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Considerations in the etiology, treatment, and repair of septal perforations
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There are many causes for septal perforations, and a very thorough history is necessary in all patients (Box 1). A history of acute, chronic, or previous systemic disease must be detennined. A history of any previous nasal surgery or instrumentation, of any previously treated epistaxis, of nose picking, of internal and external nasal trauma, of use of over-the-counter or prescription nasal sprays, of illicit drug abuse, and of smoking or other hazardous aerosol exposures should be established.
External nasal trauma A blow to the extemal nose can cause fracturing of the septum with the possibility of disruption of the mucoperichondrium with cartilaginous fractures, especially in someone who already has a deviated septum. If fractures with tears are left untreated, infection and perforations can result. An undiagnosed and untreated septal hematoma from trauma can go on to develop fibrosis and loss of the intervening cartilage or can get infected and develop an abscess leading to a perforation. Nasal trauma in a postoperative septoplasty patient is more likely to lead toward a perforation than in a nonoperated individual. Direct piercing injuries are rare, yet the author has treated one individual whose face was impaled by a motorcycle’s gearshift that went straight across the face and right through the septum. This injury resulted in a septal perforation that later required repair.
Self-inflicted trauma Nose picking is more of a problem than some individuals believe. It is amazing to see how often people insert not only their fingers but also other objects into their noses, either as a nervous habit or in an attempt to clean the nose. Some people cause severe damage to the septum and epistaxis from their nose picking. Children quite commonly insert foreign bodies into the nose, and those with hearing aids have been known to put hearing aid batteries in their noses. Battery injury can cause chemical burns to the septum, resulting in perforation.
Surgically induced trauma and previously treated epistaxis The most common cause of recognized septal perforations is seen in patients who have been treated for epistaxis and in those who have had previous nasal procedures. Nasal septal epistaxis often is treated initially by simple vasoconstriction and application of silver nitrate. Tight nasal packs are sometimes placed to prevent rebleeding, or in cases where bleeding simply cannot be controlled with cautery. Tight nasal packs, especially in patients who have had previous septoplasty, may compress the vascular supply to the septum and if left in place long enough can lead to septal perforation, secondary to interruption of mucoperichondral blood supply. Sometimes electrocautery is used on the septum, and it is quite easy to cause damage to both membranes. If septoplasty has been performed and there is no intervening protective cartilage, the risk of perforation is even greater. Some physicians sew hard intranasal septal splints into place after septoplasty. If the septal splints are sewed too tightly, they too can compromise the blood supply to the septum.
The classic cause of septal perforations is a previous septoplasty, in which there have been tears in both septal membranes in a contiguous area where intervening septal cartilage or bone has been removed. When such tears do occur, it is wise to repair them immediately and to insert an intervening cartilage or a connective tissue or acellular dermal graft to act as a barrier to perforation. In postoperative care after a septoplasty one must be quite careful, in suctioning out the nose, not to push the suction through a thin septal membrane.
Other nasal surgeries and procedures that are not performed directly on the septum can cause inadvertent damage to and subsequent perforations of it. Cautery and cryotherapy of the turbinates with an unprotected septum may cause burns and loss of septal integrity. Endoscopic sinus surgery and nasal antral window surgery have also been implicated in perforations. Trans-septal approaches to the sphenoid are causes of perforations. In certain individuals who have a large septal deviation or spur and require nasotracheal intubation, an endotracheal tube placed through that obstructed side can cause total denuding of the septum, leading to perforation. Discussions with the patient before any nasal procedure should encompass the potential for the complication of a septal perforation, and when one occurs, the physician should disclose this information to the patient postoperatively. Some perforations so caused may be tiny and asymptomatic and require no repair. The unrecognized perforation may approach enormous dimensions and significance, however, before it is brought to the patient’s attention by another physician [3].
Prevention The mucoperichondral flaps overlying the septal cartilage provide its blood supply. When there has been a tear in one side of the membrane alone, the cartilage usually can get its blood supply from the opposite, still-intact membrane and thus survive. The problem occurs when the mucoperichondrium has been disrupted on both sides of the cartilage in corresponding areas, leading to cartilage necrosis and later perforation. In a septoplasty, if corresponding tears have occurred with removal of the intervening cartilage, a perforation will be evident at the end of the procedure. As Fairbanks [4] has pointed out, nasal septal perforations need to be repaired immediately at the end of the nasal operation, no matter how small they may appear, especially when the intervening cartilage has been removed. It is foolhardy to believe that a perforation will heal on its own. It is more likely that the perforation will enlarge postoperatively with the contraction of healing.
Mucosal lacerations are common in septoplasty, especially when one encounters a very crooked septum or a septal spur posteriorly. The secret to preventing corresponding tears in both mucoperichondral flaps is to be sure that one has undermined broadly and elevated the mucoperichondrium away from the deviated cartilage or septal spur area before attempting to remove the spur or the deviation. Even in the case of a spur, where penetrating the overlying membrane is quite common, the opposite mucoperichondrium usually can be elevated easily and carefully. If one membrane remains intact, the chance of a through-and-through perforation is decreased. Elevation of the mucoperichondral flap must be in the correct plane, and often the novice surgeon will not adequately access this flap and will leave mucoperichondrium on the septum itself. Using the sharp portion of the Cottle elevator, the surgeon can assure an appropriately elevated mucoperichondral flap more accurately. Often the maxillary crest is also deviated, and perforations can quite easily occur along the crest. In these cases not only the mucoperichondrium of the septum but also the mucoperiosteum on the floor of the nose are elevated and joined. These flaps are retracted away from the cartilage and bone before excision of the obstructing cartilage or bone. When a large spur is encountered, the cartilage is separated from the bony septum and the mucoperichondrium is elevated over the bony portion of the spur on its opposite side. Becker scissors are used to cut above and below the deviation, and then the tip of the nasal speculum is used to push the spur closer to the midline as one teases the mucoperichondrium off the protruding portion of the spur.
In some cases, however, because of the inexperience of the surgeon or the difficulty of the case, corresponding tears do occur. In such cases, it is important to perform separate closure of the perforation in each membrane, followed by the placement of crushed cartilage that is reimplanted between the flaps in the area of these perforations (Fig. 3). Trenite et al [5] have shown that there is a decreased rate of perforation when autologous cartilage is used for reskeletization. It is this author’s strong opinion that reskeletization should occur when possible in septoplasty, especially when contiguous tears occur, even if the tears are sewn closed. The obstructing cartilage that has been removed, and which normally would be discarded or sent to pathology for identification, can either be crushed or placed between the mucoperichondral flaps, which are mattressed together at the end of the case. Even if the crushed cartilage does not survive postoperatively, at least it serves as a barrier against through-and-through perforation. If the cartilage used for reskeletization purposes does not survive, it may add to fibrosis and strengthen the septal flaps that have been weakened by removal of the cartilage. If no septal cartilage is available for reskeletization, as in the case of revision septoplasty or in cases where all available cartilage has been used for grafting purposes, acellular dermis or a connective tissue graft may be used.
Septal perforations are potential unwanted complications in any nasal procedure, and the patient should be warned of them preoperatively. Postoperatively, patients must be informed of the presence of a perforation so they can make decisions about how to proceed for relief of any symptoms.
Nasal sprays, smoking, and cocaine usage Shoelzel and Menzel [6] have noted that chronic use of nasal sprays may lead to septal perforations. Patients themselves can abuse some of the vasoconstrictive sprays [7], which cause intense vasoconstriction of the mucoperichondrium and can lead to perforations, especially when combined with cigarette smoking or very dry climates. The advent of the steroid nasal sprays and the rise of their longterm use in individuals have been greeted with very little heed to the potential for septal perforation. Patients on these medications should be monitored periodically to check for any septal irritation, which could later proceed to perforation.
Cocaine use is particularly damaging to the septum because the drug itself causes intense vasoconstriction, which is worsened by the fact that most street cocaine is not pure but rather adulterated with very irritating substances, such as borax or talc [4]. One-time use of intranasal street cocaine has been known to cause a septal perforation. Chronic cocaine abusers often destroy their noses because infection complicates the inflammation, irritation, and lack of blood supply. The condition worsens to such an extent that membrane, bone, and cartilage necrosis takes place and leads not only to perforation, but also to nasal collapse, intranasal stenosis, and saddling. Chronic cocaine abusers usually are easy to detect in the office, based on their jittery habits, their wired, intense appearance, and their chronic nasal sniffing. It is useless to repair a septal perforation in a patient who is stiIl using cocaine, because the perforation is certain to recur. Unfortunately, cocaine patients have a difficult time curing their addiction and often are less than truthful in their history with the physician. Operating on patients who are still using cocaine is to be avoided. Obtaining preoperative cocaine levels on such patients may be warranted. Talking with the individual’s counselor may also help with operative planning, because most cocaine addicts are unable to quit without counseling. AdditionaIly, cocaine patients need anesthetic and medical clearance because of their susceptibility to more anesthetic complications than nonusers.
On physical examination of the nose, a full diagnosis cannot be made until all crusts have been removed and decongestion of the turbinates has taken place, making it possible to visualize the entire nasal septum. Examination of some patients with a bend in the septum and enlarged turbinates is difficult, and a posterior perforation may be missed. When a perforation is noted, its circumferential size and relative position should be documented. An ominous sign is crusting that is observed not only around the edge of the perforation but all over the nasal septal and turbinate mucosa. Such a finding occurs more often in patients with causes suggestive of a granulomatous or vascilitis process. Findings of overall crusting in a cocaine user or in a patient with a granulomatous process make the prognosis for long-term operative success more guarded.
The septum should be palpated with a cotton-tip applicator to discern persistent cartilage between the mucosal flaps and to determine whether cartilage extends close to the edges of the perforation. In perforations that have occurred after septoplasty, there is usually very little cartilage left, and this makes dissection of the flaps more difficult. If one finds extensive membrane swelling and inflammation or sees synechia or collapse of the nose internally as well as externally, one should consider the possibility of an ongoing disease process or the active use of cocaine. Previous cocaine use usually results in a clean-edged perforation with cartilage present almost all the way to the edges of the mucosal perforation. A thorough head and neck and generalized examination is necessary to rule out any other system involvement.
Patients often have very little understanding of the internal nasal anatomy, do not know what the septum is, and know little about the complexity of septal perforation repair. Most patients, moreover, have no idea that they have a septal perforation when presenting their symptoms and are understandably unsettled to learn that operative attempts to repair this perforation are not always successful. It is often helpful to use an in-office endoscope attached to a monitor or to a color printer to educate the patient as to the extent of the problem (Fig. 2). Anatomic models or diagrams are especially useful in helping the patient understand what may need to be done [3]. An even more difficult situation occurs when the patient presents to the facial plastic surgeon for revision rhinoplasty after unsuccessful cosmetic surgery elsewhere and learns that the external deformity is accompanied by a crippling internal airway defect.
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Fig. 2. A paper ruler is placed in the nose to show the patient the size and shape of the perforation. |
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Chemical irritants In addition to cocaine, nasal sprays, and smoking, industrial irritants are common causes of perforations [1]. Individuals who work in chrome plating factories or in chemical plants and are exposed to chromic, sulfuric, and hydrochloric acids are at high risk for severe nasal airway irritation. Industrial and agricultural aerosolized dust, such as is found in grain and rice elevators and cement, glass, and lime factories, can cause perforations. Individuals working with swimming pool chemicals or in chemical factories are also at high risk. Prevention of nasal injury in these working situations would entail wearing proper filter masks during the irritant exposure. Any such irritant can cause more damage if the nose is further dried by the environment or by smoking.
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Fig. 3. A piece of septal cartilage is crushed in a cartilage crusher and then placed back between the mucoperichondral flaps to reskeletize the septum and help prevent a perforation. |
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Pathologic processes Serious systemic diseases, including neoplastic, inflammatory, and infectious conditions, are causes of septal perforation. When none of the previously listed causes has been determined, the physician must look elsewhere and rule out potential serious causes. Vasculitides and coIlagen vascular disorders, such as lupus, rheumatoid arthritis, and polychondritis, can lead to septal perforations as weIl as dorsal cartilaginous saddling. The problem with such conditions is that they can go into remission and then recur. Before repairing perforations in these patients, it is wise to touch base with the primary physician, rheumatologist, or infectious disease physician handling the patient. These patients must be told that even though a repair can be successful, another perforation may occur if their disease flares up again at a later time because of the process of vascular destruction-an event that this author has noted, especiaIly in patients with renal and smaIl vessel disease. Granulomatous diseases, such as Wegener’s granulomatosis and sarcoidosis, are less common causes. A CT scan of the nose and paranasal sinuses is helpful when granulomatous disease is suspected.
Neoplastic disorders, such as metastic carcinoma and squamous and adenoid carcinomas and melanomas, must be ruled out. Midline lethal granuloma is another serious destructive process for which one must evaluate when there is no clear-cut cause for the septal perforation. If the head and neck examination has not revealed any other pathology, laboratory batteries for coIlagen vascular and kidney disease, fluorescent treponemal antibody-absorption, and Epstein-Barr virus titers should be drawn, and the venereal disease research laboratory test, antineutrophil cystoplasmic antibody test, and angiotensin converting enzyme test should be performed. Nasal cultures for fungal and bacterial species may be necessary in the presence of an inflammatory process. Skin testing for anergy, tuberculosis, and fungal infections also may need to be performed. When no clear cause has been discovered, a biopsy of the perforation may be indicated before reparative surgery, although Murray and McGarry [8] would disagree. The biopsy specimen of the septum should be taken from the posterior edge of the perforation, making sure to include enough tissue so that the pathologist has a specimen away from the perforation edge from which he or she can get a definitive diagnosis. A smaIl biopsy specimen taken from the edge of the perforation is often reported as merely chronic inflammation. It is important not to perform the biopsy at the superior edge of the perforation where one would increase the vertical perforation height, which is more difficult to close. Similarly, biopsies at the anterior portion should be avoided, because that area needs to be closed to decrease symptoms.
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