Nasal Septal Perforation Repair Using an Inferior

ARTICLE

Nasal Septal Perforation Repair Using an Inferior Turbinate Flap Shaun J. Kilty, MD, Peter J. Brownrigg, MD, FRCSC, and Ali Safar, MD Rationale: Nasal septal perforation repair presents a challenging problem to the otolaryngologist. Numerous surgical techniques for the repair of this nasal defect have been described. Although the literature describes great success using the advancement of local mucoperichondrial flaps, it is often difficult to reproduce these results, especially for the closure of larger defects. Objective: To describe both the technique and the results of the senior author (P.J.B.), using a pedicled inferior turbinate flap for the closure of a nasal septal perforation in 20 patients. Design: A retrospective case series of 20 consecutive adult patients treated from 2000 to 2005 inclusive. Methods: A retrospective chart review was conducted of the 20 patients treated at the local tertiary care centre over the 5-year period. Results: In 20 consecutive patients who were operated on by the senior author, the minimum perforation size was 1 3 1 cm and the average area of the perforation was 2.4 cm2. Overall, 80% of the perforations treated in this series were completely closed. Conclusion: The pedicled inferior turbinate flap is a valuable technique for the closure of a nasal septal perforation. Key words: inferior turbinate flap, nasal septum, perforation

eptal perforation is not an uncommon presenting problem to many otolaryngologists. Patients often present with complaints of nasal obstruction, recurrent epistaxis, noisy breathing, frequent nasal crusting, and even headache.1–3 Numerous etiologies for this clinical problem have been described, with a significant proportion being of a traumatic origin.1,2 Treatment options to be considered by patients with nasal septal perforation include daily nasal hygiene and lubrication, a nasal septal button, and some form of surgical management. Complete surgical closure of large defects of the anterior septum is very difficult to achieve. The plethora of surgical techniques used to manage this problem have been reviewed elsewhere.1,4,5 The overabundance of surgical techniques is likely indicative of the reliability of each technique.6 Successful closure using an inferior turbinate flap has been described by others.2,3,6–9

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Received Shaun J. Kilty, Peter J. Brownrigg, and Ali Safar: Department of Otolaryngology, The Ottawa Hospital, Ottawa, Ontario. Presented at the Canadian Society of Otolaryngology- Head and Neck Surgery 59th Annual Meeting, St. John’s, NF, June 19–22, 2005. Address reprint requests to: Dr. Peter J. Brownrigg, Department of Otolaryngology, The Ottawa Hospital, 737 Parkdale Avenue, Suite 305, Ottawa, ON K1Y 4E9. DOI 10.2310/7070.2005.0168

We describe both the technique and the results of the senior author (P.J.B.) using an inferior turbinate mucosal flap for the closure of an anterior septal perforation in 20 consecutive patients.

Materials and Methods We performed a retrospective chart review of the 20 consecutive patients who underwent anterior nasal septum perforation repair using an inferior turbinate mucosal flap from 2000 to 2005 inclusive. Septal perforation closure, complications, and outcome were assessed. Under general anesthetic, the nasal septum and inferior turbinates were injected with 1% lidocaine with 1:100 000 epinephrine solution. The nose was decongested using 5 mL of 4% cocaine on cotton nasal pledgets. All patients received both intraoperative and postoperative antibiotics. After 5 minutes, the nasal cavities were examined. The septal perforation was examined for size. The most appropriate inferior turbinate was chosen for the surgical procedure, according to its size and location. This turbinate was then medialized and dissected from the lateral wall posteriorly to anteriorly, leaving the anterior quarter attached to the lateral nasal wall (Figure 1). The mucosa around the perforation was then incised circumferentially approximately 3 to 4 mm from its edge. This mucosa was reflected inward towards the perforation, thus

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Figure 1. Medialization and division of the inferior turbinate from the lateral nasal wall.

reducing the overall size of the perforation while providing a vascular bed for the turbinate flap (Figure 2). The posterior portion of the turbinate was delivered forward, and its mucosa was then splayed to provide the maximum surface area. The conchal bone was removed. The inferior turbinate flap was then positioned to occlude the perforation using simple interrupted 5-0 Vicryl sutures

Figure 3. The flap covers the perforation and is sutured using 5-0 Vicryl.

(Figure 3). This was augmented with a quilting stitch of 40 plain cat gut (Figure 4). Silastic splints were subsequently placed bilaterally to prevent synechiae and maintained in position with 3-0 polypropylene. Small Telfa packs were placed in each nasal cavity and were subsequently removed in surgical day care. The nasal splints were removed 1 week postoperatively in the clinic. Division of the pedicle was done under general anesthesia at least 3 weeks after the primary procedure. This allowed for the posterior margin of the turbinate flap to be trimmed, inset, and sutured to the septum.

Results Figure 2. Circumferential mucosal incision. Inward reflection of the septal mucosa.

Twenty patients (14 males, 6 females) underwent closure of their nasal septal perforation using the inferior turbinate

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Table 2. Preoperative Symptoms Symptom Crusting Epistaxis Headache Nasal obstruction Rhinorrhea Whistling

Figure 4. Quilting stitch of 4-0 plain gut.

flap technique from 2000 through 2005. The mean patient age was 43 years. The mean follow-up period was 7.6 months. The most commonly reported preoperative symptom was nasal obstruction (90%). Other commonly reported symptoms (Table 1) were nasal crusting (65%), whistling (55%), and epistaxis (55%). Predisposing factors for the development of septal perforation in our patient population are listed in Table 2. For those patients in whom the etiology of the septal perforation was unclear, testing for Wegener’s granulomatosis was done with a perinuclear or circulating antineutrophil cytoplasmic autoantibody, chest radiography, and/or nasal biopsy. In all patients, the testing was negative for Wegener’s granulomatosis. Six patients (30%) had tried treatment with a septal button, but none wanted to continue its use because they experienced ongoing discomfort. Only two (10%) patients had attempted surgical management of their perforation. One had the perforation purposely enlarged to prevent Table 1. Etiology of the Septal Perforation Etiology Cautery Cocaine abuse Nose picking Septal surgery Trauma Undetermined

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whistling, whereas the other had a mucosal advancement flap that failed. In all patients, the septal perforation was 1 3 1 cm in size or larger, with the largest measuring 3 3 2.5 cm. The mean perforation area was 2.4 cm2. The left inferior turbinate was used for two-thirds of all septal perforation repairs (Table 3). Of the 20 septal perforation repairs that were done, 13 (65%) were completely closed following division of the pedicle. Of the seven patients who had a residual perforation, two had small, millimetre-sized perforations that were closed with a local mucosal advancement flap that provided complete closure on follow-up. One patient was treated successfully with a second inferior turbinate flap for incomplete closure. Of the remaining four patients, two were treated with a septal button and the other two with daily nasal hygiene and medical therapy. No patient developed atrophic rhinitis following septal perforation repair. One patient developed a synechiae postoperatively, which was surgically excised.

Discussion Surgical closure of an anterior septal perforation can be a challenging undertaking. With the variety of techniques reported in the literature, obviously, no particular technique is universally successful. The senior author’s technique and experience have been reviewed. Although closure using the inferior turbinate flap technique initially allowed for complete closure of only 65% of the septal perforations, revision surgery in three patients allowed for closure of 80% of all septal perforations treated in this series.

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Table 3. Inferior Turbinate Flap Used for Perforation Repair Turbinate Flap Left Right Bilateral


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The results of other authors are comparable to our own. An initial series by Masing and colleagues reported a success rate of nearly 75% using an inferior turbinate flap for closure of a septal perforation.7 Vuyk and Versluis, using a variation of Masing and colleagues’ technique, were able to completely close only 30% of their perforations.3 Murakami and colleagues, using a technique similar to our own, were able to completely close three of the eight nasal septal perforations they repaired (38%).9 Two other patients in their series had residual pinpoint perforations following this repair but were symptom free. No patients in this study developed atrophic rhinitis or ozena. One patient complained of nasal obstruction postoperatively, which resolved with take-down of the pedicle. Friedman and colleagues successfully closed 7 of the 10 nasal septal perforations that they treated, after a minimum of 18 months’ follow-up.6 Again, as in Murakami and colleagues’ series, one patient complained of postoperative nasal obstruction, which, with further modification, resulted in flap failure. Lastly, Ayshford and colleagues, using a dermal allograft with an anteriorly based inferior turbinate flap, were able to close 76% (13 of 17) of their patients’ septal perforations using an endoscopic technique.2 One patient complained of nasal obstruction following pedicle takedown, which subsequently resolved on its own with time. The inferior turbinate flap technique has the advantage of bringing tissue with a hearty vascular supply into the septal defect. Padgham and Vaughan-Jones demonstrated the rich arterial network of the inferior turbinate coming from both a descending branch of the sphenopalatine artery posteriorly and a branch of the facial artery adjacent to the piriform aperture anteriorly.10 A second advantage of this flap is the volume of tissue that is available for transfer. Murakami and colleagues showed in a small cadaver study that, on average, the inferior turbinate mucosa has a surface area of nearly 5 cm2.9 It is likely that defects much larger than 3 cm2 cannot be closed with a single flap because of the loss of tissue to the pedicle. However, the wide arc of rotation of this flap and the few complications that have occurred with its use make it a popular choice. Unique to the senior author’s technique was the elevation and inward reflection of the nasal septal mucosa to both decrease the perforation size and to reduce

the surface area of the flap that must heal by secondary intention. The main drawbacks of the inferior turbinate flap, as used in this study, are the requirement of a second stage, the nasal obstruction that occurs prior to the second stage, and the requirement of the raw surface of the flap to heal by secondary intention.

Conclusions Although it is a two-stage procedure, an anteriorly based inferior turbinate flap repair does provide a reasonable success rate for the treatment of a nasal septal perforation. In this series and others,2,3,6–9 it has not resulted in significant complications or morbidity. The anteriorly based inferior turbinate flap repair is a useful technique for a moderate-sized nasal septal perforation. The procedure is relatively straightforward and provided consistent results. This method provides yet another option for surgical management of a nasal septal perforation.

References 1. Kridel RWH. Septal perforation repair. Otolaryngol Clin North Am 1999;32:695–724. 2. 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 2003;28:29–33. 3. Vuyk HD, Versluis RJJ. The inferior turbinate flap for closure of septal perforations. Clin Otolaryngol 1988;13:53–7. 4. Karlan MS, Ossoff RH, Sisson GA. A compendium of intranasal flaps. Laryngoscope 1983;92:774–82. 5. Cogswell LK, Goodacre TE. The management of nasoseptal perforation. Br J Plast Surg 2000;53:117–20. 6. Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope 2003;113:1425– 8. 7. Masing H, Gammert C, Jaumann MP. Our concept concerning treatment of septal perforations. Laryngol Rhinol Otol 1980;59:50– 6. 8. Berinstein TH, Bernstein P. The turbinate flap for reconstruction of nasal septal mucosal defects. Laryngoscope 1996;106:1047–8. 9. Murakami CS, Kriet JD, Ierokomos AP. Nasal reconstruction using the inferior turbinate mucosal flap. Arch Facial Plast Surg 1999;1: 97–100. 10. Padgham N, Vaughan-Jones R. Cadaver studies of the anatomy of arterial supply to the inferior turbinates. J R Soc Med 1991;84:728– 30.


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