Septal perforation repair.

Nasal septal perforations present a distinct challenge to the otolaryngologist-head and neck surgeon, and a problem to the patient. The techniques for repairing septal perforations that have the best physiologic result, the highest success rate, and the best long-term patient acceptance and comfort, require the use of bilateral intranasal mucosal advancement flaps with the interposition of a connective tissue graft. The presenting symptoms and findings, the history and physical examination, the causes of septal perforations, helpful hints for prevention, and surgical and nonsurgical treatment options and outcomes are discussed in this article.     

Septal perforations--prosthetic and surgical treatment

Septal perforations 4 mm or less in diameter have been successfully closed in eight out of ten patients with interposition of fascia temporalis. Larger perforations could, however, not be closed with this technique. Silicone buttons were helpful in half of the patients with perforations 5-20 mm. In larger ones they were not tolerated. With the vestibuloconchal flap technique perforations 7-20 mm were closed or markedly improved in four out of eight cases. Our conclusion is that small septal perforations should primarily be operated upon, whereas larger ones should initially be treated with silicone buttons. If uncomfortable, surgery may be successful. A preferred technique for larger perforations, however, cannot be recommended.     

Septal deviation in newborn infants

Authors report an experiment performed in a randomized group of newborns to evaluate the frequency of post-partum septal deviations. A number of 423 subjects out of 1142 have been examined in a 17-month period. Newborns have been examined with an otoscope and two different kinds of nasal lesions have been considered: (1) pyramid deformation with septum dislocation and columella deviation; (2) deviation and subluxation of the septum. A number of 315 newborns were naturally delivered and 108 by cesarean section. In the former group, 10 pyramid deformations and 12 septal deviations have been found; in the latter, only septal deviations have been revealed (5 infants). Pyramid deformations may be related to delivery(labor)trauma while for septal deviations a developmental defect may be postulated.     

Septal stapler use during septum surgery

Although discussions regarding nasal packing are still ongoing, to eliminate any possible complications, surgeons have used nasal packing for many years. Septoplasty is one of the most frequently performed operations by head and neck surgeons. Any methods to diminish the surgical time or bring comfort to the surgeon will be well appreciated. In this study, we attempted to demonstrate the usefulness of the stapler method by comparing preoperative and postoperative results from the visual analog scale (VAS), nasal obstruction symptom evaluation (NOSE), rhinosinusitis quality of life questionnaire (RQLQ), and acoustic rhinomanometry values. In addition, we evaluated pain scores, postoperative complications, and breathing after nasal packing, stapling, and trans-septal suturing techniques. Patients were divided into three groups. In the first group, deviated cartilage was removed or repositioned and mucoperichondrial flaps were closed with a bioresorbable stapler after septoplasty. Four or five staples were placed on the septum. In the second group, the septum was sutured continuously with 4/0 Pegelak (Do?san TR). In the third group, Merocel packs were used without any sutures and were kept for 48 h. Nasal packing leads to patient discomfort after septal surgery; however, there is no difference in patient comfort between closing the mucoperichondrial flaps by suturing the septum or using a stapler. After surgery, there were no differences between the groups in terms of successful breathing. This situation was assessed by endoscopic examination and acoustic rhinomanometry. Thus, there was no objective or subjective difference. Stapling increases the doctor’s comfort level and surgical time is optimized. Although experienced surgeons can easily suture the septum, less experienced ones have some difficulty; therefore, stapling may provide more benefit to the latter. Further, four staples are sufficient to close the septum.     

Septal deviation and chronic sinus disease

The introduction of computerized tomography in the identification of sinonasal pathology and associated anatomic variants has contributed to a greater understanding of the factors leading to ostiomeatal complex (OMC) obstruction and chronic sinus disease. The OMC and paranasal sinus regions were prospectively evaluated in 150 consecutive patients as a function of the degree of nasal septal deviation and compared with matched controls. These data were correlated with paranasal sinus disease, lateral nasal wall findings, and middle turbinate abnormalities. An increased incidence and severity of bilateral chronic sinus disease was present with increasing septal deviations (p < 0.05). Similarly, patients with increasing nasal septum deviations were noted to have a higher incidence of OMC obstruction (p < 0.05). Ostiomeatal complex obstruction in the direction of septal angulation was associated with nasal septal deformity; however, contralateral OMC obstruction was associated with middle turbinate and lateral nasal wall abnormalities (p < 0.05). The evaluation of the degree of septal angulation has helped better understand the factors contributing to chronic sinus disease and OMC obstruction.     

Septal perforation repair: mucosal regeneration technique

A novel method for repair of septal perforations. Fifteen volunteers with symptomatic septal perforations were recruited. Open technique rhinoplasty approach was preferred: auricular conchal cartilage graft with intact perichondrium on both sides was harvested and shaped to fit the perforated site and attached to the septum with absorbable sutures. All margins of the graft were covered with nasal mucosa. The severity of patient symptoms was assessed at preoperation, 3 and 6?months postoperatively via visual analogue scale (VAS). Crust formation, whistling, nasal blockage, epistaxis and overall comfort were evaluated. Mucosal physiology was assessed by nasal mucociliary clearance time. The mean age of the patients was 47.3?years. Average perforation size was 1.86?±?0.78?cm. 14/15 (93.3%) perforations were repaired, and only one patient required revision surgery. VAS scores improved significantly (p?<?0.001). Mean mucociliary clearance time improved from 17.6?±?3.83 to 10.3?±?3.30?min and 9.3?±?3.36?min at 3 and 6?months, respectively. This is a novel, simple and safe method for repairing the deficient mucosal area in septal perforations up to 25?mm in diameter.     

Septal perforation secondary to Mycobacterium kansasii infection

We report the first recorded case of a septal perforation caused by Mycobacterium kansasii. This atypical mycobacterium is finding increasing prevalence with the increasing incidence and longevity of human immunodeficiency (HIV) infections. Cases of chest infection, sinusitis, septic arthritis, osteomyelitis, pericarditis, brain abscess, cutaneous and oral lesions have all now been reported. This discovery represents a rare but important differential in the aetiology of septal perforation.