinology). ResultsData obtained from their answers showed that Cottle technique (64%) is the most common technique to perform septoplasty worldwide. 37% of the sample reported an occurrence of nasal septal perforation in less than 1% of patients and 75% attributed this occurrence to the skill of the surgeon, to infections, to drug use and to septal deformity. Trauma, pressure and Wegener's granulomatosis were also mentioned. The most common closure technique is the mucosal flap (75%), followed by the cartilage grafts (11%). Much less common were oral flaps, septal buttons and others. The majority agreed not to suggest septal perforation surgery in minimal (less than 3–4mm) perforations (73.5%), or limiting it to symptomatic patients (43.5%). The contraindications to repair surgery were reported to be: Wegener's granulomatosis, drug abuse, non-symptomatic perforation, its dimension and age of the patient. Septal deviation, atrophic rhinitis, smoke epistaxis and systemic diseases were also claimed. Failure in repair surgery has been observed to occur in less than 30% of cases. Discussion and conclusionsGiven the great difficulty to make random studies about controversial topics and obtain statistically significant data related to that, expert opinion shall be of great value (expert opinion, level of evidence 5)

Alloplant application for closure of the nasal septum perforation

The article presents information on the importance of this problem, as well as the experience of surgical treatment of nasal septal perforation using alloplant. The authors monitored the results of treatment of 31 patients aged 19 through 45 years, with the nasal septum perforation. Alloplant was used as the plastic material. Perforation edges suturing was performed both on two sides and on one side. The use of nasal splints in post-surgery period increases the efficacy of surgical treatment. Complete closure of the septum defect or the decrease of its size reduces the frequency and symptoms of the disease.

Nasal septal perforation in children: Presentation, etiology, and management

ObjectiveThe presentation, etiology, and treatment of nasal septal perforation have been described in the adult literature; however, reports in the pediatric population are limited. In this study, we review our experience with pediatric nasal septal perforations with a focus on presentation, pathogenesis, management, and outcomes of surgical repair. MethodsA retrospective chart review was performed on pediatric patients diagnosed with nasal septal perforations from 1998 to 2015. Data regarding patient demographics, perforation characteristics, and treatment were extracted and analyzed. ResultsTwenty-seven patients met inclusion criteria. Mean age was 10.8 years (range 2 months–17 years). Nasal crusting (n = 19, 73%) and epistaxis (n = 15, 58%) were the most common complaints at presentation. The most common etiologies were trauma (n = 9, 33%), iatrogenic sources (n = 5, 19%), and neoplasm (n = 3, 11%). Septal perforations were primarily located in the anterior septum (n = 17, 81%) and the average size was 0.9 cm (±0.37) in diameter. Four patients were managed with a nasal septal button. Successful closure was achieved in four out of six patients (66.7%) who underwent surgical repair. ConclusionsIn our series, septal perforations in children occurred most frequently due to digital nasal trauma, and crusting was the most common symptom. Factors to consider prior to repair include symptomatology, the etiology of the perforation, co-morbidities, ability to comply with post-operative care/restrictions, availability of adjacent tissue/grafts, and potential effects on nasal growth. Even with careful consideration of these factors, successful closure was limited to two-thirds of patients who were offered repair.

The Effect of Nasal Septal Perforation and its Treatment on Objective Sleep and Breathing Parameters.

BackgroundNasal septal perforation (NSP) may alter nasal airflow patterns and physiology. To the best of our knowledge, no studies in the English literature have investigated the effect of NSP and its treatment on polysomnographic parameters. In this study, we aimed to investigate polysomnographic parameters in patients with NSP as well as changes in those parameters after treatment of NSP.Material/MethodsNineteen patients diagnosed with NSP were included in the study. All patients had baseline and post-procedure polysomnographies (PSG) after insertion of silicone septal button for closure of NSP.ResultsBoth median AHI [5.30 (14.40) vs. 2.40 (14.50)] and median supine AHI [10.00 (42.10) vs. 6.60 (37.00)] decreased after correction of the perforation. There was a large reduction in median supine AHI in patients with a perforation size >66 mm2 [10.10 (34.15) vs. 1.60 (28.30)].ConclusionsWe conclude that NSP did not cause any deterioration in objective sleep parameters as determined by PSG, other than a decrease in REM sleep duration and an increase in supine AHI. Correction of NSP did not affect REM duration and supine AHI decreased after treatment.

Olfaction improvement after nasal septal perforation repair with the "cross-stealing" technique.

The surgical treatment of nasal septal perforation is known to improve nasal respiratory airflow and, thereby, should be beneficial to the patient's olfactory abilities. However, there are only limited data on the effect of nasal septal perforation repair (NSPR) on olfaction, and most studies reported contradictory results. The aim of this prospective study was to investigate the change in the olfactory abilities of 42 patients with a primary concern of nasal septal perforation. NSPR was performed with the "cross-stealing" technique. The inferior-based mucoperichondrial flap in one side and the superior-based mucoperichondrial flap from the other side of the nasal septum were passed to the opposite sides through the perforation. Surgery was completed by placing an interpositional graft between the flaps before suturing. The interpositional grafts were residual cartilage. The olfactory performance of the patients before and at 1, 3, and 6 months after the closure of the nasal septal perforation was measured by using an olfaction test kit. The success rate with complete closure of nasal septal perforation with the "cross-stealing" technique was 92.8%. Analysis of the data indicated statistically significant improvement in olfactory function scored as odor threshold (T), odor discrimination (D), odor identification (I) and TDI at 1, 3, and 6 months after NSPR (p < 0.001 for all). The mean TDI score evaluated 6 months after NSPR was improved by 64%. Analyses of variance indicated statistically significant improvement in olfactory scores within time factors were calculated as preoperative versus 1, 3, and 6 months; 1 versus 3 and 6 months; and 3 versus 6 months (p < 0.001 for all). Analysis of the present data indicates a beneficial effect of NSPR on olfactory abilities of patients with perforation. Our data on the short- and long-term olfactory abilities of 42 patients with nasal septal perforation after NSPR when using an olfaction test kit indicated statistically significant improvement in olfactory function.

Surgical outcome and complications of nasal septal perforation repair with temporal fascia and periosteal grafts.

AIMSSurgical treatment of nasal septal perforation remains a challenging field of rhinology. A large variety of techniques and grafts with promising results have been introduced for perforation repair. However, the use of fascia or fascia with periosteum has not been previously evaluated for a large sample of patients.METHODSDuring the years 2007–2014, 105 operations were performed and 98 patients were treated for nasal septal perforation at the Department of Otorhinolaryngology—Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland. We performed a retrospective review of closure rates and complications. Follow-up time ranged from 1 to 62 months.RESULTSBleeding was the most common early complication (9%), followed by postoperative infection (5%) in the whole series. Our main technique, bipedicled advancement flaps with fascia or fascia and periosteum, was performed for 81 patients. We obtained successful closure in 78% of these patients with this operative technique and the rate increased to 86% during the last 3 years of the study period.CONCLUSIONSPerforation repair with temporal fascia or fascia with periosteum requiring only one donor site seems to be a reliable option for nasal septal perforation repair.

Repair of nasal septal perforation using middle turbinate flap (monopedicled superiory based bone included conchal flap): a new unilateral middle turbinate mucosal flap technique.

The purpose of this study is to present a new approach for treatment of nasal septal perforation using middle turbinate flap. A consecutive study with follow-up of 31 patients with nasal septal perforation treated using middle turbinate flap. All patients underwent an endoscopic repair of nasal septal perforation using middle turbinate flap. All patients were followed for 18-24 months. Complete closure of the perforation was achieved in 29 of the 31 patients. Complete failure of the repair was observed in two patients. All patients showed nasal crusting in varying degrees for a period of 2-4 weeks. None of the patients showed nasal obstruction or atrophic rhinitis symptoms (stuffy nose, purulent postnasal drip, nasal crusting, epistaxis and anosmia) in postoperative follow-up. This technique provides a new method with many advantages compared to other techniques for closure of septal perforations. IV.

Transplantation of adipose-derived stem cells combined with decellularized cartilage ECM: A novel approach to nasal septum perforation repair

Nasal septal perforation, a defect of the nasal mucoperichondrium and cartilage, may induce epistaxis, persistent rhinorrhea and nasal obstruction. Cell-based tissue engineering is a promising therapeutic method for the treatment of nasal septal perforation. However, lack of an adequate source of cells and unsuitable biomaterials greatly hinder the development of cell-based therapy. In this paper, we proposed the application of adipose-derived stem cells combined with decellularized cartilage ECM as a potential graft for the damaged nasal septum, which could help to repair the mucosal and cartilage tissues in the treatment of nasal septal perforation. This new technology could play a novel role in the repair of nasal septal perforation, and in regeneration of damaged nasal cartilage.

Human Fingernail as Interpositional Graft Material in the Treatment of Nasal Septal Perforations

The etiology of nasal septal perforations involves iatrogenic, traumatic, inflammatory, infectious, neoplastic, and caustic causes. To ensure successful closure, an appropriate interpositional graft material should be selected, and this graft material should be covered with healthy tissue. The study included 18 New Zealand white rabbits weighing 2 to 2.5 kg. Nasal septal perforations were created in group 1. After the creation of defects in group 2, repair was performed with cartilage graft and bilateral mucoperichondrial advancement flaps. After septal nasal perforations in group 3, the defect was covered with fingernail and bilateral mucoperichondrial flaps. At week 12, the rabbits were sacrificed. The septum site that had been repaired with fingernail was intact. No nail exposition, wound site decomposition, or re-perforation was observed. No findings of a breach of the structural integrity of the fingernails or disintegration were encountered. Fingernails can be used as an interpositional graft material in place of cartilage in eligible cases for the repair of nasal septal perforations. Fingernails have several properties that enable their use in such cases, such as form preservation that is similar to cartilage, the lack of live cells, easy availability, and a lack of donor-site morbidity at removal.

Endoscopic sandwich technique for moderate nasal septal perforations

The aim of this article was to describe our surgical technique for the treatment of nasal septal perforations with diameters of 1 to 2 cm. Retrospective clinical research. We reviewed 13 patients with moderate nasal septal perforations (1-2 cm diameter) treated with a sandwich technique (bone or cartilage and quadriceps fascia graft as an interposition graft) by an endoscope-assisted intranasal approach from January 2008 to June 2011. Follow-up periods were 3 months. Thirteen patients were treated with the sandwich technique. Twelve cases (92.3%) were completely healed. One case received incomplete closures without any postoperative symptoms. All patients were found not to have any complications after surgery. The transnasal endoscopic sandwich technique for repairing moderate nasal septal perforation (1-2 cm) has a high success rate and is easy to perform.

Surgical closure of nasal septal perforation. Early and long term observations

Results of surgical treatment of nasal septal perforation are usually evaluated using closure of the perforation as criterion of success. Patients, however, may still have symptoms. To assess the long-term results of surgical treatment of nasal septal perforation with bilateral, posterior based mucoperichondrial septal flaps using a four-point symptom score to ultimately improve treatment and selection criteria. Patients were seen 6 months postoperatively. Questionnaires were sent to 116 surviving patients in 2008-2009. The response was 104. Patients reporting moderate or severe symptoms were seen as outpatients. Between 1987 and 2004, 126 patients were surgically treated using posterior based bilateral mucoperichondrial septal flaps. Sixteen patients had a reperforation during the first 3 months, and another 3 several years later. There was no correlation between early outcome and diagnosis, preoperative size of the perforation, gender or severity of preoperative crusting. There was an increased rate of reperforation with increasing age. Complications seen at the 6 months` follow-up of patients with closed perforations were lachrymal duct stenosis, partial vestibular stenosis, hypoesthesia, crusting and septal deviation, most of which were treatable. Long-term observation mean 10 years) of the same patients showed the following moderate or severe symptoms: crusting, obstruction and bleeding, mainly in men. Obstruction was often due to various forms of perennial rhinitis, sometimes to crusting and more rarely to septal deviation. Crusting was the only independent symptom. There was no correlation between crusting and diagnosis, preoperative size of the perforation, age or severity of preoperative crusting. Results of the surgical technique using posterior based bilateral mucoperichondrial septal flaps for treatment of nasal septal perforations were good, but depend on surgical expertise and age of the patient. Long-term results from other studies will be a guide to choose the proper surgical procedure to minimize the number of late symptoms. Prosthetic treatment cans be an alternative. Patients with return of symptoms should seek further advice.

Surgical closure of nasal septal perforation. Early and long term observations

Background: Results of surgical treatment of nasal septal perforation are usually evaluated using closure of the perforation as criterion of success. Patients, however, may still have symptoms. Aim: To assess the long-term results of surgical treatment of nasal septal perforation with bilateral, posterior based mucoperichondrial septal flaps using a four-point symptom score to ultimately improve treatment and selection criteria. Methodology: Patients were seen 6 months postoperatively. Questionnaires were sent to 116 surviving patients in 2008-2009. The response was 104. Patients reporting moderate or severe symptoms were seen as outpatients. Results: Between 1987 and 2004, 126 patients were surgically treated using posterior based bilateral mucoperichondrial septal flaps. Sixteen patients had a reperforation during the first 3 months, and another 3 several years later. There was no correlation between early outcome and diagnosis, preoperative size of the perforation, gender or severity of preoperative crusting. There was an increased rate of reperforation with increasing age. Complications seen at the 6 months` follow-up of patients with closed perforations were lachrymal duct stenosis, partial vestibular stenosis, hypoesthesia, crusting and septal deviation, most of which were treatable. Long-term observation mean 10 years) of the same patients showed the following moderate or severe symptoms: crusting, obstruction and bleeding, mainly in men. Obstruction was often due to various forms of perennial rhinitis, sometimes to crusting and more rarely to septal deviation. Crusting was the only independent symptom. There was no correlation between crusting and diagnosis, preoperative size of the perforation, age or severity of preoperative crusting. Conclusions: Results of the surgical technique using posterior based bilateral mucoperichondrial septal flaps for treatment of nasal septal perforations were good, but depend on surgical expertise and age of the patient. Long-term results from other studies will be a guide to choose the proper surgical procedure to minimize the number of late symptoms. Prosthetic treatment cans be an alternative. Patients with return of symptoms should seek further advice.

The Nose Inside and Out

Program Description: This unique seminar will bring together leaders from both the American Rhinologic Society (ARS) and American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). We will be examining both functional and aesthetic considerations in nasal surgery from workup to revision surgery. When it comes to nasal surgery, all aspects of anatomy and physiology should be considered, especially when functional and aesthetic surgery is combined. A thorough evaluation is important prior to cosmetic rhinoplasty, with or without septoplasty, including an evaluation of the septum, ostiomeatal complex and inferior turbinates, often using fiber optic endoscopy. The indications for CT scanning will be discussed in patients with sinus disease prior to rhinoplasty. Functional endoscopic sinus surgery can be performed at the same time as rhinoplasty precluding the need for a second surgical procedure. Benefits and contraindications for a combined approach will be presented. Prevention and surgical treatment of nasal septal perforations will be presented since nasal septal perforations most commonly occur following nasal surgery or cocaine abuse. Preventative measures to reduce iatrogenic occurrences will be discussed as well as surgical techniques to repair septal perforations of various sizes. “Functionally safe cosmetic rhinoplasty” will address potential functional pitfalls from cosmetic rhinoplasty. The speaker will target reduced cross-sectional area of the internal nasal valve following many standard rhinoplasty techniques. Methods for cosmetic rhinoplasty that preserve and/or enhance nasal valve function will be presented. Revision rhinoplasty is reported in 5% to 15% of patients. Based on a recent study, “Functional and aesthetic concerns of patients seeking revision rhinoplasty,” the most common complaints that patients present with, from the patients’ point of view, will be presented. This will be accompanied by a summary of these problems with tips on how to prevent them from occurring in the first place. Case presentations will highlight the above. Educational Objectives: 1) Understand the importance of a detailed workup prior to nasal surgery and rhinoplasty. 2) Understand that functional endoscopic sinus surgery can be performed concurrently with cosmetic rhinoplasty. 3) Perform safe septorhinoplasty while maintaining function; prevent sepal perforations; learn why patients seek revision surgery.

Nasal surgery in patients with systemic disorders.

Multisystemic disorders represent a heterogenous group of diseases which can primarily manifest at the nose and paranasal sinuses as limited disease or secondarily as part of systemic involvement. Rhinologists therefore play an important role in the diagnostic but also therapeutic process. Although therapy of multisystemic disorders is primary systemic, additional rhinosurgery may become necessary. The spectrum of procedures consists of sinus surgery, surgery of the orbit and lacrimal duct, septorhinoplasty and closure of nasal septal perforation. Since the prevalence of most systemic diseases is very rare, recommendations are based on the analysis of single case reports and case series with a limited number of patients only. Although data is still limited, experiences published so far have shown that autologous cartilage or bone grafts can be used in nasal reconstruction of deformities caused by tuberculosis, leprosy, Wegener’s granulomatosis, sarcoidosis and relapsing polychondritis. Experiences gained from these diseases support the concept that well-established techniques of septorhinoplasty can be used in systemic diseases as well. However, a state of remission is an essential condition before considering any rhinosurgery in these patients. Even under these circumstances revision surgery has to be expected more frequently compared to the typical collective of patients undergoing septorhinoplasty. In addition, experiences gained from saddle nose reconstruction may in part be of value for the treatment of nasal septal perforations since implantation of cartilage grafts often represents an essential step in multilayer techniques of closure of nasal septal perforations. Aside from the treatment of orbital complications sinus surgery has been proven beneficial in reducing nasal symptoms and increasing quality of life in patients refractory to systemic treatment.

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.

Treatment of nasal septal perforations with a custom-made prosthesis

We present the fabrication and clinical use of a custom-made nasal septal silicone button that can be inserted transnasally into a perforation of the nasal septum by the physician as an office procedure, or by the patients themselves in their home. Questionnaire and retrospective chart review were used to evaluate the efficacy of this prosthesis as treatment of disturbing symptoms from nasal septal perforation. The study included 41 patients (27 women) with a nasal septal perforation. The follow-up time ranged from 1 to 9 years. Symptoms investigated were nasal obstruction, crusting, feeling of dryness, pain, epistaxis, and whistling from the nose. The degree of experienced symptoms was estimated on a VAS-scale. The questionnaire was answered by 37 of the 41 patients. Fourteen patients were still using their button at the follow-up. Treatment with the prosthesis greatly diminished all the investigated symptoms. Also, use of the silicone button resulted in an improved quality of life. No case of infection was noted in connection with use of the silicone prosthesis.

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.

Nasal septal perforations: Our surgical technique

The aim of this paper was to describe our surgical technique for the treatment of nasal septal perforations. We studied 31 patients with nasal septal perforation treated with an endoscope-assisted technique, based on a bilateral dissection of monopedicled mucosal flaps from the nasal fossa floor, sutured at the edge of the perforation previously unstuck, without any graft interposed between the two mucosal layers. In our experience with 31 patients, the use of this technique led to the persistent closing (with follow-up for at least one year) of 96.3% of the perforations smaller than 3 cm. Our technique has the advantage of an endonasal approach, without any external incision, and the use of monopedicled flaps from the nasal fossa floor without any graft interposition, avoiding any other surgical procedure and morbidity in the donor site of the graft. The use of nasal endoscopy permits superior precision in all surgical steps. The high success rate in perforations smaller than 3 cm seems to confirm the effectiveness of this technique.