Perioperative Management of Nasal Septal Perforation: A Case Series and Review

AbstractNasal septal perforation is a prevalent pathology, and its successful treatment remains a significant challenge. Surgical closure is complex, and there are a plethora of accounts of various surgical techniques within the existing literature. Much less has been written about perioperative considerations, which are arguably just as important. This article therefore focuses predominantly on the pre and postoperative management of patients with septal perforation. By drawing both on the existing literature and a series of 64 cases managed over several years by our department, this review aims to consolidate guidance on patient selection, timing of surgical intervention, postoperative splinting, use of antibiotics, and patient advice. It is clear that the size of the perforation (relative to the size of the septum), health of surrounding mucosa, and the systemic health and age of the patient remain essential considerations in patient selection and operative timing. Internal and external splints are widely used to good effect, but the role of nasal packing is less clear-cut. This article suggests packing, but with an increasing preference for NasoPore over BIPP (bismuth iodoform paraffin paste). Use of prophylactic antibiotics remains controversial. The complete closure rate for the series presented here was 81.3%, with an average perforation diameter of 15.1 mm (range: of 6–32 mm), and that for perforations with a diameter below 22 mm was 97.9%.

Surgical closure of nasal septal perforation using mucosal flaps and interposed graft: a case series of 154 patients and literature review

The Journal of Laryngology & Otology ◽

10.1017/s0022215121003248 ◽

2021 ◽

pp. 1-34

Author(s):

Emily G Heywood ◽

Mahmoud Daoud ◽

Ashish Talawdekar ◽

Nadia Ashraf ◽

Ullas Raghavan

Keyword(s):

Literature Review ◽

Case Series ◽

Septal Perforation ◽

Surgical Closure ◽

Surgical closure of nasal septal perforation using mucosal flaps and interposed graft: a case series of 154 patients and literature review

The Journal of Laryngology & Otology ◽

10.1017/s0022215121003625 ◽

2021 ◽

pp. 1-33

Author(s):

Emily G Heywood ◽

Mahmoud Daoud ◽

Ashish Talawdekar ◽

Nadia Ashraf ◽

Ullas Raghavan

Keyword(s):

Literature Review ◽

Case Series ◽

Septal Perforation ◽

Surgical Closure ◽

Septal Perforation Repair Utilizing an Anterior Ethmoidal Artery Flap and Collagen Matrix

American Journal of Rhinology and Allergy ◽

10.1177/1945892418816959 ◽

2018 ◽

Vol 33 (3) ◽

pp. 256-262 ◽

Cited By ~ 4

Author(s):

Marina N. Cavada ◽

Carolyn A. Orgain ◽

Raquel Alvarado ◽

Raymond Sacks ◽

Richard J. Harvey

Keyword(s):

Corticosteroid Injection ◽

Case Series ◽

Collagen Matrix ◽

Contralateral Side ◽

Septal Perforation ◽

Closure Rate ◽

Reliable Technique ◽

Ethmoidal Artery ◽

Anterior Ethmoidal Artery

Background Nasal septal perforation repair remains a challenge with no standard technique for repair recognized. Objective To describe the combination of an anterior ethmoidal artery flap with a collagen matrix inlay as a successful technique for nasal septal perforation repair. Methods A case series of consecutive patients who underwent nasal septal perforation repair with an anterior ethmoidal artery flap with an inlay collagen graft was conducted. Demographic data, preoperative features of the perforation (size, location, and presence of chondritis), and postoperative outcomes were analyzed; closure rate, mucosalization rate (of the contralateral side at 21 and 90 days), and complications (crusting, bleeding, obstruction, infection, and rehospitalization <30 days) were documented. Results Thirteen patients (age: 49 ± 15 years, 30.8% women) were assessed. The perforation size was 1.6 ± 0.9 cm (range: 0.3–3.5 cm) and located 1.2 ± 0.5 cm (range: 0.5–2.0 cm) posterior to the columella. Chondritis was present in 69.2%. The closure rate was 100% (95% confidence interval [CI]: 77%–100%) at both 21 and 90 days. One patient required a free mucosa graft to an area of persistent crusting on the contralateral side (7.7%). Complications were low; bleeding 0%, obstruction 7.7% (requiring corticosteroid injection of anterior ethmoidal artery flap), and 0% infection/rehospitalization. Conclusion Anterior ethmoidal artery flap with an inlay collagen matrix is a reliable technique to repair nasal septal perforation. This technique, with robust vascularity and wide angle of rotation, enables the closure of perforations both large (<50% total septum) and with anterior locations.

Repair of nasal septal perforations using local mucosal flaps and a composite cartilage graft

The Journal of Laryngology & Otology ◽

10.1258/0022215011906939 ◽

2001 ◽

Vol 115 (1) ◽

pp. 22-25 ◽

Cited By ~ 33

Author(s):

T. J. Woolford ◽

N. S. Jones

Keyword(s):

Donor Site ◽

Donor Site Morbidity ◽

Observation Time ◽

Cartilage Graft ◽

Septal Perforation ◽

Surgical Closure ◽

Graft Donor ◽

Conchal Cartilage Graft ◽

Suitable Technique

The surgical closure of a nasal septal perforation is recognized as being particularly challenging. A series of 11 consecutive patients who underwent closure of a septal perforation using a mucosal flap/composite conchal cartilage graft technique are reviewed, and the surgical technique described. The size of the perforation repaired varied, with eight cases being 2 cm or more in diameter. There was no significant graft donor site morbidity and complete perforation closure was achieved in eight cases after a mean observation time of 19.8 months. These results suggest that this is a suitable technique for closing nasal septal perforation.

Nasal Septal Perforation Repair: 25-Year Experience with the Flap and Graft Technique

The American Journal of Cosmetic Surgery ◽

10.1177/074880689401100308 ◽

1994 ◽

Vol 11 (3) ◽

pp. 189-194 ◽

Cited By ~ 10

Author(s):

David N. F. Fairbanks

Keyword(s):

Connective Tissue ◽

Blood Supply ◽

Septal Perforation ◽

Surgical Closure ◽

The Past ◽

Structural Reinforcement ◽

Flap Viability ◽

Successful Technique ◽

Advancement Flaps

A predictably successful technique for surgical closure of nasal septal perforation has been employed in over 100 patients in the past 25 years. It employs bipedicled mucosal advancement flaps designed to maximize blood supply (for flap viability) and an underlying connective tissue autograft (fascia or pericranium) for structural reinforcement.

BI22: A three‐patient case series: methotrexate‐induced nasal septal perforation, mucositis and widespread ulceration

British Journal of Dermatology ◽

10.1111/bjd.20320 ◽

2021 ◽

Vol 185 (S1) ◽

pp. 152-152

Keyword(s):

Case Series ◽

Septal Perforation ◽

Patient Case ◽

Nasal Septal Perforation: Experience of Management

Bengal Journal of Otolaryngology and Head Neck Surgery ◽

10.47210/bjohns.2020.v28i3.296 ◽

2021 ◽

Vol 28 (3) ◽

pp. 255-259

Author(s):

Selçuk Kuzu ◽

Çağlar Günebakan

Keyword(s):

Nasal Septum ◽

Inflammatory Diseases ◽

Nasotracheal Intubation ◽

Septal Perforation ◽

Closure Rate ◽

Composite Tissue ◽

Common Causes ◽

Septum Perforation ◽

Nasal Septum Perforation

Introduction Nasal septal perforation is the loss of composite tissue comprising the mucosa, bone or cartilage structures that form the nasal septum. Nasal septum perforation has many causes. Though it may be idiopathic, the most common causes are iatrogenic like nasal surgeries. Among other reasons are septal hematoma, nasal picking habit, nasal cauterization due to nosebleeds, nasotracheal intubation, cocaine use, vasculitis, inflammatory diseases such as sarcoidosis, This study aims to review the approach to management of patients with nasal septal perforation who underwent repair of the perforation in a tertiary clinic, in the light of current literature. Materials and Methods In this study, the records of 27 patients who were diagnosed with nasal septal perforation and treated surgically in a tertiary clinic, between January 2015 and June 2019 were reviewed retrospectively. Results The successful closure rate of perforations was 74%. In 4 of 7 patients whose perforations were not completely closed, the perforation size was larger than 2 cm in diameter. Conclusion Successful repair of nasal septal perforation depends largely on the cause, location, size of the perforation, cartilage bone tissue on the perforation edges, surgical technique and the surgeon's experience.

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

Rhinology Journal ◽

10.4193/rhino10.081 ◽

2011 ◽

Vol 49 (4) ◽

pp. 486-491 ◽

Cited By ~ 1

Author(s):

L.K. Dosen ◽

R. Haye

Keyword(s):

Surgical Treatment ◽

Septal Deviation ◽

Long Term Results ◽

Septal Perforation ◽

Surgical Closure ◽

Perennial Rhinitis ◽

Long Term Observation ◽

Duct Stenosis

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.