Nasal Septal Perforation Repair

Relevant Anatomy

The nasal septum divides the nose into two separate nasal cavities. Each nasal cavity is bounded by the nasal septum, lateral nasal wall, and nasal floor. The nasal septum is composed of a bony and cartilagenous framework covered by a layer of mucoperichondrium and mucoperiosteum. The bony components of the septum include the nasal crest of the palatine bone, the nasal crest of the maxilla and premaxilla, the vomer, the perpendicular plate of the ethmoid, the nasal crest of the frontal bone, and the spine of the paired nasal bones. The anterior septum is composed of the quadrilateral cartilage, with its caudal most projection extending beyond the nasal spine.

The lateral nasal wall is composed of the laminae papyracea of the lacrimal bone, portions of the ethmoid bone, and the inferior and middle nasal conchae or turbinates. The inferior, middle, and superior turbinates are composed of a thin bone for structural support and covered by an adherent mucoperiosteum. Stratified squamous epithelium is found on the anterior tip of the inferior turbinate, whereas pseudostratified ciliated columnar respiratory epithelium covers all other surfaces.

Knowledge of the blood supply to the septum and lateral nasal wall is important for designing mucosal flaps for septal perforation repair. Blood supply and innervation of the nasal septum travel within the mucoperiosteal and mucoperichondrial linings. The arterial blood supply derives from the ophthalmic branch of the internal carotid artery and the maxillary and facial branches of the external carotid artery. The upper nasal septum is supplied by anastomoses of the anterior and posterior ethmoid arteries, which originate from the ophthalmic branch. The external carotid artery contributes via a major branch of the sphenopalatine artery that supplies the posterior and inferior septum. The columella and caudal septum receive blood supply from the septal branch of the superior labial artery. The septal mucosa itself contains complex arteriovenous anastomoses and venous sinusoids that can become engorged or constricted via neural or extrinsic pathways.

The blood supply to the lateral nasal wall is supplied posteroinferiorly by the sphenopalatine artery via the posterior lateral nasal artery and by the anterior and posterior ethmoid arteries superiorly. The posterior lateral nasal artery runs inferiorly on the perpendicular plate of the palatine bone and courses downward at approximately 1 cm anterior to the posterior end of the middle turbinate and approximately 1.5 cm anterior to the posterior end of the superior turbinate. The posterior lateral nasal artery occasionally gives off branches to the superior turbinate and is the predominant supplier of blood to the middle and inferior turbinates.

The arterial supply to the inferior turbinate runs in a direction parallel to the turbinate and nasal floor. Thus, in cases where relaxing incisions are needed to gain length on a mucoperichondrial flap, these incisions should be made immediately below the inferior turbinate bone so as to avoid arterial disruption.

Incidence and Etiology

The incidence of nasal septal perforations in adults is 0.9%. In a retrospective review of 74 patients with nasal septal perforations and ulcers, Diamantopoulos and Jones found that 80% of perforations were seen anteriorly, 11% were located posteriorly or superiorly, and 9% were classified as total or subtotal. Although the size of the perforations varied, the majority (39%) had a perforation size of 1 to 2 cm in diameter with an almost equal distribution of perforations less than 1 cm and greater than 2 cm. Crusting, minor bleeding, and erythema were the most common findings on initial presentation.

The etiology of nasal septal perforations is quite varied ( Table 37-1 ). The most common cause of perforation is the result of previous septal surgery. Other causes include nose picking, cocaine use, vasculitis, malignancy, and idiopathic. Proper workup of a patient with a nasal septal perforation should include a thorough history with specific attention to questions that address the wide differential diagnosis.

The history should be followed by a complete nasal endoscopy with documentation of the size and location of the perforation as well as any other findings such as crusting, bleeding, or granulation tissue. The septum should also be inspected to assess the degree of remaining cartilage. This can be assessed by gentle palpation with a cotton swab. In terms of laboratory studies, if the patient does not have a history to suggest a traumatic etiology, then a c-ANCA, antinuclear antibodies, rheumatoid factor, and erythrocyte sedimentation rate tests are sufficient. If any of these are positive, then a rheumatology referral may be warranted.

The previously accepted dogma that all septal perforations should be biopsied has recently come into question. Several studies have shown that septal biopsies have very little diagnostic value. Frequently, septal perforation biopsies are nondiagnostic even in the case of known vasculitis or malignant disease. It is therefore suggested that in patients with a clinically unremarkable septal perforation, even in the absence of a diagnostic history, biopsy of the edges does not add to the management of the patient and should not be performed. Biopsy should be reserved for patients in whom a clinical suspicion of malignancy exists and repeated biopsies may be needed to confirm the diagnosis.

Morbidity of Nasal Septal Perforation

Patients with nasal septal perforations commonly have a dry and obstructed nose. They also may complain of crusting, bleeding, and a whistling noise during breathing. Pathophysiologically, the airflow jet is directed toward the posterior aspect of the perforation. This leads to an increase in airflow turbulence, which in turn causes desiccation, bleeding, and crusting. These complaints are usually associated with anterior, rather than posterior, perforations. The reason for this finding is that by the time the nasal airflow reaches the posterior nasal cavity, it is sufficiently conditioned at that point. Likewise, smaller perforations are less likely to cause symptoms as would large ones.

Lindemann et al. studied the effects of closure of septal perforations on intranasal humidity and temperature. In a prospective study of 10 patients, surgical closure of the perforation was shown to have a statistically significant increase in nasal airway humidity and temperature. Moreover, clinical symptoms of recurrent epistaxis and nasal dryness were shown to improve after repair. The study provides further evidence to support the proposed mechanism that intranasal dryness secondary to turbulent airflow with septal perforations is responsible for the morbidity of this condition.

Management of Nasal Septal Perforations

The first step in the management of nasal septal perforations is to determine whether the perforation needs to be closed. Often, small perforations are asymptomatic and can be left alone. Also, patients with nasal septal perforations may have chronic rhinosinusitis and their symptoms may be attributable to this condition rather than to the perforation. In these circumstances, appropriate medical therapy may provide more benefit than closure of the perforation.

If the patient's symptoms are minor with minimal crusting, then the use of saline sprays or topical petroleum jelly may be sufficient. With more severe crusting, saline irrigation or similar sinus rinses may be needed.

For the patient who does require closure of the septal perforation, two options exist: mechanical obturation and surgical closure.