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Considerations in the etiology, treatment, and repair of septal perforations
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An asymptomatic perforation, such as those that are located posteriorly and have weIl-healed edges, rarely requires any treatment at all. Mild symptoms, with the exception of obstruction, usuaIly can be managed by medical therapy. Often just keeping the nose moist is enough, and the daily application of petroleum jeIly on a cottontipped applicator to the inside of the nose may be satisfactory. Topical nasal estrogen spray may be added to help reduce squamous metaplasia and subsequent dryness; Chmiel [9] suggests 25 mg of conjugated estrogen solution mixed to one 30 cc bottle of nasal saline spray, with two puffs each side three times a day.
Patients who have a great deal of intranasal crusting need more frequent therapy with nasal irrigations, as well as ointments and emollients. Fairbanks [4] suggests an antiseptic wash of one teaspoon of table salt dissolved in a quart of warm water to be used to irrigate the nose. A rubber bulb syringe or a nasal adapter for the Water Pik are good delivery systems. Adding a moisturizing and coating substance, such as a cup of com syrup (Karo) or glycerin (which is readily available at the drugstore) further serves to reduce nasal crusting. Adding a teaspoon of vinegar or 1 to 3 tablespoons of boric acid powder is effective in decreasing Staphylococcus areas and Pseudomonas aeruginosa growth. These irrigations can be followed in particularly dry noses with bacitracin or Bactroban, especially if there is a chronic infection.
If these treatments are unsuccessful, if the patient is unwilling to care consistently for the nose, if the sensation of nasal obstruction is dominant, or if the patient declines surgery or is not a surgical candidate, a silicone grommet prosthesis may be helpful (Fig. 4). Unfortunately, the protheses that are available commercially are generally of one size and do not adequately fit larger perforations [10].
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Fig. 4. A silicone grommet button prosthesis can be placed in the perforation in a non operative candidate. |
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In these cases, a custom-made silicone button easily can be made by the local prosthetist if the facial plastic surgeon provides the dimensions of the perforation. Price et al [11] use reformatted CT images to obtain measurements. Alternatively, it is usually quite simple to insert a piece of paper against the perforation after topically anesthetizing the nose; then, through the opposite nostril, one may use a marking pen to outline the perforation itself. Usually the standard or custom-made septal buttons can be inserted in the office under local anesthesia. When the perforation is especially large, sedation may be necessary. When buttons are in place, occasional nasal irrigations are still suggested to keep the obturator clean. If there is a chondritis or lowgrade infection present, the button will not cure this problem, and continued observation and treatment by the physician are necessary. Silicone septal buttons should also be used in patients who, for other medical reasons, are not good surgical candidates. They should certainly be considered in patients with chronic or recurrent disease processes, as well as patients with continued cocaine use.
Surgical goals
The primary goal of surgery should be not only to repair the perforation but also to restore normal function and physiology to the nose. Many different techniques have been described for closure, but only those that use intranasal advancement flaps are able to achieve normal physiology, because they use the normal respiratory epithelium for closure. However, in the long-term septal perforation patient, squamous metaplasia may have replaced the normal respiratory mucosa of the advanced flaps, and dryness may persist despite closure. Other methods that use skin grafts or buccal mucosal grafts may be effective in closing the perforation, but these leave the patient with a dry nose that continues to crust because skin normally sheds, and normal respiratory epithelium is not present. From experience, one readily knows that when one goes to the dentist and has air blown by the mucosa, an uncomfortable dry feeling ensues. When buccal mucosa grafts are used in the nose for perforation repair, the normal flow of air through the nose dries these grafts and does not solve the problem.
A second goal of surgery should be a tension-free closure so that the repair will not break down postoperatively with healing scar contraction. Because there is no elastic tissue in septal mucosa, adequate mobilization of septal flaps must be performed [4]. The open external rhinoplasty approach affords necessary access and exposure for repairing the perforation and for the development of these mucosal flaps [12,13]. By using sliding bipedicled or unipedicled flaps taken from the floor of the nose extending laterally under the inferior turbinate, one can close the mucosal portion of the perforation with normal nasal mucosa. It is absolutely crucial that in addition to both mucoperichondral flaps being closed, a connective tissue interposition graft be placed between the corresponding perforations to act as a template on which the edges of the sewn perforation can migrate and mucosalize closed. Fairbanks [4,13], Gollom [14], Kridel et al [15,16], Goodman and Strelzow [17], and others have described using this method with over 90% success rates in perforations of up to 2 cm to 3 cm. As perforations increase in size, the chances of success decrease proportionally. The anterior to posterior length of the perforation is not critical in closure because the tension of closure is from the floor of the nose to the dorsum, which is perpendicular to this axis.
In evaluation of a septal perforation for surgery, the height of the perforation is a helpful determinant of the potential for successful repair. The absolute size of the perforation is not as important as the proportion of septal membrane remaining. For example, a 1-cm perforation in a young child with a small nose could be much more difficult to repair than a 2-cm perforation in an adult patient with a very large nose and septum. Perforations that extend all the way to the nasal dorsum are almost impossible to repair, unless there is some small cuff of membrane to which the inferior advanced flap can be sewn. Similarly, perforations that extend all the way down onto the floor are technically difficult. If multiple adhesions between the remaining septal membranes and turbinates or lateral nasal wall are present, the surgeon may wish to lyse these adhesions in a separate preceding procedure and place Silastic sheeting on the septum for several weeks to prevent reformation, then go back into the nose for the definitive perforation repair. In addition to the height of the perforation, another prognostic indicator is the amount of cartilage remaining in the rest of the septum. When a fairly aggressive septoplasty has been performed previously, the dissection of the adherent mucosal flaps is extremely difficult and can lead to worsening of the perforation during mucoperichondral envelope separation.
Finally, one of the most important determinants of success is quite simply the experience and skill of the operative surgeon. Because septal perforations commonly are caused by novice nasal surgeons, it follows that a gentle and experienced touch is the key to their repair. The separation of the mucoperichondral flaps can be tedious and must be done quite carefully, so as not to cause an increase in the size of the perforation or another perforation elsewhere along the septum. When septal flaps are sewn together, the use of a cutting needle facilitates closure, but if used with any amount of force the suture needle can easily tear the residual membranes, making the closure much more difficult. Operative time decreases as the 458 surgeon becomes more agile with the operation. Hemostasis can be the determining factor in early operative success and can be a problem in prolonged surgery. Effective hemostastis can be assured by reinjecting vasoconstrictors periodically during a technically more difficult perforation repair.
Surgical options
David Fairbanks [4,13] uses the endonasal or closed approach with a full transfixion incision in his repairs. Although his method is highly successful, it is extremely difficult, especially in large perforations or in patients with small nostrils. Fairbanks at times will do a lateral alotomy to gain better access and visualization, but this leaves the patient with the potential for a more visible incision.
The open-external approach has multiple advantages in that it allows access to the anterior, superior, and posterior aspects of the perforation and not only increases surgical exposure but also provides a field without the distortion that normal intranasal retraction causes. The external approach gives the surgeon excellent binocular vision and furthermore allows the assistant to retract so that the surgeon can use both of his hands simultaneously. By avoiding a transfixion or hemitransfixion incision intranasally in the anterior portion of the septal membrane, the open technique preserves the anterior septal blood and lymphatic supply and may even improve nasal advancement flap viability. The small transverse columellar skin incision is a small price to pay for the improved access to the perforation. This incision and its minimal scar are much less noticeable than the scar from an alar crease incision, and, if the principles of scar camouflage and layered closure are followed, the scar will fade quickly and become imperceptible with time. The most noticeable scars from transcolumellar incisions are from those that are not closed in layers and those in which the surgeon may not have meticulously closed the skin incision.
One of the decided disadvantages of the open approach is that the medial crura are totally dissected away from themselves and from the septum. The fibrous connections between the medial crura and the septum and the overlying skin are supporting attachments that normally help preserve tip projection. It is incumbent upon the surgeon to reconstitute this support mechanism after the perforation is repaired. The medial crura and tip cartilages should be sewn back together with interrupted permanent or semipermanent sutures, and sometimes a columellar strut should be placed between the medial crura to support the nasal tip further. Tip-drop otherwise will almost invariably result, creating a cosmetic deformity that was not present before the perforation.
Bilateral bipedicled floor and dorsum mucosal advancement flaps require mobilization and borrowing of septal mucosa in vertical dimensions. The upper lateral cartilages are separated from the septum, and, as the membrane that is still attached to the upper lateral cartilages is pulled down for a closure attempt, the upper lateral cartilages themselves will have a tendency to be pulled inferiorly. A pinched appearance to the middle third of the nose may result. Sometimes grafting materials must be placed over these upper laterals so as to maintain the contour of the nasal dorsum. Likewise, as the mucosal defect is closed and the bipedicled flaps are pulled into place, a certain amount of tension is placed on the caudal septal mucosa and the medial crura, producing a definite cephalad rotation of the nasal tip. If the patient has a ptotic tip, these maneuvers actually will help improve the aesthetic result. If a nose is already over-rotated or foreshortened, however, the problem may be worsened by repair, and corrective methods will have to be added to the procedure to counteract these effects. For example, through-andthrough sutures placed between the dissected septal flaps anterior to the caudal septum and the medial crura may help prevent columellar retraction.
Other authors use advancement flaps with a connective tissue interposition graft, as advocated here, but use a different approach. Romo et al [18] have described a midfaced degloving technique. Karlan et al [19] used a sub labial incision, and Kuriloff [1] described a modification of the open technique to further increase exposure. This author prefers the external approach whose description follows, because it gives the surgeon the opportunity to perform rhinoplasty or revision rhinoplasty procedures at the same time. Friedman et al [20], Murakami et al [21], and Ayshford et al [22] have advocated inferior turbinate flap repairs for mid- and anterior perforations, especially in cases where previous septal flaps have been unsuccessful. Readers are encouraged to review these articles for alternative surgical approaches.
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