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Predictive factors for the outcome of nasal septal perforation repair
Auris Nasus Larynx 38 (2011) 52–57 www.elsevier.com/locate/anl
Predictive factors for the outcome of nasal septal perforation repair Il Joon Moon a, Sang-Wook Kim a, Doo Hee Han a,c, Seung-Tae Kim a, Yang-Gi Min a, Chul Hee Lee a,b, Chae-Seo Rhee a,b,c,d,* a
Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul, Republic of Korea b Sensory Organ Research Institute, Seoul, Republic of Korea c Institute of Allergy & Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea d Department of Immunology, Seoul National University Graduate School of Medicine, Seoul, Republic of Korea Received 10 November 2009; accepted 26 May 2010 Available online 23 June 2010
Abstract Objectives: The aim of this study was to determine the important predictive factors for successful repair of nasal septal perforation. Materials and methods: In this study, we examined 35 symptomatic patients (27 males and 8 females, aged from 16 to 76 years) with a nasal septal perforation. In order to correlate pre- and intra-operative factors to the respective results, preoperative symptoms, etiologies, size of the perforation, operation methods and postoperative results from the patients were reviewed and analyzed using logistic regression. Results: Nasal obstruction, crust and epistaxis were common preoperative symptoms. In most cases, perforations were observed to evolve after the patients’ trauma caused from their previous nasal surgery experience. The overall reperforation rate was 48% and turned out to be associated with both large perforation size and unilateral mucosal flap coverage. However, we found no strong evidence that other factors such as graft materials and medical conditions were related with surgical failure. The surgical operations for our examinees resulted in complete healing of epistaxis and whistling, whereas nasal obstruction and crusting persisted after the surgeries. In addition, symptom improvement was negatively correlated with large perforation size and nasal trauma history including previous nasal surgeries. Conclusion: Precise and complete coverage with bilateral flaps might be the most important factor for successful closure in a septal perforation. Moreover, both trauma history and large perforation size might be at risk for persistent symptoms after septal perforation repair. # 2010 Elsevier Ireland Ltd. All rights reserved. Keywords: Nasal septum; Wound healing; Risk; Symptom
1. Introduction A nasal septal perforation, an anatomic defect in any portion of the cartilaginous or bony septum, is responsible for various forms of nasal malfunction. This is known to result from a number of diseases: inflammatory diseases such as Wegener’s granulomatosis and systemic lupus erythematosus, infectious diseases like syphilis, drugs and malignant neoplasm, and most frequently traumas received from nasal septal surgery [1]. Patients without symptoms * Corresponding author at: Department of Otorhinolaryngology, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea. Tel.: +82 2 2072 3991; fax: +82 2 745 2387. E-mail address: [email protected] (C.-S. Rhee).
need no further treatment. In addition, patients that suffer light symptoms only need conservative treatments such as nasal irrigation with normal saline or application of ointment or estrogen-containing oil. However, if symptoms persist after these treatments, the surgical repair of the perforation is an inevitable next step. Over the years, a large number of surgical approaches have been introduced to close nasal septal perforations. Some of the approaches can be categorized by the protocols of the surgical processes: mucosal flap such as local rotation flap or flap transposition [2], inferior turbinate flap [3] and bipedicled advancement flap [4] with various graft materials like septal and conchal cartilages, mastoid bone, alloderm [5], temporalis fascia [6] and bioactive glass [7]. Alternative approaches include the insertion of the septal button [8], in which both intranasal
0385-8146/$ – see front matter # 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2010.05.006
I.J. Moon et al. / Auris Nasus Larynx 38 (2011) 52–57
and open external approaches have been used. To date, however, there is no standardized technique applicable to treatment of all perforations. Moreover, analysis on the influence of variables during the surgical processes has been lacking. The objective of this study was to correlate postoperative results with variables such as preoperative symptoms, etiologies, the size of septal perforation, operation methods and interposition graft materials.
53
Table 1 Interposition grafts used in the closure of septal perforation. Graft
N (%)
Allograft Conchal cartilage Septal cartilage Temporalis fascia Perpendicular plate
16 10 6 1 1
Total, N
34
(47.2%) (29.4%) (17.6%) (2.9%) (2.9%)
2. Materials and methods Thirty-five patients (27 males and 8 females) received surgery to repair their nasal septal perforations between January 1997 and December 2008 at Seoul National University Hospital. Then, the preoperative symptoms, etiologies, size of the septal perforation, postoperative symptomatic changes and reperforation rates of the patients were recorded for a comprehensive and comparative analysis. The patients, ranging 16 from 76 years old, were at the average age of 46.5 and followed up for 26 months on the average, ranging between 3 and 96 months. The Institutional Review Board of the Clinical Research Institute at Seoul National University Hospital approved the study protocol. The Statistical Package for the Social Science, version 17.0 software system (SPSS, Inc., Chicago, IL, USA) was used to perform statistical analysis. The data were analyzed using chi-square test. To select predictive factors, logistic regression with forward selection option was conducted. The most commonly used entry and removal criteria with P-value of 0.05 were used. First, the vertical and horizontal lengths of a perforation were measured using a ruler during operation, and the perforation was trimmed (Fig. 1). Then, the perforation size was defined as the longer dimension between two lengths, perforations larger than 10 mm are considered as large perforations in this study. Seventeen out of 35 patients (48.6%) were operated via an intranasal approach and 18 patients (51.4%) via an external approach. The decision of taking either approach was largely based on the perforation size: the perforations larger than 20 mm were repaired via
the external approach. Exceptions included the cases where patients requested the correction of their external nose deviation or asked for augmentation rhinoplasty. In such cases, the external approach was taken although their perforations were smaller than 20 mm. No intra-operative complications were encountered in any cases. We used various kinds of interpostion grafts between sutured septal flaps in all patients (Fig. 3). Most recurrently used (16 cases) of the graft materials inserted in the perforations were allografts such as AlloDerm (LifeCell Corp, The Wodlands, TX, USA), Gore-tex (WL Gore and Assoc Inc, Flagstaff, AZ, USA) or Lyodura (Braun, Melsungen, Germany) (Table 1). The conchal cartilage was used in 10 cases and the septal cartilage in 6 cases. The temporalis fascia and the perpendicular plate of ethmoid bone were also employed as interposition grafts. Depending on the size and location of the perforations, we used various local mucosal flaps (Table 2). The bipedicled advancement flap was most repeatedly used (22 cases) (Fig. 2), outnumbering the use of the second-most heavily used unilateral advancement flap (5 cases) by a huge margin. The rotation flap was applied to 3 patients, while the advancement flap with inferior turbinate flap, transposition flap and unilateral mucosal free graft were adopted in 2, 1 and 1 cases, respectively. After the surgeries, the perforation site was covered bilaterally with mucosal flaps for 28 patients (80%) (Fig. 3), whereas for the other 7 patients (20%), the wound had to be covered unilaterally simply because there were not enough viable intranasal tissues to use as flap materials.
[(Fig._1)TD$IG]
Fig. 1. (a) Schematic illustration of sagittal section, and (b) schematic illustration of coronal section. Before the submucoperichondrial detachment, the margin of the septal perforation was trimmed. Then, the detachment procedure was performed carefully with preservation of the integrity of the mucoperichondrium.
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I.J. Moon et al. / Auris Nasus Larynx 38 (2011) 52–57
Table 2 Surgical techniques used in the repair of septal perforation. Operation method
N (%)
Bipedicled advancement flap Unilateral advancement flap Rotation flap Advancement flap with inferior turbinate flap Flap transposition Flap transposition with mucosal free graft Unilateral mucosal free graft
22 5 3 2 1 1 1
Total, N
35
(62.9%) (14.3%) (8.6%) (5.7%) (2.8%) (2.8%) (2.8%)
3. Results Preoperative symptoms include nasal obstruction (71.4%), crusting (40%), epistaxis (37.1%), postnasal drip (20%), whistling (11.4%), parosmia (11.4%), malodorous discharge (5.7%) and sense of perforation (5.7%). A trauma that a patient received while undergoing a previous nasal surgery was responsible for a septal perforation (65.7%). In 1 case (2.9%), a foreign body (magnet) had induced a septal perforation, and in 2 cases, chronic inflammation including Wegener’s granulomatosis was the cause of the perforation; however, in 9 cases (25.7%), the etiologies remained unclear despite an effort to find the cause. The vertical length of the [(Fig._2)TD$IG]perforation ranged from 2 to 40 mm (mean 12 mm) and the
horizontal one from 1 to 24 mm (mean 9.7 mm). In all cases, the perforation was located at the cartilaginous portion of the nasal septum. Nine patients (25.7%) experienced external nose deformities such as a saddle nose or a deformed nose, which were treated via an external approach. The patients were asked to follow-up on the progress of their surgical wound by taking monthly examinations at an outpatient clinic. In 17 cases (48.6%), a perforation reoccurred, although at a much smaller size than the original ones, during the follow-up period, 5.06 months on average with a range of 1–36 months. An average length of long diameter of the septal perforation before surgery in this reperforation group (13.71 mm) was longer than that in the success group (9.83 mm) (P = 0.168, by Student’s t-test). The influence of the operational procedures on the reperforation was examined and statistically analyzed using chi-square test (Table 3) and logistic regression. The use of different graft materials and the presence of trauma history yielded little or no difference in the reperforation rate. Seven patients did not have enough viable tissues in their nasal cavity, and therefore we were not able to cover the perforation site with pedicled flaps in a bilateral fashion, which would have otherwise been a desirable route. Six of these patients were diagnosed with reperforation during their follow-up visits. The reperforation rate in these patients was remarkably higher than in the 28 patients whose
Fig. 2. (a) Schematic illustration of sagittal section, and (b) schematic illustration of coronal section. Relaxing incision along the nasal floor was made and inferior bipedicled flap was advanced toward the wall of the septum to close the perforation. If this inferior floor flap was not enough for closure, additional superior bipedicled flap may be necessary. The other incision for the superior bipedicled flap was made on the septal dorsum.
[(Fig._3)TD$IG]
Fig. 3. (a) Schematic illustration of sagittal section, and (b) schematic illustration of coronal section. The interposition graft that would cover the perforation was placed between the 2 mucosal flaps for an optimal result. Then, bipedicled flaps were elevated and advanced in the other nasal cavity in the same manner to close the perforation bilaterally. Mattress sutures between the bilateral mucosal flaps may be helpful to prevent migration of the graft.
I.J. Moon et al. / Auris Nasus Larynx 38 (2011) 52–57
55
Table 3 Parameters related to the surgical success in patients with septal perforation. Reperforation
P-Value
( )
(+)
Causes Traumatic Others
10 8
13 4
Flaps Bipedicled Others
14 4
Approaches Intranasal External
Symptom improvement
P-Value
(+)
( )
0.289
15 11
8 1
0.121
8 9
0.086
18 8
4 5
0.243
6 12
11 6
0.094
14 12
3 6
0.443
9 9
8 9
1.000
11 15
6 3
0.264
Mucosal Flap covering Unilateral Bilateral
1 17
6 11
0.041
5 21
2 7
1.000
Perforation size >10 mm 10 mm
4 14
9 8
0.086
19 7
3 6
0.050
Interposition graft Allograft Others
Data were analyzed using Pearson’s chi-square test.
perforation sites were covered with mucosal flaps bilaterally (P = 0.041, by Pearson’s chi-square test). The risk factors for the surgical failure were adjusted with the logistic regression model (Table 4). The risk-adjustment model consisted of 2 risk factors including perforation size and mucosal flap coverage, which were found to have statistically significant effects on the surgical failure. The cstatistics (0.78) and Hosmer–Lemeshow test (P = 0.96) showed that the model’s performance was good. Using this model, the likelihood of developing reperforation after the surgery was considerably higher in patients with large perforation size (OR, 6.00; 95% CI, 1.17–30.71) or in patients whose perforation was blanketed with unilateral mucosal flaps (OR, 14.63; 95% CI, 1.34–159.65). Postoperatively, 26 out of 35 (74.3%) patients were symptomatically improved without regard to the development of reperforation. Among this group, 20 patients (57.2%) were free of symptoms and 6 patients (17.1%) reported gradual relief from previous symptoms (Table 5).
Five out of 18 patients without reperforation still complained of nasal obstruction and crust, whereas 10 out of 17 patients with reperforation reported symptomatic improvement after the surgery. When the reperforation was not developed, epistaxis and whistling vanished but the nasal obstruction and crusting improved in only 56% and 50% of all the cases, respectively (Table 6). The risk factors in terms of persistent symptoms were adjusted with the logistic regression model, also (Table 7). The c-statistics (0.81) and Hosmer– Lemeshow test (P = 0.98) showed that the performance of
Table 4 The predictive factors for the success of the surgery.
Symptoms
Preoperative symptoms
Ta
Ib
Sc
Nasal obstruction Crust Epistaxis Postnasal drip Whistling Parosmia Malodorous discharge Sense of perforation
25 14 13 7 4 4 2 2
14 7 13 5 4 3 1 2
3 3 0 0 0 0 0 0
8 4 0 2 0 1 1 0
Size Flap coverage
OR
95% CI
P-Value
6.00 14.63
1.17–30.71 1.34–159.65
0.03 0.03
c-Statistics
[Equation] Success = 1.203 + 1.79 [size] + 2.68 [flap_coverage] 0.96* 0.78 * The P-value was calculated by Hosmer–Lemeshow goodness of fit statistic.
Table 5 Postoperative changes of symptoms.
No reperforation Reperforation
Free
Improved
Stationary
13 6
3 4
2 7
Table 6 Postoperative changes of symptoms.
Numbers are not mutually exclusive. a Totally reversed postoperatively. b Improved status. c Stationary status.
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I.J. Moon et al. / Auris Nasus Larynx 38 (2011) 52–57
Table 7 The predictive factors of the symptom improvement of the surgery.
Size Trauma
OR
95% CI
P-Value
24.59 32.43
2.13–284.66 1.71–616.15
0.01 0.02
[Equation] symptom improvement = 5.033 + 3.20 [size] + 3.48 [trauma] 0.98* 0.81 * The P-value was calculated by Hosmer–Lemeshow goodness of fit statistic.
this model was good. Symptoms of patients with large perforation size (OR, 24.59; 95% CI, 2.13–284.64) and nasal trauma history including surgery (OR, 32.43; 95% CI, 1.71– 616.15) had a tendency to persist or recur by using this model.
4. Discussion The statistical analysis of the study on patients whose septal perforation was repaired surgically points to a conclusion that the bilateral flap coverage results in the suppressed reperforation rate, compared to the unilateral flap coverage. This observation embodies the significance of the covering process during an operation: bilateral approximation of the mucosal flap reduces the reoccurrence of perforations regardless of other surgical processes. A few reports published elsewhere have claimed conflicting results [4,9]. For example, Newton proposed that coverage of only one side of nasal septum with bipedicled advancement flap, remaining the other side exposed expecting that it could be healed secondarily, could maintain complete closure during follow-up period in 92% of cases [4]. Meanwhile, other authors have reported success with using a unilateral flap via endoscopic approach [9,10]. In our study, however, 6 out of 7 cases with unilateral mucosal flap coverage ended up with reperforation. Despite the small number of studied cases, the remarkably high reperforation rate deserves the attention on the detrimental effect of the unilateral coverage. Perforation repair via external approach discourages the recurrence of perforations, thus improving overall success ratio of the surgery, even though the difference was not statistically significant. This finding is linked to previously reported observations, in which an open rhinoplasty approach was found to give rise to higher success rate due to greater mucoperichondrial mobilization and thus easier access to the perforation site [11,12]. This external approach also allows surgeons to use their both hands during surgery. Since patients with a septal perforation tend to develop external nose deformities, the external approach provides an added benefit of performing both septal perforation repair and corrective rhinoplasty at one surgical operation process. However, the open approach has a down
side. Compared to an intranasal approach, the medial crura are totally dissected from the septum, which may lead to the tip depression as tips can no longer be supported by fibrous connections between the medial crura and the septum. To address this drawback, a tip support can be reconstructed by using onlay graft, shield graft or columellar strut. We tried to cover the wound tension-freely without opposing suture lines. Closure of the perforation with tension can lead to rupture of the flaps postoperatively with a healing scar contraction. In order to approximate flaps without tension, the adequate mobilization of septal flaps with complete dissection is required because septal mucosa has no elastic tissue [13]. The effect of flap materials used in closing the perforation site was also studied. The flaps used in this study include bipedicled advancement flaps, rotation flaps, inferior turbinate flaps, buccal mucosal flaps and skin grafts. Among these various flaps, we preferred to use bipedicled advancement flaps because of both including excellent blood supply and containing normal respiratory epithelium. For larger perforations, both superiorly and inferiorly based bipedicled flap were necessary. Depending on patients’ conditions, e.g. the amount of viable tissue in the nasal cavity, other flaps such as a rotation flap or an inferior turbinate flap were employed. In the case of a large perforation, approximating the mucosal flap almost always brings up tension in the perforation site. Consequently, the success rate tends to decrease with an increased perforation size. The vertical height of a perforation has been envisioned to play a more important role in determining the surgical success than the horizontal length because a main tension between the floor of the nose and the dorsum was found to be critical [13]. However, no significant outpowering of one variable over another between horizontal and vertical dimensions was noticed in our study. It was possible to harvest and rotate flaps in vertical direction via external approach to repair the perforation. It turned out that the interposition graft application as well as the bilateral use of mucoperichondrial flaps helped improve the success rate of the surgery, i.e. suppression of reoccurrence of a perforation. In the past decade, surgeons have reported the use of a wide variety of graft materials including septal cargilage, conchal cartilage, pericranium, periosteum, temporalis fascia, ethmoid bone and mastoid cortex as well as acellular human dermal allograft [5–7,14]. While these graft materials exhibited the respective good and bad properties, the postoperative results collated from the multiple groups suggest that the kind of graft materials used in the operation does not dictate the success of the surgery. The results from this study point to the ultimately same finding: graft materials do not matter. The follow-up examinations revealed an interesting point: symptoms were selectively cleared. In all cases where the closure of the nasal perforation was confirmed before the last follow-up visit, epistaxis and whistling did no
I.J. Moon et al. / Auris Nasus Larynx 38 (2011) 52–57
longer turn up. On the other hand, nasal obstruction and crusting still persisted in some cases. Among several factors evaluated by the logistic regression model, large perforation size and nasal trauma history had a negative impact on symptom improvement after surgery. In case of large septal perforation, creation of large mucoperiosteal flaps in the nasal cavity inevitably results in large denuded area, also leading to the generation of nasal obstruction and crusting. Previous nasal trauma including surgery had a possibility of damaging other nasal structures, such as turbinate and nasal valve area. Therefore, other abnormalities except septal perforation may exist in nasal cavity and repairing perforation only may not be enough to improve all symptoms. These abnormalities can be responsible for poor results in terms of symptoms. Preoperative counseling to the patients with previous nasal trauma history regarding postoperative symptoms is necessary. In addition, these patients should be followed up carefully after surgery because the trauma history is associated with persistent symptoms. However, further studies are needed to clarify the exact association between previous nasal trauma history and symptom improvement after surgery. Creation of large denuded area during surgery could be attributed to the postoperatively developed mucosal dryness that in turn results in nasal obstruction and crusting. The ‘‘improvement’’ of these symptoms in fact could have resulted from the decreased perforation size, as described in the Results section. On this account, patients with these 2 symptoms – nasal obstruction and crusting – after the surgery are recommended to moisturize their nasal cavity with oil or saline until the conditions of the mucosal flap is improved. Topical nasal estrogen spray may also reduce squamous metaplasia in applied flaps and thus help eliminating nasal dryness and crust subsequently [11]. We also suggest the instruction about the symptomatic change be given to the patients, especially those who the cause of the perforation is previous nasal trauma or surgery, prior to a septal perforation repair. The reoccurrence of a perforation in our study (70–100%) was relatively more frequented than in other published studies [5,10,14,15]. Asians have smaller nasal cavity and septum; therefore, viable tissue to cover the perforation site may not be enough. This, of course, is the subject of a further study – comprehensive multi-ethnic analysis is central to elucidating such deviation.
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Herein, we studied the cases in which nasal septal perforations were surgically repaired and evaluated the effect of variables. In conclusion, effective repair of nasal septal perforation located in the cartilaginous septum was possible through bilateral and tensionless approximation of the local flaps. In addition, previous nasal trauma history and large perforation size might be risk factors for persistent symptoms after septal perforation repair.
References [1] Romo 3rd T, Jablonski RD, Shapiro AL, McCormick SA. Long-term nasal mucosal tissue expansion use in repair of large nasoseptal perforations. Arch Otolaryngol Head Neck Surg 1995;121:327–31. [2] Schultz-Coulon HJ. Experiences with the bridge-flap technique for the repair of large nasal septal perforations. Rhinology 1994;32:25–33. [3] Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope 2003;113:1425–8. [4] Newton JR, White PS, Lee MS. Nasal septal perforation repair using open septoplasty and unilateral bipedicled flaps. J Laryngol Otol 2003;117:52–5. [5] Kridel RW, Foda H, Lunde KC. Septal perforation repair with acellular human dermal allograft. Arch Otolaryngol Head Neck Surg 1998;124:73–8. [6] Nunez-Fernandez D, Vokurka J, Chrobok V. Bone and temporal fascia graft for the closure of septal perforation. J Laryngol Otol 1998;112:1167–71. [7] Stoor P, Grenman R. Bioactive glass and turbinate flaps in the repair of nasal septal perforations. Ann Otol Rhinol Laryngol 2004;113:655– 61. [8] Osma U, Cureoglu S, Akbulut N, Meric F, Topcu I. The results of septal button insertion in the management of nasal septal perforation. J Laryngol Otol 1999;113:823–4. [9] Lee HR, Ahn DB, Park JH, Kim YH, Sin CM, Youn SJ, et al. Endoscopic repairment of septal perforation with using a unilateral nasal mucosal flap. Clin Exp Otorhinolaryngol 2008;1:154–7. [10] Ayshford CA, Shykhon M, Uppal HS, Wake M. Endoscopic repair of nasal septal perforation with acellular human dermal allograft and an inferior turbinate flap. Clin Otolaryngol Allied Sci 2003;28:29–33. [11] Kridel RW. Considerations in the etiology, treatment, and repair of septal perforations. Facial Plast Surg Clin N Am 2004;12:435–50. [12] Watson D, Barkdull G. Surgical management of the septal perforation. Otolaryngol Clin North Am 2009;42:483–93. [13] Kridel RW. Septal perforation repair. Otolaryngol Clin North Am 1999;32:695–724. [14] Goh AY, Hussain SS. Different surgical treatments for nasal septal perforation and their outcomes. J Laryngol Otol 2007;121:419–26. [15] Ambro BT, Zimmerman J, Rosenthal M, Pribitkin EA. Nasal septal perforation repair with porcine small intestinal submucosa. Arch Facial Plast Surg 2003;5:528–9.
Predictive factors for the outcome of nasal septal perforation repair Il Joon Moon a, Sang-Wook Kim a, Doo Hee Han a,c, Seung-Tae Kim a, Yang-Gi Min a, Chul Hee Lee a,b, Chae-Seo Rhee a,b,c,d,* a
Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul, Republic of Korea b Sensory Organ Research Institute, Seoul, Republic of Korea c Institute of Allergy & Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea d Department of Immunology, Seoul National University Graduate School of Medicine, Seoul, Republic of Korea Received 10 November 2009; accepted 26 May 2010 Available online 23 June 2010
Abstract Objectives: The aim of this study was to determine the important predictive factors for successful repair of nasal septal perforation. Materials and methods: In this study, we examined 35 symptomatic patients (27 males and 8 females, aged from 16 to 76 years) with a nasal septal perforation. In order to correlate pre- and intra-operative factors to the respective results, preoperative symptoms, etiologies, size of the perforation, operation methods and postoperative results from the patients were reviewed and analyzed using logistic regression. Results: Nasal obstruction, crust and epistaxis were common preoperative symptoms. In most cases, perforations were observed to evolve after the patients’ trauma caused from their previous nasal surgery experience. The overall reperforation rate was 48% and turned out to be associated with both large perforation size and unilateral mucosal flap coverage. However, we found no strong evidence that other factors such as graft materials and medical conditions were related with surgical failure. The surgical operations for our examinees resulted in complete healing of epistaxis and whistling, whereas nasal obstruction and crusting persisted after the surgeries. In addition, symptom improvement was negatively correlated with large perforation size and nasal trauma history including previous nasal surgeries. Conclusion: Precise and complete coverage with bilateral flaps might be the most important factor for successful closure in a septal perforation. Moreover, both trauma history and large perforation size might be at risk for persistent symptoms after septal perforation repair. # 2010 Elsevier Ireland Ltd. All rights reserved. Keywords: Nasal septum; Wound healing; Risk; Symptom
1. Introduction A nasal septal perforation, an anatomic defect in any portion of the cartilaginous or bony septum, is responsible for various forms of nasal malfunction. This is known to result from a number of diseases: inflammatory diseases such as Wegener’s granulomatosis and systemic lupus erythematosus, infectious diseases like syphilis, drugs and malignant neoplasm, and most frequently traumas received from nasal septal surgery [1]. Patients without symptoms * Corresponding author at: Department of Otorhinolaryngology, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea. Tel.: +82 2 2072 3991; fax: +82 2 745 2387. E-mail address: [email protected] (C.-S. Rhee).
need no further treatment. In addition, patients that suffer light symptoms only need conservative treatments such as nasal irrigation with normal saline or application of ointment or estrogen-containing oil. However, if symptoms persist after these treatments, the surgical repair of the perforation is an inevitable next step. Over the years, a large number of surgical approaches have been introduced to close nasal septal perforations. Some of the approaches can be categorized by the protocols of the surgical processes: mucosal flap such as local rotation flap or flap transposition [2], inferior turbinate flap [3] and bipedicled advancement flap [4] with various graft materials like septal and conchal cartilages, mastoid bone, alloderm [5], temporalis fascia [6] and bioactive glass [7]. Alternative approaches include the insertion of the septal button [8], in which both intranasal
0385-8146/$ – see front matter # 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2010.05.006
I.J. Moon et al. / Auris Nasus Larynx 38 (2011) 52–57
and open external approaches have been used. To date, however, there is no standardized technique applicable to treatment of all perforations. Moreover, analysis on the influence of variables during the surgical processes has been lacking. The objective of this study was to correlate postoperative results with variables such as preoperative symptoms, etiologies, the size of septal perforation, operation methods and interposition graft materials.
53
Table 1 Interposition grafts used in the closure of septal perforation. Graft
N (%)
Allograft Conchal cartilage Septal cartilage Temporalis fascia Perpendicular plate
16 10 6 1 1
Total, N
34
(47.2%) (29.4%) (17.6%) (2.9%) (2.9%)
2. Materials and methods Thirty-five patients (27 males and 8 females) received surgery to repair their nasal septal perforations between January 1997 and December 2008 at Seoul National University Hospital. Then, the preoperative symptoms, etiologies, size of the septal perforation, postoperative symptomatic changes and reperforation rates of the patients were recorded for a comprehensive and comparative analysis. The patients, ranging 16 from 76 years old, were at the average age of 46.5 and followed up for 26 months on the average, ranging between 3 and 96 months. The Institutional Review Board of the Clinical Research Institute at Seoul National University Hospital approved the study protocol. The Statistical Package for the Social Science, version 17.0 software system (SPSS, Inc., Chicago, IL, USA) was used to perform statistical analysis. The data were analyzed using chi-square test. To select predictive factors, logistic regression with forward selection option was conducted. The most commonly used entry and removal criteria with P-value of 0.05 were used. First, the vertical and horizontal lengths of a perforation were measured using a ruler during operation, and the perforation was trimmed (Fig. 1). Then, the perforation size was defined as the longer dimension between two lengths, perforations larger than 10 mm are considered as large perforations in this study. Seventeen out of 35 patients (48.6%) were operated via an intranasal approach and 18 patients (51.4%) via an external approach. The decision of taking either approach was largely based on the perforation size: the perforations larger than 20 mm were repaired via
the external approach. Exceptions included the cases where patients requested the correction of their external nose deviation or asked for augmentation rhinoplasty. In such cases, the external approach was taken although their perforations were smaller than 20 mm. No intra-operative complications were encountered in any cases. We used various kinds of interpostion grafts between sutured septal flaps in all patients (Fig. 3). Most recurrently used (16 cases) of the graft materials inserted in the perforations were allografts such as AlloDerm (LifeCell Corp, The Wodlands, TX, USA), Gore-tex (WL Gore and Assoc Inc, Flagstaff, AZ, USA) or Lyodura (Braun, Melsungen, Germany) (Table 1). The conchal cartilage was used in 10 cases and the septal cartilage in 6 cases. The temporalis fascia and the perpendicular plate of ethmoid bone were also employed as interposition grafts. Depending on the size and location of the perforations, we used various local mucosal flaps (Table 2). The bipedicled advancement flap was most repeatedly used (22 cases) (Fig. 2), outnumbering the use of the second-most heavily used unilateral advancement flap (5 cases) by a huge margin. The rotation flap was applied to 3 patients, while the advancement flap with inferior turbinate flap, transposition flap and unilateral mucosal free graft were adopted in 2, 1 and 1 cases, respectively. After the surgeries, the perforation site was covered bilaterally with mucosal flaps for 28 patients (80%) (Fig. 3), whereas for the other 7 patients (20%), the wound had to be covered unilaterally simply because there were not enough viable intranasal tissues to use as flap materials.
[(Fig._1)TD$IG]
Fig. 1. (a) Schematic illustration of sagittal section, and (b) schematic illustration of coronal section. Before the submucoperichondrial detachment, the margin of the septal perforation was trimmed. Then, the detachment procedure was performed carefully with preservation of the integrity of the mucoperichondrium.
54
I.J. Moon et al. / Auris Nasus Larynx 38 (2011) 52–57
Table 2 Surgical techniques used in the repair of septal perforation. Operation method
N (%)
Bipedicled advancement flap Unilateral advancement flap Rotation flap Advancement flap with inferior turbinate flap Flap transposition Flap transposition with mucosal free graft Unilateral mucosal free graft
22 5 3 2 1 1 1
Total, N
35
(62.9%) (14.3%) (8.6%) (5.7%) (2.8%) (2.8%) (2.8%)
3. Results Preoperative symptoms include nasal obstruction (71.4%), crusting (40%), epistaxis (37.1%), postnasal drip (20%), whistling (11.4%), parosmia (11.4%), malodorous discharge (5.7%) and sense of perforation (5.7%). A trauma that a patient received while undergoing a previous nasal surgery was responsible for a septal perforation (65.7%). In 1 case (2.9%), a foreign body (magnet) had induced a septal perforation, and in 2 cases, chronic inflammation including Wegener’s granulomatosis was the cause of the perforation; however, in 9 cases (25.7%), the etiologies remained unclear despite an effort to find the cause. The vertical length of the [(Fig._2)TD$IG]perforation ranged from 2 to 40 mm (mean 12 mm) and the
horizontal one from 1 to 24 mm (mean 9.7 mm). In all cases, the perforation was located at the cartilaginous portion of the nasal septum. Nine patients (25.7%) experienced external nose deformities such as a saddle nose or a deformed nose, which were treated via an external approach. The patients were asked to follow-up on the progress of their surgical wound by taking monthly examinations at an outpatient clinic. In 17 cases (48.6%), a perforation reoccurred, although at a much smaller size than the original ones, during the follow-up period, 5.06 months on average with a range of 1–36 months. An average length of long diameter of the septal perforation before surgery in this reperforation group (13.71 mm) was longer than that in the success group (9.83 mm) (P = 0.168, by Student’s t-test). The influence of the operational procedures on the reperforation was examined and statistically analyzed using chi-square test (Table 3) and logistic regression. The use of different graft materials and the presence of trauma history yielded little or no difference in the reperforation rate. Seven patients did not have enough viable tissues in their nasal cavity, and therefore we were not able to cover the perforation site with pedicled flaps in a bilateral fashion, which would have otherwise been a desirable route. Six of these patients were diagnosed with reperforation during their follow-up visits. The reperforation rate in these patients was remarkably higher than in the 28 patients whose
Fig. 2. (a) Schematic illustration of sagittal section, and (b) schematic illustration of coronal section. Relaxing incision along the nasal floor was made and inferior bipedicled flap was advanced toward the wall of the septum to close the perforation. If this inferior floor flap was not enough for closure, additional superior bipedicled flap may be necessary. The other incision for the superior bipedicled flap was made on the septal dorsum.
[(Fig._3)TD$IG]
Fig. 3. (a) Schematic illustration of sagittal section, and (b) schematic illustration of coronal section. The interposition graft that would cover the perforation was placed between the 2 mucosal flaps for an optimal result. Then, bipedicled flaps were elevated and advanced in the other nasal cavity in the same manner to close the perforation bilaterally. Mattress sutures between the bilateral mucosal flaps may be helpful to prevent migration of the graft.
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Table 3 Parameters related to the surgical success in patients with septal perforation. Reperforation
P-Value
( )
(+)
Causes Traumatic Others
10 8
13 4
Flaps Bipedicled Others
14 4
Approaches Intranasal External
Symptom improvement
P-Value
(+)
( )
0.289
15 11
8 1
0.121
8 9
0.086
18 8
4 5
0.243
6 12
11 6
0.094
14 12
3 6
0.443
9 9
8 9
1.000
11 15
6 3
0.264
Mucosal Flap covering Unilateral Bilateral
1 17
6 11
0.041
5 21
2 7
1.000
Perforation size >10 mm 10 mm
4 14
9 8
0.086
19 7
3 6
0.050
Interposition graft Allograft Others
Data were analyzed using Pearson’s chi-square test.
perforation sites were covered with mucosal flaps bilaterally (P = 0.041, by Pearson’s chi-square test). The risk factors for the surgical failure were adjusted with the logistic regression model (Table 4). The risk-adjustment model consisted of 2 risk factors including perforation size and mucosal flap coverage, which were found to have statistically significant effects on the surgical failure. The cstatistics (0.78) and Hosmer–Lemeshow test (P = 0.96) showed that the model’s performance was good. Using this model, the likelihood of developing reperforation after the surgery was considerably higher in patients with large perforation size (OR, 6.00; 95% CI, 1.17–30.71) or in patients whose perforation was blanketed with unilateral mucosal flaps (OR, 14.63; 95% CI, 1.34–159.65). Postoperatively, 26 out of 35 (74.3%) patients were symptomatically improved without regard to the development of reperforation. Among this group, 20 patients (57.2%) were free of symptoms and 6 patients (17.1%) reported gradual relief from previous symptoms (Table 5).
Five out of 18 patients without reperforation still complained of nasal obstruction and crust, whereas 10 out of 17 patients with reperforation reported symptomatic improvement after the surgery. When the reperforation was not developed, epistaxis and whistling vanished but the nasal obstruction and crusting improved in only 56% and 50% of all the cases, respectively (Table 6). The risk factors in terms of persistent symptoms were adjusted with the logistic regression model, also (Table 7). The c-statistics (0.81) and Hosmer– Lemeshow test (P = 0.98) showed that the performance of
Table 4 The predictive factors for the success of the surgery.
Symptoms
Preoperative symptoms
Ta
Ib
Sc
Nasal obstruction Crust Epistaxis Postnasal drip Whistling Parosmia Malodorous discharge Sense of perforation
25 14 13 7 4 4 2 2
14 7 13 5 4 3 1 2
3 3 0 0 0 0 0 0
8 4 0 2 0 1 1 0
Size Flap coverage
OR
95% CI
P-Value
6.00 14.63
1.17–30.71 1.34–159.65
0.03 0.03
c-Statistics
[Equation] Success = 1.203 + 1.79 [size] + 2.68 [flap_coverage] 0.96* 0.78 * The P-value was calculated by Hosmer–Lemeshow goodness of fit statistic.
Table 5 Postoperative changes of symptoms.
No reperforation Reperforation
Free
Improved
Stationary
13 6
3 4
2 7
Table 6 Postoperative changes of symptoms.
Numbers are not mutually exclusive. a Totally reversed postoperatively. b Improved status. c Stationary status.
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I.J. Moon et al. / Auris Nasus Larynx 38 (2011) 52–57
Table 7 The predictive factors of the symptom improvement of the surgery.
Size Trauma
OR
95% CI
P-Value
24.59 32.43
2.13–284.66 1.71–616.15
0.01 0.02
[Equation] symptom improvement = 5.033 + 3.20 [size] + 3.48 [trauma] 0.98* 0.81 * The P-value was calculated by Hosmer–Lemeshow goodness of fit statistic.
this model was good. Symptoms of patients with large perforation size (OR, 24.59; 95% CI, 2.13–284.64) and nasal trauma history including surgery (OR, 32.43; 95% CI, 1.71– 616.15) had a tendency to persist or recur by using this model.
4. Discussion The statistical analysis of the study on patients whose septal perforation was repaired surgically points to a conclusion that the bilateral flap coverage results in the suppressed reperforation rate, compared to the unilateral flap coverage. This observation embodies the significance of the covering process during an operation: bilateral approximation of the mucosal flap reduces the reoccurrence of perforations regardless of other surgical processes. A few reports published elsewhere have claimed conflicting results [4,9]. For example, Newton proposed that coverage of only one side of nasal septum with bipedicled advancement flap, remaining the other side exposed expecting that it could be healed secondarily, could maintain complete closure during follow-up period in 92% of cases [4]. Meanwhile, other authors have reported success with using a unilateral flap via endoscopic approach [9,10]. In our study, however, 6 out of 7 cases with unilateral mucosal flap coverage ended up with reperforation. Despite the small number of studied cases, the remarkably high reperforation rate deserves the attention on the detrimental effect of the unilateral coverage. Perforation repair via external approach discourages the recurrence of perforations, thus improving overall success ratio of the surgery, even though the difference was not statistically significant. This finding is linked to previously reported observations, in which an open rhinoplasty approach was found to give rise to higher success rate due to greater mucoperichondrial mobilization and thus easier access to the perforation site [11,12]. This external approach also allows surgeons to use their both hands during surgery. Since patients with a septal perforation tend to develop external nose deformities, the external approach provides an added benefit of performing both septal perforation repair and corrective rhinoplasty at one surgical operation process. However, the open approach has a down
side. Compared to an intranasal approach, the medial crura are totally dissected from the septum, which may lead to the tip depression as tips can no longer be supported by fibrous connections between the medial crura and the septum. To address this drawback, a tip support can be reconstructed by using onlay graft, shield graft or columellar strut. We tried to cover the wound tension-freely without opposing suture lines. Closure of the perforation with tension can lead to rupture of the flaps postoperatively with a healing scar contraction. In order to approximate flaps without tension, the adequate mobilization of septal flaps with complete dissection is required because septal mucosa has no elastic tissue [13]. The effect of flap materials used in closing the perforation site was also studied. The flaps used in this study include bipedicled advancement flaps, rotation flaps, inferior turbinate flaps, buccal mucosal flaps and skin grafts. Among these various flaps, we preferred to use bipedicled advancement flaps because of both including excellent blood supply and containing normal respiratory epithelium. For larger perforations, both superiorly and inferiorly based bipedicled flap were necessary. Depending on patients’ conditions, e.g. the amount of viable tissue in the nasal cavity, other flaps such as a rotation flap or an inferior turbinate flap were employed. In the case of a large perforation, approximating the mucosal flap almost always brings up tension in the perforation site. Consequently, the success rate tends to decrease with an increased perforation size. The vertical height of a perforation has been envisioned to play a more important role in determining the surgical success than the horizontal length because a main tension between the floor of the nose and the dorsum was found to be critical [13]. However, no significant outpowering of one variable over another between horizontal and vertical dimensions was noticed in our study. It was possible to harvest and rotate flaps in vertical direction via external approach to repair the perforation. It turned out that the interposition graft application as well as the bilateral use of mucoperichondrial flaps helped improve the success rate of the surgery, i.e. suppression of reoccurrence of a perforation. In the past decade, surgeons have reported the use of a wide variety of graft materials including septal cargilage, conchal cartilage, pericranium, periosteum, temporalis fascia, ethmoid bone and mastoid cortex as well as acellular human dermal allograft [5–7,14]. While these graft materials exhibited the respective good and bad properties, the postoperative results collated from the multiple groups suggest that the kind of graft materials used in the operation does not dictate the success of the surgery. The results from this study point to the ultimately same finding: graft materials do not matter. The follow-up examinations revealed an interesting point: symptoms were selectively cleared. In all cases where the closure of the nasal perforation was confirmed before the last follow-up visit, epistaxis and whistling did no
I.J. Moon et al. / Auris Nasus Larynx 38 (2011) 52–57
longer turn up. On the other hand, nasal obstruction and crusting still persisted in some cases. Among several factors evaluated by the logistic regression model, large perforation size and nasal trauma history had a negative impact on symptom improvement after surgery. In case of large septal perforation, creation of large mucoperiosteal flaps in the nasal cavity inevitably results in large denuded area, also leading to the generation of nasal obstruction and crusting. Previous nasal trauma including surgery had a possibility of damaging other nasal structures, such as turbinate and nasal valve area. Therefore, other abnormalities except septal perforation may exist in nasal cavity and repairing perforation only may not be enough to improve all symptoms. These abnormalities can be responsible for poor results in terms of symptoms. Preoperative counseling to the patients with previous nasal trauma history regarding postoperative symptoms is necessary. In addition, these patients should be followed up carefully after surgery because the trauma history is associated with persistent symptoms. However, further studies are needed to clarify the exact association between previous nasal trauma history and symptom improvement after surgery. Creation of large denuded area during surgery could be attributed to the postoperatively developed mucosal dryness that in turn results in nasal obstruction and crusting. The ‘‘improvement’’ of these symptoms in fact could have resulted from the decreased perforation size, as described in the Results section. On this account, patients with these 2 symptoms – nasal obstruction and crusting – after the surgery are recommended to moisturize their nasal cavity with oil or saline until the conditions of the mucosal flap is improved. Topical nasal estrogen spray may also reduce squamous metaplasia in applied flaps and thus help eliminating nasal dryness and crust subsequently [11]. We also suggest the instruction about the symptomatic change be given to the patients, especially those who the cause of the perforation is previous nasal trauma or surgery, prior to a septal perforation repair. The reoccurrence of a perforation in our study (70–100%) was relatively more frequented than in other published studies [5,10,14,15]. Asians have smaller nasal cavity and septum; therefore, viable tissue to cover the perforation site may not be enough. This, of course, is the subject of a further study – comprehensive multi-ethnic analysis is central to elucidating such deviation.
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Herein, we studied the cases in which nasal septal perforations were surgically repaired and evaluated the effect of variables. In conclusion, effective repair of nasal septal perforation located in the cartilaginous septum was possible through bilateral and tensionless approximation of the local flaps. In addition, previous nasal trauma history and large perforation size might be risk factors for persistent symptoms after septal perforation repair.
References [1] Romo 3rd T, Jablonski RD, Shapiro AL, McCormick SA. Long-term nasal mucosal tissue expansion use in repair of large nasoseptal perforations. Arch Otolaryngol Head Neck Surg 1995;121:327–31. [2] Schultz-Coulon HJ. Experiences with the bridge-flap technique for the repair of large nasal septal perforations. Rhinology 1994;32:25–33. [3] Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope 2003;113:1425–8. [4] Newton JR, White PS, Lee MS. Nasal septal perforation repair using open septoplasty and unilateral bipedicled flaps. J Laryngol Otol 2003;117:52–5. [5] Kridel RW, Foda H, Lunde KC. Septal perforation repair with acellular human dermal allograft. Arch Otolaryngol Head Neck Surg 1998;124:73–8. [6] Nunez-Fernandez D, Vokurka J, Chrobok V. Bone and temporal fascia graft for the closure of septal perforation. J Laryngol Otol 1998;112:1167–71. [7] Stoor P, Grenman R. Bioactive glass and turbinate flaps in the repair of nasal septal perforations. Ann Otol Rhinol Laryngol 2004;113:655– 61. [8] Osma U, Cureoglu S, Akbulut N, Meric F, Topcu I. The results of septal button insertion in the management of nasal septal perforation. J Laryngol Otol 1999;113:823–4. [9] Lee HR, Ahn DB, Park JH, Kim YH, Sin CM, Youn SJ, et al. Endoscopic repairment of septal perforation with using a unilateral nasal mucosal flap. Clin Exp Otorhinolaryngol 2008;1:154–7. [10] Ayshford CA, Shykhon M, Uppal HS, Wake M. Endoscopic repair of nasal septal perforation with acellular human dermal allograft and an inferior turbinate flap. Clin Otolaryngol Allied Sci 2003;28:29–33. [11] Kridel RW. Considerations in the etiology, treatment, and repair of septal perforations. Facial Plast Surg Clin N Am 2004;12:435–50. [12] Watson D, Barkdull G. Surgical management of the septal perforation. Otolaryngol Clin North Am 2009;42:483–93. [13] Kridel RW. Septal perforation repair. Otolaryngol Clin North Am 1999;32:695–724. [14] Goh AY, Hussain SS. Different surgical treatments for nasal septal perforation and their outcomes. J Laryngol Otol 2007;121:419–26. [15] Ambro BT, Zimmerman J, Rosenthal M, Pribitkin EA. Nasal septal perforation repair with porcine small intestinal submucosa. Arch Facial Plast Surg 2003;5:528–9.