Nasal Septum Perforation Repair: Simplicity and low Morbidity Using the Temporalis Fascia and Silicone Films

Abstract

Aim: We present a new, simple, and effective method for the closure of nasal septal perforations based on prolonged isolation of the surgical site. Nasal septal perforation usually results after rhinological surgical operations, primarily to correct septum deviation. When symptomatic, conservative and surgical treatments are required. Current techniques more often attempt direct mucosal closure by mobilizing local nasal mucosal flaps with or without interposed grafts. The reported success rates are sufficiently high approaching ≥ 90%. Method: Our current practice includes the insertion of a temporalis fascia graft between the septal mucosal flaps to cover the perforation, avoiding any effort to achieve mucosal closure. Instead of using sophisticated techniques and multiple synthetic grafts, we propose that the entire septum remains protected after perforation repair for 6 weeks between two thin silicone sheets which permit surgical site inspection and mucosal regrowth. We present our experience with 10 consecutive patients, two of whom had fairly large defects. Results: All cases, except one, had a successful outcome with complete closure of the defect after one year’s follow up. No serious complications were reported and the silicone sheets were well tolerated by the patients. Conclusion: Our method is simple and consequently fast, resulting in high success rates, low morbidity, and high tolerance from the patients.

Key Messages

• Nasal septum perforations must be repaired occasionally. So far, sophisticated surgical techniques are proposed.

• Using a simple surgical technique with a temporalis fascia graft yields the same success rates as with a sophisticated vascular flap provided the surgical site is isolated for a long period.

• Silicone sheets permit surgical site inspection and protection of the mucosa during the regrowth process.

• Prolonged isolation and protection of the surgical site is the key for a successful repair irrelevant the surgical technique or the graft.

Introduction

Nasal septal perforation (NSP) is usually caused by trauma (e.g., surgery [1], cautery, and nose picking), cocaine abuse, malignancy, and systemic diseases [2]. Perforations are divided as follows: anterior and posterior; symptomatic and asymptomatic; and small, medium, and large (usually > 2–3 cm) depending on their size [3–5]. The prevalence of perforations is estimated to be 1–2% in the general population.

The main symptoms of NSP are difficulty in nasal breathing, crust formation, epistaxis, whistling sounds during breathing, and foul odor. However, not all perforations present with symptoms, particularly the posterior ones.

Conservative treatment comprises the topical application of moisturizing ointments and water saline rinses. Covering the defect with a silicone button may also be helpful but does not offer a permanent solution.

Anterior perforations usually present with symptoms and are often considered for surgical treatment. The surgical closure of a defect is considered to be a challenging operation even though the success rates reported are sufficiently high [6].

Numerous surgical techniques to close a defect have been proposed using either local or regional flaps and interposed grafts, either autografts or allografts. Conversely, few investigators have placed importance on nostril dressing and postoperative treatment.

In our practice, we opt for simplicity, not attempting mucosal closure, but choosing temporalis fascia as the interposed graft, which is abundant and its harvesting does not impose high morbidity. Furthermore, we emphasize the importance of protecting the material used for the closure of the defect and the entire operative site against the traumatizing and dehydrating effects of the inhaled air using thin silastic films for a prolonged time. A case series of consecutive patients is presented.

Materials and Methods

Between 2018 and 2021, 10 patients with symptomatic NSP underwent surgery at our department. The gender distribution was eight men and two women. The age distribution varied from 23 to 76 years. All patients had a history of previous surgical correction of septal deviation complicated by septal perforation. In two patients, septal correction was combined with esthetic rhinoplasty, and in one patient, concomitant polyp removal and correction of chronic sinusitis were performed.

Six patients presented with small perforations (< 2 cm) (Fig. 1), two with medium perforations (between 2 and 3 cm) and another two with large perforations (> 3 cm). Preoperative computed tomography was performed only in patients with active concomitant symptoms from the paranasal sinuses.

Fig. 1.

Endoscopic view of a septal perforation defect through the right nasal cavity

The same surgical technique was applied to all patients. General anesthesia was introduced in all cases, after which an inverted V columella incision was made and supraperichondrial dissection ensued until full exposure of the lateral crura of the lower lateral cartilages, the upper lateral cartilages, the dorsal surface of the quadrilateral cartilage, and just beyond the connection of the cartilages with the nasal bones and frontal process of the maxilla.

Continuous dissection was performed from between the medial crura of the lower lateral cartilages till the remnants of the quadrilateral cartilage. From this point, dissection is usually difficult, because of the scar tissue from the previous operation, particularly in the areas where no cartilage was left between the mucosal surfaces.

The cephalic border of the quadrilateral cartilage after the division of the upper laterals is a possibly intact area where dissection can be facilitated. In most cases, sharp separation of the opposing septal mucosal flaps is achieved using a no. 15 blade, although from time to time, applying pressure with the suction tube or a blunt elevator can also be successful.

After completing the separation of the two opposing mucosal flaps beyond the boundaries of the defect, the operative field becomes ready to receive the interposing graft. In all cases, we obtained the temporalis fascia from the right side of the patient. The graft size was estimated to be slightly larger than that of the defect. Fascialis grafts tend to shrink after their removal from their anatomical beds, and this was considered.

The next surgical step was to insert the fascia graft between the two septal mucosal flaps. The anterior border of the graft was sutured using an absorbable stitching material at two or occasionally more points on the right septal mucosal flap just anterior to the anterior border of the perforation. After stabilizing the graft, we stretched it between the two mucosal flaps to cover the entire perforation and then sutured the anterior part of the two mucosal flaps using mattress absorbable sutures. The graft is now lying between the mucosal flaps stabilized only by the two initial stitches (Fig. 2). If possible, more absorbable stitches are used to secure the graft. No effort is attempted to cover all or even part of the perforation and the interposed graft by mobilization and approximation of the nasal mucosa. The healing process relies completely on mucosal migration to cover the exposed interposing graft.

Fig. 2.

Endoscopic view of the fascia lying between the mucosal flaps covering the entire perforation. No mucosal approximation is attempted

After completing the insertion and stabilization of the graft and covering of the defect, two thin silicone sheets were inserted, one in each nostril, to cover the entire septal mucosa that enveloped the complex of the mucosal flaps containing the fascia graft.

Two silk sutures were used to stabilize the silicone sheets, again in a mattress fashion. If possible, the stitches are placed in the anterior border of the sheets, just in front of the anterior border of the graft (Fig. 3). The last step is to suture the inverted V columella. No tamponade is used. The surgical site is inspected through the silicone sheets. The silicone sheets are removed in the office after six or more weeks.

Fig. 3.

Silicone sheets fixated on both sides of the nasal septum. Secure in place for 6 or more weeks

Results

Graft take was successful in all cases. Furthermore, septal perforation closure was complete in all cases and remained so during the 1-year follow-up, except one case with a large perforation (> 3 cm) where a small (< 5 mm) defect developed again 4 months after the operation at the posterior limit (90% success rate) (Fig. 4).

Fig. 4.

The surgical site one year after repair. Mild discoloration of the mucosa

No serious complications were reported. Silicone sheets were well tolerated with slight crusting formation. Nasal breathing was restored gradually starting 1 week after surgery due to the gradual attenuation of the postoperative edema and was completed with the removal of silicones 6 weeks later.

Symptoms were relieved in all patients, particularly improvement in nasal breathing capability and cessation of crust formation and nose bleeding.

Discussion

Our experience from surgically treating nasal septum perforations leads us to the conclusion that the most critical point of the effort is the prolonged protection through isolation of the surgical site. And this is irrelevant of the technique or the type of graft used.

NSP is a fairly common situation. The patients who are usually brought to the operating room have experienced posttraumatic or postsurgical complications. Postsurgical cases are probably more difficult because of the absence of intervening cartilage or bone between the mucosal flaps, which renders their separation more difficult.

Conservative treatment consisting of water saline rinses and/or moisturizing cream application is only supportive. Historically, efforts for surgical repair began early, probably following initial attempts of septal deviation correction, which is considered the main cause of NSP. Surgical techniques mainly involve mobilization of unilateral or bilateral local mucosal flaps [7], interposition of an autograft or synthetic material between septal mucosal flaps, or a combination of interposed materials covered by a local flap.

The surgical techniques are evolving and have become particularly complex, particularly after the insertion of endoscopes [8–12]. Today, the use of an endoscope at any point of the operation is considered a common practice and is valid for almost any rhinological operation. Furthermore, the dilemma of using an open or a closed approach is of lesser importance as long as the operative field is sufficiently visualized. High rates of success have been reported [4] using various techniques, although there exists a unanimous admission that the surgical repair of NSP remains challenging.

Many studies on the surgical repair of the NSPs have focused on the materials used to cover the defect. Only a few investigators have stressed the importance of protecting the surgical site and the materials used for the closure of the defect [3, 4, 9, 13–15]. A possible explanation might be that the nose provides a false impression of a well - protected cavity, rendering any further supportive measures unnecessary. However, even the flow of air inside the nasal chambers is a potentially traumatizing factor necessitating the take of additional measures to protect the area of the restored perforation.

Our concept concerning the surgical repair of a nasal septal perforation is that the need for prolonged postoperative protection of the operative field is of equal importance to the choice of surgical technique or interposing material.

A review of recent literature revealed that different investigators report similar results, regardless of the surgical technique used. This is the reason why we chose perhaps the simplest technique of the straightforward separation of the two septal mucosal flaps, the use of a simple autograft that is abundant in a neighboring anatomical region, applying a rudimentary fixation, making no attempt for mucosal closure, and protecting our graft long enough to secure its survival and facilitate mucosal migration.

Our technique results in high success rates comparable with those of the rest of the literature, with minimal morbidity and sufficient tolerance by the patient. In the case of concomitant pathology, such as chronic rhinosinusitis [16, 17] or the need for esthetic rhinoplasty [1, 18, 19], we considered that our technique adds little to the burden of the operation compared with the use of nasal flaps of any kind. Our technique can be easily used in an operation of larger magnitude.

The fascia temporalis is easy to harvest, and can provide a graft with a fairly large surface. It is easy to manipulate and allows for mucosal migration and angiogenesis, which is not the case when using a bone or cartilage graft [5, 20]. Finally, it is a more natural solution comparing than a synthetic material [21, 22]. In the recent literature, we found only one paper suggesting that connective tissue from the temporal region can be used as a solo graft without mucosa apposition [15].

Of equal importance as the choice of the surgical technique and the interposition graft is the prolonged protection of the surgical site, a concept that is not emphasized. Covering both sides of the nasal septum bearing the repaired perforation for 6 weeks with thin silicone sheets [15, 23, 24] seems to allow for the successful acquisition and survival of the free fascial graft. In fact, we applied the same concept of prolonged protection of the surgical site with silicone sheets prophylactically in cases of tedious efforts to correct septal deviations, leading to extensive damage of the septal mucosa and thus increasing the possibility of septal perforation.

The successful outcome of our cases provides us with strong evidence to believe that our concept is valid and to continue applying this technique in more patients, regardless of the defect size, which seems to be the most important factor that influences success rates [25, 26].

Conclusion

NSP is not uncommon. Recalcitrant symptoms prompt surgical correction. We advocate a simple, fast, and straightforward technique of interposing the fascia temporalis between the septal mucosal flaps.

We emphasize the need for the prolonged protection of the surgical field using silicone sheets.

This surgical technique results in similar success rates with a faster and simpler technique, causing less morbidity than cumbersome flap mobilization.

Author Contribution

Anastasopoulos George (Corresponding Author): Conceptualization, data curation, investigation, methodology, project administration, writing – original draft. Pappas Nikolaos: Data curation, software. Grigoriadis George: Data curation, investigation. Shihada Amir: Formal analysis, software. Troupis Theodore: Methodology, supervision. All co-authors have reviewed and approved of the manuscript prior to submission

Funding

No funding was received for conducting this study.

Declarations

Research Involving Human Participants

The study was conducted according to the ethical standards of the Department of Anatomy of the National and Kapodistrian University of Athens and the ENT Department of the Metropolitan General Hospital in Athens. The research was completed in accordance with the Declaration of Helsinki as revised in 2013.

Informed Consent

Informed consent was obtained from all the patients.

Conflict of Interest

Not applicable.