Surgical Closure of Nasal Septal Perforations

Overview

Nasal septal perforation is often troublesome for the patient. It is manifested by crustformation, epistaxis, impaired nasal ventilation, headache, a whistling sound during breathing,leakage of mucus into the nasopharynx, rhinorrhea, hyposmia, snoring, vocal changes, recurrentupper airways infections, odour in nose. Previous laminar air ventilation changes into turbulent.The streaming air dries the perforation margins, crusts are formed that after removal cause bleedingand the perforation enlarges progressively. In these patients complex therapy is indicated.Every nasal septal perforation that enlarges progressively and causes the mentioned problems isindicated for surgical or conservative treatment. In the literature there are many methods of variousmucosal and cutaneous flaps used for covering the perforation, insertion of silastic buttons or onlyregular intarnasal toilette and moisture of the nasal mucosa by ointment.From 1989 30 patients were operated on for a perforation of the nasal septum of various origin. Threemethods of covering perforations are presented. The operative challenge depended on the size ofthe perforation, quality of nasal mucosa, position of nasal septum and nasal airways passage. Thefirst described method was used in 20 patients, the second in 3 and the third in 7 patients.In covering a small perforation we used for a long time the method of local mucoperichondrial andmucoperiosteal flaps with insertion of an aural cartilagineous graft into the original defect.Long-lasting (more than one year) results were not favourable. The perforation was closed in onehalf of the patients, in some patients the defect diminished, nasal ventilation improved also inconnection with a corrected nasal septal deformity and treated allergic rhinitis. In three cases witha large perforation (2 - 3 cm) the method of a buccal and vestibular mucosal flap with insertion ofcartilage or bone between them was used. This method failed in all cases because of flap necrosis.The perforation gradually reached the original size. One patient with a bony implant had theperforation covered for six months.This lead us to seek a more effective and safer method. We developed a method of inverted flaps thatare drawn through the perforation on the opposite side. In the literature we did not find a reporton such a technique. The method of bilateral inverted flaps has certain advantages.1. After the flap is turned into the perforation it is automatically covers the posterior and inferiormargin of the perforation because flaps cover it by their pedicle. Stiches have to be situated at thesuperior margin and just behind the columella. These places are usually accessible and insertion ofthe suture does not cause a problem.2. Flaps are quite thick after suture, they have a good blood supply and when covering smallerperforations there is no need to insert a cartilage between them.3. Behind the perforation and on the base of the nasal cavity there is enough material for coveringa perforation even greater than 1.5 cm diameter.The method of inverted flaps is suitable in all perforations where cartilage or bone around the defectis preserved. Patients after resection of septal cartilage and after partial removal of septal bone arenot acceptable candidates for this method. Their septum is created by two layers of mucoperichon-drium grown together. If there is a perforation in soft bleeding tissue with atrophy, it is not possibleto create on adequate mucoperichondrial flap, because such tissue is resistent to surgical prepara-tion. Another method has to be chosen in that case.

Key words:
nasal septal perforation, surgery of a perforation, local transposition flaps, flapsfrom buccal mucosa, inverted flaps, midfacial degloving.