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Snoeks S, Velasco E, Talavera K, Hellings PW. Nasal Obstruction: Overview of Pathophysiology and Presentation of a Clinically Relevant Preoperative Plan for Rhino(Septo)plasty. Facial Plast Surg 2024; 40:275-286. [PMID: 38224694 DOI: 10.1055/s-0043-1777850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
Impairment of nasal breathing is a highly prevalent and bothersome symptom that affects daily functioning and/or sleep quality. Those surgeons dealing with patients seeking rhinoplasty need to carefully analyze the preoperative nasal breathing capacity and predict the positive or even negative impact of rhino(septo)plasty on nasal breathing. Given the lack of correlation between the subjective feeling of suboptimal nasal breathing and the objective measurements of nasal flow and nasal resistance, a critical and mainly clinical evaluation of all anatomical, mucosal, and sensory mechanisms involved in nasal obstruction is mandatory. Indeed, thermo-, mechano-, and chemosensory receptors on the nasal mucosa, airflow, and respiratory dynamics might all contribute to the overall perception of nasal breathing capacity. In this review, we provide an overview of the factors determining suboptimal nasal breathing including different diagnostic and experimental tests that can be performed to evaluate nasal flow and nasal resistance and current limitations in our understanding of the problem of nasal breathing in an individual patient. An algorithm for the preoperative or diagnostic workup for nasal obstruction is included that might be useful as a guide for clinicians dealing with patients seeking nose surgery.
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Affiliation(s)
- Simon Snoeks
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospitals, Leuven, Belgium
| | - Enrique Velasco
- Department of Cellular and Molecular Medicine, Catholic University of Leuven Faculty of Medicine, Leuven, Belgium
| | - Karel Talavera
- Department of Cellular and Molecular Medicine, Catholic University of Leuven Faculty of Medicine, Leuven, Belgium
| | - Peter W Hellings
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospitals, Leuven, Belgium
- Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands
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Donaldson LB, Deeb RH, Momin S, Eide JG, Craig JR. Cadaveric and Computed Tomography Analysis of the Anterior Ethmoidal Artery Flap. Laryngoscope 2024; 134:2100-2104. [PMID: 37950636 DOI: 10.1002/lary.31162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/09/2023] [Accepted: 10/17/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND The anterior ethmoidal artery (AEA) flap has been successful in repairing anterior nasal septal perforations and has been presumed to be axially based on AEA branches coursing through or around the cribriform plate (CP). However, limited evidence supports the flap's axial supply. The purposes of this cadaveric and computed tomography (CT) study were to assess the arterial anatomy from the CP to the septum, and to determine AEA flap length to predict ideal flap base width. METHODS Ten fresh latex-injected cadavers were utilized for endoscopic dissection to identify arteries traversing the CPs on each side. First, arterial trajectories along the dorsal septum were recorded. Measurements were then made bilaterally along the septum from the middle turbinate (MT) axilla to the nasal branch of the AEA (NBAEA) traversing the CP. Additionally, 100 sinus CTs were reviewed to measure AEA flap lengths bilaterally. RESULTS From 10 cadavers, 20 sides were utilized for measurements. In all cadavers, the AEA septal branches coursed diagonally or horizontally along the dorsal septum, and never directly vertically. The mean distance from the MT axilla to the NBAEA was 1.24 ± 1.93 cm (range = 1-1.5 cm). Based on CTs, the mean AEA flap length was 6.40 ± 0.60 cm. CONCLUSIONS Based on the non-vertical courses of AEA septal branches, the AEA flap is more likely a random transposition flap than an axial flap. Average AEA flap length ranged from 6.0 to 7.0 cm. Assuming 3:1 length:width ratios, AEA flap base widths should be about 2.0-2.3 cm. LEVEL OF EVIDENCE NA Laryngoscope, 134:2100-2104, 2024.
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Affiliation(s)
- Lane B Donaldson
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, U.S.A
| | - Robert H Deeb
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, U.S.A
| | - Suhael Momin
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, U.S.A
| | - Jacob G Eide
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, U.S.A
| | - John R Craig
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, U.S.A
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Alobid I, Bernal-Sprekelsen M. "Boot-on-Donut" procedure for anterior and large septal perforation. Eur Arch Otorhinolaryngol 2024; 281:2761-2765. [PMID: 38498188 DOI: 10.1007/s00405-024-08497-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/22/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Surgical closure of large nasoseptal perforation (NSP) is challenging. The use of an extended anterior ethmoidal artery (eAEA) flap to reconstruct NSP may present with difficulties for NSPs which have their upper edge in a high position. METHOD We propose adding a "donut-shape" flap from surrounding septal tissue to the eAEA flap. Thus, the inverted edges of this flap allow to cover the uppermost aspect of the NSP. A series of 18 patients with complete closure of NSPs was included. CONCLUSION This novel "Boot-on-Donut" technique consisting of the eAEA flap (Boot) and inverted edges (Donut) is a feasible procedure that allows to reconstruct large NSP located superiorly.
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Affiliation(s)
- Isam Alobid
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clínic, IDIBAPS, CIPERES, Universitat de Barcelona, Barcelona, Spain.
- Unidad Alergo Rino, Centro Médico Teknon, Barcelona, Spain.
| | - Manuel Bernal-Sprekelsen
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clínic, IDIBAPS, CIPERES, Universitat de Barcelona, Barcelona, Spain
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Bier J, Klingner A, Stadlhofer R, Betz CS, Böttcher A. The "fascia taco" for nasal septum perforation closure-A retrospective Cohort study on success rates and patient reported outcomes. Laryngoscope Investig Otolaryngol 2024; 9:e1248. [PMID: 38651076 PMCID: PMC11034486 DOI: 10.1002/lio2.1248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/24/2024] [Accepted: 04/07/2024] [Indexed: 04/25/2024] Open
Abstract
Objective Nasal septum perforation (NSP) is a common condition affecting ~1.2% of the general population and is still considered challenging to treat. Therapeutic strategies range from conservative local treatments and septal button closures to over 40 different surgical approaches. This study aimed to present a novel secure approach. Methods We describe our novel and unique NSP closure approach using a "fascia taco," in which conchal cartilage is enveloped by temporalis fascia like a taco and splints are left in place for 6-8 weeks. A review of patient charts was conducted and questionnaires including the German-SNOT-22 and D-NOSE were sent by mail to all eligible patients who received a fascia taco between 2016 and 2021. Results Thirty-three patients were identified. The questionnaire response rate was 54.5%. The mean operative time (cut to sew) for all patients who only underwent NSP closure was 90.4 min. The overall success rate in terms of postoperative NSP closure was 81.8%. We found an apparent but nonsignificant association between closure failure and smoking (failure rate 66.6% in smokers vs. 15.4% in nonsmokers; X 2 = 3.4188, p = .064). Questionnaire analysis showed a significant postoperative reduction of mean values in D-NOSE from 60.8 to 33.1 (p = .009) and in German-SNOT-22 from 38.6 to 21.2 (p = .005). Conclusion The fascia taco technique is an easy-to-apply, safe procedure for NSP closure that is short in duration and associated with a low morbidity, resulting in excellent patient satisfaction. Level of Evidence 4.
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Affiliation(s)
- Johannes Bier
- Department of OtorhinolaryngologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Alexandra Klingner
- Department of OtorhinolaryngologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Rupert Stadlhofer
- Department of OtorhinolaryngologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Christian S. Betz
- Department of OtorhinolaryngologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Arne Böttcher
- Department of OtorhinolaryngologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
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Bansberg SF, Taylor CM, Marino MJ, Courson AM, Miglani A. Autologous Interposition Grafts for Mucosal Flap Septal Perforation Repair. Facial Plast Surg Aesthet Med 2024; 26:111-116. [PMID: 37358819 DOI: 10.1089/fpsam.2022.0179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023] Open
Abstract
Background: Nasal septal perforation repair is commonly attempted utilizing bilateral nasal mucosal flaps supported with an interposition graft. Objectives: To compare the failure rates for bilateral flap repairs utilizing four different autologous interposition grafts. Methods: This is a retrospective review of a single surgeon's bilateral flap perforation repairs supported with an autologous interposition graft. Study inclusion over the 18-year review period required at least one examination 1 month after surgery. Repair failure rates were calculated and compared for each graft type, and logistic regression was performed for multivariate analysis. Results: For the 356 study patients, median (range) age was 51 years (14-81) and 63.0% were women. Mean (range) perforation length was 13.9 mm (1-45). Median (range) at last follow-up was 11.2 months (1-192). Graft types used (percentage of patients and failure rate) were temporalis fascia (58.7/4.4), septal cartilage (23.3/7.3), auricular perichondrium (13.8/4.1), and septal bone (4.2/6.7) (p > 0.05). Conclusion: There was no significant difference in bilateral mucosal flap perforation repair failure rate when either a temporalis fascia, septal cartilage, auricular perichondrium, or septal bone interposition graft was used.
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Affiliation(s)
- Stephen F Bansberg
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Cullen M Taylor
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Michael J Marino
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Amar Miglani
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
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Chien L, Yver CM, Shohat S, Friedman O. Predictors of Success of Endonasal Septal Perforation Repair: A 10-Year Experience. Facial Plast Surg Aesthet Med 2024; 26:117-123. [PMID: 37782906 DOI: 10.1089/fpsam.2022.0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Background: There is no consensus on optimal repair technique for nasal septal perforations (NSPs). Objective: To measure success rate and evaluate predictors of success for NSP repair. Methods: Medical records of patients who underwent NSP repair from 2010 to 2020 were reviewed. Included patients had at least 60 days of postsurgical follow-up. Surgical technique involves an endonasal approach; subperichondrial dissection with local flap mobilization; and multilayer closure using cartilage interposition graft, fascia graft, and mucoperichondrial flaps. A chi-squared test or Fisher exact test was used for statistical analysis. Results: Eighty-one repairs were performed with a closure rate of 86%. The median patient age was 46 years (range 13-77); 34.6% of perforations were ≥2 cm. Conchal (77.8%), rib (7.4%), or septal (7.4%) cartilage was used as graft material. A complication rate of 8.6% was reported. Perforation size or graft material had no impact on successful closure rate. Of patients with failed repairs, 55% had perioperative complications or conditions associated with poor healing. Conclusion: An endonasal approach for NSP repair showed a high success rate across diverse presentations; however, NSP repair was significantly more likely to be successful in patients without perioperative complications or pre-existing conditions associated with poor wound healing.
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Affiliation(s)
- Lillian Chien
- Division of Facial Plastic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christina M Yver
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shirly Shohat
- Department of Plastic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Oren Friedman
- Division of Facial Plastic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Joo HA, Jang YJ. Factors Affecting the Surgical Outcome in Nasal Septal Perforation Repair. Ann Otol Rhinol Laryngol 2024; 133:14-21. [PMID: 37357889 DOI: 10.1177/00034894231178964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Nasal septal perforation (NSP) repair is challenging surgery considered in patients with symptomatic NSP intractable to conservative treatments. This study aimed to assess the success rate and identify factors affecting the surgical outcome of NSP by analyzing consecutive series of NSP repairs by a single surgeon. METHODS We enrolled 84 patients diagnosed with NSP and who underwent surgical repair of NSP by a single surgeon (Y.J.J.) between November 2007 and July 2022. Medical records were retrospectively reviewed regarding variables involving preoperative symptoms, rhinologic history, etiology, surgical techniques, and the outcome of surgery. In addition, features of NSP were objectively evaluated using computed tomography scans. RESULTS The overall success rate of NSP repair was 64.3% (54 of 84). Nasal obstruction (79.8%), crusting (34.5%), and epistaxis (27.4%) were frequent preoperative symptoms. Iatrogenic injury from previous nasal surgery (70.2%) was the most common cause. The average size of NSP on preoperative CT was 9.53 ± 6.68 mm. Patients with incomplete NSP closure had significantly larger perforations (12.21 ± 7.92 mm) than those with successful closure (8.04 ± 5.41 mm) preoperatively (P = .005). Patients with smoking history (OR = 2.971, 95% CI 1.170-7.548, P = .020) and NSP repair with combined rhinoplasty (OR = 3.811, 95% CI 1.401-10.370, P = .007) were more likely to experience incomplete closure. Patients whose perforations were reinforced with interposition graft were more likely to result in successful repair (OR = 6.752, 95% CI 2.496-18.262, P < .001). The bilaterality of mucosal flap coverage, surgical approach, types of mucosal flap and interposition graft, perforation shape, mucosal thickness around perforation, and distance from the nasal floor were not significantly related to the surgical outcome. CONCLUSIONS Significant factors affecting the outcome of NSP repair were patient's smoking status, combined rhinoplasty, application of interposition graft, and perforation size.
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Affiliation(s)
- Hye Ah Joo
- Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Ju Jang
- Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Tumlin P, Assi S, Armeni M, Ramadan HH, Reyes C, Makary CA. Outcome of Endoscopic Repair of Nasal Septal Perforation. Ann Otol Rhinol Laryngol 2023; 132:1617-1620. [PMID: 37246364 DOI: 10.1177/00034894231176610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION The anterior ethmoidal artery (AEA) flap has been demonstrated to be a reliable option for endoscopic repair of symptomatic nasal septal perforations. The purpose of this study is to study the outcome of this technique. METHODS A retrospective case series of all consecutive patients who underwent repair of nasal septal perforation utilizing the AEA flap among 2 institutions from August 2020 to July of 2022 was conducted. Demographics and comorbidities were collected preoperatively and postoperatively. The main outcome of this study was to identify the risk factors for surgical failure. RESULTS Forty-one patients were included. Mean perforation size was 2.2 cm (range 0.5-4.5 cm). Mean age was 42.5 years (range 14-65 years), 53.6% were female, 39% were active smokers, mean body-mass-index (BMI) was 31.9 (range 19.1-45.5), 20% with history of CRS and 31.7% had diabetes mellitus (DM). Etiologies of the perforation included idiopathic (n = 12), iatrogenic (n = 13), intranasal drug use (n = 7), trauma (n = 6), and secondary to tumor resection (n = 3). Overall success rate for complete closure was 73.2%. Active smoking, history of intranasal drug use, and DM were significantly associated with surgical failure (72.7%vs 26.7%, P = .007; 36.4%vs 10%, P = .047; and 63.6%vs 20%, P = .008 respectively). CONCLUSION The endoscopic AEA flap is a reliable technique for closure of nasal septal perforation. It may not work when the etiology is intranasal drug use. Close attention to diabetes and smoking status is also needed.
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Affiliation(s)
- Parker Tumlin
- Department of Otolaryngology, West Virginia University, Morgantown, WV, USA
| | - Sahar Assi
- American University of Beirut, Beirut, Lebanon
| | - Mark Armeni
- Department of Otolaryngology, West Virginia University, Morgantown, WV, USA
| | - Hassan H Ramadan
- Department of Otolaryngology, West Virginia University, Morgantown, WV, USA
| | - Camilo Reyes
- Department of Otolaryngology, Augusta University, Augusta, GA, USA
| | - Chadi A Makary
- Department of Otolaryngology, West Virginia University, Morgantown, WV, USA
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Garaycochea O, Santamaría-Gadea A, Alobid I. State-of-the-art: septal perforation repair. Curr Opin Otolaryngol Head Neck Surg 2023; 31:11-16. [PMID: 36729895 DOI: 10.1097/moo.0000000000000857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW To provide a comprehensive overview of the evolution of the different techniques described for the surgical repair of nasal septal perforation, and a surgical decision-making algorithm for its surgical treatment. RECENT FINDINGS Septal perforation surgery has evolved and improved in recent years. It has gone from being an avoided or discouraged surgical procedure to a procedure with success rates of >90%. Nowadays, there is no standard approach or single technique. The different techniques described include unilateral random pattern flaps, interposition grafts, unilateral pedicle septal local flaps, free mucosal grafts and bilateral random patter flaps. The incidence of success is higher in pediculated septal flaps such as the anterior ethmoidal artery flap or the greater palatine artery pedicled flap combined with additional techniques. SUMMARY Nowadays, surgical closure of septal perforation is possible and should be an option to consider in symptomatic patients without response to medical treatment. The surgical approach that we recommend when planning the surgical closure of nasal septum (or nasoseptal) perforation is based on the osseocartilaginous support and the location of the defect.
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Affiliation(s)
- Octavio Garaycochea
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clínic, IDIBAPS, CIPERES, Barcelona University. Barcelona
- Department of Otorhinolaryngology, Clinica Universidad de Navarra, University of Navarra, Pamplona
| | - Alfonso Santamaría-Gadea
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Universitario Ramón y Cajal
| | - Isam Alobid
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clínic, IDIBAPS, CIPERES, Barcelona University. Barcelona
- Unidad Alergo Rino, Centro Médico Teknon, Barcelona, Spain
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Taylor CM, Marino MJ, Bansberg SF. Presenting Symptomatology for Patients With Nasal Septal Perforation: Application of the
NOSE‐Perf
Scale. Laryngoscope 2022; 133:1315-1320. [PMID: 35869840 DOI: 10.1002/lary.30299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/15/2022] [Accepted: 06/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To objectively identify and quantitate presenting nasal symptoms in patients with a septal perforation using the validated NOSE-Perf scale. STUDY DESIGN Case series retrospective review. METHODS The medical records from August 2018 through January 2022 of patients at a tertiary care academic center with a septal perforation, and who completed the NOSE-Perf questionnaire, were reviewed. Perforation symptoms were identified and quantified using the 12-item NOSE-Perf scale (score range 0-48). NOSE-Perf findings were correlated to patient demographics, perforation etiology, and perforation length. NOSE-Perf scores of patients who pursued treatment were compared with those who did not. RESULTS NOSE-Perf data were collected from 202 patients. Nasal crusting was noted in 94.1% of patients and was the most severe symptom reported (mean 2.9 of 4.0). Nasal congestion, difficulty breathing, and nasal obstruction followed in prevalence and severity. The mean total NOSE-Perf score was 23.7. Linear regression analysis demonstrated a weakly negative association of NOSE-Perf score with patient age and weakly positive association with increasing perforation length. NOSE-Perf scores were significantly higher in women and in patients pursuing treatment. CONCLUSION This is the first study to use the validated NOSE-Perf scale to objectively characterize and establish baseline septal perforation symptomatology. The NOSE-Perf scale can play a role in the standardization of perforation evaluation and treatment outcomes assessment. Laryngoscope, 133:1315-1320, 2023.
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Affiliation(s)
- Cullen M. Taylor
- Department of Otolaryngology–Head and Neck Surgery Mayo Clinic in Arizona Phoenix Arizona U.S.A
| | - Michael J. Marino
- Department of Otolaryngology–Head and Neck Surgery Mayo Clinic in Arizona Phoenix Arizona U.S.A
| | - Stephen F. Bansberg
- Department of Otolaryngology–Head and Neck Surgery Mayo Clinic in Arizona Phoenix Arizona U.S.A
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