Repair of nasal septal perforations using local mucosal flaps and a composite cartilage graft

A contemporary review of "realistic" success rates after surgical closure of nasal septal perforations

OBJECTIVE

The surgical closure of septal perforations is a challenging procedure. Various techniques exist. Each perforation proves that there is not the one precise procedure for all perforations. Nevertheless, success rates of about 90% are reported, although the procedure for closing the defect is challenging. Our goal was to evaluate the existing data.

METHODS

We performed a contemporary review of published closure rates of septal perforations on order to compare the present results in the literature. The limitations of the respective studies were analyzed.

RESULTS

We found closure rates from 30 to 100%. Numerous procedures were described and combined. Prospective studies comparing different techniques are missing. The follow-up time in studies was quite short or not even specified. Studies on long-term success rates are rare.

CONCLUSION

The closure of septal defects is one of the most challenging rhinosurgical interventions. Closure rates ≥90% as described in literature seem relatively high. One reason might be short follow-ups and retrospective study designs. Frequently, precise information on the follow-up and the method of follow up is missing. Thoroughly designed prospective studies are absent. Longer follow-up times are associated with lower complete closure rates. A long-term success rate between 70 and 80% seems realistic.

Septal Perforation Repair Using Bilateral Rotational Flaps With Interposed Mastoid Periosteal Graft

OBJECTIVES/HYPOTHESIS

To evaluate the outcomes of endonasal repair of septal perforations utilizing opposing bilateral rotational flaps and a periosteum interposition graft.

METHODS

Retrospective review of a single surgeon, tertiary referral center experience of patients who underwent septal perforation repair. Patient demographics, etiology of perforation, closure rate, and complication data were obtained. Patients screening positively for cocaine use or anti-neutrophil cytoplasmic antibodies (ANCA) were not offered repair.

RESULTS

A total of 104 patients were included, 65 male and 39 female with mean age of 45.4 years. Etiology of perforations included prior surgery in 45, trauma in 15, and unknown in 44, and the average perforation size in each etiologic group were 1.35 cm, 1.25 cm, and 1.30 cm, respectively. The greatest dimension of perforations repaired ranged from 0.5 cm to 1.5 cm. The overall success rate was 87.5% at 6 month follow-up. Successful closure was achieved in 95.6%, 86.7%, and 79.5%, respectively (χ²  = 5.264, P = .0218).

CONCLUSION

Our described technique is a reliable endonasal approach with predictable outcomes in septal perforations up to 1.5 cm in size. Having an unknown etiology of septal perforation may be a risk factor for failure.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1497-1500, 2021.

Cartilage Sparing Septal Perforation Repair using Rotation Flaps and a Collagen Interposition Graft: A Case Series

OBJECTIVE

Septal Perforations may be asymptomatic or can cause significant problems including nasal obstruction, crusting, bleeding, whistling and in severe cases a change in nasal shape and even pain.

METHOD

The author would like to present a single surgeon case series of septal perforation repairs, managed using an endo-nasal technique, with no external scars. There were 54 consecutive cases between 2011 and 2017. The repair was carried out using mucosal rotation flaps with an interposition graft of porcine collagen matrix. Patients were grouped according to the size of the perforation as measured at the time of the surgery. The patients were then clinically followed up for 1 year, and the recorded outcome measures were: the success of the surgical repair and the patient reported symptoms.

RESULTS

Surgical success was 70% up to 1 cm diameter, 77% from 1 to 2 cm and 82% in perforations from 2 to 3 cm in diameter. No perforation over 3 cm in diameter was successfully closed. Patients were rendered asymptomatic even if the perforation was not closed in between 81% and 91% of patients up to perforations 3 cm in size. Over 3 cm in size 50% of patients reported being asymptomatic.

CONCLUSIONS

This technique is an effective and low morbidity option for patients with small to medium sized septal perforations. For perforations over 3 cm in diameter other options may be more suitable.

Simultaneous Septal Perforation and Deviation Repair with a Chondromucosal Transposition Flap

Nasal septal perforations can cause issues of epistaxis, whistling, crusting, saddle deformity, and obstruction, which motivate patients to seek surgical repair. Numerous methods of septal perforation repair have been described, with surgical success rates ranging from 52% to 100%, but few studies address situations with concomitant septal deviation. In treating patients with septal perforation and deviation, both issues should be addressed for optimal outcomes. While routine septoplasty involves the removal of septal cartilage, septal perforation repair involves the addition of interposition grafts. The composite chondromucosal septal rotation flap harmoniously combines these seemingly conflicting goals as an effective and efficient technique for septal perforation repair. We present 3 patients successfully treated for their septal perforation and septal deviation concurrently with this technique.

Unilateral Inner Mucoperichondrium Flap From Upper Lateral Cartilage and Inferior Mucosal Advancement Flap Technique for Repair of Septal Perforations

BACKGROUND

Many surgical technique have been described for repair of nasal septal perforations with different success rates. This study aimed to describe authors' surgical technique and discuss its results as well as those reported in the literature.

METHODS

Nineteen patients with nasal septal perforation were operated on between March 2009 and February 2015 at Istanbul University, Istanbul Medical Faculty. The technique described in this article, closure of the perforation with unilateral upper lateral cartilage inner mucoperichondrial flap and inferior meatal advancement flap is an alternative surgical technique.

RESULTS

Nineteen patients with symptomatic nasal septal perforation were operated with this technique. All surgical procedures were performed by the same surgeon. Neither intraoperative nor postoperative major complications were observed in any patients. Preoperative and postoperative symptom scores for nasal obstruction, epistaxis, nasal discharge, crusting, whistling, snoring, and olfactory loss as well as overall discomfort levels were compared using a visual analog scale. Complete closure of the perforation was achieved in 18 patients (95%).

CONCLUSIONS

Small and large perforations may be reliably closed with this technique. Also, this technique can be easily applied via closed or external approach.

Effectiveness of degradable and non-degradable implants to close large septal perforations in an experimental model

Background Reparation of large nasal septum perforations continues to be challenging. Bipedicled mucoperichondrial and inter-positional grafts currently show the most promising results. New implants have emerged to be used as a support membrane to carry on the mucosal cells, taking advantage of the innate proliferative properties of the mucosal tissue. Objective To compare the effectiveness of two kinds of material; non-absorbable dimethylsiloxane (silicone elastomers) and absorbable porcine small intestinal submucosa (Surgisis), both used as an inter-positional graft without neighbouring flaps to close nasal septal perforations in an experimental model. Methods Fifteen dogs were divided into three groups. One group received Surgisis, the other sheets of dimethylsiloxane and the last group a sham group. The dogs were followed for 6 weeks. Results The initial perforation of the nasal septum showed complete mucosal closure in the dimethylsiloxane group. The Surgisis group, on the other hand, had a smaller reduction than that at the beginning (final mean area = 23.0 ± 5.4 mm(2) (p < 0.05); however, complete closure was not achieved. Sham animals showed an inconstant and slight reduction in dimension from 100 mm(2) to 70 ± 16 mm(2) of mucosa and cartilage, but closure was not achieved. A significantly higher number of capillaries were observed in the Surgisis group compared to the dimethylsiloxane group (p < 0.05) without differences in inflammation, fibrosis, or necrosis. Conclusions The non-absorbable implant; dimethylsiloxane facilitates a better closure of the nasal septum.

Repair of nasal septal perforation using middle turbinate flap (monopedicled superiory based bone included conchal flap): a new unilateral middle turbinate mucosal flap technique

The purpose of this study is to present a new approach for treatment of nasal septal perforation using middle turbinate flap. A consecutive study with follow-up of 31 patients with nasal septal perforation treated using middle turbinate flap. All patients underwent an endoscopic repair of nasal septal perforation using middle turbinate flap. All patients were followed for 18-24 months. Complete closure of the perforation was achieved in 29 of the 31 patients. Complete failure of the repair was observed in two patients. All patients showed nasal crusting in varying degrees for a period of 2-4 weeks. None of the patients showed nasal obstruction or atrophic rhinitis symptoms (stuffy nose, purulent postnasal drip, nasal crusting, epistaxis and anosmia) in postoperative follow-up. This technique provides a new method with many advantages compared to other techniques for closure of septal perforations.

LEVEL OF EVIDENCE

IV.

Three layer interlocking: a novel technique for repairing a nasal septum perforation

OBJECTIVE

Many techniques to repair a septal perforation using local flaps with or without an interpositioning graft with various rates of success have been described. Our aim was to describe a new and relatively easy technique for repairing these perforations.

METHODS

Twenty-two patients with nasal septal perforations smaller than 2 cm in diameter were operated on between 2010 and 2012 at Eskişehir Osmangazi University. The described 3-layer interlocking method was applied to repair the septal perforation in all of the cases.

RESULTS

Twenty-two patients were operated on using this technique. The follow-up time ranged from 30 months to 10 months, with a mean follow-up time of 20.9 months. In 19 of the 22 patients, complete closure of the perforation was achieved (86.3%). We did not encounter any early or late postoperative complications.

CONCLUSION

A novel technique that uses a temporalis fascia-conchal cartilage complex as an interpositioning material to repair septal perforations is described. This complex was endoscopically introduced to the perforation after elevating the edges of the perforation. We concluded that the low morbidity, short operating time, and high success rate make this technique a good choice for repairing small- to medium-sized perforations.

A new approach to objective evaluation of the success of nasal septum perforation

Background

Perforations in the nasal septum (NSP) give rise not only to disintegration of the septum anatomy but also impairment in normal nasal physiology. The successes of these surgical techniques are usually equated to anatomical closure of the perforation. The goal of this study is to evaluate the subjective and objective results of our surgical technique for septal perforation surgery.

Methods

All NSPs in the six patients were closed by inferior turbinate flap. The Nasal Obstruction Symptom Evaluation (NOSE) instrument was used to evaluate the preoperative and postoperative subjective sensation of nasal obstruction. Measurement of preoperative and postoperative nasal airway resistance was performed using active anterior rhinomanometry which is an objective test. Wilcoxson signed rank test and Spearman correlation test were used to analyze correlation between NOSE scores and rhinomanometric measurements.

Results

The full closure of the septal perforations was noted in 100% of patients. The total NOSE score was 14 preoperatively and one postoperatively. The improvement in NOSE scores was statistically significant (P≤0.002). The mean preoperative total resistance (ResT150) value was 0.13 Pa/cm³s^-1, which is below the normal range (0.16-0.31 Pa/cm³s^-1), while the mean postoperative ResT150 value was 0.27 Pa/cm³s^-1. The correlation between the improvement in NOSE scores and improvements in ResT150 values was statistically significant.

Conclusions

Surgical approaches should aim to solve both the anatomical and physiological problems of NSP. The application of subjective and objective tests in the postoperative period will help surgeons assess the applied techniques.

Mucociliary transport and histopathological changes in rotation flaps of the nasal mucosa

Normal mucociliary transport in the mucoperichondrium of the nasal septum is from a distal (anterior) to proximal (posterior) direction. This study was to determine the direction of mucociliary transport and histopathological changes in nasal mucosal rotation flaps when their transport directions were anatomically reversed. Thirty-two rabbits were divided into four groups. Surgical septal rotational flaps were prepared in the experimental groups. Group I was the control group. The distal aspect of the flap was sutured through a large septal window to the other side of the nasal septum, thus changing the direction of the flap. Evaluation was performed 1 week, 1 month and 9 months later with each of these groups named as groups II, III, and IV, respectively. The rate and direction of the mucociliary transport was determined and histopathological investigations were performed from the flaps. The direction of mucociliary transport was observed to continue as distal to proximal direction in the rotated segments. The mucociliary transport rate was found to be decreased in group II, nearly normal in group III, and in normal limits in group IV after surgery. Intense inflammation and decreased number of cilia were present in group II. The inflammation was milder in group III and the epithelium was found to be nearly normal in group IV. The originally programmed direction of mucociliary transport in the nasal rotation flaps is maintained and is not altered or reprogrammed. Histopathological changes revert back to normal from an inflammatory state to reach pre-surgical status over time.

Nasal septal perforation repair: predictive factors and systematic review of the literature

PURPOSE OF REVIEW

Although numerous surgical techniques have been introduced thus far in order to achieve the surgical closure of nasal septal perforation, the repair of nasal septal perforation is still challenging for surgeons and operative techniques are not standardized. Furthermore, predictive factors for successful closure have not been elucidated. This review aimed to investigate predictive factors for complete closure of nasal septal perforation.

RECENT FINDINGS

The size of perforation was the most significant factor for complete closure. Surgical failure occurred more frequently in patients with large perforation (>2 cm) than those with small-to-moderate perforation (≤2 cm). The bilateral coverage over the perforation with vascularized mucosal flap also helped complete closure. Interposition of grafts appeared to assist complete closure, although it was statistically insignificant.

SUMMARY

This review provides information for surgeons on how to predict surgical outcomes of the repair of nasal septal perforation and which surgical techniques to choose in order to obtain better results.

Large nasal septal perforation repair by closed endoscopically assisted approach

Options for the surgical closure of large symptomatic perforations are limited and consist of an open or closed approach using skin or mucosal flaps, with or without different grafts. The aim of this study is to review our experience in treating large nasal perforations using a closed approach with endoscopic assistance, undertaking a 3-layer reconstruction of the septum. We reviewed 14 consecutive patients with large (2-4 cm) nasal septal perforations, who were treated using an endonasal/endoscope-assisted approach. In these cases, the mucosal defect was reconstructed through a horizontal advancement of the bipedicled mucoperichondrial flaps and sutured using absorbable sutures. The cartilagineous defect was consistently reconstructed using autogenous auricular conchal grafts. Pre- and postoperative nasal symptom scores were used for the study; a decline in the number of Nasal Obstruction Symptom Evaluation Scale symptoms were recorded in 12 of 14 patients (85.7%), and visual analogue scale scores for crusting, bleeding, nasal discharge, whistling, headache, nasal pain, snoring, olfactory loss, and overall discomfort levels also decreased. It was concluded that bipedicled mucoperichondrial flaps with the insertion of auricular cartilage for a 3-layer septal reconstruction seem to give reasonably good results. The use of nasal endoscopy is an endonasal approach, which offers superior precision in all surgical steps and provides a way to obtain excellent closure of the perforation without external incisions.

Experiences with a new surgical technique for closure of large perforations of the nasal septum in 55 patients

BACKGROUND

The surgical closure of nasal septal perforation is still an unsolved clinical problem. In this study the experiences with a novel surgical technique for closure of large perforations of the nasal septum are presented.

METHODS

A total of 55 patients with symptomatic nasal septal perforation measuring 23 ± 3 mm (range, 11-38 mm) at the widest point were enrolled in the study. The closure of the nasal septal perforation was performed with a new and simple surgical technique using a nasal mucosal flap consisting of the defect-corresponding mucosa of the floor of the nose, inferior nasal meatus, and inferior turbinate.

RESULTS

A symptomatic improvement of nasal symptoms was noted in all treated patients. In only 3 of 55 cases was the perforation closing incomplete.

CONCLUSION

Our experience with this flap shows its reliability and safety in repairing large nasal septal perforations, with many advantages compared with other techniques for septal perforation repair.

Assessment of biphasic calcium phosphate to repair nasal septum defects in sheep

BACKGROUND

Saddle nose and septal perforations are among the most surgically challenging situations in nasal reconstruction. They require a significant volume of autologous graft and a complex surgical procedure. The aim of this study was to evaluate the biocompatibility of the biphasic calcium phosphate implant in the nasal septum and its ability to replace septal skeleton with unilateral or bilateral exposure.

METHODS

Thirty sheep underwent anterior nasal septum perforation. Only 20 septa were repaired with the implant exposed to nasal content on bilateral (group 2) and unilateral (group 3) sides. After 45 days of spontaneous cicatrization, the surface of new airway mucosa covering implants and the amount of closure were evaluated macroscopically. Light microscopy, histomorphometry, immunohistochemistry, and transmission electron microscopy were performed to assess soft-tissue growth and differentiation. Statistical analysis was performed by means of the Mann-Whitney test.

RESULTS

The mean rate of mucoperichondrial flap recovery of the implant was 66 percent in group 2 and 82 percent in group 3, and was significantly different from that of the control group (p < 10(-4)). The mean amount of closure was 32 and 64 percent, respectively (p < 10(-3)). The thickness of the perichondrium was greater than the control on both sides (p < 10(-4)). Vascularized soft tissues and bone formation invaded pores of implants. No pathologic inflammation was observed in submucosa. Moderately differentiated and well differentiated newly formed epithelium were the most frequent types observed, with good correlation between immunostaining and morphologic features.

CONCLUSION

These data suggest a good biocompatibility of biphasic calcium phosphate and its ability to repair the nasal septum in sheep.

Outcome of surgical closure of nasal septal perforation

OBJECTIVE

To assess success rates and symptom control after surgical treatment of nasal septal perforation.

METHOD

A prospective study was undertaken of 28 consecutive patients with symptomatic nasal septal perforation treated surgically by one surgeon between 2005 and 2007. All patients underwent an open rhinoplasty approach with bilateral superior and inferior nasal mucosal advancement flaps and acellular porcine collagen placed in between. Symptom severity was assessed pre- and post-operatively using a validated visual analogue score. The nasal valve angle was assessed pre- and post-operatively by two independent assessors.

RESULTS

Patients comprised 12 women and 16 men, with a mean age of 45 years (range: 21-76). The mean follow up was 16 months (range: 6-24). The mean vertical and horizontal diameters of the perforations were 22 mm (range: 10-35) and 27 mm (range: 10-37), respectively. Twenty-seven (96 per cent) patients had complete closure of nasal septal perforation. There were statistically significant differences between the pre- and post-operative mean visual analogue scale scores for epistaxis (p < 0.001), crusting (p < 0.001), whistling (p < 0.001) and nasal obstruction (p < 0.001). Epistaxis, crusting and whistling resolved in all patients, and 92 per cent reported improvement in nasal blockage.

CONCLUSION

Closure of nasal septal perforation using an open rhinoplasty approach with nasal mucosal advancement flaps and a porcine collagen sandwich is a pertinent and reliable technique for the management of nasal septal perforation.

Biphasic calcium phosphate to repair nasal septum: the first in vitro and in vivo study

Our objective was to evaluate the cytocompatibility and biocompatibility of biphasic calcium phosphate (BCP) in the nasal respiratory airway. In vitro, the attachment rate was quantified on BCP disks with normal human epithelial cells at 1, 3 and 24 h by determining N-acetyl beta-D-hexosaminidase activity. Proliferative activity of cells was indirectly assessed by MTT assay at 3, 9, 15 and 21 days. Plastic surfaces were used as positive control. In vivo, 15 rabbits underwent anterior nasal septum perforation and 10 septa were repaired with BCP disks. Five non-implanted animals were sacrificed at 3 months. Two groups of five implanted animals were sacrificed at 1 and 2 months. The surface of new airway mucosa covering BCP disks was evaluated macroscopically. During both steps, light microscopy, immunohistochemistry and scanning electron microscopy were performed. Statistical analysis was performed with the Mann-Whitney U-test. In vitro, at 1 and 3 h, the attachment rates were significantly better than on the plastic surface (p < 10(-2)). Mitochondrial activity increased on both surfaces but began 6 days later than on plastic. After 21 days of culture, cells were confluent and formed a monolayer covering the implant even in the bottom of the pores. In vivo, no perforations in the control group closed spontaneously. The mean rate of closure was 63% in the 1 month group and 64% in the 2 month group (p > 0.05). Implants were invaded by inflammatory reaction covered by incomplete differentiated respiratory epithelium. Throughout the study, all immunohistochemical findings remained positive. These data suggest a good affinity between BCP and nasal epithelial cells. BCP could be used to rebuild nasal septa.

Repair of nasal septal perforation using a simple unilateral inferior meatal mucosal flap

Nasal septal perforation may cause recurrent epistaxis, nasal obstruction, discharge, crusting, dryness, pain and whistling. Many surgical approaches for the repair of septal perforations have been reported in the literature, however most of the available closure techniques are technically difficult, require experienced surgeons and have a high rate of re-perforations. A new and simple surgical technique for the treatment of nasal septal perforations is described in the present study. A total of 13 patients with symptomatic nasal septal perforation measuring 17+/-3mm (range 5-26 mm) at the widest point were enrolled in the present study. All patients were treated with a unilateral inferior meatal mucosal flap and had their septal defects closed. Complete symptomatic resolution was documented among all of these patients. This technique provides a new method with many advantages compared to other techniques for closure of septal perforations. Our first experiences with this flap show its reliability in repairing septal perforations.

Endoscopic repairment of septal perforation with using a unilateral nasal mucosal flap

Objectives

Nasal septal perforation is an anatomic defect of the cartilaginous and bone tissues of the nasal septum. Many approaches and techniques to repair nasal septal perforations have been reported on. The purpose of this paper is to report on our surgical technique and the results of the treatment for nasal septal perforations.

Methods

From May 2001 to March 2008, 14 patients (12 males and 2 females; mean age: 41.3 yr) were enrolled. The mean perforation size was 15 mm, and all the perforations were located at the cartilaginous portion. Our surgical technique is based on an endoscope-assisted endonasal approach, with dissection of unilateral advanced mucosal flaps with using a temporalis fascia graft. The follow-up periods ranged from 3 to 23 months (mean follow-up period: 8 months).

Results

Using our surgical technique on 14 patients, 12 cases (85.7%) of septal perforation were closed without complication. The remaining two patients (14.3%) had incomplete closures (about 2-3 mm) without any significant symptoms related to the remaining perforation.

Conclusion

Our technique is a viable procedure with a high success rate for achieving closure of nasal septal perforations. It has the advantages of shortening the operative time, no external incision and avoiding any other perforation during the operation. Therefore, we consider it to be a good alternative for repairing nasal septal perforations.

The comparison of acellular dermal matric (Alloderm), Dacron, Gore-Tex, and autologous cartilage graft materials in an experimental animal model for nasal septal repair surgery

BACKGROUND

The aim of this study was to compare the compatibility of Alloderm, Dacron, Gore-Tex, and autologous cartilage graft materials with host tissues in nasal septal perforation repair surgery.

METHODS

The materials were placed into the nasal septum of 16 New Zealand rabbits. At the end of the 3rd month, septums of the rabbits were removed totally and reactions, such as inflammation;foreign body giant cell; or fibrosis that developed in the surrounding tissue against the implant material were evaluated.

RESULTS

Acute inflammation reactions occurred mostly with Gore-Tex. There were no differences between groups according to chronic inflammation. When the number of reactions and tissue compatibility were taken into consideration, cartilage performed the best followed by Alloderm. There were more reactions with Dacron, but it still showed compatibility.

CONCLUSION

Cartilage was found to be the best material followed by Alloderm and Dacron, but Gore-Tex was found unsuitable.

Nasal septal perforations: our surgical technique

OBJECTIVE

The aim of this paper was to describe our surgical technique for the treatment of nasal septal perforations.

STUDY AND DESIGN

We studied 31 patients with nasal septal perforation treated with an endoscope-assisted technique, based on a bilateral dissection of monopedicled mucosal flaps from the nasal fossa floor, sutured at the edge of the perforation previously unstuck, without any graft interposed between the two mucosal layers.

RESULTS

In our experience with 31 patients, the use of this technique led to the persistent closing (with follow-up for at least one year) of 96.3% of the perforations smaller than 3 cm.

CONCLUSIONS

Our technique has the advantage of an endonasal approach, without any external incision, and the use of monopedicled flaps from the nasal fossa floor without any graft interposition, avoiding any other surgical procedure and morbidity in the donor site of the graft. The use of nasal endoscopy permits superior precision in all surgical steps.

SIGNIFICANCE

The high success rate in perforations smaller than 3 cm seems to confirm the effectiveness of this technique.

Nasal septal perforation 1981-2005: changes in etiology, gender and size

Background

Septal perforation is an uncommon but very bothersome illness and treatment is difficult particularly with large perforations. We wanted to establish the etiology and size of nasal septal perforations in an attempt to implement preventive measures.

Methods

This is an open, prospective clinical study of patients seen at our hospital from 1981 to 2005. The clinical data of size, gender and etiology have been recorded consecutively.

Results

One hundred and ninety seven patients (100 male, 97 female) were evaluated. Between 1981 and 1995 nasal septal perforation was caused by surgery in 40 of 102 (39.2 %). In the period 1995 to and inclusive of 2005 this percentage decreased as septal resection has been replaced by septo/septorhinoplasty. The latter was the cause for septal perforation in 14.7% in the last period. Nasal steroid and decongestive sprays have emerged as an important cause (28.4 %) during the last ten years particularly in females. In the first period 44 (43.1 %) and in the last 53 (55.7 %) patients were females. There was a noticeable reduction in the number of septal perforations 15 mm or larger in the last period.

Conclusion

Nasal steroid and decongestive sprays are now important causes for septal perforation. Information about this complication should be given with an advice to immediately report increasing and bothersome crusting and bleeding. Warning of the simultaneous use of nasal steroid and decongestive sprays should be addressed particularly to females. All patients with symptoms of septal perforation should promptly be referred to otolaryngologists for treatment.

[Endoscopic closure of septal perforations by mucosal rotation flaps]

OBJECTIVES

We present a technique of endoscopic endonasal closure of average sized (0.5 - 2 cm) to large (>2 cm) septal perforations.

MATERIAL AND METHODS

The surgical technique involves a mucosal rotation flap on a unilateral posterior pedicle without interposition material. We reviewed our experience with eleven patients with average sized and large septal perforations treated over an 8-year period.

RESULTS

We based our evaluation on the model proposed by Younger and Blokmanis. Our results were comparable with earlier publications. One-phase closure was achieved in 75% of patients (55% to 90% in the literature reporting all techniques, including external septorhinoplasty and midfacial degloving).

CONCLUSION

Our preliminary series provides a basis for a new approach to this condition. The technique is promising for large perforations. This technique could also be considered for other nasal fossae in the event of failed closure. It also offers a way to obtain excellent closure of the anterior portion of the perforation, relieving the patient of the most annoying symptoms. The technique does not contraindicate other procedures which may be performed during the same operation or later.

[Pigmented villonodular synovitis of the temporo mandibular joint. Differential diagnosis and therapy]

For the temporomandibular joint (TMJ), functional disorders are common but tumors and tumor like lesions are rare, although these are often mistaken for functional ailments. Early examination by computed tomography or, as a method of choice, magnetic resonance imaging is recommended in case of persisting TMJ problems. Pigmented villonodular synovitis (PVNS) is a rare benign but locally destructive fibrohistiocytic lesion originating in synovial tissue. Involvement of the temporomandibular joint is extremely rare, with the average age of patients being 44.6 years. This paper reports on a 13-year-old patient with diffuse PVNS involving the middle ear and middle cranial fossa. The treatment of choice involves wide local excision and reconstruction of the temporomandibular joint with long-term follow-up. Pathogenesis and differential diagnosis are discussed.

[Transvestibular closure with an autologous bone graft as surgical repair of a nasoseptal defect due to Le Fort-I osteotomy]

Defects of the nasal septum are a common complication after nasal surgery. Affected patients frequently suffer from bleeding, crusting and impaired nasal air flow. The surgical closure of septal defects remains a distinctive challenge. Though many different techniques have been described, the failure rate of this procedure remains high. In the case presented here, a large basal septum defect occurred after a prosthetic Le Fort-I osteotomy. The attempt to cover the distance between the bony nasal floor and the nasal septum with pedicled mucosal flaps failed due to extensive scar formation of the nasal mucosa. Therefore a nasal floor elevation by insertion of an autologous bone graft from the iliac crest was conducted. The bone graft was connected with the hard palate via two titanium screws. Other than with an autologous cartilage graft, no major resorption of the bone graft is to be expected. This indirect method for the closure of a basal nasal septum defect is new.