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Septal Perforation Repair
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The otolaryngologist usually discovers a septal perforation during his examination as an incidental finding in a patient without symptoms, or he or she is presented with a patient complaining of symptoms whose cause is found to be a perforation. A number of septal perforations are asymptomatic if they are placed posteriorly within the nose where there is good humidification. The more anterior the perforation is, the more likely it is for the patient to seek evaluation and treatment for symptoms. The major symptoms of septal perforation are:
Crusting
Bleeding
Whistling
Nasal obstruction
Pain
Rhinorrhea
Crusting and bleeding usually occur with septal perforations at the edge of the circumference of the perforation, because of the inability of the mucosa to heal well over the exposed cartilage. If there is no circumferential cartilage at the edge of the perforation and there are just two adherent mucoperichondral flaps, the perforation is less likely to crust or bleed (Fig. 1). When there is septal cartilage right up to the edge of the perforation, however, the mucosa has a more difficult time healing, and there is usually a low-grade chondritis present that creates an inflammatory response, leading to crusting and bleeding in this nonhealing area. Some patients present with increasing frequency of epistaxis, and, upon examination, one finds huge amounts of crusts and dried blood, which are extremely difficult to remove from the perforation without causing further bleeding. These patients need to be put on emollients and irrigations and then brought back into the office after a week of such treatment for improved evaluation.
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Figure 1. An endoscopic view of a septal perforation in a patient who had a previous septoplasty with removal of almost all the septal cartilage and bone. Note the paper-thin adherent flaps with a small bridge of tissue within the perforation. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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Presence of dried blood and crusts certainly can lead to airway obstruction, which may clear when the crusts are removed. Obstruction can be a major presenting symptom, however, even in a clean nasal perforation. The septum divides the nasal cavity into two distinct chambers through which normal lamellar airflow takes place.15 When a perforation is present, the lamellar airflow is disturbed and turbulence occurs, decreasing the flow of air and producing a definite sense of nasal obstruc-tion.1 Whistling in the nose is a common nuisance noted usually in the smaller perforations because of the noise created secondary to the aerodynamics of flow through a small opening. Whistling usually is noted during sleep by a partner, but also can be embarrassing and troublesome to the patient during the day. Pain is noted often in conjunction with bleeding and crusting because of chondritis, and in severe cases is caused by the cellulitis and inflammation, especially in the cocaine abuser. The larger the perforation, the more turbulent the airflow, and the greater the incidence of rhinorrhea. A dried nose attempts to rehydrate itself through increased secretions. Long-term septal perforations with turbulent airflow result in further destruction of respiratory epithelium within the nose, with loss of cilia and loss of function. Normal respiratory epithelium changes into dry mucosa, such that eventually a majority of the internal structure of the nose is extremely dry.
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 so that the entire nasal septum is visualized. 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 exists when there is crusting not only around the edge of the perforation, but all over the nasal septal and turbinate mucosa. A finding of such is seen more often in patients with causes suggestive of a granulomatous or vasculitis process. Findings of overall crusting in a cocaine user or in a patient with a granulomatous process makes 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 definitely should consider 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. The more inflamed the mucosa is and the more crusting there is around a perforation, the more one needs to be suspicious of a generalized process. 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, often do not know what the septum is, and generally know little about the complexity of septal perforation repair. Most patients, in addition, have no idea that they have a septal perforation when presenting with symptoms and are horrified to learn that the operative attempt to repair this perforation is not always successful. It is often helpful to use an in-office endoscope attached to a monitor or to a color printer to show and educate the patient as to the extent of the problem (Fig. 2). Additionally, anatomic models or diagrams are especially helpful so that the patient can understand what may need to be done.8
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