Surgical outcome and complications of nasal septal perforation repair with temporal fascia and periosteal grafts

Predictors of Success of Endonasal Septal Perforation Repair: A 10-Year Experience

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.

Nasal Septal Perforation Reconstruction with Polydioxanone Plate: A Systematic Review

Nasal septal perforation is an uncommon pathology that is difficult to surgically repair and may significantly impact patients' quality of life. Existing treatments have high complication and failure rates. The use of polydioxanone (PDS) plates to repair septal perforations is an innovative approach that has demonstrated superior outcomes to the conventional techniques. This study aimed to review the literature on PDS plates for nasal septal perforation reconstruction. PubMed, OVID Medline, and OVID Embase databases were searched for relevant articles in June 2021. Search terms included nasal septal perforation, polydioxanone, septal perforation, septal repair, nasal septum, and PDS plate. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were adhered to for this systematic review. Database searches yielded 80 articles. Seven articles were included representing 74 patients. All studies reported the use of PDS plates in addition to other materials. They all reported closure rates of at least 80%. The majority of studies reported no postoperative complications. Nasal septal perforation reconstruction with PDS plates is a promising approach that has demonstrated positive outcomes. Further larger studies are required to evaluate the long-term efficacy of using PDS plates on patients with septal perforations.

Efficacy of TnR Nasal Mesh for prevention of septal perforation during septoplasty

OBJECTIVE

Septoplasty has been reported as the most common cause of the septal perforation. The interposition of the graft materials between the flaps at the site of the tear may be helpful to decrease the likelihood of septal perforation. The purpose of this study was to investigate the efficacy of TnR Nasal Mesh on the prevention of septal perforation following septoplasty.

METHODS

Among 46 patients had septal perforation after septoplasty, 35 patients were treated with TnR Nasal Mesh and 11 with autologous septal cartilage for bilateral mucosal tears at the corresponding area of the nasal septum. TnR Nasal Mesh or septal cartilage was placed between the injured mucoperichondrial flaps and confirmed in its original position at both sides under nasal endoscope. Objective endoscopic examination for septal mucosa status was evaluated between the patients who were treated with TnR Nasal Mesh or septal cartilage.

RESULTS

Twenty patients (57.1%) showed complete bilateral mucosa healing and nine (25.7%) had unilateral healing after TnR Nasal Mesh insertion. However, complete bilateral and unilateral mucosa healing was observed in 4 (36.4%) and 1 patients (9.1%) treated with septal cartilage, respectively. Complete healing rate for septal perforation was significantly higher in TnR Nasal Mesh than in septal cartilage insertion (p=0.022). None of the patients showed complications or adverse reactions after TnR Nasal Mesh or septal cartilage treatment.

CONCLUSION

TnR Nasal Mesh insertion after bilateral septal mucosal tear during septoplasty reduces permanent septal perforation without an apparent adverse effect. Therefore, TnR Nasal Mesh may be a safe and effective graft material for the prevention of septal perforation following septoplasty.

Perioperative Management of Nasal Septal Perforation: A Case Series and Review

Nasal septal perforation is a prevalent pathology, and its successful treatment remains a significant challenge. Surgical closure is complex, and there are a plethora of accounts of various surgical techniques within the existing literature. Much less has been written about perioperative considerations, which are arguably just as important. This article therefore focuses predominantly on the pre and postoperative management of patients with septal perforation. By drawing both on the existing literature and a series of 64 cases managed over several years by our department, this review aims to consolidate guidance on patient selection, timing of surgical intervention, postoperative splinting, use of antibiotics, and patient advice. It is clear that the size of the perforation (relative to the size of the septum), health of surrounding mucosa, and the systemic health and age of the patient remain essential considerations in patient selection and operative timing. Internal and external splints are widely used to good effect, but the role of nasal packing is less clear-cut. This article suggests packing, but with an increasing preference for NasoPore over BIPP (bismuth iodoform paraffin paste). Use of prophylactic antibiotics remains controversial. The complete closure rate for the series presented here was 81.3%, with an average perforation diameter of 15.1 mm (range: of 6-32 mm), and that for perforations with a diameter below 22 mm was 97.9%.

Correction of Septal Perforation/Nasal Airway Repair

Rhinoplasty is a double-edged sword regarding the functional nasal airway; it can enhance and improve the nasal airway if done properly, and can severely compromise the nasal airway if not done properly. The composition of the nasal airway includes the internal and external nasal valves, nasal septum, and inferior turbinates. Each of these areas can be addressed by several techniques, described in the body of the text. Nasal septal perforation is another potential complication that may result from septal surgery, which has nonsurgical and surgical methods to treat, and is also described in the body of the text.

Application of a Thermosensitive In Situ Gel of Chitosan-Based Nasal Spray Loaded with Tranexamic Acid for Localised Treatment of Nasal Wounds

The integrity of the nasal epithelium plays a crucial role in the airway defence mechanism. The nasal epithelium may be injured as a result of a large number of factors leading to nose bleeds, also known as epistaxis. However, local measures commonly used to treat epistaxis and improve wound healing present several side effects and patient discomfort. Hence, this study aims to address some of these drawbacks by developing a new formulation for nasal epithelial wound healing. Chitosan, a biodegradable and biocompatible polymer, was used to develop a thermosensitive nasal formulation for the delivery of tranexamic acid (TXA), one of the most effective pharmacological options to control bleeding with cost and tolerability advantages. The in situ gelation properties of the formulation upon administration in the nasal cavity were investigated in terms of gelation time and temperature. It was found that the developed formulation can undergo rapid liquid-to-gel phase change within approximately 5 min at 32°C, which is well within the human nasal cavity temperature range. The spray pattern, deposition and droplet size generated by the nasal spray was also characterised and were found to be suitable for nasal drug delivery. It was also observed that the in situ gelation of the formulation prevent nasal runoff, while the majority of drug deposited mainly in the anterior part of the nose with no lung deposition. The developed formulation was shown to be safe on human nasal epithelium and demonstrated six times faster wound closure compared to the control TXA solution.

A Novel Approach to Septal Perforation Repair: Septal Cartilage Cells Induce Chondrogenesis of hASCs In Vitro

The aim of this study was to investigate the effect of medium harvested from septal cartilage cells on chondrogenic differentiation of adipose stem cells (hASCs) and to compare/contrast its properties to those of a commonly used standard medium formulation in terms of induction and maintenance of chondrogenic hASCs. Differentiation was carried out under three different conditions: septal cartilage medium-SCM, chondrogenic differentiation medium-CM, and 50:50 mixture of CM/SCM. Mesenchymal stem cells (MSCs) markers were determined by flow cytometry. The cytotoxic and apoptotic effects were determined by MTS and Annexin V assay, respectively. The differentiation status of the cells was confirmed by Alcian blue staining, and quantitative real-time flow cytometry showed that hASCs were positive for MSCs, negative for hematopoietic stem cells and endothelial cell surface markers. According to MTS analysis, the first condition was not toxic at any concentration tested. Annexin V assay revealed that the application of different concentrations of SCM did not result in any cell death. The Alcian blue and gene expression analyses showed that the cells in the SCM group underwent the highest cartilage cell formation. The observed increase in chondrogenesis may offer better treatment options for the cartilage defects seen in nasal septum perforation.

Three-dimensional printing of large nasal septal perforations for optimal prosthetic closure

BACKGROUND

Since 1972, patients with large nasal perforations, who were symptomatic, and who were not candidates for surgery, had the option of custom prosthetic closure at Mayo Clinic. Although septal prostheses have helped many patients, 27% of pre-1982 patients chose not to keep the prosthesis in place. Two-dimensional computed tomography (CT) sizing resulted in more of the patients choosing to retain the prosthesis. The introduction of three-dimensional (3-D) printing to the sizing process offered the potential of further improved retention by refinement in prosthesis fit.

OBJECTIVE

To describe the fabrication of nasal septal prostheses by using 3-D printing for sizing and to compare the retention rate of 3-D-sized prostheses with those that used previous sizing methods.

METHODS

Twenty-one consecutive patients who had placement of septal prostheses sized by using 3-D printed templates were studied. CT image data were used to print 3-D templates of the exact shape of the patient's septal perforation, and medical-grade silastic prostheses were fabricated to fit. In four cases, the 3-D printed template allowed preoperative surgical simulation. Metrics collected included prosthesis retention; symptoms, including intranasal crusting and epistaxis; and previous prosthetic closure failures.

RESULTS

Twenty of the twenty-one patients had improvement in symptoms. The mean diameter of the perforations was 2.4 cm; the mean closure time by the end of the study period was 2.2 years. All but two patients chose to keep their prosthesis in place, for a retention rate of 90%. Seven patients with successful closure had failed previously with prior prosthesis sized without the current 3-D printing methodology. This 90% retention rate exceeded the previous rates before the introduction of 3-D sizing.

CONCLUSION

Sizing done by 3-D printing for prosthetic closure of nasal septal perforations resulted in a higher retention rate in helping patients with these most-challenging nasal septal perforations.

Endonasal septal perforation repair using posterior and inferiorly based mucosal rotation flaps

IMPORTANCE

Repair of nasal septal perforations is challenging regardless of surgical technique due to their location and the health of surrounding tissue. There is currently no surgical procedure which is completely effective in the treatment of anteriorly located perforations.

OBJECTIVE

To report a novel method of closing anterior septal perforations using an inferiorly based mucosal rotation flap and an acellular dermal interposition graft, as well as expand upon a previous series.

DESIGN

The study includes patients who underwent surgical repair for septal perforations by the senior author between 2003 and 2015.

SETTING

The study took place at MetroHealth Medical Center in Cleveland, Ohio.

PARTICIPANTS

Thirty-nine patients (15 male) with septal perforations of various size and etiology underwent endonasal repair using rotation flaps. The average age of patients was 42-years old (range 10-67years). INTERVENTION FOR CLINICAL TRIALS OR EXPOSURE FOR OBSERVATIONAL STUDIES: Five patients had perforations such that we used inferiorly based flaps, while 35 cases utilized posteriorly based flaps. Acellular dermis was used in addition to a unilateral rotation flap.

MAIN OUTCOMES AND MEASURES

The primary outcome desired was a complete closure of the septal perforation. The success, or lack thereof, was monitored after healing from surgery.

RESULTS

Thirty-seven of the forty surgical procedures demonstrated complete closure of the perforation, a 92.5% success rate. Perforations were separated based upon size. Small perforations (<1cm) had a 93.3% success rate, medium (1-2cm) 88.9%, and all seven large perforations (>2cm) were closed successfully. In addition, all five of the inferiorly based procedures resulted in complete closure of the perforation. Of the failed repairs, one required revision surgery to repair a recurring perforation, while the other two were asymptomatic following the procedure.

CONCLUSIONS AND RELEVANCE

Endonasal repair using inferiorly based mucosal rotation flaps coupled with an acellular dermal interposition graft is a valid technique for the repair of septal perforations. Posterior rotation flaps are preferred due to major septal blood supply from branches of the sphenopalatine artery, but inferiorly based flaps are also viable options for repair for perforations located in the anterior septum.

Effect of Temporal Fascia and Pedicle Inferior Turbinate Mucosal Flap on Repair of Large Nasal Septal Perforation via Endoscopic Surgery

BACKGROUND

The repair of large nasal septal perforations (NSPs) is one of the most challenging procedures in nasal surgery. The aim of this prospective clinical study was to determine the efficacy of using a pedicle inferior turbinate mucosal flap combined with temporal fascia to repair a large NSP.

METHOD

Between January 2008 and December 2015, 17 consecutive patients with large NSPs underwent septal perforation repair via an endoscopic approach using a pedicle inferior turbinate mucosal flap combined with temporal fascia.

RESULTS

Complete closure of the perforation was achieved in all patients.

CONCLUSION

The pedicle inferior turbinate mucosal flap combined with the temporal fascia technique can easily solve this challenging problem, and the current data from this prospective study suggest that this technique shows promising results.

Surgical repair of nasal septal perforations: an update

PURPOSE OF REVIEW

Nasal septal perforations can have a substantial impact on patient's nasal breathing and subsequent quality of life. Various surgical techniques have previously been described for the repair of these perforations. In this review, we examine the most recent literature evaluating surgical techniques for the repair of nasal septal perforations.

RECENT FINDINGS

Twenty-seven studies evaluating 646 patients were included. None of these studies compared different surgical techniques. Four major categories of surgical techniques are described: multilayer, single layer, patch, and resection. Within these broad categories there is much heterogeneity in both the individual surgical technique and material used for reconstruction. However, the overall closure rate in all studies evaluated was 88%.

SUMMARY

The diversity in surgical techniques demonstrated in this review would indicate that surgeons are not satisfied with the current surgical approaches for the repair of nasal septal perforations. However, the overall closure rates presented in this review are very favorable. Future comparative studies are needed to better evaluate these techniques.