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Pediatric nasal septal perforation
International Journal of Pediatric Otorhinolaryngology 118 (2019) 15–20
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Pediatric nasal septal perforation a,∗
b
T
Jesse J. Jennings , Amber D. Shaffer , Amanda L. Stapleton a b
a,b
Department of Otolaryngology, University of Pittsburgh Medical Center, 200 Lothrop Street Suite 500, Pittsburgh, PA, 15213, USA Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, 4401 Penn Avenue #3, Pittsburgh, PA, 15224, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Pediatric otolaryngology Nasal septal perforation Sinonasal disorders
Objective: 1.) Describe demographic and clinical characteristics of pediatric nasal septal perforations (NSP), 2.) Analyze efficacy of treatment modalities in symptom management and resolution of pediatric NSP, 3.) Describe the surgical technique of external rhinoplasty with vascularized nasal septal flaps in the treatment of nasal septal perforations. Methods: IRB-approved retrospective chart review of pediatric patients ages 0–18 years with nasal septal perforations treated at a tertiary care pediatric otolaryngology practice. Demographic and clinical characteristics including gender, age, race, and presenting symptoms, and location, size, and etiology of perforation were collected. Outcomes including persistence of perforation and symptoms at 1 year and most recent visit were recorded. A total of 20 patients were included. Statistical analysis used Fisher's t-test for categorical variables and Wilcoxon rank-sum for continuous variables. Results: Median age was 167.5 months (1.5–221.0). The most common etiology was iatrogenic (40%), followed by button battery (20%). Thirty percent of patients underwent surgical repair. Fifty percent of patients who underwent surgical repair achieved closure of their perforation at most recent follow up. Conclusion: Pediatric NSP is a challenging issue with limited literature to date. Iatrogenic causes (40%) and button batteries (20%) were the most common etiologies of nasal septal perforation in our study. We introduce an advancement in our center's surgical technique with a case illustration with repair via external rhinoplasty and bilateral vascularized nasal septal flaps. Future larger studies may further elucidate characteristics and treatment modalities associated with successful closure.
1. Introduction Nasal septal perforation is a physical defect of the nasal septum, causing an abnormal connection between the adjacent nasal cavities. This can result in turbulent airflow, especially in perforations of the anterior nasal septum, and damage to the normal respiratory mucosa and cilia [1,2]. This damage can lead to nasal crusting, congestion, whistling, pain, and mucosal dryness all of which can result in chronic epistaxis. While nasal septal perforation in the adult population has been relatively well studied, there is limited literature describing nasal septal perforations in children. The incidence of nasal septal perforation in the general Swedish adult population is 9 per 1000 people [3], but the incidence in the general pediatric population is unknown. Common etiologies of nasal septal perforations in adults include trauma, intranasal drug use, neoplasm, infection, and autoimmune disorders [4,5]. Given the higher incidence of digital trauma and nasal foreign body placement in children, as well as the lower incidence of neoplasm
∗
and autoimmune disorders, it can be expected that the etiologies may vary from the adult to the pediatric population. The goal of this study is to describe the clinical and demographic characteristics of pediatric nasal septal perforations, as well as delineate the treatment options and outcomes in our cohort. We also present a case report of a newly adopted advanced surgical technique to repair a pediatric nasal septal perforation. 2. Materials and methods This retrospective study was approved by the University of Pittsburgh Institutional Review Board prior to the initiation of chart review and all guidelines were followed. All patients under the age of 18 years seen at Children's Hospital of Pittsburgh outpatient otolaryngology clinic with the diagnosis of nasal septal perforation between 2008 and 2016 based on ICD-9 and ICD-10 codes were included in this study. Demographic and clinical characteristics including gender, age, race, presenting symptoms, location and size of perforation, etiology of
Corresponding author. E-mail address: [email protected] (J.J. Jennings).
https://doi.org/10.1016/j.ijporl.2018.12.001 Received 8 July 2018; Received in revised form 30 November 2018; Accepted 1 December 2018 Available online 04 December 2018 0165-5876/ © 2018 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 118 (2019) 15–20
J.J. Jennings et al.
Table 1 Demographic and clinical characteristics of 20 pediatric patients with nasal septal perforation. Characteristics
N
%
Gender, male Race Caucasian African American Other Age (years), mean (SD) Symptoms Crusting Obstruction Congestion Epistaxis Asymptomatic Rhinorrhea Whistling Pain Comorbid sinonasal disorders Allergic rhinitis Chronic rhinosinusitis Diameter (cm), mean (SD) Location Anterior Mid-septum Posterior
13
65%
17 2 1 11.2
85% 10% 5% 5.8
13 12 11 7 3 2 1 1
65% 60% 55% 35% 15% 10% 5% 5%
7 3 1.16
35% 15% 0.63
18 2 0
90% 10% 0%
Fig. 1. Pie chart representing breakdown of etiologies of nasal septal perforationsa. a Of note, some patients had multiple etiologies of perforations and thus total does not add to 100%.
underwent multiple procedures. Successful closure at most recent follow up was achieved in three of the six patients who underwent surgical repair. The clinical and outcome measurements of the patients who were managed conservatively are summarized in Tables 3 and 4. Four patients were excluded from outcome analysis as there was no outcome data available on chart review. One patient had closure with conservative treatment with nasal saline and ointment. Median follow up was 15.6 months with a range from 0 to 129 months.
perforation, both medical and surgical treatments, and outcomes were collected. The primary outcome of this study was status of perforation at one year follow up. Secondary outcomes included status of perforation at most recent follow up, control of symptoms, and need for secondary interventions for perforations. Statistical analysis was performed using Fisher's t-test for categorical variables and Wilcoxon ranksum for continuous variables. A p-value of less than 0.05 was considered statistically significant. Analyses were conducted using Stata/ SE 13.1 (StataCorp, College Station, TX).
3.1. Case illustration: external rhinoplasty approach with bilateral nasal septal flaps
3. Results
A 15-year-old male with a history of allergic rhinitis, chronic nose picking, and recurrent epistaxis presented to our outpatient clinic for evaluation of a nasal septal perforation for two years. He had undergone nasal cauterization twice by an outside provider, two years and one year prior to presentation. On examination, he had a 2.0 cm anterior nasal septal perforation with no external nasal deformity. He was treated with bactroban ointment twice daily without improvement and the patient and his family elected to undergo surgical repair of his perforation. He was taken to the operating room and underwent bilateral nasal endoscopy (Fig. 3). Bilateral pedicled extended posterior nasal septal flaps were raised endoscopically. The edges of the septal perforation were raised in a submucoperichondrial plane. The nasal septal flap cuts were connected to the edges of the perforation and the flaps were rotated to ensure adequate coverage of the perforation. An external rhinoplasty approach was then carried out through an inverted-V columellar incision. Dissection was carried posteriorly in the midline in a subcutaneous plane between the medial crura until the septum was encountered. A submucoperichondrial pocket was elevated posteriorly to expose the septal perforation. A 3 cm by 1.5 cm rectangle of Biodesign SURGISIS® was placed in the septal defect and positioned to cover the posterior perforation. This was secured in three places to the surrounding cartilage with a 4-0 plain gut suture. The extended nasal septal flaps were then rotated to cover the septal perforation and SURGISIS® bilaterally and were sutured in place with 4-0 plain gut quilting stitches (Figs. 4 and 5). Doyle splints were placed and the external rhinoplasty incision was closed. The patient was discharged home with nasal saline spray four times daily and bactroban ointment twice daily. His doyle splints were removed two weeks postoperatively. He had no postoperative complications and at his last visit 15 months postoperatively, his nasal septal perforation remains closed and is well
A total of 20 patients met inclusion criteria for this study. Patient demographics, symptoms at presentation, and characteristics of nasal septal perforation are delineated in Table 1. Thirteen (65%) of patients were male and 7 (35%) were female. Seventeen (85%) patients were Caucasian, which is representative of the overall patient population at our center. The mean age was 11.2 years with a range from 1.5 months to 18 years. The most common presenting symptoms included nasal crusting (65%) and nasal obstruction (60%). Ten patients had comorbid sinonasal complaints (Table 1). Sixteen patients had data available on perforation size, with a mean size of 11.6 mm and a range from 2 mm to 20 mm. Eighteen (90%) perforations were of the anterior nasal septum. There was a wide range of etiologies of nasal septal perforations in this series of patients, summarized in Fig. 1. The most common cause of perforation was iatrogenic (n = 9, 45%), which included subcategories of nasal surgery, cauterization, nasal packing, and frequent suctioning. Four (20%) patients had perforations due to nasal button batteries. Less frequent etiologies included infection (n = 1, 5%) and nasal steroid spray (n = 1, 5%). There were no perforations as a result of radiation or sinonasal malignancy. Nine (45%) patients elected surgical management for their nasal septal perforations. Three of the nine patients were managed with septal button placement, while the remaining six underwent some type of surgical closure, as described in Table 2. Repair techniques included simple suture closure, free synthetic graft placement with AlloDerm (LifeCell Corporation Branchburg, NJ), local rotational flaps, and pedicled nasal septal flaps, or a combination of these techniques. Two (10%) patients underwent external rhinoplasty, while the remainder underwent repair with an endonasal approach (Fig. 2). One patient 16
International Journal of Pediatric Otorhinolaryngology 118 (2019) 15–20
J.J. Jennings et al.
Etiology of perforation Location of perforation Size of perforation (mm) Treatment with nasal saline Treatment with nasal ointment Type of surgical repair
Nasal obstruction
None
Nasal congestion
Nasal septal perforation is a rare but challenging issue seen in an otolaryngologic practice. The existing body of literature addressing this issue is sparse, and studies that focus on the pediatric population are especially limited. To our knowledge, there is only one prior study that investigated nasal septal perforations in a cohort of children [6]. Chang et al. described pediatric nasal septal perforations in 27 patients and found the most common etiologies to include trauma (33%), iatrogenic (19%), and neoplasm (11%). The most common presenting symptoms included crusting (73%), epistaxis (58%), and congestion (31%) [6]. Six patients underwent surgical repair, with 3 patients (50%) achieving sustained closure at most recent follow up with a mean of 2.4 years. The structure and function of the nasal airway differs from the pediatric to the adult population, as do the potential causes of injury to the nasal septum leading to perforations and the ability of patients to comply with treatment options. It thus stands to reason that the management of nasal septal perforations should be tailored accordingly. In this series, the most common presenting symptoms in patients with a nasal septal perforation included crusting (65%) and nasal obstruction (60%). Thirty-five percent of patients presented with epistaxis. This differs from the results of the study by Chang, which found epistaxis to be present in over half of pediatric patients with nasal septal perforations [6]. Studies of septal perforation in adults have shown epistaxis to be the most common presenting symptom (58%), followed by crusting (43%). The incidence of whistling and pain were equivalent to prior pediatric and adult studies [1,4–6]. Interestingly, 15% of perforations in this study were discovered incidentally and patients were asymptomatic at the time of diagnosis. The occurrence of perforations in predominantly the anterior nasal septum was also consistent with existing literature in both adults and children [5,6]. This is likely influenced by the fact that the anterior septum is cartilaginous and dependent on the overlying mucoperichondrial layer for vascular supply, and thus more susceptible to necrosis than the posterior bony nasal septum. The most common etiology of nasal septal perforations in this cohort was iatrogenic (40%). This varies somewhat from the prior study of a pediatric cohort, which found trauma, primarily nose picking, to be the most common etiology. Iatrogenic causes were second most common in that cohort [6]. In the adult population, the most common etiology of nasal septal perforations is idiopathic (47%), followed by trauma (39%). Autoimmune (11%), neoplastic, and infectious (3%) causes also occur in adults, but are limited in children [1,7]. In our study, the broader iatrogenic category was further subdivided into nasal surgery (25%), nasal cautery (10%), nasal packing (5%), and frequent nasal suctioning (5%). Providers must be aware of the vulnerability of the nasal mucosa and the underlying cartilage when manipulating the nose in a variety of settings. This is especially important in surgical procedures such as repair of a cleft palate in which the nasal septum and airway is not of primary focus, although no patients in our cohort fell into this category. Careful dissection in a submucoperichondrial plane and avoiding tears in the mucoperichondrial flaps is of utmost importance when addressing the cartilaginous septum operatively, as is compliance with postoperative care. Patient factors including nutritional status, comorbid conditions, and wound healing abilities must also be considered. Repetitive or prolonged pressure or injury to the nasal mucosa can lead to nasal septal perforations as a result of inflammation of the mucosa with eventual secondary infection or necrosis. It is thought that patients with injury to the bilateral nasal septal mucosa are at particular risk of developing a perforation. In patients who require nasal cautery or frequent nasal suctioning, injury to bilateral nasal septal mucosa should be avoided. Humidified oxygen, nasal saline sprays, and possibly antibiotic ointment may be of benefit in preventing inflammation and infection in these cases.
129.0 Open
Crusting
48.1 Closed
None
None
36.2 Open
4. Discussion
Length of follow up (months) Outcome of surgical repair at last follow up Symptoms at last follow up
Button battery Mid-septum 5 Yes Yes AlloDerm graft x2
Nasal surgery, nasal packing Anterior septum 14 Yes No External rhinoplasty with nasal septal flap 4.1 Closed
Nasal surgery Anterior septum 12 No No AlloDerm graft
21.4 Open
Nasal cautery Anterior septum 20 No Yes External rhinoplasty with nasal septal flap 15.0 Closed
181 Male Caucasian None
51 Male Caucasian Nasal congestion, obstruction Button battery Mid-septum 3.5 Yes No Primary repair (suture) 214 Female African-American Crusting 203 Male Other Nasal obstruction 174 Male African-American Crusting, epistaxis
3 Female Caucasian Crusting, epistaxis, nasal congestion, obstruction, pain Nasal suctioning Anterior septum 5 Yes Yes AlloDerm graft Age (months) Gender Race Presenting symptoms
2 1
Table 2 Description of 6 patients who underwent surgical repair of nasal septal perforation.
3
4
5
6
healed.
17
International Journal of Pediatric Otorhinolaryngology 118 (2019) 15–20
J.J. Jennings et al.
Fig. 2. Pie chart representing surgical techniques of nasal septal perforation repairsb. b Of note, some patients had combinations of procedures and thus total does not add to 100%. Table 3 Demographic and clinical characteristics of 14 patients treated conservatively for nasal septal perforation. Age (months)
Gender
Race
Presenting symptoms
Etiology of perforation
Location of perforation
Size of perforation (mm)
1
1.5
Female
Caucasian
None
Anterior
Not recorded
2 3 4
140 198 60
Female Female Male
Caucasian Caucasian Caucasian
Anterior Anterior Anterior
4 20 11
5 6
93 97
Male Male
Caucasian Caucasian
Button battery Unknown
Anterior Anterior
10 10
7 8 9 10
172 176 97 191
Female Female Male Male
Caucasian Caucasian Caucasian Caucasian
Crusting, nasal congestion, obstruction Epistaxis, crusting, nasal congestion, obstruction Crusting, nasal congestion, obstruction, rhinorrhea Crusting, whistling Crusting, nasal congestion, obstruction, rhinorrhea Crusting, nasal congestion, obstruction Epistaxis, crusting Nasal congestion, obstruction None
Nasal suctioning, nasal surgery Nasal surgery, infection Nasal steroid spray Button battery
Nose picking Nose picking Nasal surgery Nose picking
Anterior Mid-septal Anterior Anterior
Not recorded 13 Not recorded 15
Table 4 Treatments and outcomes of 14 patients treated conservatively for nasal septal perforation.
1 2 3 4 5 7 8 9 11 13
Treatment with nasal saline
Treatment with nasal ointment
Treatment with septal button
Length of follow up (months)
Outcome at last follow up
Symptoms at last follow up
Yes Yes Yes Yes Yes Yes No No No Yes
No No No Yes No Yes No No No Yes
No No Yes No No Yes No No No No
98.3 15.7 105.5 8.7 50.6 5.4 22.4 14.9 27.5 15.4
Open Closed Open Open Open Open Open Open Open Open
None None None Crusting None Crusting Nasal obstruction Epistaxis, pain Nasal obstruction Nasal obstruction
advanced techniques of surgical closure. Over the course of this study, there was a clear advancement in the techniques of surgical repair at our center. Earlier techniques included septal button placement, primary suture repair, and placement of nonvascularized AlloDerm grafts over septal defects. Given the lack of underlying vascularized tissue, it is understandable that appropriate healing and long-term closure of septal perforations was limited in these cases. In more recent years, the endoscopic skill-set of the surgeons advanced to include techniques such as raising and rotating bilateral pedicled nasal septal flaps to close septal defects as seen in the adult literature [9–12]. This is often supplemented with an external rhinoplasty approach. The rhinoplasty approach allows the surgeon to
The second most common etiology of nasal septal perforation in this study was nasal button battery, which is an issue primarily particular to the pediatric population. Button batteries generate an external current when contacting mucosa, which hydrolyzes tissue and can cause leakage of caustic alkaline fluid. This results in severe liquefactive necrosis of surrounding tissue [8]. There can be significant destruction of nasal structures, including those crucial to mucociliary clearance, humidification, and nasal support. These patients are at risk for severe crusting and external deformity, often requiring surgical intervention. Septal perforations due to button batteries can pose a particular challenge in repair, however, as the extensive destruction of surrounding mucosa can limit reconstructive options and may require more 18
International Journal of Pediatric Otorhinolaryngology 118 (2019) 15–20
J.J. Jennings et al.
that series was 12 mm and this patient required multiple graft revisions to achieve closure of his perforation [13]. Fairbanks achieved a closure rate of 32/35 (91.4%) using temporalis fascia graft placement in adult patients [14]. Mastoid periosteum grafts combined with external rhinoplasty and pedicled mucosal flaps have also been described in the adult population, with a success rate of 88% [15]. The use of an inferior turbinate flap has been described, again in the adult population, to address caudal septal perforations in particular. This technique involves a staged procedure, with a second surgery required to transect the pedicle of the flap. Friedman et al. report successful closure in 7/10 (70%) patients using an inferior turbinate flap [16]. Finally, an interesting case report by Pirsig et al. describes the growth of de novo autogenic cartilage when demineralized bovine bone matrix is enveloped in native auricular perichondrium and covered with multiple bipedicled mucosal advancement flaps [17]. This technique, with its promotion of chondroneogenesis, may prove to be very useful in the pediatric population. Consideration of patient age is an important factor in the decision to proceed with surgical repair of a nasal septal perforation. Availability of healthy tissue may be limited in young patients, especially in those with large perforations or otherwise compromised nasal mucosa. Young patients also may not be compliant with postoperative care such as nasal saline irrigations, which can be crucial to appropriate healing. Additionally, there is no literature focused on the effects of septal perforation repair in pediatric patients on long-term nasal growth. Primary septoplasty literature does suggest that raising either unilateral or bilateral mucoperichondrial flaps does not affect nasal growth [9]. To our knowledge, there is not enough literature to draw a definitive conclusion on the effects of rotating vascularized septal flaps on longterm growth. Finally, there is particular challenge in revision nasal septal surgery, with scar tissue and distorted tissue planes to contend with. In many cases, it is prudent to delay primary repair of a nasal septal perforation if possible until there is adequate tissue to optimize the chances of successful repair with the initial surgery. A septal button can be considered as a temporizing or long-term solution for nasal symptoms if a child does not meet criteria for surgical repair of his or her septal perforation, or if a family elects against definitive surgical treatment. This involves placement of a synthetic device, often silicone, to mechanically obliterate a nasal septal defect. This can control epistaxis, whistling, crusting, and nasal obstruction, especially when combined with an aggressive nasal hygiene regimen. Three patients in our study underwent septal button placement. Two patients had good control of their nasal symptoms with septal button placement, and one continued to have nasal crusting and ultimately elected to undergo definitive surgical repair with AlloDerm graft placement. There are several limitations of this study. This is a retrospective chart review, and data was limited to the existing documentation in the electronic medical record, which may not include all desired clinical details or decision-making pathways. Second, although this is one of the largest studies focusing on nasal septal perforations in children, the cohort size of 20 patients is still quite small and limits the power of statistical analysis. Finally, with a median follow up time of 15.6 months, it is certainly possible that patients could have recurrence of their perforations outside of our follow up window. This is especially salient given the recent advancement in techniques of repair at our center. Further studies to investigate the long-term outcomes with external rhinoplasty approach and bilateral vascularized nasal septal flaps are indicated.
Fig. 3. Intraoperative endoscopic photograph of patient's nasal septal perforation prior to repair with bilateral nasal septal flaps.
Fig. 4. Intraoperative endoscopic photograph of same patient with pedicled nasal septal flap coverage of septal perforation, right naris.
Fig. 5. Intraoperative endoscopic photograph of same patient with pedicled nasal septal flap coverage of septal perforation, left naris.
insert a graft, such as a piece of Biodesign SURGISIS® as used in the case illustration, between the medial crura of the lower lateral cartilages. The graft can then be advanced between the bilateral flaps to ensure adequate coverage at the caudal-most aspect of the septum. Two patients in this study underwent external rhinoplasty approach and bilateral vascularized septal flap closure of their septal perforations, one of whom is described in the case illustration. Figs. 3–5 depict this patient's intraoperative photographs. Both patients have sustained closure of their perforations at most recent follow up. This technique provides a promising advancement toward higher rates of successful closure at our center, particularly in patients who have severe damage to their nasal mucosa. Additional surgical techniques are reported in the literature with varying degrees of success. Interestingly, the report of auricular conchal cartilage graft placement by Chua et al. showed good success in pediatric patients with nasal septal perforations due to button battery injuries, with 3/3 patients achieving lasting closure [13]. Of note, however, the perforations were smaller on average (8.3 mm) than those included in our study (11.6 mm). The largest perforation included in
5. Conclusion Pediatric nasal septal perforation is a challenging issue with limited literature to date. Iatrogenic causes (40%) and button batteries (20%) were the most common etiologies of nasal septal perforation in our study. We introduce an advancement in our center's surgical technique 19
International Journal of Pediatric Otorhinolaryngology 118 (2019) 15–20
J.J. Jennings et al.
with the description of a case illustration with repair via external rhinoplasty and bilateral vascularized nasal septal flaps. Future larger studies may further elucidate characteristics and treatment modalities associated with successful closure, as well as investigate the long-term results of an external rhinoplasty approach with bilateral nasal septal flap repair of pediatric nasal septal perforations.
[5] I.I. Diamantopoulos, N.S. Jones, The investigation of nasal septal perforations and ulcers, J. Laryngol. Otol. 115 (2001) 541–544. [6] D.T. Chang, A.L. Irace, K. Kawai, et al., Nasal septal perforation in children: presentation, etiology, and management, Int. J. Pediatr. Otorhinolaryngol. 92 (2017) 176–180. [7] N. Williams, What are the causes of a perforated nasal septum? Occup. Med. (Lond.) 50 (2000) 135–136. [8] M. Yamashita, S. Saito, K. Koyama, et al., Esophageal electrochemical burn by button-type alkaline batteries in dogs, Vet. Hum. Toxicol. 29 (1987) 226–230. [9] S. Dayton, N. Chhabra, S. Houser, Endonasal septal perforation repair using posterior and inferiorly based mucosal rotation flaps, Am. J. Otolaryngol. 38 (2017) 179–182. [10] J.H. Park, D.W. Kim, H.R. Jin, Nasal septal perforation repair using intranasal rotation and advancement flaps, Am. J. Rhinol. Allergy 27 (2013) 42–47. [11] I.J. Moon, S.W. Kim, D.H. Han, et al., Predictive factors for the outcome of nasal septal perforation repair, Auris Nasus Larynx 38 (2011) 52–57. [12] S.W. Kim, C.S. Rhee, Nasal septal perforation repair: predictive factors and systematic review of the literature, Curr. Opin. Otolaryngol. Head Neck Surg. 20 (2012) 58–65. [13] D.Y. Chua, H.K. Tan, Repair of nasal septal perforations using auricular conchal cartilage graft in children: report on three cases and literature review, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 1219–1224. [14] D.N. Fairbanks, Closure of septal perforations, Arch. Otolaryngol. Head Neck Surg. 106 (1980) 509–513. [15] J.F. Teichgraeber, R.C. Russo, The management of septal perforations, Plast. Reconstr. Surg. 91 (1993) 229–235. [16] M. Friedman, H. Ibrahim, V. Ramakrishnan, Inferior turbinate flap for repair of nasal septal perforation, Laryngoscope 113 (2003) 1425–1428. [17] W. Pirsig, J.K. Bean, H. Lenders, et al., Cartilage transformation in a composite graft of demineralized bovine bone matrix and ear perichondrium used in a child for the reconstruction of the nasal septum, Int. J. Pediatr. Otorhinolaryngol. 32 (1995) 171–181.
Conflicts of interest No conflicts of interest to disclose. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] B. Lanier, G. Kai, G. Marple, et al., Pathophysiology and progression of nasal septal perforation, Ann. Allergy Asthma Immunol. 99 (2007) 473–479. [2] D. Pless, T.M. Keck, K.M. Wiesmiller, et al., Numerical simulation of airflow patterns and air temperature distribution during inspiration in a nose model with septal perforation, Am. J. Rhinol. 18 (2004) 357–362. [3] D. Oberg, A. Akerlund, L. Johansson, et al., Prevalence of nasal septal perforation: the Skovde population-based study, Rhinology 41 (2003) 72–75. [4] L.W. Kridel, Considerations in the etiology, treatment, and repair of septal perforations, Facial. Plast. Surg. Clin. North Am. 12 (2004) 435–450.
20
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Pediatric nasal septal perforation a,∗
b
T
Jesse J. Jennings , Amber D. Shaffer , Amanda L. Stapleton a b
a,b
Department of Otolaryngology, University of Pittsburgh Medical Center, 200 Lothrop Street Suite 500, Pittsburgh, PA, 15213, USA Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, 4401 Penn Avenue #3, Pittsburgh, PA, 15224, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Pediatric otolaryngology Nasal septal perforation Sinonasal disorders
Objective: 1.) Describe demographic and clinical characteristics of pediatric nasal septal perforations (NSP), 2.) Analyze efficacy of treatment modalities in symptom management and resolution of pediatric NSP, 3.) Describe the surgical technique of external rhinoplasty with vascularized nasal septal flaps in the treatment of nasal septal perforations. Methods: IRB-approved retrospective chart review of pediatric patients ages 0–18 years with nasal septal perforations treated at a tertiary care pediatric otolaryngology practice. Demographic and clinical characteristics including gender, age, race, and presenting symptoms, and location, size, and etiology of perforation were collected. Outcomes including persistence of perforation and symptoms at 1 year and most recent visit were recorded. A total of 20 patients were included. Statistical analysis used Fisher's t-test for categorical variables and Wilcoxon rank-sum for continuous variables. Results: Median age was 167.5 months (1.5–221.0). The most common etiology was iatrogenic (40%), followed by button battery (20%). Thirty percent of patients underwent surgical repair. Fifty percent of patients who underwent surgical repair achieved closure of their perforation at most recent follow up. Conclusion: Pediatric NSP is a challenging issue with limited literature to date. Iatrogenic causes (40%) and button batteries (20%) were the most common etiologies of nasal septal perforation in our study. We introduce an advancement in our center's surgical technique with a case illustration with repair via external rhinoplasty and bilateral vascularized nasal septal flaps. Future larger studies may further elucidate characteristics and treatment modalities associated with successful closure.
1. Introduction Nasal septal perforation is a physical defect of the nasal septum, causing an abnormal connection between the adjacent nasal cavities. This can result in turbulent airflow, especially in perforations of the anterior nasal septum, and damage to the normal respiratory mucosa and cilia [1,2]. This damage can lead to nasal crusting, congestion, whistling, pain, and mucosal dryness all of which can result in chronic epistaxis. While nasal septal perforation in the adult population has been relatively well studied, there is limited literature describing nasal septal perforations in children. The incidence of nasal septal perforation in the general Swedish adult population is 9 per 1000 people [3], but the incidence in the general pediatric population is unknown. Common etiologies of nasal septal perforations in adults include trauma, intranasal drug use, neoplasm, infection, and autoimmune disorders [4,5]. Given the higher incidence of digital trauma and nasal foreign body placement in children, as well as the lower incidence of neoplasm
∗
and autoimmune disorders, it can be expected that the etiologies may vary from the adult to the pediatric population. The goal of this study is to describe the clinical and demographic characteristics of pediatric nasal septal perforations, as well as delineate the treatment options and outcomes in our cohort. We also present a case report of a newly adopted advanced surgical technique to repair a pediatric nasal septal perforation. 2. Materials and methods This retrospective study was approved by the University of Pittsburgh Institutional Review Board prior to the initiation of chart review and all guidelines were followed. All patients under the age of 18 years seen at Children's Hospital of Pittsburgh outpatient otolaryngology clinic with the diagnosis of nasal septal perforation between 2008 and 2016 based on ICD-9 and ICD-10 codes were included in this study. Demographic and clinical characteristics including gender, age, race, presenting symptoms, location and size of perforation, etiology of
Corresponding author. E-mail address: [email protected] (J.J. Jennings).
https://doi.org/10.1016/j.ijporl.2018.12.001 Received 8 July 2018; Received in revised form 30 November 2018; Accepted 1 December 2018 Available online 04 December 2018 0165-5876/ © 2018 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 118 (2019) 15–20
J.J. Jennings et al.
Table 1 Demographic and clinical characteristics of 20 pediatric patients with nasal septal perforation. Characteristics
N
%
Gender, male Race Caucasian African American Other Age (years), mean (SD) Symptoms Crusting Obstruction Congestion Epistaxis Asymptomatic Rhinorrhea Whistling Pain Comorbid sinonasal disorders Allergic rhinitis Chronic rhinosinusitis Diameter (cm), mean (SD) Location Anterior Mid-septum Posterior
13
65%
17 2 1 11.2
85% 10% 5% 5.8
13 12 11 7 3 2 1 1
65% 60% 55% 35% 15% 10% 5% 5%
7 3 1.16
35% 15% 0.63
18 2 0
90% 10% 0%
Fig. 1. Pie chart representing breakdown of etiologies of nasal septal perforationsa. a Of note, some patients had multiple etiologies of perforations and thus total does not add to 100%.
underwent multiple procedures. Successful closure at most recent follow up was achieved in three of the six patients who underwent surgical repair. The clinical and outcome measurements of the patients who were managed conservatively are summarized in Tables 3 and 4. Four patients were excluded from outcome analysis as there was no outcome data available on chart review. One patient had closure with conservative treatment with nasal saline and ointment. Median follow up was 15.6 months with a range from 0 to 129 months.
perforation, both medical and surgical treatments, and outcomes were collected. The primary outcome of this study was status of perforation at one year follow up. Secondary outcomes included status of perforation at most recent follow up, control of symptoms, and need for secondary interventions for perforations. Statistical analysis was performed using Fisher's t-test for categorical variables and Wilcoxon ranksum for continuous variables. A p-value of less than 0.05 was considered statistically significant. Analyses were conducted using Stata/ SE 13.1 (StataCorp, College Station, TX).
3.1. Case illustration: external rhinoplasty approach with bilateral nasal septal flaps
3. Results
A 15-year-old male with a history of allergic rhinitis, chronic nose picking, and recurrent epistaxis presented to our outpatient clinic for evaluation of a nasal septal perforation for two years. He had undergone nasal cauterization twice by an outside provider, two years and one year prior to presentation. On examination, he had a 2.0 cm anterior nasal septal perforation with no external nasal deformity. He was treated with bactroban ointment twice daily without improvement and the patient and his family elected to undergo surgical repair of his perforation. He was taken to the operating room and underwent bilateral nasal endoscopy (Fig. 3). Bilateral pedicled extended posterior nasal septal flaps were raised endoscopically. The edges of the septal perforation were raised in a submucoperichondrial plane. The nasal septal flap cuts were connected to the edges of the perforation and the flaps were rotated to ensure adequate coverage of the perforation. An external rhinoplasty approach was then carried out through an inverted-V columellar incision. Dissection was carried posteriorly in the midline in a subcutaneous plane between the medial crura until the septum was encountered. A submucoperichondrial pocket was elevated posteriorly to expose the septal perforation. A 3 cm by 1.5 cm rectangle of Biodesign SURGISIS® was placed in the septal defect and positioned to cover the posterior perforation. This was secured in three places to the surrounding cartilage with a 4-0 plain gut suture. The extended nasal septal flaps were then rotated to cover the septal perforation and SURGISIS® bilaterally and were sutured in place with 4-0 plain gut quilting stitches (Figs. 4 and 5). Doyle splints were placed and the external rhinoplasty incision was closed. The patient was discharged home with nasal saline spray four times daily and bactroban ointment twice daily. His doyle splints were removed two weeks postoperatively. He had no postoperative complications and at his last visit 15 months postoperatively, his nasal septal perforation remains closed and is well
A total of 20 patients met inclusion criteria for this study. Patient demographics, symptoms at presentation, and characteristics of nasal septal perforation are delineated in Table 1. Thirteen (65%) of patients were male and 7 (35%) were female. Seventeen (85%) patients were Caucasian, which is representative of the overall patient population at our center. The mean age was 11.2 years with a range from 1.5 months to 18 years. The most common presenting symptoms included nasal crusting (65%) and nasal obstruction (60%). Ten patients had comorbid sinonasal complaints (Table 1). Sixteen patients had data available on perforation size, with a mean size of 11.6 mm and a range from 2 mm to 20 mm. Eighteen (90%) perforations were of the anterior nasal septum. There was a wide range of etiologies of nasal septal perforations in this series of patients, summarized in Fig. 1. The most common cause of perforation was iatrogenic (n = 9, 45%), which included subcategories of nasal surgery, cauterization, nasal packing, and frequent suctioning. Four (20%) patients had perforations due to nasal button batteries. Less frequent etiologies included infection (n = 1, 5%) and nasal steroid spray (n = 1, 5%). There were no perforations as a result of radiation or sinonasal malignancy. Nine (45%) patients elected surgical management for their nasal septal perforations. Three of the nine patients were managed with septal button placement, while the remaining six underwent some type of surgical closure, as described in Table 2. Repair techniques included simple suture closure, free synthetic graft placement with AlloDerm (LifeCell Corporation Branchburg, NJ), local rotational flaps, and pedicled nasal septal flaps, or a combination of these techniques. Two (10%) patients underwent external rhinoplasty, while the remainder underwent repair with an endonasal approach (Fig. 2). One patient 16
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Etiology of perforation Location of perforation Size of perforation (mm) Treatment with nasal saline Treatment with nasal ointment Type of surgical repair
Nasal obstruction
None
Nasal congestion
Nasal septal perforation is a rare but challenging issue seen in an otolaryngologic practice. The existing body of literature addressing this issue is sparse, and studies that focus on the pediatric population are especially limited. To our knowledge, there is only one prior study that investigated nasal septal perforations in a cohort of children [6]. Chang et al. described pediatric nasal septal perforations in 27 patients and found the most common etiologies to include trauma (33%), iatrogenic (19%), and neoplasm (11%). The most common presenting symptoms included crusting (73%), epistaxis (58%), and congestion (31%) [6]. Six patients underwent surgical repair, with 3 patients (50%) achieving sustained closure at most recent follow up with a mean of 2.4 years. The structure and function of the nasal airway differs from the pediatric to the adult population, as do the potential causes of injury to the nasal septum leading to perforations and the ability of patients to comply with treatment options. It thus stands to reason that the management of nasal septal perforations should be tailored accordingly. In this series, the most common presenting symptoms in patients with a nasal septal perforation included crusting (65%) and nasal obstruction (60%). Thirty-five percent of patients presented with epistaxis. This differs from the results of the study by Chang, which found epistaxis to be present in over half of pediatric patients with nasal septal perforations [6]. Studies of septal perforation in adults have shown epistaxis to be the most common presenting symptom (58%), followed by crusting (43%). The incidence of whistling and pain were equivalent to prior pediatric and adult studies [1,4–6]. Interestingly, 15% of perforations in this study were discovered incidentally and patients were asymptomatic at the time of diagnosis. The occurrence of perforations in predominantly the anterior nasal septum was also consistent with existing literature in both adults and children [5,6]. This is likely influenced by the fact that the anterior septum is cartilaginous and dependent on the overlying mucoperichondrial layer for vascular supply, and thus more susceptible to necrosis than the posterior bony nasal septum. The most common etiology of nasal septal perforations in this cohort was iatrogenic (40%). This varies somewhat from the prior study of a pediatric cohort, which found trauma, primarily nose picking, to be the most common etiology. Iatrogenic causes were second most common in that cohort [6]. In the adult population, the most common etiology of nasal septal perforations is idiopathic (47%), followed by trauma (39%). Autoimmune (11%), neoplastic, and infectious (3%) causes also occur in adults, but are limited in children [1,7]. In our study, the broader iatrogenic category was further subdivided into nasal surgery (25%), nasal cautery (10%), nasal packing (5%), and frequent nasal suctioning (5%). Providers must be aware of the vulnerability of the nasal mucosa and the underlying cartilage when manipulating the nose in a variety of settings. This is especially important in surgical procedures such as repair of a cleft palate in which the nasal septum and airway is not of primary focus, although no patients in our cohort fell into this category. Careful dissection in a submucoperichondrial plane and avoiding tears in the mucoperichondrial flaps is of utmost importance when addressing the cartilaginous septum operatively, as is compliance with postoperative care. Patient factors including nutritional status, comorbid conditions, and wound healing abilities must also be considered. Repetitive or prolonged pressure or injury to the nasal mucosa can lead to nasal septal perforations as a result of inflammation of the mucosa with eventual secondary infection or necrosis. It is thought that patients with injury to the bilateral nasal septal mucosa are at particular risk of developing a perforation. In patients who require nasal cautery or frequent nasal suctioning, injury to bilateral nasal septal mucosa should be avoided. Humidified oxygen, nasal saline sprays, and possibly antibiotic ointment may be of benefit in preventing inflammation and infection in these cases.
129.0 Open
Crusting
48.1 Closed
None
None
36.2 Open
4. Discussion
Length of follow up (months) Outcome of surgical repair at last follow up Symptoms at last follow up
Button battery Mid-septum 5 Yes Yes AlloDerm graft x2
Nasal surgery, nasal packing Anterior septum 14 Yes No External rhinoplasty with nasal septal flap 4.1 Closed
Nasal surgery Anterior septum 12 No No AlloDerm graft
21.4 Open
Nasal cautery Anterior septum 20 No Yes External rhinoplasty with nasal septal flap 15.0 Closed
181 Male Caucasian None
51 Male Caucasian Nasal congestion, obstruction Button battery Mid-septum 3.5 Yes No Primary repair (suture) 214 Female African-American Crusting 203 Male Other Nasal obstruction 174 Male African-American Crusting, epistaxis
3 Female Caucasian Crusting, epistaxis, nasal congestion, obstruction, pain Nasal suctioning Anterior septum 5 Yes Yes AlloDerm graft Age (months) Gender Race Presenting symptoms
2 1
Table 2 Description of 6 patients who underwent surgical repair of nasal septal perforation.
3
4
5
6
healed.
17
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Fig. 2. Pie chart representing surgical techniques of nasal septal perforation repairsb. b Of note, some patients had combinations of procedures and thus total does not add to 100%. Table 3 Demographic and clinical characteristics of 14 patients treated conservatively for nasal septal perforation. Age (months)
Gender
Race
Presenting symptoms
Etiology of perforation
Location of perforation
Size of perforation (mm)
1
1.5
Female
Caucasian
None
Anterior
Not recorded
2 3 4
140 198 60
Female Female Male
Caucasian Caucasian Caucasian
Anterior Anterior Anterior
4 20 11
5 6
93 97
Male Male
Caucasian Caucasian
Button battery Unknown
Anterior Anterior
10 10
7 8 9 10
172 176 97 191
Female Female Male Male
Caucasian Caucasian Caucasian Caucasian
Crusting, nasal congestion, obstruction Epistaxis, crusting, nasal congestion, obstruction Crusting, nasal congestion, obstruction, rhinorrhea Crusting, whistling Crusting, nasal congestion, obstruction, rhinorrhea Crusting, nasal congestion, obstruction Epistaxis, crusting Nasal congestion, obstruction None
Nasal suctioning, nasal surgery Nasal surgery, infection Nasal steroid spray Button battery
Nose picking Nose picking Nasal surgery Nose picking
Anterior Mid-septal Anterior Anterior
Not recorded 13 Not recorded 15
Table 4 Treatments and outcomes of 14 patients treated conservatively for nasal septal perforation.
1 2 3 4 5 7 8 9 11 13
Treatment with nasal saline
Treatment with nasal ointment
Treatment with septal button
Length of follow up (months)
Outcome at last follow up
Symptoms at last follow up
Yes Yes Yes Yes Yes Yes No No No Yes
No No No Yes No Yes No No No Yes
No No Yes No No Yes No No No No
98.3 15.7 105.5 8.7 50.6 5.4 22.4 14.9 27.5 15.4
Open Closed Open Open Open Open Open Open Open Open
None None None Crusting None Crusting Nasal obstruction Epistaxis, pain Nasal obstruction Nasal obstruction
advanced techniques of surgical closure. Over the course of this study, there was a clear advancement in the techniques of surgical repair at our center. Earlier techniques included septal button placement, primary suture repair, and placement of nonvascularized AlloDerm grafts over septal defects. Given the lack of underlying vascularized tissue, it is understandable that appropriate healing and long-term closure of septal perforations was limited in these cases. In more recent years, the endoscopic skill-set of the surgeons advanced to include techniques such as raising and rotating bilateral pedicled nasal septal flaps to close septal defects as seen in the adult literature [9–12]. This is often supplemented with an external rhinoplasty approach. The rhinoplasty approach allows the surgeon to
The second most common etiology of nasal septal perforation in this study was nasal button battery, which is an issue primarily particular to the pediatric population. Button batteries generate an external current when contacting mucosa, which hydrolyzes tissue and can cause leakage of caustic alkaline fluid. This results in severe liquefactive necrosis of surrounding tissue [8]. There can be significant destruction of nasal structures, including those crucial to mucociliary clearance, humidification, and nasal support. These patients are at risk for severe crusting and external deformity, often requiring surgical intervention. Septal perforations due to button batteries can pose a particular challenge in repair, however, as the extensive destruction of surrounding mucosa can limit reconstructive options and may require more 18
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that series was 12 mm and this patient required multiple graft revisions to achieve closure of his perforation [13]. Fairbanks achieved a closure rate of 32/35 (91.4%) using temporalis fascia graft placement in adult patients [14]. Mastoid periosteum grafts combined with external rhinoplasty and pedicled mucosal flaps have also been described in the adult population, with a success rate of 88% [15]. The use of an inferior turbinate flap has been described, again in the adult population, to address caudal septal perforations in particular. This technique involves a staged procedure, with a second surgery required to transect the pedicle of the flap. Friedman et al. report successful closure in 7/10 (70%) patients using an inferior turbinate flap [16]. Finally, an interesting case report by Pirsig et al. describes the growth of de novo autogenic cartilage when demineralized bovine bone matrix is enveloped in native auricular perichondrium and covered with multiple bipedicled mucosal advancement flaps [17]. This technique, with its promotion of chondroneogenesis, may prove to be very useful in the pediatric population. Consideration of patient age is an important factor in the decision to proceed with surgical repair of a nasal septal perforation. Availability of healthy tissue may be limited in young patients, especially in those with large perforations or otherwise compromised nasal mucosa. Young patients also may not be compliant with postoperative care such as nasal saline irrigations, which can be crucial to appropriate healing. Additionally, there is no literature focused on the effects of septal perforation repair in pediatric patients on long-term nasal growth. Primary septoplasty literature does suggest that raising either unilateral or bilateral mucoperichondrial flaps does not affect nasal growth [9]. To our knowledge, there is not enough literature to draw a definitive conclusion on the effects of rotating vascularized septal flaps on longterm growth. Finally, there is particular challenge in revision nasal septal surgery, with scar tissue and distorted tissue planes to contend with. In many cases, it is prudent to delay primary repair of a nasal septal perforation if possible until there is adequate tissue to optimize the chances of successful repair with the initial surgery. A septal button can be considered as a temporizing or long-term solution for nasal symptoms if a child does not meet criteria for surgical repair of his or her septal perforation, or if a family elects against definitive surgical treatment. This involves placement of a synthetic device, often silicone, to mechanically obliterate a nasal septal defect. This can control epistaxis, whistling, crusting, and nasal obstruction, especially when combined with an aggressive nasal hygiene regimen. Three patients in our study underwent septal button placement. Two patients had good control of their nasal symptoms with septal button placement, and one continued to have nasal crusting and ultimately elected to undergo definitive surgical repair with AlloDerm graft placement. There are several limitations of this study. This is a retrospective chart review, and data was limited to the existing documentation in the electronic medical record, which may not include all desired clinical details or decision-making pathways. Second, although this is one of the largest studies focusing on nasal septal perforations in children, the cohort size of 20 patients is still quite small and limits the power of statistical analysis. Finally, with a median follow up time of 15.6 months, it is certainly possible that patients could have recurrence of their perforations outside of our follow up window. This is especially salient given the recent advancement in techniques of repair at our center. Further studies to investigate the long-term outcomes with external rhinoplasty approach and bilateral vascularized nasal septal flaps are indicated.
Fig. 3. Intraoperative endoscopic photograph of patient's nasal septal perforation prior to repair with bilateral nasal septal flaps.
Fig. 4. Intraoperative endoscopic photograph of same patient with pedicled nasal septal flap coverage of septal perforation, right naris.
Fig. 5. Intraoperative endoscopic photograph of same patient with pedicled nasal septal flap coverage of septal perforation, left naris.
insert a graft, such as a piece of Biodesign SURGISIS® as used in the case illustration, between the medial crura of the lower lateral cartilages. The graft can then be advanced between the bilateral flaps to ensure adequate coverage at the caudal-most aspect of the septum. Two patients in this study underwent external rhinoplasty approach and bilateral vascularized septal flap closure of their septal perforations, one of whom is described in the case illustration. Figs. 3–5 depict this patient's intraoperative photographs. Both patients have sustained closure of their perforations at most recent follow up. This technique provides a promising advancement toward higher rates of successful closure at our center, particularly in patients who have severe damage to their nasal mucosa. Additional surgical techniques are reported in the literature with varying degrees of success. Interestingly, the report of auricular conchal cartilage graft placement by Chua et al. showed good success in pediatric patients with nasal septal perforations due to button battery injuries, with 3/3 patients achieving lasting closure [13]. Of note, however, the perforations were smaller on average (8.3 mm) than those included in our study (11.6 mm). The largest perforation included in
5. Conclusion Pediatric nasal septal perforation is a challenging issue with limited literature to date. Iatrogenic causes (40%) and button batteries (20%) were the most common etiologies of nasal septal perforation in our study. We introduce an advancement in our center's surgical technique 19
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with the description of a case illustration with repair via external rhinoplasty and bilateral vascularized nasal septal flaps. Future larger studies may further elucidate characteristics and treatment modalities associated with successful closure, as well as investigate the long-term results of an external rhinoplasty approach with bilateral nasal septal flap repair of pediatric nasal septal perforations.
[5] I.I. Diamantopoulos, N.S. Jones, The investigation of nasal septal perforations and ulcers, J. Laryngol. Otol. 115 (2001) 541–544. [6] D.T. Chang, A.L. Irace, K. Kawai, et al., Nasal septal perforation in children: presentation, etiology, and management, Int. J. Pediatr. Otorhinolaryngol. 92 (2017) 176–180. [7] N. Williams, What are the causes of a perforated nasal septum? Occup. Med. (Lond.) 50 (2000) 135–136. [8] M. Yamashita, S. Saito, K. Koyama, et al., Esophageal electrochemical burn by button-type alkaline batteries in dogs, Vet. Hum. Toxicol. 29 (1987) 226–230. [9] S. Dayton, N. Chhabra, S. Houser, Endonasal septal perforation repair using posterior and inferiorly based mucosal rotation flaps, Am. J. Otolaryngol. 38 (2017) 179–182. [10] J.H. Park, D.W. Kim, H.R. Jin, Nasal septal perforation repair using intranasal rotation and advancement flaps, Am. J. Rhinol. Allergy 27 (2013) 42–47. [11] I.J. Moon, S.W. Kim, D.H. Han, et al., Predictive factors for the outcome of nasal septal perforation repair, Auris Nasus Larynx 38 (2011) 52–57. [12] S.W. Kim, C.S. Rhee, Nasal septal perforation repair: predictive factors and systematic review of the literature, Curr. Opin. Otolaryngol. Head Neck Surg. 20 (2012) 58–65. [13] D.Y. Chua, H.K. Tan, Repair of nasal septal perforations using auricular conchal cartilage graft in children: report on three cases and literature review, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 1219–1224. [14] D.N. Fairbanks, Closure of septal perforations, Arch. Otolaryngol. Head Neck Surg. 106 (1980) 509–513. [15] J.F. Teichgraeber, R.C. Russo, The management of septal perforations, Plast. Reconstr. Surg. 91 (1993) 229–235. [16] M. Friedman, H. Ibrahim, V. Ramakrishnan, Inferior turbinate flap for repair of nasal septal perforation, Laryngoscope 113 (2003) 1425–1428. [17] W. Pirsig, J.K. Bean, H. Lenders, et al., Cartilage transformation in a composite graft of demineralized bovine bone matrix and ear perichondrium used in a child for the reconstruction of the nasal septum, Int. J. Pediatr. Otorhinolaryngol. 32 (1995) 171–181.
Conflicts of interest No conflicts of interest to disclose. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] B. Lanier, G. Kai, G. Marple, et al., Pathophysiology and progression of nasal septal perforation, Ann. Allergy Asthma Immunol. 99 (2007) 473–479. [2] D. Pless, T.M. Keck, K.M. Wiesmiller, et al., Numerical simulation of airflow patterns and air temperature distribution during inspiration in a nose model with septal perforation, Am. J. Rhinol. 18 (2004) 357–362. [3] D. Oberg, A. Akerlund, L. Johansson, et al., Prevalence of nasal septal perforation: the Skovde population-based study, Rhinology 41 (2003) 72–75. [4] L.W. Kridel, Considerations in the etiology, treatment, and repair of septal perforations, Facial. Plast. Surg. Clin. North Am. 12 (2004) 435–450.
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