Septal perforation repair: mucosal regeneration ... - Springer Link

Eur Arch Otorhinolaryngol (2012) 269:2505–2510 DOI 10.1007/s00405-012-1964-0

RHINOLOGY

Septal perforation repair: mucosal regeneration technique Alper Yenigun · Aysenur Meric · Aysegul Verim · Berke Ozucer · Husamettin Yasar · Murat Haluk Ozkul

Received: 6 November 2011 / Accepted: 3 February 2012 / Published online: 15 February 2012 © Springer-Verlag 2012

Abstract A novel method for repair of septal perforations. Fifteen volunteers with symptomatic septal perforations were recruited. Open technique rhinoplasty approach was preferred: auricular conchal cartilage graft with intact perichondrium on both sides was harvested and shaped to Wt the perforated site and attached to the septum with absorbable sutures. All margins of the graft were covered with nasal mucosa. The severity of patient symptoms was assessed at preoperation, 3 and 6 months postoperatively via visual analogue scale (VAS). Crust formation, whistling, nasal blockage, epistaxis and overall comfort were evaluated. Mucosal physiology was assessed by nasal mucociliary clearance time. The mean age of the patients was 47.3 years. Average perforation size was 1.86 § 0.78 cm. 14/15 (93.3%) perforations were repaired, and only one patient required revision surgery. VAS scores improved signiWcantly (p < 0.001). Mean mucociliary clearance time improved from 17.6 § 3.83 to 10.3 § 3.30 min and 9.3 § 3.36 min at 3 and 6 months, respectively. This is a novel, simple and safe method for repairing the deWcient mucosal area in septal perforations up to 25 mm in diameter.

A. Yenigun · A. Meric · B. Ozucer (&) Department of Otorhinolaryngology and Head and Neck Surgery, Medical Faculty, Bezmiâlem Vakif University, Fatih, Istanbul, Turkey e-mail: [email protected] A. Verim Otorhinolaryngology Clinic, Haydarpasa Training and Research Hospital, Haydarpasa, Istanbul, Turkey H. Yasar · M. H. Ozkul Otorhinolaryngology Clinic, Haseki Training and Research Hospital, Haseki, Istanbul, Turkey

Keywords Septal perforation · Nasoseptal perforation · Mucosal regeneration

Introduction Main purpose of septal perforation repair is to relieve patient’s symptoms, restore the normal nasal mucosa and provide laminar air Xow. Surgical treatment options available for the closure of nasal septal perforations are based principally on the repair of the deWcient nasal mucosa with or without interposed grafts. There is a wide range of operative techniques that vary in complexity with diVerent approaches, such as open or endonasal to gain access to the perforation site. Diverse rotational or advancement Xaps from the adjacent area are designed to repair the mucosal lining. These include sublabial mucosal Xaps [1], bipedicled mucosal advancement Xaps [2], inferior turbinate Xap pedicled anteriorly [3], bullous middle turbinate pedicle Xap [4] and facial artery musculomucosal pedicled Xaps [5]. Titanium membrane [6], irradiated homograft costal cartilage [7, 8] acellular human allograft [9], radial forearm fascial free Xap [10], porcine small intestine mucosa [11], temporal fascia graft, mastoid periosteum, septal bone, conchal cartilage [12] are the graft materials interposed between the mucosal Xaps to complete the perforation closure. Feasible techniques that have high success rates even in less experienced hands are preferred; however, the operative techniques for septal perforation repair described in the literature are time-consuming, diYcult to master, require experience and the success rate is not always achievable by others.

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The composition of the nasal septum consists of a layer of mucosa and perichondrium on each side and interposed cartilage between the mucoperichondria. Therefore, an adequate repair of the septum should incorporate all these layers. Bilateral reconstruction of the mucosal linings and interposed cartilage in between with intact perichondrium on both sides appears to be the ideal method to repair septal perforations. In addition, auricular conchal cartilage with bilateral perichondrium is suitable for septal cartilage reconstruction for an ideal graft material which is deWned with biocompatibility, low complication rate and stable for a long time [13]. The nasal cavities have to be lined by intact mucosa for normal respiration, smelling, Wltering and conditioning. Defects and perforations of the original mucosal surfaces’ alters the physiology and lead to functional disturbances. In this respect, we enhanced a novel method for repair of septal perforations with sizes ranging from 15 to 25 mm based on the regeneration ability of the original mucosa to recover.

Materials and methods The present study was conducted at Bezmialem VakÂf University, Medical Faculty, Otorhinolaryngology Department according to Helsinki Declaration (WMA 2010). All procedures were carried out under informed consent with the approval of University Ethics Committee and in accordance with the guidelines of the National Health and Medical Research. All volunteers were provided with adequate information about the procedures and written informed consents were taken before study. Fifteen volunteers with symptomatic septal perforations smaller than 25 mm were recruited from May 2008 to August 2010. Volunteers were questioned for aetiological factors. Chronic granulomatous diseases, systemic diseases, such as hypertension and diabetes, smoking, chemical addiction and exposure to heavy metal acid fumes were criteria of exclusion. Nasal endoscopic examination Perforations were examined with 0° endoscope prior to surgery. Localization of the perforation was noted and the largest dimension of the perforation was measured with a Xexible ruler to the nearest millimetre (Fig. 1). Follow-up controls were carried out at Wrst week, at 3 and 6 months postoperatively. Total closure without any residue was evaluated as a successful result. Visual analogue scale The severity of patient symptoms was assessed at pre, at 3 and 6 months postoperatively via visual analogue scale

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Eur Arch Otorhinolaryngol (2012) 269:2505–2510

Fig. 1 Endoscopic measurement of perforation size

(VAS). VAS is a horizontal line marked from 0 to 10. 0 minimal symptoms is located at left end and 10 maximal symptoms located at right end of the line. Patients were asked to mark Wve parameters separately based on Wve symptoms: crust formation, whistling, nasal blockage, epistaxis and overall comfort. Data analysis was carried out based on the separate sub-scores and total (mean § SD) scores. Mucociliary clearance time Nasal mucosal physiology was assessed by nasal mucociliary clearance time (MCT) measurement by means of the saccharin test. 1 mm3 saccharin was placed antero-inferior to the inferior turbinate, duration between application of saccharin to perception of saccharin taste was recorded. Nasal MCT measurement was repeated 6 months postoperatively, measurements were compared statistically with preoperative values. Surgical technique Procedure was performed under general anaesthesia. Nasal mucosa was decongested with nasal packing soaked with 1:10,000 adrenaline diluted in 2 ml of saline solution preoperatively. InWltration anaesthesia was carried out with 6 ml of lidocaine hydro chloride 20 mg/ml and epinephrine 0.0125 mg/ml applied to septum and nasal dorsum. Transcolumellar inverted V incision was applied and dorsal skin Xap was elevated. Open technique rhinoplasty approach was the preferred method for each volunteer. Upper and lower tunnels were formed by meticulous elevation in the submucoperichondrial plane on both sides of the septum. The perforation edges were trimmed to ensure the neovascularization. This procedure is similar to desepithelization of the tympanic membrane as in a tympanoplasty operation. Diameter of the septal defect was


Fig. 2 Harvesting auricular cartilage via anterior approach

measured intraoperatively following elevation of the mucosa and a viable interposition graft was harvested from the auricular conchal cartilage with perichondrium via anterior approach based on these measurements (Fig. 2). The graft was just shaped to Wt the cartilaginous and osseous defect and attached to the remnants of septal cartilage and bone with 4-0 absorbable polydioxanone (PDS) sutures. Elevated superior and inferior mucosal Xaps’ edges were left to spontaneous regeneration and mucosalization on the auricular conchal cartilage graft with intact perichondrium on both sides like cartilage island technique in tympanoplasty operation without tension and using sutures (Fig. 3). Rotational or advancement Xaps were not intended to avoid alteration in blood supply. Bilateral intranasal tamponing was performed bilaterally by thin and soft silicone stent over 3 mm width gelfoam soaked in antibiotic ointment. Patients were discharged from the hospital on Wrst postoperative day, nasal splints were kept for 10 days. Donor site was sutured with 5-0 polypropylene suture. Hydrophilic cotton pad impregnated in saline solution was placed over the curvature of the pinna and mastoid dressing was applied for 1 week. Systemic antibiotics were prescribed postoperatively. As long as the packings were kept in the nasal cavities, mupirocin nasal ointment and saline sprays were applied twice a day to control humidity and bacterial infection. Statistical analysis Data analysis was carried out using SPSS version 17.0 software system (SPSS, Inc., Chicago, IL, USA). The results

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Fig. 3 Inferior and superior mucosal Xaps move on the auricular conchal cartilage graft with intact perichondrium on both sides and regeneration occurs

were calculated as mean § standard deviation (SD) and Friedman test followed by Dunn test was used for statistical analysis. p < 0.05 was accepted as statistically signiWcant.

Results Mean age of the patients was 47.3 § 12.20 (mean § SD, range 32–67) years, six were females (40%) and nine were males (60%). Male patients were 46.8 § 12.70 (mean § SD, range 32–67) years old, whereas female patients were 48.2 § 12.54 (mean § SD, range 33–66) years old. Most common aetiological factor was former nasal surgery in 8 (53%) patients, followed by nasal trauma in 3 (20%) patients. 4 (27%) of 15 perforations were idiopathic. Preoperative endoscopic measurements revealed average perforation size of 1.86 § 0.78 cm (mean § SD, range 0.40–2.50). Postoperative examinations at 3 and 6 months postoperatively disclosed 14/15 (93.3%) total repairs without any residue (Fig. 4), only one patient was not successfully repaired and required revision surgery. Each patient was followed for 1 year postoperatively. Patient symptom scores improved signiWcantly on VAS evaluations at 3 and 6 months postoperatively as compared to preoperative scores (p < 0.001). Epistaxis score reduced from 1.7 to 1.0 and crust formation score reduced from 3.3 to 1.7 but improvement was not signiWcant (p > 0.05). VAS subscore analysis is further detailed in Table 1. Intragroup comparison of VAS scores identiWed overall comfort to be the less improved symptom after perforation repair. Improvement in whistling and epistaxis were excellent, whereas crust formation, nasal blockage and overall comfort showed less improvement (Fig. 5).

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Mean preoperative mucociliary clearance time was 17.6 § 3.83 (mean § SD, range 10–25) min. Mean mucociliary clearance time improved to 10.3 § 3.30 (mean § SD, range 7–20) min and 9.3 § 3.36 (mean § SD, range 6– 19) min at 3 and 6 postoperative months, respectively.

When comparing with postoperative results, preoperative mean nasal mucociliary clearance time was lower as compared to postoperative values, and the diVerence was statistically signiWcant (p < 0.05).

Discussion

Fig. 4 Total closure of the perforation after surgical repair

The open rhinoplasty approach was preferred for the reasons that it oVers better view, easy access, wide exposition of surgical Weld and ambidexterity during surgery [4, 14]. HemitransWxion incision and mucoperichondrial tunnel elevation during closed approach risks integrity of the blood supply to mucosa and mucosal integrity. Septal reconstruction and rhinoplasty in the presence of dorsal saddling or an external deformity is also possible with open approach. Open approach has its disadvantages, such as longer operative time, greater blood loss and potential development of a columellar scar. The greatest disadvantage of the open rhinoplasty technique is columellar scar formation [16]. However, authors experienced on open approach does not report unsatisfactory scar formations with meticulous suturation [17].

Table 1 Preoperative and postoperative VAS sub-scores (mean § SD) Symptom

Preoperative score (range)

Postoperative third month score (range)

Postoperative sixth month score (range)

Crust formation

7.0 § 1.20 (5–9)

3.3 § 0.90 (2–5)

1.7 § 0.82 (1–3)

Whistling

5.9 § 1.44 (3–8)

1.1 § 0.26 (1–2)

1.1 § 0.26 (1–2)

Nasal obstruction

4.7 § 1.67 (3–8)

2.4 § 0.74 (1–3)

2.4 § 0.74 (1–3)

Epistaxis

5.6 § 1.64 (3–8)

1.7 § 0.70 (1–3)

1.0 § 0.00 (1–1)

Overall comfort

7.9 § 1.60 (6–10)

4.2 § 1.37 (2–6)

3.1 § 0.99 (2–5)

Overall symptoms

6.4 § 1.51

2.5 § 0.79

1.9 § 0.56

Improvement from postoperative third to postoperative sixth month was not statistically signiWcant (p > 0.05) Postoperative third month scores improved signiWcantly compared to preoperative scores (p < 0.001) Postoperative sixth month scores improved signiWcantly compared to preoperative scores (p < 0.001)

Fig. 5 Preoperative and postoperative VAS scores

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We preferred the auricular conchal cartilage graft with intact perichondrium on both sides. It was designed to be exactly equal to the surface of the perforation so that when sutured to the remnants of the septum it was in continuity with the rims of the septal defect. All margins of the graft were covered with nasal mucosa surrounding the perforation. Neither incisions nor sutures were performed to protect the mucoperichondrial vascularity. We primarily intended to escape every potential impairment of the wound’s nourishment and to preserve the viability of the mucosa. Multiple techniques with advancement or rotational Xaps are designed by diverse authors to suture the perforated edges [18, 19]. Main intention was self mucosalization with the adherent support of the cartilage and perichondrium from below. To prevent damage to the mucosal microcirculation, we intended to escape potential impairment of the wound’s vascularization and to preserve the viability of the mucosa. This procedure resembles the epithelization process of the perforated tympanic membrane repaired with perichondrium cartilage island graft technique. Synthetic alloplastic implants are not well tolerated by the nose; they induce foreign body response and have high rates of infection and extrusion [20]. Autologous materials remain the preferred graft material for use in rhinoplasty since they have high biocompatibility, low metabolic requirements, and low risk of extrusion. In addition, autologous cartilage grafts do not evoke immunogenic and inXammatory reactions [21]. In these respects, autografts were conWrmed to be materials preferred in our septal perforation repair. Our primary intention to utilise auricular conchal cartilage as an interposition graft was to provide a cartilage graft covered with perichondrium on both sides. The cartilage and perichondrium apart from their properties of being supportive frame for the defective septum are also mutual nutrients’ providers and are resistant to resorption. The perichondrium when correctly juxtaposed enables the vascular continuity from the adjacent tissues. Once revascularized, it ensures the blood Xow to the cartilage and produces new cartilage cells due to its inner chondrogenic layer containing cells which will transform later on to chondrocytes [22]. Studies with septal perforation patients elicited that the regeneration duration of a total layer injury of the nasal mucosa continues up to 3 months [9]. Papers on the neomorphogenesis of cartilaginous tissue deWne the period of time needed for the completion of the chondroneogenesis to be longer than the mucosalization time [23]. Therefore, thin silicone sheeting over the gelfoam are kept for 10 days to stabilize the interposition graft until the mucosalization completes. This may be compared with the external ear

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canal packing in a tympanoplasty operation until the tympanic membrane epithelizes. The problems to be faced when using the auricular conchal cartilage as an interposition graft are curved shape of the graft, the decrease in the growth potential of the cartilage, the necessity for an extra-surgical procedure, additional operative time and donor site morbidity [24]. Distinctively from the majority of recent scientiWc papers, symptoms’ outcomes after septal repair were evaluated via VAS. We observed that the repair of medium sized perforations have a very positive eVect on symptoms improvement. There is a lack of assessment of the mucosal physiology after perforation repair in the literature; nasal mucosal physiology was evaluated with mucociliary clearance time measurements and observed a similar improvement on mucosal function. Preoperative longer MCT values in this study is probably due to nasal obstruction caused by the turbulent airXow resulting from septal perforation and compensatory hypertrophy of the lower turbinates. Improvement on MCT scores at 3 and 6 months was interpreted as the evidence of recovered laminar air Xow following perforation repair [15]. A wide variety of Xaps have been used to repair septal perforations including unilateral or bilateral, unipedicled or bipedicled, and anteriorly or posteriorly based Xap designs. There is not a particular method superior to others, each technique has its own advantages and shortcomings. Goh and Hussain in their reports mentioned in detail about these techniques and emphasized the importance of the Xap’s blood supply and advised to perform unilateral Xap to leave less exposed septal area [12]. In this respect, the inferior turbinate Xap provides a very strong vascularity to perforation sides [25, 26]. However, the success rate of this operation does not exceed 80%, the voluminous structure of the inferior turbinate gives rise to a secondary nasal obstruction and needs another stage to separate the pedicle. Apart from all these complex manipulations, our technically easier method avoids the detrimental eVect of a Xap elevation on the vascularity of the residual mucosa. With a shorter operative time, we gained lower risk of complication. Our treatment rates in terms of perforation closure were as high as 93%. We may deduce that operative closure of nasal septal perforation oVers more enthusiastic and deWnitive results for symptomatic patients. The only problem in our study was in one patient. Quite likely, there was a displacement of the interposed graft due to incomplete Wxation to the residual septum. Symptoms and nasal physiology were improved in all patients signiWcantly at third postoperative month and the healing process was stabilized in the follow-up periods. In the context of mucociliary clearance, our study presented an additional parameter to recent literature on septal perforations.

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This technique without sutures for mucosa is unique among all perforation repairs using sutures that are technically diYcult to perform. This is an approach with minimal mucosal elevation and easy to achieve regarding the techniques with challenging Xaps. In the context of cost-eVectiveness, safety and tissue compatibility, this method that provides grafts from the patient’s own ear may be preferred as an excellent method with good results. In this study, we did not investigate the histological aspect of the newly created septal mucosa. In the future, histologic study can be done on newly created septal mucosa and observe whether it is scar or functioning respiratory mucosa. Therefore, the reason for persistent crusting, nasal blockage and the nasal comfort which did not improve enough would be explained.

Conclusion The mucosal regeneration technique introduce a new standpoint to perforation repair. This is a novel simple and safe method for repairing the deWcient mucosal area in septal perforations up to 25 mm in diameter. However, when interpreting the data, caution must be exercised due to the relatively small number of patients included here. A larger study is required to further validate our Wndings. With further experience, we expect to get more promising results in the future. ConXict of interest

None.

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