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Inicio Acta Otorrinolaringológica Española Surgical treatment of nasal septal perforations: SIR (Italian Society of Rhinolo...
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Vol. 68. Núm. 4.
Páginas 191-196 (Julio - Agosto 2017)
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Vol. 68. Núm. 4.
Páginas 191-196 (Julio - Agosto 2017)
Original article
DOI: 10.1016/j.otorri.2016.10.001
Acceso a texto completo
Surgical treatment of nasal septal perforations: SIR (Italian Society of Rhinology) experts opinion
Tratamiento quirúrgico de las perforaciones del tabique nasal: una opinión de los expertos de la SIR (Sociedad Italiana de Rinología)
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Desiderio Passalia,
Autor para correspondencia
d.passali@virgilio.it

Corresponding author.
, Maria Carla Spinosia, Lorenzo Salernia, Michele Cassanob, Hugo Rodriguezc, Francesco Maria Passalid, Luisa Maria Bellussia
a ENT Clinic, Policlinico S. M. alle Scotte Siena, Italy
b ENT Clinic, Azienda Ospedaliera Universitaria di Foggia, Italy
c ENT Clinic, Hospital Nacional de Pediatría Juan P. Garrahan, Buenos Aires, Argentina
d ENT Clinic, Policinico Tor Vergata, Roma, Italy
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Table 1. The International Study Group.
Table 2. Questionnaire.
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Abstract
Background and aim

The aim of our study has been to investigate the perception of aspects related to nasal perforation among experts in Rhinology and ENT surgeons. Our aim was reporting the situations in different Countries to improve the knowledge of colleagues interested in this topic.

Methods

A panel of experts prepared a 20-question questionnaire regarding nasal perforations and their surgical repair, that were emailed to all the members of SIR (Società Italiana di Rnologia – Italian Society of Rhinology).

Results

Data obtained from their answers showed that Cottle technique (64%) is the most common technique to perform septoplasty worldwide. 37% of the sample reported an occurrence of nasal septal perforation in less than 1% of patients and 75% attributed this occurrence to the skill of the surgeon, to infections, to drug use and to septal deformity. Trauma, pressure and Wegener's granulomatosis were also mentioned. The most common closure technique is the mucosal flap (75%), followed by the cartilage grafts (11%). Much less common were oral flaps, septal buttons and others. The majority agreed not to suggest septal perforation surgery in minimal (less than 3–4mm) perforations (73.5%), or limiting it to symptomatic patients (43.5%). The contraindications to repair surgery were reported to be: Wegener's granulomatosis, drug abuse, non-symptomatic perforation, its dimension and age of the patient. Septal deviation, atrophic rhinitis, smoke epistaxis and systemic diseases were also claimed. Failure in repair surgery has been observed to occur in less than 30% of cases.

Discussion and conclusions

Given the great difficulty to make random studies about controversial topics and obtain statistically significant data related to that, expert opinion shall be of great value (expert opinion, level of evidence 5)

Keywords:
Nasal septum
Nasal septal perforations
Nasal septal perforation surgery
Resumen
Antecedentes y objetivo

El objetivo de nuestro estudio ha sido investigar la percepción de aspectos relacionados con la perforación nasal entre los expertos en cirugía nasal e informar sobre la situación en diferentes países para mejorar el conocimiento de los colegas interesados en este tema.

Métodos

Un panel de expertos preparó un cuestionario de 20 preguntas sobre las perforaciones y su reparación quirúrgica, que fue enviado por correo electrónico a todos los miembros de la Sociedad Italiana de Rinología (SIR).

Resultados

Los datos obtenidos de sus respuestas mostraron que la técnica de Cottle (64%) es la técnica más común para realizar la septoplastia, el 37% de la muestra informó de una ocurrencia de perforación del tabique nasal en menos del 1% de los pacientes y el 75% atribuye este hecho a la habilidad del cirujano, a las infecciones, al consumo de drogas y a las deformidades del tabique. Los traumatismos y la granulomatosis de Wegener también se mencionaron. La técnica de cierre más común es el colgajo de la mucosa (75%), seguido por los injertos de cartílago (11%). La mayoría estuvo de acuerdo en no sugerir la cirugía del tabique en perforaciones de menos de 3-4mm o limitándola a los pacientes sintomáticos (43,5%). Las contraindicaciones de cirugía de reparación son: la granulomatosis de Wegener, la drogadicción, la perforación no sintomática y la edad del paciente.

Discusión y conclusiones

Es muy difícil hacer estudios sobre este tema tan controvertido, la opinión de expertos será de gran valor (nivel de evidencia 5).

Palabras clave:
Tabique nasal
Perforaciones del tabique nasal
Cirugía de las perforaciones del tabique nasal
Texto completo
Introduction

A nasal septal perforation is defined as a defect in the continuity of the mucosal, cartilaginous or osteocartilaginous septum, allowing direct communication between the two nasal cavities impairing nasal function. Nasal septal perforation can be classified according to size and location (anterior, middle and posterior), which may be related to a variety of symptoms. This anatomic defect alters physiologic laminar airflow,1 and the producing turbulent air flow causing associated complaints.2 Small perforations (5mm or less) are often asymptomatic but might cause whistling sounds, while larger perforations (1cm or larger) are frequently associated with crusting, bleeding, impairment of nasal air flow, with the sensation of nasal airway obstruction and that of a foreign body, as well as feeling of dryness, pressure, discomfort and pain.3 The occurrence of the above-listed symptoms is more likely when the perforation is anterior (closer to the nostrils).

The prevalence of nasal septal perforations is estimated at 1%4 and might be due to long-term topical drugs application, including either cocaine or the overuse of nasal decongestant/constrictors, or idiopathic and iatrogenic causes, such as septoplasty or combined septorhinoplasty as well as chronic epistaxis with aggressive cauterization. Other less common causes of nasal septal perforation neoplasms, tuberculosis, granulomatous inflammatory conditions like Wegener's and chemotherapy.3

Non-symptomatic perforations are usually easily managed even if the perforation persists. In case of inflammation or ulceration, the local application of creams are usually beneficial in preventing nasal drying, bleeding and crusting.

Currently various surgical techniques are available, for the closure of a nasal septal perforation including: resurfacing the defect with respiratory mucosa (inferior turbinate flap, quadrangular cartilage flap and mucoperiosteal flap). Combined intranasal mucosal flap and interposition graft such as temporalis fascia, mastoid periosteum, nasal septal cartilage and or bone acellular human dermal graft, conchal cartilage and porcine small intestine mucosa.5 The documented surgical approaches may be closed endonasal, with a unilateral hemitransfixion, an external rhinoplasty or midfacial degloving techniques.5

The international scientific literature offers an extensive range of surgical repair techniques; however, there are only a few reported cases where the results are statistically significant.5 Nonetheless, each technique has its own advantages and drawbacks.

Many surgeons are developing new and interesting repairing techniques6,7 and in a not so distant future new findings will hopefully lead to further improvement for patients, such as better sense of smell,8 better moistening of the nose and, in general, better quality of life.

Methods

The executive board of the Italian Society of Rhinology designed a questionnaire consisting of 20 questions (Table 1) about nasal septum perforations and its treatment. Questionnaires were emailed to all SIR members that are expert otorhinolaryngologists and rhinologists from different Countries all around the world (Table 2). The otorhinolaryngologists and rhinologists to answer the questionnaire were internationally recognized as experts in Rhinology and/or directing departments or clinics where nasal functional surgery and Rhinology are their major interest and area of expertise. Questionnaires were sent between the beginning of December 2014 to the end of January 2015. Forty three otorhinolaryngologists and rhinologists returned their answers completed and thus were taken into account for this study.

Table 1.

The International Study Group.

Albania  Boci Prof. Besim 
Algeria  Hasbellaoui Prof. Mokhtar 
Armenia  Shukuryan Prof. Arthur K 
Azerbaijan  Talishinskiy Prof. Azizagha 
Bangladesh  Tarafder Prof. Kamrul Hassan 
Belgium  Bachert Prof. Claus 
Chile  Stott Caro Dr. Carlos 
China  Chen Prof. Lei 
Croatia  Mladina Prof. Ranko 
Croatia  Baudoin Prof. Tomislav 
Cyprus  Charalambous Prof. Mikalis 
Czech Republic  Plzac Ass. Prof. Jan 
Denmark  Von Buchlwald Prof. Christian 
Ecuador  Silvia Chachon Prof. Fernando 
El Salvador  Perdomo Flores Prof. Edgar Arturo 
Finland  Alho Prof. Olly-Pekka 
Greece  Papavassilious Prof. Anthony G. 
Guatemala  Kiesling Calderon Prof. Victor 
Iran  Mesbahi Prof. Alireza 
Israel  Fliss Prof. Dan M. 
Kazakhstan  Tulebayev Prof. Rais Kazhkenovich 
Korea  Rhee Prof. Chae-Seo 
Lebanon  Hadi Prof. Usamah 
Lithuania  Balsevicius Prof. Tomas 
Malaysia  Gendeh Prof. Balwant 
Mexico  Cuilty Siller Prof. Carlos 
Mongolia  Erdenechuluun Prof. Bat 
Nepal  Bhattarai Prof. Hari 
Pakistan  Syed Muhammad Rafi Prof. Tariq 
Panama  Melendez Prof. Amarilis 
Poland  Golisinski Prof. Wojciech 
Romania  Sarafoleanu Prof. Caius-Codrut 
Russia  Lopatin Prof. Andrey 
Serbia  Stankovic Prof. Milan 
Slovak Republic  Sicak Prof. Marian 
Slovenia  Jenko Prof. Klemen 
South Africa  Lubbe Prof. Darlene 
Spain  Sarandeses Garcia Prof. Adolfo 
Taiwan  Yeh Prof. Te-Huei 
Thailand  Bunnag Prof. Chaweewan 
Turkey  Onerci Prof. T. Metin 
Ukraine  Zabolotnyi Prof. Dmytro 
U.S.A.  Kern Prof. Eugene 
Table 2.

Questionnaire.

Which technique do you use to perform septoplasty? 
How many cases of nasal perforation did you find after your septoplasty surgeries? What percentage of the total number of your septoplasty cases? 
Which are the causes of nasal perforation that you find in the patients you operated on? 
Do you suggest repair of a nasal septalperforation in a cocaine addict? (y/n)? If yes, during the period of drug abuse or after the interruption? If you suggest to wait the interruption, which span do you request between interruption of drug abuse and surgery? 
Which are absolute and relative contraindications to a septal repair surgery? 
Which is the largest perforation diameter on which it is possible to operate on? 
Do you suggest repair in minimal (less than 3–4mm) perforations? 
Which preoperative exams do you perform before nasal septal perforations repair? 
Which technique of repair do you use in nasal septal perforations? 
10  Do you use flaps sometimes? If yes, of which kind? 
11  Do you use grafts sometimes? If yes, of which kind? 
12  How much larger than the perforation should be the graft harvested for repair? 
13  What do you use to stabilize your flaps or grafts? (Fibrin glue, sutures?) 
14  Do you put a splint to protect the septum after surgery? (y/n) 
15  When do you control (follow) the patient after surgery? (Days, months...) 
16  When do you remove the septal protection (splint, etc.) after surgery? (If applicable) 
17  How long do you control (follow) the patient after surgery? 
18  How many failures did you see in you nasal septal perforation repair? (Percentage) 
19  Are there, in your experience, prognostic factors that can help to foresee failure? 
20  What do you suggest in case of failure? Re-operation, septal button? 
Results

Of the 43 otorhinolaryngologists and rhinologists returning questionnaires, 64% used the Cottle technique to perform septoplasty while 13% preferred endoscopy, 15% of them indicated both techniques, and 8% of surgeons stated that they used a personal technique (Fig. 1A). Twenty-seven surgeons reported an occurrence of nasal septal perforation after septoplasty in less than 1% of patients while 13 surgeons reported an incidence of perforation between 1 and 5%, while 3 surgeons reported an incidence of perforation over 5%. Out of 43, 33 surgeons attributed the occurrence of perforation to the skill of the surgeon, 11 to the septal surgery, 8 to infections, 7 to drug use and 6 to septal deformity. Trauma, pressure and Wegener's granulomatosis were also mentioned (Fig. 1B).

Figures 1–4.

Results to the questionnaire about nasal septum perforations and its treatment.

(0,56MB).

The most common closure technique was the mucosal flap (75%), followed by the cartilage grafts (11%). Much less common were oral flaps, septal buttons and others (Fig. 1C). As regards grafts, cartilage was by far the most common material (60%), followed by fascia, skin and bone.

Forty percent of the specialists responding stated that the largest perforation (in diameter) suitable for surgical closure would be of 3cm, less than 1.5cm according to 25.8%, less than 2cm according to 20%, more than 3cm, up to 3.5 or 4cm according to 14.2%. The majority agreed not to suggest septal perforation surgery in minimal (less than 3–4mm) perforations (73.5%), or limiting it to symptomatic patients (43.5%).

The graft collected should be approximately 0.5–1cm larger than the perforation according to the 44.5% of the sample (Fig. 2A).

The vast majority of surgeons (86.2%) uses sutures to stabilize the flaps/grafts and in a smaller percentage of cases glue (Fig. 2B); 72.5% of them puts a splint to protect the septum after surgery which is commonly removed in 7 days (53%), in 14 days (31.2%), in less than 3 days (15.6%) or within the month (12.5%).

Standard follow up is commonly in less than 7 days (70%), and 1/3 of these surgeons claims to check patients within the first 3 days.

The contraindications to repair surgery were reported to be: Wegener's granulomatosis, drug abuse, non-symptomatic perforation, its dimension and age of the patient. Septal deviation, atrophic rhinitis, smoke, epistaxis and systemic diseases were also claimed (Fig. 3A). Before surgery only a small percentage of physicians performed second level diagnostic test such as CT (33%), biopsy (1%), Wegener diagnosis (22%) sarcoidosis test (2%), however the majority believes nasal endoscopy to be reliable enough (Fig. 3B).

Standard follow up is reported to be distributed as follows: 30.6% 1 year, 25% less than 3 months, 25% up to 3 months, 16.7% 6 months and only 2.7% more than 1 year.

Failure in repair surgery has been observed to occur in less than 30% of cases by 43% of the sample, and in less than 10% in 37.1%. 17.1% of the sample attested failures in between 30 and 50% of cases, and only one physician reported the occurrence in more than 50% of cases (Fig. 3C).

Among the prognostic factors that could help to foresee failures, the interviewed surgeons and rhinologists identified: the dimension of the perforation, infections, dryness, surgeon skill, systemic diseases, inflammation, bleeding, smoke and mucosa attributes. Nonetheless, 15.1% did not identify any prognostic factor (Fig. 4A).

In case of failure 62.5% of the interviewed suggests a reoperation, whereas 37.5% recommends a septal button (Fig. 4B).

76.4% of the sample does not recommend repair surgery in cocaine addicts, the others consider it only after at least 6 months (8.8%), 1 year (11.8%), or 3 months (3%) from the suspension.

Discussion and conclusions

Nasal septal perforations are a not too common occurrence in population, but ENT surgeons come across them quite frequently, especially after nasal surgery (septoplasty and rinoplasty).

Nonetheless data related to its epidemiology, distribution, etiological risk factors, surgical approach, and natural history cannot still be considered sufficient.

The aim of our survey has been to investigate the perception of aspects related to nasal perforation among Italian Society of Rhinology Honorary Members experts in Rhinology and ENT surgeons coming from all over the world.

Given the great difficulty to make random studies about controversial topics and obtain statistically significant data related to this topic shall be of great value.

The reading of the opinions coming from many ENT specialists, according to us can be useful to make a comparison between countries and surgeons, and give references to those who carry out reparation surgery.

It could also help the specialists who come across this occurrence to correctly inform their patients about its occurrence during septoplasty, its main causes and all the possibility of recovery, giving them a complete guidance of its management not based on personal experience only.

The collected data could be considered as a “first step” towards international guidelines or consensus nowadays not available.

Funding

We declare that no founding was obtained for this article.

Conflict of interest

We declare that no conflict of interest.

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Copyright © 2017. Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello
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