Endonasal septal perforation repair using posterior and inferiorly based mucosal rotation flaps

Predictors of Success of Endonasal Septal Perforation Repair: A 10-Year Experience

Background: There is no consensus on optimal repair technique for nasal septal perforations (NSPs). Objective: To measure success rate and evaluate predictors of success for NSP repair. Methods: Medical records of patients who underwent NSP repair from 2010 to 2020 were reviewed. Included patients had at least 60 days of postsurgical follow-up. Surgical technique involves an endonasal approach; subperichondrial dissection with local flap mobilization; and multilayer closure using cartilage interposition graft, fascia graft, and mucoperichondrial flaps. A chi-squared test or Fisher exact test was used for statistical analysis. Results: Eighty-one repairs were performed with a closure rate of 86%. The median patient age was 46 years (range 13-77); 34.6% of perforations were ≥2 cm. Conchal (77.8%), rib (7.4%), or septal (7.4%) cartilage was used as graft material. A complication rate of 8.6% was reported. Perforation size or graft material had no impact on successful closure rate. Of patients with failed repairs, 55% had perioperative complications or conditions associated with poor healing. Conclusion: An endonasal approach for NSP repair showed a high success rate across diverse presentations; however, NSP repair was significantly more likely to be successful in patients without perioperative complications or pre-existing conditions associated with poor wound healing.

Endoscopic Techniques for Nasal Septal Perforation Repair: A Systematic Review

OBJECTIVES

Surgical repair of nasal septal perforations (NSPs) is technically challenging. Advantages associated with endoscopic NSP repair (ENSPR) include enhanced visualization and its minimally invasive nature. Purely endoscopic techniques have successful outcomes with low morbidity. This study provides a review of clinical features, surgical techniques, and outcomes in patients who underwent ENSPR.

METHODS

A systematic review was conducted using PubMed/MEDLINE, Cochrane library, and Embase databases. Manual bibliography search produced additional articles. Studies reporting purely endoscopic approaches for NSP repair were included. Patient demographics, NSP size, etiology, repair strategy, incidence of closure, and follow-up were analyzed.

RESULTS

A total of 329 cases from 20 studies were included. The mean age was 37.2 years (range, 12.3-51 years) and 55.0% were male. Common etiologies were iatrogenic (n = 180, 60.0%), trauma (n = 66, 22.0%), and idiopathic (n = 36, 12.0%). The mean NSP size was 17.1 mm (range, 4-23). Repair techniques included unilateral random pattern flaps (n = 205, 62.3%), interposition grafts (n = 137, 41.6%), and unilateral axial pedicled local flaps (n = 81, 24.6%). 222 patients (67.5%) underwent a 2-layered repair, while 70 (21.3%) and 37 (11.2%) patients underwent single and 3-layered repairs, respectively. Successful closure was achieved in 296 patients (90.0%). When stratified by layers of repair, 65 single-layered (92.9%), 196 2-layered (88.3%), and 34 3-layered repairs (91.9%) were successful at a mean follow-up of 16.3 months (range, 3-31 months).

CONCLUSIONS

ENSPR generally achieves NSP closure with high rates of success among varying types of repairs. Further studies may determine how clinical factors and surgical methods impact the likelihood of obtaining successful closure.

Surgical repair of nasal septal perforations: A systematic review and meta-analysis

BACKGROUND

A wide variety of techniques for the surgical repair of nasal septal perforations (NSPs) have been described. Surgical management of NSPs can be broadly divided into open versus endonasal approaches, with additional variables involving unilateral or bilateral flaps, use of grafts, and placement of splints. The objective of this study was to compare surgical approaches and their outcomes.

METHODS

PubMed, EMBASE, and CINAHL Plus databases were examined for patients undergoing NSP repair. English-language studies reporting surgical management of patients with the primary diagnosis of NSP were included. Outcome measures of interest included perforation size, surgical approach characteristics, and success rate defined as complete closure assessed by surgeon postoperatively. The quality of articles was assessed with the methodological index for nonrandomized studies (MINORS) criteria. A random-effects model was used to calculate pooled proportions for the different outcomes.

RESULTS

The electronic database search yielded 1076 abstracts for review. A total of 64 articles met the inclusion criteria, with 1591 patients: 1127 (71%) underwent an endonasal approach and 464 (29%) an open approach. The median (range) MINORS score was 10 (5-12) out of 16 points. Overall, 91% of patients had total closure (95% confidence interval [CI], 0.89-0.93, p < 0.01), with moderate heterogeneity between studies (I²  = 42.03%). There was no difference in closure success between open and endonasal approaches. Use of bilateral versus unilateral flaps, interposition grafts, and intranasal splints and packing were not associated with differences in outcomes.

CONCLUSION

Nasal septal perforation surgical repair success rates are comparable regardless of technique.

Long Term Outcomes of Nasoseptal Perforation Repair With an Anterior Ethmoidal Artery Flap

BACKGROUND

Nasoseptal perforation repair is a challenging condition with no standard technique for repair recognized.

METHODS

A case series of consecutive patients who underwent nasoseptal perforation repair with an anterior ethmoidal artery flap was conducted. Demographic data, preoperative features of the perforation and postoperative outcomes were analyzed. Closure rate, complications and persistence of nasal symptoms were documented.

RESULTS

Thirty-two patients were included in the study. The average perforation diameter was 1.48 cm (range: 0.4-3 cm). Iatrogenic trauma was the most common cause (56% of patients). Nine cases ended up being idiopathic. The overall closure rate was 81%, but 87.5% when perforation had a 2-cm diameter or less. Of the six failures, 2 were due to flap necrosis and 4 to a residual anterior perforation. Despite the persistence, 2 patients solved their symptoms. One patient underwent revision surgery.

CONCLUSION

The anterior ethmoidal artery flap is a reliable and minimal invasive technique for closure of symptomatic perforations. For defects larger than 2 cm, a lower success rate and additional reconstructive measures should be considered. Objective questionnaires are needed in order to evaluate functional outcomes.

A contemporary review of "realistic" success rates after surgical closure of nasal septal perforations

OBJECTIVE

The surgical closure of septal perforations is a challenging procedure. Various techniques exist. Each perforation proves that there is not the one precise procedure for all perforations. Nevertheless, success rates of about 90% are reported, although the procedure for closing the defect is challenging. Our goal was to evaluate the existing data.

METHODS

We performed a contemporary review of published closure rates of septal perforations on order to compare the present results in the literature. The limitations of the respective studies were analyzed.

RESULTS

We found closure rates from 30 to 100%. Numerous procedures were described and combined. Prospective studies comparing different techniques are missing. The follow-up time in studies was quite short or not even specified. Studies on long-term success rates are rare.

CONCLUSION

The closure of septal defects is one of the most challenging rhinosurgical interventions. Closure rates ≥90% as described in literature seem relatively high. One reason might be short follow-ups and retrospective study designs. Frequently, precise information on the follow-up and the method of follow up is missing. Thoroughly designed prospective studies are absent. Longer follow-up times are associated with lower complete closure rates. A long-term success rate between 70 and 80% seems realistic.

Cartilage Sparing Septal Perforation Repair using Rotation Flaps and a Collagen Interposition Graft: A Case Series

OBJECTIVE

Septal Perforations may be asymptomatic or can cause significant problems including nasal obstruction, crusting, bleeding, whistling and in severe cases a change in nasal shape and even pain.

METHOD

The author would like to present a single surgeon case series of septal perforation repairs, managed using an endo-nasal technique, with no external scars. There were 54 consecutive cases between 2011 and 2017. The repair was carried out using mucosal rotation flaps with an interposition graft of porcine collagen matrix. Patients were grouped according to the size of the perforation as measured at the time of the surgery. The patients were then clinically followed up for 1 year, and the recorded outcome measures were: the success of the surgical repair and the patient reported symptoms.

RESULTS

Surgical success was 70% up to 1 cm diameter, 77% from 1 to 2 cm and 82% in perforations from 2 to 3 cm in diameter. No perforation over 3 cm in diameter was successfully closed. Patients were rendered asymptomatic even if the perforation was not closed in between 81% and 91% of patients up to perforations 3 cm in size. Over 3 cm in size 50% of patients reported being asymptomatic.

CONCLUSIONS

This technique is an effective and low morbidity option for patients with small to medium sized septal perforations. For perforations over 3 cm in diameter other options may be more suitable.

Bilateral mucosal flap septal perforation repair in the adolescent

INTRODUCTION

Perforations of the nasal septum are rare in the pediatric age group. High success rates for attempted perforation closure utilizing mucosal flap techniques in adults are frequently reported. This study reviews our experience with pediatric patients diagnosed with a septal perforation who underwent attempted closure during adolescence. Our endonasal bilateral mucosal flap technique is present.

METHODS

This study is an observational case series with retrospective chart review of a single surgeon's experience of attempted septal perforation repair utilizing bilateral mucosal flaps with an interposition graft in patients diagnosed with a perforation prior to age 19. The study period was from November 1991 to April 2019. Patient demographics, perforation characteristics (etiology, symptoms and size), surgical closure technique and outcomes are presented.

RESULTS

Twenty-three patients (13 females) met the study criteria. Mean age at diagnosis was 14.3 (range, 3-18) years. Crusting (82.6%), nasal obstruction/congestion (60.9%) and epistaxis (47.8%) were the most frequent reported symptoms at presentation. Fourteen patients who underwent attempted closure during adolescence had a minimum of three months follow-up. Mean age at the time of bilateral mucosal flap repair was 17.4 (range, 13-19) years. Mean perforation length was 14.2 (range, 8-22) mm and mean height 10.6 (range, 5-15) mm. Complete closure was noted in all but one patient (92.8%) at the time of last follow-up, mean 16.9 (range, 3-92) months. Every patient noted partial to complete resolution in presenting symptoms. Four patients required revision surgery to address persistent postoperative obstruction.

CONCLUSION

Our experience demonstrates septal perforation repair utilizing a bilateral mucosal flap technique can be successfully employed in the adolescent patient.

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.

Endoscopic repair of septal perforation in children

OBJECTIVE

Being increasingly faced with the problem of pediatric nasal septal perforations, we have found that the surgical management of nasal septal perforations in children is not widely described in the litrature. The objective of our study was to demonstrate the results of different surgical techniques, including two original endoscopic techniques, in the septal perforation repair in children.

METHODS

24 children, ranging between 6 and 17 years of age, with nasal septal perforations were operated using different endoscopic techniques from February 2015 to May 2019 at the special tertiary referral clinic. Apart from well-known techniques, such as anterior ethmoidal artery flap, intranasal bipedicled advancement flap, sublabial flap, free temporal fascia graft, we used two original techniques - inverted edges technique and cross-septal returned flap.

RESULTS

The total rate of complete perforation closure was 79% (19 of 24 patients). Regarding the reduction of symptoms, the efficacy of surgery was approaching 100%. The combination of inverted edges technique and anterior ethmoidal artery septal flap demonstrated the best results with no reperforations in all 10 cases. Using cross-septal returned flap, we achieved complete closure of perforation in 5 (83%) of 6 patients. The remaining techniques were performed rare and showed relatively low rates of success. There were 2 cases of complications (oronasal fistula), both developed in patients with sublabial mucosal flap.

CONCLUSION

Use of endoscopic assistance, vascularized mucoperichondrial flaps and bilateral closure demonstrates high effectiveness in septal perforation surgical repair in children.

LEVEL OF EVIDENCE

4.

Cross-septal returned flap: modified endoscopic technique for bilateral closure of septal perforation

Endoscopic approaches for septal perforation closure have achieved a certain popularity. Many of the flaps described provide unilateral closure of the perforation. Thus, complete restoration of the normal multilayer septal anatomy is still challenging, particularly in children. This article presents a modified technique for endoscopic bilateral surgical repair of nasal septal perforations. A novel cross-septal returned flap was performed in nine patients with nasal septal perforations. The mean size of the perforation was 17.7mm in the sagittal axis and 16.9mm in the vertical axis. All patients were followed up for a minimum of 12 months (range 12-31 months). There was only one case of residual septal perforation during the follow-up period, but with a significant decrease in the severity of symptoms. The results of the surgical technique presented show its high efficacy. We believe that the best indication for this technique is non-epithelized perforation edges that cannot be used as a reliable bridge for the preparation of any cross-over flaps. Use of the cross-septal returned flap allows the complete bilateral repair of nasal septal perforations to be achieved.

Custom Nasal Septum Prosthesis Fabricated from a 3D-Printed Working Model: A Clinical Report

This clinical report describes the treatment of a 47-year-old female patient with a nasal septum perforation. The treatment used a 2-piece magnetic custom prosthesis fabricated from a 3D-printed model. By using an existing medical CT scan to generate the printed working model, the number of clinical appointments was reduced. The workflow expanded the purpose of the radiologic images from simply diagnostic to include the prosthetic aspect of treatment.

Pediatric nasal septal perforation

OBJECTIVE

1.) 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.

METHODS

IRB-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.

RESULTS

Median 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.

CONCLUSION

Pediatric 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.

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

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.