Nasal septal perforation and its

management

By

Dr. T. Balasubramanian M.S. D.L.O.

Introduction: Septal perforation happens to the common disorder of nasal septum. In most patients
septal perforations are incidental finding without any symptoms. Septal perforations may cause
crusting, whistling sound during inspiration, epistaxis, nasal obstruction and pain. Whistling will be
more when the perforation is small.
These symptoms depend on the location of perforation, size, shape and conditon of the margins
of the perforation. Surgical closure happens to be the best option, but a prudent decision will have
to be made taking into consideration all the above said parameters as well as the competancy of the
surgeon involved.

Classification of septal perforation:

Septal perforations can be classified according to the following parameters:

1. Cause
2. Symptoms
3. Location
4. Size
5. Shape
6. Condition of margins
7. Presence / absence of cartilage or bone around the defect

Causes of septal perforation:

1. Septal surgery (commonest cause) – Cartilage / bone around the perforation is usually
missing
2. Repeated nose picking – Cartilage / bone around the perforation is usually present
3. Repeated bilateral coagulation for epistaxis (in pts with hereditary teleangiectasis)
4. Trauma
5. Cocaine abuse
6. Septal abscess – Cartilagenous portion of nasal septum is totally destroyed
7. Granulomatous infections of nasal septum. In wegener's granulomatosis conservative
management is preferred over surgery
8. Tumor surgeries of nose
9. Exposure of caustics – Poor quality of mucosa surrounding the perforation should be borne
in mind before embarking on surgery

Symptoms:

1. Asymptomatic
2. Severe crusting
3. Epistaxis
4. Whistling sound during inspiration – common in small perforations. Larger the perforation
lesser becomes the whistling
5. Perforations involving the anterior portion of the septum is more symptomatic than those
involving the posterior portion
6. Symptoms are severe in small perforations than larger ones

Location of perforation: Location of the perforation plays a vital role in the symptomatology. It
should also be considered before deciding the management modality. Anterior perforations cause
more problems and are also amenable to surgical closure since it is easily accesible and can be
managed endonasally. Posterior perforations are asymptomatic and are difficult to manage
surgically because of poor access. Endonasal approach is virtually ruled out for repairing posterior
perforations. The ideal route of surgical approach is mid facial degloving, as this would provide
good visualisation and access to the perforated area.

Figure showing various areas of septal perforation. 1 – Large oval central perforation, 2 – small
anterior cartilagenous perforation, 3 – anterior basal in the region of premaxilla and maxillary crest

Shape of perforation:

Slit like perforation cause fewer problems and are easy to close.
Oval / oblong perforations are symptomatic and are difficult to close.

Condition of mucosal margins:

This factor should also be taken into consideration before deciding on surgical closure. Infection,
crusting and bleeding are signs of poor quality of mucosa around perforation. This mucosa is likely
to tear when repair is being performed. It is always better to manage the patient conservatively till
the mucosal infection subsides before embarking on surgical closure.

Presence of cartilage / bone around the defect:

The presence of cartilage / bone around the defect makes flap elevation easier, thereby helping the
surgeon. Membranous perforation, may actually enlarge when attempts are made to elevate
mucocutaneous flap around the perforation.
Coronal CT scan of a patient with septal perforation

Endoscopic view of septal perforation

In Killian era septal perforation due to septal surgeries was quite common. In fact 10 – 15 % of
patients who underwent septal surgery in this era developed septal perforation. In modern septal
surgeries this risk is eliminated to a large extent due to excellent illumination, better instruments
and surgical technique (less than 1%).

Prevention of septal perforation:

Knowledge of preventing septal perforation is much more important than the skill acquired to repair
it. Prevention is always better than cure.
Guidelines which will minimize the risk of septal perforation:
1. Ensure good illumination, sufficient exposure and blood less field. This will go a long way
in minimizing the risk of septal perforation
2. Elevation of septal mucosa should be performed in the proper plane. Proper instruments
should be used. The movements should be gentle. Elevation should always be done in the
 mucoperichondrial / mucoperiosteal plane. Blunt septal elevators should be used to elevate
the mucoperichondrial flap / mucoperiosteal flap. The septal elevator should be moved in an
upward and downward direction in a sweeping movement (akin to car windshield wipers).
When mucoperichondrium is elevated the sharp end of the septal elevator should be used.
Pressure should be applied only over the bone. Care must be taken to ensure that the
instrument is in continuous contact with bone. Scar tissue should be cut using sharp scissors
and cutting is usually done from inferior to superior direction for better visibility.
3. Safeguarding mucosal laceration: During surgery if mucosal laceration occurs it should first
be isolated and safe guarded. Dissection should be continued either above or below the
laceration thus releasing the mucosal tension around laceration. This enables the laceration
to heal faster.
4. Tears involving the septal mucosa if any should be immediatly repaired. This is more so if
the tear is more than 1cm. The septal mucosal tear should be closed immediatly using
absorbable atruamatic sutures. Mucosa around the tear should be elevated to enable the
edges of perforation to be closed without tension. When suturing the mucosal margins
should be everted towards the nasal cavity.

Figure showing mucosal tear over nasal septum being isolated

Figure showing torn mucosa being sutured

5. Careful adjustment of the torn edges of the mucosa over nasal septum is one excellent way
 of preventing septal perforation. This will be of immense help even if suturing is not
resorted to. The mucosal edges of the perforation is held in place by appropriately
positioned dressing on both sides of the nose. The edges should be meticulously adjusted
with the blunt end of the septal elevator. Care should be taken to ensure that intra nasal
dressing doesnot protrude between the edges of the perforation
6. Reconstruction of damaged septum by inserting plates of cartilage / bone in patients with
extensive nasal septal laceration will prevent septal perforation. Compressed gelfoam can
be used to hold these plates in position. Internal dressing (intranasal) can then be applied.
7. A mucosal tear when it appears close to the basal crest should be closed immediatly.

Figure showing mucosal tear over basal crest and the resultant suturing after reducing the height of
the nasal septum to reduce the tension over sutured margins.

Treatment:

1. No treatment: May be difficult for a surgeon to digest, a significant number of septal

perforations do well without repair. Sometimes a failed repair will make the patient worse.
2. Conservative management: Application of bland ointments / vaselin over the edges of
perforation using a cotton applicator will cause symptomatic relief and prevent excessive
crusting. Regular nasal douching using alkaline saline will prevent infection. If the
mucosal edges around the perforation are infected then antibiotic steriod ointment can be
applied.
3. Surgical closure: of the perforation is still the best option. The results are ofcourse
dependent on the size of the perforation. Mucosal margins should be healthy for closure of
perforation to be successful. Any attempt to close a septal perforation caused by repeated
cauterization of septum may fail because of the poor quality of mucosa lining the edges of
the perforation. Similarly it is surgically difficult to close an irregularly shaped perforation
when compared to a regular oval shaped one. Anterior perforations can be closed easily
when compared to posterior ones due to better access. Four methods of surgical closure
have been accepted. They include: Direct closure, Rotation flap technique, Bridge flap
technique and Bucco gingival flap technique.

Direct closure: This method is ideal in cases of immediate repair of septal mucosal laceration.
This can be performed only when the size of the perforation is small, and there is also associated
septal deviation. By correcting the deviation of nasal septum sufficient slack can be achieved to
facilitate tension free primary closure of mucosa. For direct closure the nasal septal mucosa should
be undermined. The undermined mucosa should be sufficient for tension free closure of the
perforation.
Rotation flap technique: This method is very useful in closing anterior based perforation which is
less than 2 cms. The margins should be of good quality, and there is adequate bone / cartilage
around the perforation. Two pedicled mucosal flaps are created. One flap (upper septal flap) on
one side and another one from the floor on the opposite side are created. The upper septal flap is
based cranio posteriorly and is supplied by anterior and posterior ethmoidal arteries. The lower
septal flap is pedicled caudo posteriorly and is supplied by the palatine artery.

Figure showing the incision for superior flap (Rotation flap technique)

Diagram showing inferior flap incision (Rotation flap technique) should be performed on the side
opposite to that of the superior flap

Since these two flaps are cut from different areas of nasal cavity, the septum will not get denuded of
its mucosal covering.

Steps of this procedure include:

Step 1: Creation of superior and inferior tunnels on opposite sides
Step 2: The inferior tunnel is extended along the floor up to the lateral nasal wall
Step 3: Posterior pedicled flap is cut cranial to the perforation and is rotated into the defect from
above.
Step 4: An inferior based pedicle flap is cut inferior to the perforation on the opposite side and
rotated into the defect from below.
Step 5: These two flaps are sutured to each other across the perforation using atraumatic sutures

If possible a strip of autologous septal cartilage when inserted between these flaps will improve the
results.

Bridge flap technique: This method is the most complicated but reliable in treating large anterior
and posterior perforations. If done properly results are good and fairly predictable. This procedure
is helpful in closing septal perforations of more than 3 cms. This method is more traumatic than
rotation flap technique.

Procedure:

The septum is approached via four tunnel approach. The superior tunnels are extended up to the
roof of the cartilagenous and the bony pyramid. The inferior tunnels on both sides are continued
over the floor of the nasal cavity and the lateral wall of nasal cavity up to the arrachment of inferior
turbinate. The incisive nerve will be damaged in this procedure.
Longitudinal incisions are made in the nasal mucosa close to the nasal roof. These two flaps are
advanced downwards towards the defect. Longitudinal incisions are made at the attachment of
inferior turbinate and these flaps are advanced medially and superiorly towards the defect.

Diagram showing bilateral bridge flap technique

Bucco gingival flap technique: This technique is used to manage large anterior perforations.
Bilateral oblong flaps are gut from the orogingival mucosa including its submucosa with their
attachment medially. These flaps are rotated through a small tunnel into the nasal cavity sealing the
perforation. It is a complicated procedure will risk of upper lip deformity / stenosis of nasal
vestibule.

Procedure:

1. Superior and inferior septal tunnels are created.

2. Another incision is made in the posterior and inferior margins of perforation. Mucosa is
dissected while preserving the margins of the perforation.
3. Labiogingival area is exposed using retractors. The area of flaps are marked after
identifying the parotid duct.
4. The mucosa and submucosa are incised without damaging the periosteum. The lower arm
of the incision is made longer than that of the upper arm to facilitate rotation of flap. These
flaps are dissected using curved scissors.
5. Small tunnels are created on either side of anterior nasal spine intraseptally.
6. A curved hemostat is introduced into the para spinal tunnel through the nose and the flap is
pulled into the septal defect.
7. The ends of the flaps are thinned and trimmed and is sutured over the defect.
8. Unnecessary torsion of the flap should be avoided.
9. Oral wound should be closed with catgut after undermining its margins to get some slack.
Careful attention should be paid to maintain upper lip symmetry.

Figure showing buccogingival flap being raised

Figure showing buccogingival flap rotated into the nasal cavity

A combination of more than one method may also be resorted to in managing difficult situations or
in failure cases.
Use of free facial grafts and composite cartilage and skin grafts have been abandoned due to poor
results.
With the advent of nasal endoscope, it has become easy to visualize the whole nasal cavity while
performing any of these reconstruction procedures. It is a valuable tool in the hands of a surgeon
performing these surgical procedures.

Midfacial degloving approach:

This approach was first used by Portmann in 1927 to perform maxillectomy.

Conley and Price in 1979 used this approach to remove benign nasal masses.
Casson in 1974 performed the first septal perforation closure using this procedure.
Maniglia in 1986 extensively used this approach for septal perforation closure.

This approach is very useful in repairing large septal defects as well as posterior septal defects. The
advantage of this procedure is excellent exposure of surgical field without the need for any external
incisions on the face. Cosmetically this procedure is acceptable.
Surgical procedure involves:

1. Midfacial degloving surgical procedure with exposure of the whole nasal cavity
2. Developement of posterior based mucosal flaps bilaterally
3. Septoplasty if necessary need to be performed
4. Intranasal closure of the perforation

The surgical field is liberally injected with 2% xylocaine with 1 in 1lakh units adrenaline. This will
ensure a relatively bloodless field during surgery.

Intranasal incisions: These should be performed first. Bilateral intercartilagenous incisions are
given. They are connected to each other at the septal angle thus forming a complete transfixation
incision. The intercartilagenous incision should be extended inferiorly and laterally up to the level
of the floor of the nose. This limb is also connected to the complete transfixation incision.

Gingivobuccal incision: is performed next. It extends between the first molars of both sides across
the midline. This incision is joined to the already performed complete transfixation incision. This
union is performed at the level of anterior nasal spine. The osseocartilagenous nose is degloved
exposing the nasal architecture completely.

Closure of septal perforation: Nasal septum and its perforation is exposed. The mucosal lining
over the nasal septum is elevated using 1% xylocaine with 1in 100000 adrenaline injections.
Deviations involving the septum if any should be corrected at this juncture. The edges of the
perforation are cut and undermined. Posterior based unipedicle flap is elevated on both sides. This
flap is used to cover the perforation. Flaps should be sutured in place without tension.

Complications:

Complications of this procedure include:

1. Reperforation
2. Vestibular stenosis
3. Facial oedema during immediate post op phase
4. Infraorbital nerve area anesthesia
Figure showing exposure of nasal vault in midfacial degloving approach

Use of synthetic prosthesis to close septal perforation:

Synthetic prosthesis like septal buttons, and obturator have been used with varying degrees of
success to close septal perforations.

Indications for the use of these prosthesis:

1. Large and difficult to repair septal perforations

2. Failed septal perforation repair
3. Poor surgical candidates

Silastic is the most preferred material. These prosthesis can be inserted under local anesthesia and
can be performed as an office procedure.

Before introducing the obturator the following procedures should ideally be followed:

1. The width and the height of the perforation should be accurately measured using a
calibrator. Sometimes sagittal CT scan will have to be done in difficult to measure cases.
2. The nasal mucosa is anesthetised and decongested using 4% xylocaine solution.
3. The commercially available prosthesis is cut to the precise shape and size of the perforation.
4. To facilitate atraumatic insertion of the prosthesis, both the prosthesis and the nasal cavity
are greased by applying a bland ointment / vaseline.
5. A button is commonly inserted through the left nostril. The posterior end of the medial
 flange is pushed through the perforation. It is delivered through the perforation by
introducing an instrument into the right nasal cavity, and the prosthesis is rotated into place.
6. Care should be taken to ensure that the flanges dont come into contact with the floor / roof
of the nasal cavity.

The insertion of septal prosthesis give good and predictable results.

Inferior turbinate flap technique:

This technique has been used to repair caudal septal perforations under 2 cms in size. Unilateral
flaps are preferable. Normal sized healthy inferior turbinate should be used. Inferior turbinates
which have been operated / inferior turbiantes in patients with atrophic rhinitis are not ideal flap
candidates.

Septoplasty should be performed. If possible septal cartilage should be harvested. If septal

cartilage is not available then conchal cartilage should be harvested to be used as interposition graft
material. The dimensions of the cartilagenous graft should be larger than that of the dimensions of
the septal perforation.
The cartilage graft is placed over the perforation whose edges have already been freshened. This
graft is stabilized using matress sutures which passes through the mucosa on both sides. This
mattress sutures not only holds the graft in position, it also prevents hematoma formation.

Creation of inferior turbiante flap:

The inferior turbinate is liberally infiltrated with 1% xylocaine with 1 in 100000 concentration of
adrenaline. Adequate sized inferior turbinate flap based on posterior pedicle is created and is
sutured to the mucosal edges of the perforation. A small gelfoam pack is left behind the flap. The
turbinate flap is cut 3 weeks after the surgical procedure.

Figure showing nasal septal perforation

Figure showing cartialge interposition to close the perforation

Figure showing inferior turbinate flap sutured to the edges of the perforation

Advantages of inferior turbinate flap:

1. This flap has a good vascularity

2. It has a wide ring of rotation
3. It provides both skeletal and epithelial support
4. Since it is covered with respiratory mucosa it helps in the nasal septum achieving
physiological normalcy

Weerda slightly modified this technique by using only a small portion of the inferior turbinate
tissue.