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Septal Perforation Repair
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An asymptomatic perforation, such as those that are located posteriorly and have well-healed edges, rarely requires any treatment at all. Those patients with mild symptoms, except for obstruction, usually can be managed by medical therapy. Often just keeping the nose moist may be enough, and the daily application of petroleum jelly on a cotton-tipped applicator to the inside of the nose may be satisfactory.
Patients that have a great deal of intranasal crusting need more frequent therapy with nasal irrigations, as well as ointments and emollients. Fairbanks3 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 corn syrup (Karo) or glycerin (which is readily available at the drugstore) serves to further reduce nasal crusting. Adding a teaspoon of vinegar or 1 to 3 tablespoons of boric acid powder is effective in decreasing Staphylococcus aureus and Pseudomonas aeruginosa growth. These irrigations also can be followed in particularly dry noses with bacitracin or Bactroban, especially if there is a chronic infection.
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Figure 4. A silicone grommet button prosthesis can be placed in the perforation in a nonoperative candidate. (Courtesy of Russell W. H. Kridel, MD, FACS, Houston, Texas.) |
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If these treatments are unsuccessful, if the patient is unwilling to consistently care for the nose, or if the sensation of nasal obstruction is dominant, a silicone grommet prosthesis may be helpful (Fig. 4). Unfortunately, the ones that are available commercially are generally of one size and do not adequately fit larger perforations. In these cases, a custommade silicone button easily can be made by the local prosthetist if the otolaryngologist provides the dimensions of the perforation. After topically anesthetizing the nose, it usually is quite simple to insert a piece of paper against the perforation, and, then through the opposite nostril, 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 an-esthesia, however. When the perforation is especially large, sedation may be necessary. When buttons are in place, occasional nasal irrigations still are suggested to keep the obturator clean. It should be noted that if there is a chondritis or low-grade infection present, the button will not cure this problem, and continued observation and treatment by the physician is necessary. Silicone septal buttons also should be used in patients who, for other medical reasons, are not good surgical candidates, and certainly should be considered in patients with chronic or recurrent disease processes, as well as patients with continued cocaine usage.
Surgical Goals
The major goal of surgery should be to not only 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 the normal respiratory epithelium is used for closure. Other methods that use skin grafts or buccal mucosal grafts may be effective in closing the perforation, but unfortunately 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 mucosal 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 breakdown postoperatively with healing scar contraction. Because there is no elastic tissue in septal mucosa, adequate mobilization of septal flaps must be carried out.3 The open external rhinoplasty approach affords necessary access and exposure for repairing the perforation and for the development of these mucosal flaps.10 By using sliding bipedicled or unipedicled flaps taken from the floor of the nose and under the inferior turbinate, the mucosal portion of the perforation can be closed with normal nasal mucosa. It is absolutely crucial that in addition to closing both mucoperichondral flaps, a connective tissue interposition graft be placed between the corresponding perforation repairs in order to prevent recommunication and perforation and in order to act as a template on which the edges of the sewn perforation can migrate and mucosalize closed. Fairbanks,2, 3 Gollom,4 Wright and Kridel,10 Goodman and Strelzow,5 as well as others, have described this method with over 90% success rates in perforations 2 to 3 centimeters. As perforations increase in size, the chances of success decrease proportionately. 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.
When evaluating a septal perforation for surgery, the height of the perforation is a helpful determinant for the possibility and success of repair. It is not the absolute size of the perforation that is as important as the proportion of septal membrane remaining. For example, a 1 centimeter perforation in a young child with a small nose could be much more difficult to repair than a 2 centimeter 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, and then go back into the nose later for the definitive perforation repair. In addition to the height of the perforation, another prognostic indicator is the amount of septal cartilage remaining within 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 further 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 surgeons, it follows that a gentle and experienced touch is indeed the key in the repair of septal perforations. 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 result in 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 easily can tear the residual membranes, making the closure much more difficult. Operative time decreases, as the 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 hemostasis can be assured if a frequent reinjection is used during a technically more difflcult perforation repair.
Surgical Options
David Fairbanks uses the endonasal or closed approach to 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 provides a field without the distortion that normal intranasal retraction causes. The external approach allows excellent binocular vision for the surgeon and furthermore allows the assistant to retract so that the surgeon can use both of his hands simultaneously. A transfixion or hemitransfixion incision intranasally is avoided in the anterior portion of the septal membrane, whereas the open technique preserves the anterior septal blood and lymphatic supply, and may even improve nasal advancement flap viability. The small transverse columellar incision is a small price to pay for the improved access to the perforation. This incision and minimal scar is much less noticeable than the scar from alar crease incision and, if the principles of scar camouflage and layered closure are used, the scar will fade quickly and become imperceptible with time. Most noticeable scars from transcolumellar incisions are 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 can be sewn back together with interrupted sutures, and sometimes a columellar strut should be placed between the medial crura to further support the nasal tip. Tip-drop otherwise will result almost invariably and create a cosmetic deformity that was not present prior to 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 closure attempt, the upper lateral cartilages themselves will have a tendency to be pulled inferiorly also. A potential pinched appearance to the middle one 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 esthetic result. If a nose is already over-rotated or foreshortened, however, the problem may be worsened by the repair, and corrective methods will have to be added to the procedure to counteract these effects.
Other authors use similar advancement flaps with a connective tissue interposition graft, as advocated, but use still a different approach. Romo et al16 have described a midfaced degloving technique. Karlan and his colleagues7 used a sublabial incision, and Kuriloff15 described a modification of the open technique to further increase exposure. The author prefers the external approach as described, because it also will allow the surgeon the opportunity to perform rhinoplasty or revision rhinoplasty procedures at the same time.
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