Background

Septal perforations are a diagnostic challenge because various potential causes are possible.
Therefore, elucidating the cause of the septal perforation requires obtaining a thorough
history. Although several surgical options are available for the treatment of symptomatic
septal perforations (see Septal Perforation: Surgical Aspects), this article focuses on the
medical management of septal perforations.

Pathophysiology
The nasal septal mucoperichondrium provides the blood supply to the septal quadrangular
cartilage. Any insult (eg, chemical, physical, iatrogenic) to this normal anatomy can lead to
the development of a perforation.

Epidemiology
Mortality/Morbidity

Septal perforations can cause significant morbidity. The symptoms associated with septal
perforations include nasal congestion or obstruction, nasal crusting and drainage, recurrent
epistaxis, and a whistling sound from the nose. In addition to the symptoms related to nasal
septal perforations, manifestations of the disease process that caused the perforation (eg,
lupus, Wegener granulomatosis) may also carry significant morbidity.

Proceed to Clinical Presentation

History
Septal perforations are usually asymptomatic. However, some patients may present with a
history of nasal obstruction, crusting, intermittent episodes of epistaxis, malodorous
discharge from the nose, or a whistling sound during nasal breathing.

A thorough medical history is essential in the evaluation because septal perforations are
associated with many systemic diseases. Inflammatory diseases such as collagen vascular
diseases, sarcoidosis, and Wegener granulomatosis may cause septal perforations. In addition,
infectious processes such as tuberculosis, syphilis, and fungal diseases may result in septal
perforations. Rarely, septal perforation is the initial finding of sinonasal malignancy.

Traumatic causes of septal perforation may be divided into external, self-inflicted, and
iatrogenic causes. External trauma includes nasal-septal fracture. A septal hematoma results
in elevation of the mucoperichondrium from the quadrangular cartilage, ischemia, and
subsequent necrosis of the cartilage, with resultant perforation. Self-inflicted trauma, such as
digital manipulation, may cause a septal perforation. Iatrogenic trauma includes a history of
septoplasty, nasal packing or cauterization for epistaxis, and nasotracheal intubation.
Medication usage should be reviewed. Chronic use of vasoconstrictive nasal sprays and
steroid nasal sprays may cause septal perforations. In addition, the use of cocaine may result
in septal perforations.

In addition to the possibility of cocaine abuse, a study by Peyrire et al indicated that in

patients with nasal damage who abuse drugs, clinicians should also determine whether the
patient has been inhaling heroin. In the study, the investigators found that among 24 patients
with a history of chronic nasal inhalation of heroin (median daily consumption, 5 g) over a
period of two months to more than ten years (including six patients who also had a history of
cocaine abuse), the following damage had occurred[1] :

Nasal septum necrosis (five patients)

Nasal perforation (11 patients)
Nasal erythema or ulceration (five patients)
Palate damage (5 patients)
Pharyngeal ulceration (three patients)

Exposure to industrial fumes, wood dust, nickel-refining processes, and leather tanning may
result in sinonasal malignancy and the development of septal perforation. Exposure to
mineral oils, chromium, lacquer paint, soldering, and welding have also been associated with
an increased incidence of sinonasal malignant tumors.

Physical
Physical examination of the nose begins with an evaluation of the external nose. Large
perforations may result in loss of support to the dorsum of the nose and subsequent saddle
nose deformity.

Most septal perforations are identified incidentally during routine physical examination.
Thorough intranasal examination with anterior rhinoscopy is essential. Anterior rhinoscopy
may demonstrate severe crusting; all crusting should be removed to attain a thorough
evaluation of the septum. Topical nasal decongestants may further assist in the intranasal
inspection of the entire septum.

The location of septal perforations is important because posterior perforations are typically
asymptomatic compared with anterior perforations. Nasal endoscopy may assist in the
evaluation of the entire septum. The position and diameter of the perforation should be noted.
Palpation of the septum with a cotton-tipped applicator provides valuable information
regarding the integrity of the quadrangular cartilage in the remainder of the septum. Crusting
of the entire septum, edematous mucosa, or inflammation of the mucosa should alert the
physician to systemic diseases as the etiology of the perforation.

In patients with an identifiable cause of the septal perforation, no further workup may be
necessary. However, patients with an unidentifiable cause should undergo further
investigation (see Workup).

Causes
The causes of septal perforation are many and varied. Attempting to find the inciting cause,
or at least ruling out many of the dangerous causes, is important. If one can successfully
surgically close a septal perforation but cannot alter the course of the initial inciting cause,
then the perforation is often doomed to recur. Additionally, by closing the perforation, the
physician may hide a manifestation of an undiagnosed disease process.

The causes of septal perforations can be conveniently placed into several categories that can
help the physician more easily determine the causative agent or process. A good history,
physical examination, and select laboratory studies can help focus the investigation.

Traumatic causes
o Previous surgery
o Cauterization for epistaxis
o Nose picking
o Nasogastric tube placement
o Septal hematoma that results from any blunt trauma
o Battery or other foreign body in nose
o Chronic nasal cannula use
o Turbulent airflow
Inflammatory or infectious causes
o Sarcoidosis
o Wegener granulomatosis
o Systemic lupus erythematosus
o Tuberculosis
o Syphilis
o AIDS
o Diphtheria
o Crohn disease
o Dermatomyositis
o Rheumatoid arthritis
Neoplastic causes
o Carcinoma
o T-cell lymphomas
o Cryoglobulinemia
Other causes
o Inhaled substances (eg, cocaine, topical corticosteroids, long-term
oxymetazoline or phenylephrine use)
o Chromic acid fumes
o Lime dust exposure
o Renal failure[2]

Laboratory Studies
Because of the varied etiologies of nasal septal perforations, performing a detailed laboratory
evaluation on every patient is cost prohibitive. Because of this, an algorithm (as seen in the
image below) is proposed to guide the physician when obtaining more detailed laboratory and
other studies:
 Proposed algorithm for a
systematic evaluation of newly diagnosed septal perforations.

In patients without a likely cause for the perforation or in patients with rheumatologic
complaints, basic laboratory studies may be performed.

A significantly elevated erythrocyte sedimentation rate can indicate an underlying

rheumatologic disorder. Unfortunately, a value within the reference range does not
rule out a rheumatologic or inflammatory disorder. The erythrocyte sedimentation rate
can be elevated significantly in dermatomyositis-polymyositis, rheumatoid arthritis,
sarcoidosis, lupus, Wegener granulomatosis, temporal arteritis, and many other
disorders.
In patients with cough, hemoptysis, sinusitis, bloody nasal discharge, or eye
abnormalities (episcleritis or conjunctivitis), an antineutrophil cytoplasmic
autoantibody (C-ANCA) test should be obtained to assess for Wegener
granulomatosis.
The rheumatoid factor level may be elevated in persons with rheumatoid arthritis,
mixed connective tissue diseases, lupus, scleroderma, or other disorders.
Elevated angiotensin-converting enzyme (ACE) levels can indicate the presence of
sarcoidosis. Chest radiography can also be performed to assess for this disease.
If any of the results are positive, consult with a rheumatologist regarding further
testing.

Imaging Studies
Chest radiography may be performed to assess for sarcoidosis.

Procedures
A biopsy of the perforation edge to rule out sinonasal malignancy may be indicated if
malignancy is suspected based on history or constitutional symptoms.

Medical Care
Although several surgical options are available for the treatment of septal perforations, this
article focuses on the nonsurgical management.

Abstinence of the causative agent is of utmost importance in the medical management of

septal perforations if the patient has a history of drug abuse (such as cocaine) or the use of
nasal decongestants or nasal steroid sprays.

Perforations of the posterior septum are typically asymptomatic and, as such, rarely require
treatment. However, intranasal crusting may be problematic for the patient, especially if the
edges of the perforation are not well healed. These patients may benefit from medical
treatments aimed at keeping the nose moist. These include the daily application of petroleum
jelly on a cotton-tipped applicator to the inside of the nose, the application of a nasal
emollient such as Ponaris oil, or nasal irrigations. In addition, a humidifier in the home may
benefit the patient.

Perforations of the anterior septum may cause the sensation of nasal obstruction or result in a
whistling sound upon nasal breathing. A silicone button prosthesis may relieve these
symptoms. In the office, a silicone button prosthesis may be placed with the help of a local
anesthetic.

In individuals who remain symptomatic despite the aforementioned nonsurgical treatments,

surgical management may be of benefit (see Septal Perforation: Surgical Aspects).

Consultations
If the cause of the nasal septal perforation is not clear, consider obtaining a consultation with
a medical specialist or rheumatologist.

Medication Summary
The medications used in the treatment of nasal septal perforations generally involve the
topical application of agents that clean and humidify the nose or that alter the nasal mucosa.

Topical decongestants
Class Summary

These agents are used to shrink nasal mucosa to allow better visualization, to allow easier
insertion of nasogastric tubes with less trauma, and to provide temporary management of
epistaxis.

View full drug information

Oxymetazoline 0.05% (Dristan, Allerest, Afrin)

Topical vasoconstrictor; decreases swelling and congestion in the nose.

Topical hormones
Class Summary

These agents are used to induce trophic changes in nasal mucosa (thickening of thin, delicate
nasal mucosa).

View full drug information

Conjugated estrogen (Premarin)

When mixed with nasal saline, can be applied topically to thicken nasal mucosa to decrease
epistaxis; 25 mg of conjugated estrogen (Premarin Secule kit) mixed with 1 bottle of saline
nasal spray; keep refrigerated and discard after 30 d; discuss with patient that this is an off-
label use of the drug. Discuss risks and benefits of using this drug; only for use in patients
with severe epistaxis due to the perforation.

Topical antibiotics
Class Summary

These agents, when applied to nasal mucosa, can keep tissue moist. Drying of nasal mucosa
can induce epistaxis.

View full drug information

Mupirocin (Bactroban cream)

Apply topically to nasal septal mucosa to keep nasal tissue moist.

SURGICAL ASPECT

Background
A nasal septal perforation is a through-and-through defect in any portion of the cartilaginous
or bony septum with no overlying mucoperichondrium or mucoperiosteum on either side. A
nasal septal perforation provides direct communication between the right and left nasal
cavities.

Nasal septal perforations may be stratified based on size, as follows:

Small perforations - Diameter 0.5 cm

Medium perforations - Diameter between 0.5-2 cm
Large perforations - Diameter > 2 cm

The location and size of perforation impacts the symptoms patients experience.

Many nasoseptal perforations are unrecognized, though a subsection of patients experience

bothersome symptoms including but not limited to crusting, recurrent epistaxis, and nasal
whistling on respiration that lead patients to seek treatment.

History of the Procedure

Treatment falls into 3 main categories:

Medical treatment aims to reduce symptoms rather than correct the perforation.
Placement of a nasal-septal prosthesis is a conservative intervention that may act as a
temporary or long-term solution.
Surgical repair may provide a definitive solution though is accompanied by increased
potential morbidity and failure.

High failure rates can be attributed to two unfavorable factors: an inadequate blood supply
and a scarred host bed. Failure rates range from 60% for procedures in early studies to 18%
for the best of the modern 2-stage procedures. More than 90% of small perforations can be
closed reliably, whereas 70-80% of large defects can be completely closed with the newer
techniques.

Although many techniques for repairing septal perforations have been described, no
standardized surgical protocol has been established.

The image below depicts the blood supply to the septum.

 Surgical aspects of septal
perforation. Blood supply to the nasal septum.

Epidemiology
Frequency

The frequency of nasal septal perforations is correlated with the number of nasal procedures
performed and history of cocaine use ingested by the nasal route. The incidence has no
geographic correlation, and the condition is not clearly and directly associated with age, sex,
diabetes, or smoking.

A broad examination of the Swedish population revealed a 0.9% prevalence of septal

perforation.

Etiology
The etiology of nasal septal perforations can be classified into the following main categories:

traumatic, iatrogenic, inflammatory/malignant, infectious, and inhalant related. See the image
below.
 Different Etiologies of Nasal
Septal Perforations

Most traumatic or iatrogenic perforations result from mucosal lacerations on corresponding

sides of the septum with exposure of the underlying cartilage or a fracture of the cartilaginous
septum. Cartilage relies on the overlying mucoperichondrium for its blood supply and
nutrients. Defects in the mucoperichondrium cause ischemia of the underlying cartilage,
resulting in breakdown and subsequent perforation. Traumatic injuries may be self-induced
from nose picking or may result from facial trauma.

Iatrogenic causes include nasal surgical procedures and nasal intubation or nasogastric tube
placement. Overall, prior nasal septal surgery (septoplasty) is the most common cause of
septal perforations with a risk of roughly 1%. A review found that patients are not at
increased risk of nasal septal perforation when undergoing septoplasty if they carry the
diagnosis of allergic rhinitis.[1]

Septal hematoma, if not identified and treated early, may also result in perforation secondary
to loss of cartilaginous structure, infection, and/or abscess formation.

Infectious and inflammatory etiologies, including tuberculosis, syphilis, Wegener

granulomatosis, and sarcoidosis, should always be considered in the differential diagnosis.

Newly identified, bevacizumab, an anti-angiogenesis monoclonal antibody, may be

associated with nasoseptal perforation.[2]

Abuse of nasal inhalants is often implicated in septal perforation. Irritants including chromic
or sulfuric acid fumes, glass dust, mercurials, and phosphorous have been associated.

Septal perforation is more commonly associated with cocaine abuse or, in a similar
mechanism, use of vasoconstrictive nasal sprays. These patients often present with large and
expanding perforations. See Pathophysiology for a more detailed explanation of the role of
cocaine in nasal-septal perforation.

Pathophysiology
Nasal septal perforations result from trauma to the mucoperichondrium of the septum.
Diminished blood supply can lead to cartilaginous and mucosal necrosis. After perforation
occurs, the mucosal edges epithelialize, preventing closure of the defect. Symptoms arise
from altered nasal laminar airflow and may be severely disturbing to the patient. Some
patients may be completely asymptomatic.

The mechanism of cocaine induced nasal septal perforation is multifaceted: First,

vasoconstrictive properties lead to ischemia and subsequent breakdown of the cartilage.
Second, illicit cocaine contains adulterants that act as chemical irritants damaging the nasal
mucosa. Third, vasoconstriction may produce a micro-aerophilic environment suitable for
anaerobic infection. Chronic abuse leads to physiologic changes in the mucosa making
repairs difficult and increasing the rate of failure.

Presentation
Symptoms tend to be related to the size and location of the perforation. Most symptomatic
perforations are large and anterior. Posterior perforations tend to be less symptomatic than
others because of humidification from the nasal mucosa and turbinates. A low-grade
perichondritis may persist and require long-term antibiotic treatment.

Nasal obstruction, crusting, epistaxis, nasal discharge, parosmia, and neuralgia are commonly
reported symptoms. Small perforations can cause a whistling sound with inspiration.[3] Larger
perforations can lead to atrophic rhinitis. Long-standing large perforations may even result in
a saddle-nose deformity from a lack of dorsal nasal support producing both an aesthetic and
functional problem.

Indications
Surgical repair is an elective procedure reserved for patients who seek resolution of the
aforementioned symptoms.

Relevant Anatomy
The nasal septum is composed of 2 major structural components: the anterior quadrangular
cartilage and the posterior bony portion, predominately consisting of the vomer and
perpendicular plate of the ethmoid bone. According to data from cadaveric studies, the
cartilaginous septum accounts for approximately 34% of the nasal septum. The septum is
inferiorly attached to the crest of the maxillary and palatine bones by dense fibrous tissue.

The arterial supply is a rich anastomosis of 4 major blood supplies (see the image below),
which is important, especially when repair with various flaps is considered. The anterior and
posterior ethmoid arteries supply the septum superiorly. Branches of the facial artery supply
the septum anteriorly. The sphenopalatine artery supplies the septum posteriorly, and the
greater palatine artery supplies the septum inferiorly.
 Surgical aspects of septal
perforation. Blood supply to the nasal septum.

Contraindications
Current use of cocaine is an absolute contraindication for surgical repair. Postoperative
cocaine abuse inevitably results in repeat perforation. If an obvious specific cause for
perforation cannot be clearly identified or if the perforated edges do not appear well
mucosalized, biopsy should be considered before repair is attempted. Further laboratory
evaluation to rule out autoimmune or infectious etiologies may also be warranted. Control of
autoimmune disease must precede attempt at nasal septal perforation closure. Lastly, active
infection is a contraindication to repair.

Medical Therapy
Symptoms caused by septal perforations may be managed with saline nasal irrigations or
regular humidification to reduce crusting. Patients who complain of pain and dryness at the
perforation site often experience an improvement with antibiotic ointment or a petroleum-
based ointment applied intranasally a few times a day. Although nasal hygiene and
lubrication may provide some symptomatic relief, progressive enlargement of the septal
perforation is a continued risk with medical therapy alone.[4]

Surgical Therapy
Closing a nasal septal perforation can be broadly divided into:

Placement of a nasal septal prosthesis

Surgical repair
Repair techniques can be classified broadly into several groups, from the most conservative
to the most radical. These techniques include local flaps, various autologous and
biocompatible grafts, 2-stage procedures, and free-flap repair. Some specific techniques are
outlined below, followed by detailed explanation of how septal perforations are dealt with at
select institutions.

Nasal Septal Prosthesis

The nasal septal prosthesis (ie, button) is the most conservative approach (see the image
below). It may serve as a temporary or long-term solution, especially in patients who may
have a comorbid condition that precludes them from undergoing surgical treatment. The
prosthesis has been available since the 1970s and may be placed in the office setting.

Surgical aspects of septal

perforation. Photo of 1- and 2-piece septal button prostheses.

Prostheses are available in various materials (eg, acrylic, plastic, silicone). The basic design
is that of 2 flat disks connected to a central solid hub. In general, placement requires that the
septum, anterior and posterior to the perforation, is relatively straight. Sometimes, a simple
septoplasty may be necessary to straighten the septum surrounding the perforation before the
prosthesis is placed. Insertion is not always easy. New devices have been made with flexible
disks and hubs to improve accommodation of any irregularities of the neighboring septum.

Insertion begins with topical nasal decongestion and anesthesia. The perforation can be
measured by placing a piece of white paper on 1 side and marking the perforation from the
other side. Disks may be trimmed but must remain larger than the perforation. The button is
lubricated well, passed into 1 side, and grasped with a clamp and pulled through the
contralateral side. Ensure the flanges fit against the upper lateral cartilageseptum junction,
and avoid pressure against the septal floor. Two-piece buttons (each with a flange, 1 with a
male end and the other with a female end) can be used for small perforations.

For irregularly-shaped perforations, Federspil et al have reported on the use of custom-made

septal buttons, formed by the surgeon using silicon and an intranasal cast as a template.[5] The
study reported success in symptom relief and patient satisfaction using this technique.
CT has been used as a tool to accurately tailor custom silicone buttons. This technique is
specifically helpful for large (> 3 cm) perforations. A durable prosthesis must to fit precisely
into large perforations because of a lack of surrounding soft tissue on which to hinge it.

Preoperative Details
Preoperative evaluation is crucial for providing the best procedure for the patient at the
proper time. A small posterior perforation may not cause any symptoms and likely does not
require correction. Comorbidity (eg, uncontrolled diabetes, heavy tobacco use) may decrease
the likelihood of successful surgical repair secondary to vascular compromise. Systemic
causes, malignancy, or any other ongoing process must be excluded prior to repair. CT of the
paranasal sinuses may be indicated to evaluate for the presence of concomitant paranasal
sinus disease.

The surgeon must stabilize the nasal mucosa and decrease inflammation before repair is
contemplated. Success of the repair depends on the condition of surrounding tissues, cartilage,
and blood supply. Proper nasal hygiene plays a vital role in success and requires patient
cooperation. This care includes lavage with frequent saline nasal irrigations or water picks;
application of emollients; weekly nasal toilet, including suctioning and debriding of crust; use
of nasal steroids; and antibiotic treatment for infection.

Intraoperative Details
Local flaps

Many patients with symptomatic perforations seek surgical repair to avoid the long-term care
necessary with the prosthesis. Various flaps of local endonasal mucosa have been described
in the literature. Knowledge of the vascular supply is paramount for success. Mucosal flaps
may be taken from nearby healthy septum or from the inferior turbinate and pedicled
posteriorly. Posteriorly based mucoperichondrial flaps have been described. A bilateral,
hinged technique leaves 1 side pedicled superiorly and the other side pedicled inferiorly,
creating donor defects at nonopposing sites.

Tardy proposes a sublabial mucosal flap.[6] Advantages to this procedure include a large
amount of available mucosal tissue, minimal patient discomfort, and relative technical ease of
the procedure. The ipsilateral mucoperichondrium is elevated 0.5-0.8 cm around the
perforation to achieve fresh bleeding edges, which are controlled with epinephrine-soaked
pledgets. The upper lip is then exposed, and the ipsilateral buccal mucosa is raised and
pedicled medially just lateral to the frenulum and 15-20% larger than the defect. A midline
sublabial-nasal fistula is created, and the flap is then tunneled beneath the mucoperichondrial
flap.

In 1980, Fairbanks described bipedicled mucosal advancement flaps with an underlying

connective tissue autograft (ie, temporalis fascia, fascia lata, external oblique fascia) for
support.[7, 8] Twenty patients were followed for 7 years. The success rate, which was
measured as the relief of symptoms and complete closure of the perforation, was 95%.
Defects as large as 3 cm were closed. Large (> 4-cm) perforations were deemed inoperable
due to inadequate local mucosa to cover the defect.
In 1986, Bridger described a 2-procedure plan. For perforations smaller than 2 cm, a posterior
inverting septal flap composed of mucoperiosteum from the bony septum is used and the
now-exposed bone is left to granulate.[9] This procedure was successful in 7 of 8 patients. For
defects larger than 2 cm, a 2-stage nasolabial skin flap is used, similar to that used in head
and neck cancer surgery for anterior floor-of-mouth defects. The flap is introduced into the
nasal passage through a facial incision. The second stage involves dividing the pedicle. The
procedure was successful in 2 patients.

Kridel has popularized the external septorhinoplastic approach.[10] This method allows direct
access to the usually undisturbed dorsal septum, it allows for improved exposure to the
superoposterior portion of the perforation, and it affords binocular vision and frees both of
the surgeon's hands. Septal mucoperichondrial advancement flaps are combined with a
supporting graft, usually mastoid periosteum, cartilage, or ethmoid bone. In 22 patients from
1981-1983, Kridel reported a 77% complete closure rate, including defects as large as 4 cm,
and symptomatic improvement in all 22 patients.

His recent reports utilizing an acellular human allograft as the supporting graft showed
upwards of 90% closure in perforations up to 3 cm. In patients in whom the defect was too
large to be closed primarily, Kridel noted remucosalization in most patients, resulting in
complete closure or significant reduction in the perforation after 3 months.[11]

Freidman et al described an inferior turbinate flap pedicled anteriorly.[12] This technique is

particularly advantageous for caudal septal perforations that are difficult to close by using
local advancement flaps. Abundant vascular tissue can be harvested and rotated to cover large
defects. Moreover, this is relatively simple endoscopic alternative for difficult septal
perforations. A bullous middle turbinate pedicle flap, described by Kazkayasi, decreases
nasal obstruction prior to pedicle transaction and has shown promising results,[13] but patient
follow-up and case numbers have been limited. Nonetheless, in a subsequent study, of 31
patients, Hanci and Altun reported on the use of an endoscopic technique using a middle
turbinate flap, with complete perforation closure achieved in 29 cases.[14]

Kazkayasi and Yalcinozan, in Turkey in 2011, described the use of an overmedialized

uncinate process to repair a septal perforation.[15]

Daneshi et al utilizes a titanium membrane with an open rhinoplasty approach for repair.
Bilateral mucoperichondrium is elevated around the defect. Nasal floor mucoperiosteum is
elevated up to the inferior turbinate and any dorsal hump is removed to provide extra mucosa.
A titanium membrane is placed at the septal defect and the mucoperichondrium is closed
primarily. If primary closure is not possible, the flaps are reapproximated with quilting
sutures in order to allow mucosalization of the membrane. Perforations up to 3 cm were
closed with this technique, and, after 1 year, 8 out of 10 patients had complete mucosalization.
All 10 patients reported decrease in symptoms at 1 year following surgery even if complete
mucosalization had not occurred.[16]

For more extensive perforations, the use of facial artery musculomucosal (FAMM) pedicled
flaps has been described. The flap is raised along the intraoral course of the facial artery
(demarcated with Doppler imaging) to the gingivobuccal sulcus region. A full-thickness skin
graft harvested from the posterior auricular region lines the distal raw of the musculomucosal
flap. The flap is then tunneled into the nasal cavity and sutured into the defect. Heller and
others reported their experience with 6 patients by using FAMM flap reconstruction for septal
perforations larger than 2 cm. Complete symptom resolution and full closure of the septal
perforation was noted in 100% of patients who were followed up for a mean of 17 months.

Chhabra and Houser described endonasal repair of septal perforations using a unilateral
rotational mucosal flap and acellular dermal interposition graft. Their results show that out of
20 patients, 17 demonstrated successful closure in 85%. Only one of the three failure patients
required revision for symptoms. The authors believe that native septal tissue is advantageous
due to a rich vascular supply and proximity to the defect, whereas interposition grafts act as a
scaffold for the migration of respiratory mucosa.[17]

Authors' selected technique

A 3-tier comprehensive approach is used with the patient under general anesthesia. The
images below show schematic representations of a graduated approach to the repair of nasal
septal perforations. Anterior perforations smaller than 0.5 cm are closed by means of a
transnasal approach by using opposing septal mucosal flaps similar to the aforementioned
techniques. Perforations larger than 0.5 cm and smaller than 2 cm are routinely corrected with
a transnasal approach by using the extended external rhinoplasty technique. This alteration in
the standard approach for external rhinoplasty eliminates the need to dissect between the
medial crura and membranous septal flaps, enabling direct visualization of the caudal nasal
septum.

Surgical aspects of septal perforation.

Exposure of a nasal septal perforation by using the extended external rhinoplasty approach. A
is the retracted columella flap, B is a cartilaginous perforation, C is a mucosal perforation,
and D is mucosa elevated and reflected laterally.
 Surgical aspects of septal perforation.
Bilateral closure of mucosal flaps with an interposition graft of acellular dermal graft
(AlloDerm). A is AlloDerm dermal matrix covering a septal perforation, and B is a mucosal
perforation closed with interrupted sutures.

Surgical aspects of septal perforation.

Completion of flap elevation rotation and repair of perforation. A is the middle turbinate, B is
the posterior naris, C is the inferior turbinate infractured, D is the raw surface area left by flap
rotation, E is a full-thickness skin graft on the floor of the nose, F is the rotated flap, and G is
the anterior septal angle. Surgical aspects
of septal perforation. Closure of the perforation and nasal packing. A is the AlloDerm dermal
graft, B is the rotated nasal floor mucosal flaps, C is the thin silicone sheeting secured to
nasal mucosal flaps, D is a surgical sponge (Telfa) dressing, E is a surgical sponge (Merocel),
and F is a skin graft covering the donor site.

Surgical aspects of septal perforation. A 1

X 3-cm tissue expander is inserted into a submucoperiosteal pocket on the nasal floor. A is
the nasal septal perforation, B is the long-term expanded nasal floor mucosa (arrows), and C
is the peripheral port implanted onto the maxillary fossa.
 Surgical aspects of septal perforation.
Incision used for midfacial degloving. A is the intercartilaginous incision, B is the septal
perforation, C is the complete transfixion incision, D is the nasal floor sill incision, and E is

the gingivobuccal incision. Surgical

aspects of septal perforation. Areas of dissection for midfacial degloving over the nasal
dorsum, upper lateral cartilages, and premaxilla (periosteal elevator through
intercartilaginous incision). Surgical
aspects of septal perforation. Completing midfacial degloving. A is the nasal bone, B is the
upper lateral cartilages, C is the infraorbital nerve, D is the anterior septal angle, and E is soft
tissue lateral to the pyriform aperture being divided by electrocautery.

A 2-stage procedure is performed for perforations larger than 2 cm or when additional

endonasal mucosa is needed for closure. First, tissue expanders are placed bilaterally under
the nasal floor mucosa. Next, the expanders are removed by means of a midface degloving
approach, and the perforation is closed by rotating the bilateral, posteriorly pedicled flaps.

Defects 0.5-2 cm

First, the nose is packed with Merocel sponges (Xomed, Jacksonville, Fla) soaked with 3 mL
of 0.25% phenylephrine solution. Then, the nasal and paranasal soft tissues are injected with
1% lidocaine with 1:100,000 epinephrine. A transcolumellar incision is made at the
columella-philtrum junction and carried inferiorly under the feet of the medial crura. It is
carried posteriorly to meet the caudal septum. Elevation of the entire columella improves
maneuverability and eliminates the lower lateral cartilages from impeding exposure. A full
transfixion incision is performed through the membranous septum over the anterior septal
angle. Columella and medial crural flaps are elevated superiorly by using a single hook to
expose the caudal septum.

By using a no. 15 scalpel or round otologic knife, the perforation is incised along its
circumference and bilateral posterior tunnels are developed. Any deviated septal cartilage or
bone is straightened or removed. Next, with a Cottle elevator, the mucoperichondrium is
elevated superiorly to the septalupper lateral cartilage junction, anteriorly to the caudal
septum and inferiorly to the maxillary crest. A transverse mucosal incision is now made from
the nasal spine across the anterior nasal sill onto the lateral pyriform aperture to the level of
the inferior turbinate insertion.
A curved Cottle elevator is now used to elevate the nasal floor and inferior meatus
mucoperichondrium posteriorly to the junction of the hard and soft palate. Dissection
continues laterally to the insertion of the bony inferior turbinate stalk and medially to the
maxillary crest. Densely adherent fibers are incised with fine scissors or a scalpel in an
anterior-to-posterior direction. After the inferior turbinate is infractured, a full-thickness
incision is carried through the inferior meatal mucosa, just inferior to the turbinate insertion.
At the posterior portion of the incision, a back-cut is made toward the nasal floor to facilitate
medialization of the posteriorly based floor and inferior meatal flaps.

Intranasal mucosa is now freed from the upper lateral cartilages and nasal floor and up to the
inferior turbinate. Posteriorly based mucosal flaps are medialized, with the inferior edge of
the perforation advanced to the superior edge. Mucosal edges are then closed posterior to
anterior using interrupted 5-0 Vicryl sutures. To reduce tension on the superior flap, a
unilateral incision may be needed in the mucosa near the junction of the septum and upper
lateral cartilage to create a bipedicled flap and allow for inferior displacement of the superior
flap.

An AlloDerm (LifeCell, Branchburg, NJ) decellularized dermal matrix graft is used as an

interposition graft between the opposing mucosal flaps. AlloDerm has several advantages,
including the elimination of donor site morbidity, an unlimited size, and convenience. The
material comes packaged in a freeze-dried form, which, on rehydration, becomes soft, pliable,
and suturable. The graft is sutured to the septal cartilage superior to the perforation on one
side with 5-0 Vicryl sutures and draped to completely cover the defect. Mucoperichondrial
flaps are placed into position, and the exposed nasal floor is covered with a previously
harvested full-thickness postauricular skin graft. The graft is secured to the nasal sill and
medialized mucosal flap with interrupted 5-0 Vicryl sutures. Placing these skin grafts over
the exposed bone of the nasal sill helps prevent vestibular stenosis.

The intercartilaginous and transfixion incisions are closed with 4-0 chromic sutures, and the
columellar incision is closed with 6-0 nylon sutures. Bilateral silastic sheeting is secured to
the flaps with a single 4-0 nylon mattress suture. Finally, both sides are packed with Telfa
pads over Merocel sponges.

Large defects

A 2-stage procedure is performed when closure requires additional endonasal mucosa,

usually with perforations larger than 2 cm. In the first stage, small tissue expanders are placed
beneath the bilateral nasal floor mucosa, with the peripheral ports placed onto the
premaxillary fossae. An incision is made in the mucosa of the anterior nasal sill and carried
laterally onto the pyriform aperture. The nasal floor and inferior meatal mucosa are raised
using a curved Cottle elevator.

A 1 X 3-cm tissue expander (PMT AccuSpan, Chanhassen, Minn) is inset into the nasal-floor
pocket. Maximal gain of 5 cm in flap length can be expected when an expander of this size is
used. Premaxillary soft tissues are elevated through the pyriform mucosal incision. Peripheral
ports are placed onto the maxilla and connected to the expander, paying particular attention to
not kink or bend the tubing. Next, 0.2 mL of sterile saline dyed with methylene blue is
instilled into the peripheral port to enlarge the expander. The mucosal incision is closed with
interrupted 4-0 chromic sutures, and no nasal pack is used.
Two weeks later, 0.5- to 1-mL aliquots of sterile saline are intraorally injected into the
peripheral port. Transcutaneous injections may be performed but typically require an
infraorbital nerve block with local anesthesia. Expansion typically requires 6-8 weekly
injections to reach a final volume of 4-7 mL.

The second stage entails a midface degloving approach to fully expose the endonasal vault
and septal perforation. Bilateral tissue expanders are removed, and posteriorly based
expanded mucosal flaps are raised and medialized. The perforation is closed (as described
earlier) over an AlloDerm graft.

Bilateral intercartilaginous incisions are connected to a complete transfixion incision.

Intercartilaginous incisions are extended laterally and inferiorly into the nasal floor and sill
region, where they are connected to the transfixion incision. Next, a complete gingivobuccal
sulcus incision is made between the right and left first upper molars by using cautery. The
osseocartilaginous nose is then degloved over the upper lateral cartilages and nasal bones. By
using sharp scissors, the gingivobuccal and intranasal incisions are connected from 1
pyriform aperture across the nasal spine to the contralateral side.

The maxillary face is stripped with a periosteal elevator, identifying the pyriform aperture
and infraorbital nerves. Tip structures and the upper lip are retracted superiorly, and the last
remaining tissue connections lateral to the pyriform aperture and upper lateral cartilages are
divided with cutting cautery. Midface degloving is now complete, isolating the nasal fossae at
the level of the pyriform apertures, nasal valve, and septal angle. The nasal tip, upper lip, and
midface are retracted superiorly and secured with 0.5-in Penrose drains.

The nasal floor and inferior meatal mucoperiosteum are elevated in a manner similar to that
previously described, with additional removal of tissue expanders and peripheral ports.
Posteriorly based expanded intranasal flaps are medialized to close the perforation (as
described above).

Midface soft tissues are reapproximated, and intranasal incisions are closed with 4-0 and 5-0
chromic sutures. A 3-0 chromic suture is used in a running fashion for the intraoral incision.
The previously described nasal pack is placed.

Postoperative Details
All packing and external splints are removed on the seventh postoperative day, but the
internal nasal silicone stent is removed at the fourth to sixth postoperative week. Patients
receive maintenance therapy with nasal saline irrigations to decrease crusting and to maintain
a moist environment for healing.

Follow-up
Septal prosthesis

Follow-up requires routine nasal irrigation and nasal toilet every few months for an indefinite
period. Forewarn patients that constant nasal toilet is required.

Surgery
Patients are examined postoperatively every week for nasal toilet until crusting subsides.

Complications
Septal prosthesis

Failures may be related to poor fit, patient intolerance, or poor hygiene. They occur usually
within the first few months. Any mobility of the button may lead to enlargement of the
perforation.

Surgery

Potential postoperative complications include repeat perforation, vestibular stenosis, nasal

deformity, and oronasal fistula.

Outcome and Prognosis

Septal prosthesis

In 22 patients from 2 institutions (ie, New York Eye and Ear Infirmary, University of
California Medical Center), septal prosthesis were placed in conjunction with septoplasty.
Successful maintenance has been achieved for as long as 21 years in 21 patients. One patient
required removal of the prosthesis secondary to complaints of pressure against the junction of
the upper lateral cartilage and septum. Two patients underwent reinsertion of new prostheses
because the original prostheses were too small and were expelled during sneezing.

Surgery

Thirty-six patients have undergone repair by using 1 of the 2 approaches: (1) Fourteen
patients underwent extended external rhinoplasty, with total closure noted in 13 patients
(93%). One patient had a small inferior septal perforation; at 1 year after surgery, this patient
underwent second closure for symptomatic whistling. (2) Twenty-two patients underwent
midfacial degloving, and 18 (82%) were had total closure at 1 year. Four patients had repeat
perforation at the posterior superior margin. However, to date, none has required revision.
Other than repeat perforation, no clinically significant complications including vestibular
stenosis, nasal deformity, and oronasal fistula, were encountered.

Moon et al in 2010 describe predictive factors for the outcome of nasal septal perforation in
35 patients. Data showed nasal obstruction, crusting, and epistaxis are the most common
preoperative symptoms. The study found a reperforation rate of 48% which was associated
with both large size and unilateral mucosal flap coverage. This study may suggest that
bilateral flap coverage improved outcomes. The study examined an assortment of graft types
and materials and saw no relationship with outcome. Overall, patients had improvement in
epistaxis and whistling, but remained with a complaint of nasal obstruction. Symptom
improvement was negatively correlated with large perforation, nasal trauma, and a history of
prior nasal surgeries.[18]
Rokkjaer et al looked at perforations of less than 2.5 cm and found good results after
endonasal cartilage closure of nasoseptal perforation. The techniques varied in endonasal
approach and included bilateral bipedicled mucoperichondrial-periosteal advancement flaps
as well as interposition of septal or conchal cartilage graft. They evaluated 19 patients with a
mean perforation size of 13 mm. They showed 95% symptomatic improvement and a 16%
reperforation rate in this group. No graft donor morbidity was noted.[19]

Future and Controversies

In 1997, Murrell et al described the first reported use of a radial forearm fascial free flap for
repair of a septal perforation in a 24-year-old man.[20] The authors used an external
septorhinoplastic approach with a left lateral alotomy. The radial artery was anastomosed to
the facial artery, and paired venae comitantes were anastomosed to 2 branches of the facial
vein. An advantage of this technique is an abundance of thin, pliable, highly vascular tissue
that carries its own blood supply. It may be used with or without a cutaneous component.
Disadvantages of this technique include the technical expertise needed to perform the
procedure and donor-site morbidity.

New variations on already described techniques are likely. No single technique has been
standardized, but all successful repairs share similar basic principles. Advances in other
rhinological procedures may modify current techniques for septal perforation closure . Tami
et al recently reported the use of bioresorbable staples for mucoperichondrial flap coaptation
in septoplasty. Although this has not been specifically reported in the closure of
mucoperichondrial flaps during septal perforation, it may be preferred to the quilting stitch by
some surgeons.[21] Each surgeon should perform the technique with which he or she is most
comfortable and which yields the optimal success rate with the fewest complications.