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Septal Perforation Repair
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There are many causes for septal perforations, and a very thorough history is necessary in all patients (Table 1). A history of acute, chronic, or previous systemic disease must be determined. 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 determined.
External Nasal Trauma
A blow to the external nose can cause fracturing of the septum with the possibility, especially in someone who already has a deviated septum, of disruption of the mucoperichondrium with cartilaginous fractures.
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Figure 2. A paper ruler is placed in the nose to show the patient the size and shape of the perforation. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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Table1.SEPTALPERFORATIONCAUSES
Trauma
External
Fracture
Septal hematoma
Piercing injuries
Self-inflicted
Nose picking
Foreign bodies
Iatrogenic
Nasal surgery
Septoplasty
Sinus surgery
Turbinate surgery
Rhinoplasty
Septal cauterization
Septal packing
Septal splinting
Cryosurgery
Trans-sphenoidal hypophysectomy
Postoperative suctioning
Nasotracheal intubation
Drugs-legal and otherwise
Vasoconstrictive nasal sprays
Steroid nasal sprays
Cocaine
Smoking
Chemical Irritants
Chromic, sulfuric, and hydrochloric acids
Chlorines and bromines
Agricultural aerosolized dust
Rice and grain elevator dust
Chemical and industrial dusts
Lime
Cement
Glass
Salt
Dust
Heavy metal
Cyanide, arsenicals
Neoplastic Causes
Adenocarcinoma
Squamous cell carcinoma
Metastatic carcinoma
Midline destructive granuloma
Inflammator y Causes
Vasculitides
Collagen vascular diseases
Sarcoidosis
Wegener's granulomatosis
Infections
Tuberculosis
Syphilis
Rhinoscleroma
Lepromatous leprosy
Rhinosporidiosis
Multiple fungal species
Mucor
Typhoid
Diphtheria
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 non-operated individual. Direct piercing injuries are rare, yet the author has treated one individual whose face was impaled by a motorcycle gearshift that went straight across the face and right through the septum. This injury resulted in a septal perforation, and later required perforation repair.
Self-lnflicted 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 nose as either 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 into their nose. Battery injury can cause chemical burns to the septum resulting in perforation.
Surgically Induced Trauma and Previously Treated Epistaxis
The greatest cause of recognized septal perforations is seen in those who have been treated for epistaxis and in patients who have had previous nasal procedures. Nasal septal epistaxis often is treated initially by simple vasoconstriction and application of silver nitrate. Tight nasal packs sometimes are placed in order 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 done and there is no intervening protective cartilage, the risk of perforation is even greater. Some physicians use hard intranasal septal splints after septoplasty, and these are sewn into place. If the septal splints are sewed too tight, they also can compromise the blood supply to the septum.
The most classic cause of septal perforations comes from a previous septoplasty itself, in which there have been tears in both septal membranes in a contiguous area where intervening septal cartilage or bone have been removed. When such tears do occur, it is wise to repair them immediately and to insert an intervening cartilage or a connective tissue graft to act as a barrier to perforation. In the postoperative care after a septoplasty one must be quite careful in suctioning out the nose so as not to push the suction through a thin septal membrane.
Other nasal surgeries not directly on the septum can cause inadvertent damage and subsequent perforations to the septum. Cryotherapy to the turbinates with an unprotected septum has been known to cause freezing burns and loss of septal integrity. Endoscopic sinus surgery and nasal antral window surgery also have been implicated in perforations. Transseptal 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 one side where there is a nasal spur or deviation can cause total denuding of the septum leading to perforation. Preoperative discussions with the patient prior to any nasal procedure should include the potential for the complication of a septal perforation, and the physician should disclose to the patient postoperatively if one has occurred. Some perforations so caused may be tiny and asymptomatic, and require no repair. The unknown perforation may approach enormous dimensions and significance, however, when first brought to the patient's attention by another physician.8
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 therefore 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 Fairbanks3 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. Otherwise, the contraction of healing itself will enlarge the perforation. 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 prior to attempting to remove the spur or the deviation. Even with 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 access adequately this flap and will leave mucoperichondrium on the septum itself. Using the sharp portion of the Cottle elevator the surgeon can assure more accurately an appropriately elevated mucoperichondral flap. Often the maxillary crest is deviated also and perforations can occur along the crest quite easily. 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 prior to excision. 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 the opposite side of the spur. 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 indeed occur. In such cases, closure of the perforation in each membrane separately is important, followed by the placement of crushed cartilage reimplanted between the flaps in the area of these perforations (Fig. 3). Trenite et al18 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 all cases of septoplasty. The obstructing cartilage removed that normally would be discarded or sent to pathology for identification, either can be crushed or placed between the mucoperichondral flaps which are then 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. Septal perforations are potential unwanted complications in any nasal procedure, and the patient should be so warned preoperatively. Postoperatively, patients must be informed of the presence of a perforation so they can make decisions as to how to proceed for relief of any symptoms.
Nasal Sprays, Smoking, and Cocaine Usage
Schoelzel and Menzel17 have noted that chronic use of nasal sprays may lead to septal perforations. Patients themselves can abuse some of the vasoconstrictive sprays, which cause intense vasoconstriction of the mucoperichondrium and, especially if combined with cigarette smoking, can lead to perforations. The advent of the steroid nasal sprays and their long-term use in individuals has gone 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 usage 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 and is adulterated with very irritating substances, such as borax or talc.3 One time usage 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. Continuing cocaine abusers usually are easy to pick-up in the office, based upon their often jittery habitus, their wired intense appearance, and by their chronic nasal sniffing. It is useless to repair a septal perforation in a patient who is still using cocaine because the perforation is certain to recur.
Unfortunately, cocaine patients have a difficult time in curing their addiction and often will be less than truthful in their history with the physician. Cocaine levels on such patients may be warranted. Talking with that individual's counselor also may help with operative planning, because most cocaine addicts are unable to quit without counseling. Additionally, cocaine patients need anesthetic and medical clearance because of their increased susceptibility to more anesthetic complications than nonusers.
Chemical Irritants
In addition to cocaine, nasal sprays, and smoking, industrial irritants are large causes of perforations.15 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 seen 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 areas would include wearing proper filter masks during the irritant exposure. Any such irritant encountered can cause more damage if the nose is further dried by the environment or by smoking.
Pathologic Processes
Serious systemic diseases, including neoplastic, inflammatory, and infectious conditions, are causes of septal perforation, and when none of the previously listed causes have been determined, the physician must then look elsewhere and rule out potential serious causes.Vasculitides and collagen vascular disorders, such as lupus, rheumatoid arthritis, and polychondritis, can lead to septal perforations. The problem with such entities is that they can go into remission and then recur. Prior to 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, if their disease flares up again at a later time another perforation may occur because of the process of vascular destruction, an event that this author has noted, especially in patients with renal and small vessel disease. Granulomatous diseases, such as Wegener’s granulomatosis and sarcoidosis, are less common causes. A CT scan of the nose and paranasal sinuses helps when granulomatous disease is suspected.
Neoplastic disorders, such as metastatic carcinoma, as well as squamous and adenoid carcinomas and melanomas, must be ruled out. Midline lethal granuloma is another serious destructive process for which one must also evaluate, if there is no clear cut cause for the septal perforation. If the head and neck examination has not revealed any other pathology, including but not limited to collagen vascular and kidney screens, flourescent treponemal antibody-absorption (FTA-ABS), venereal disease research laboratory test (VDRL), antineutrophil cytoplasmic antibody test (C-ANCA), and Epstein-Barr virus titers should be drawn. 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 is indicated prior to any surgery. The biopsy of the septum should be taken from the posterior edge of the perforation, with certainty to include enough tissue so that the pathologist has a specimen away from the perforation edge so that he or she can get a definitive diagnosis. A small biopsy taken from the edge of the perforation often is reported as just chronic inflammation. It is important not to 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 preferentially to decrease symptoms.
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