Septal perforation

What repeats

Five findings that hold across the literature.

Previous nasal surgery is the commonest cause

Across 329 endoscopically repaired cases, the causes were iatrogenic in 60.0%, trauma in 22.0% and idiopathic in 12.0%. In a single-surgeon series of 84, injury from previous nasal surgery accounted for 70.2%. Among 408 patients with perforations of 20 mm or more, causes were iatrogenic in 61.2%, idiopathic in 36.5%, trauma in 31.4% and drug use in 28.4%.

Rests on: Gravina et al., endoscopic systematic review · Joo and Jang, single-surgeon series · Cheung et al., large perforation meta-analysis · and septoplasty.

Blockage, crusting and bleeding are what patients report

In the single-surgeon series the pre-operative complaints were nasal obstruction in 79.8%, crusting in 34.5% and bleeding in 27.4%. Among large perforations, obstruction was reported by 62.0%, crusting by 49.9% and bleeding by 45.7%. In a smaller series the order ran crusting 71%, whistling 53%, obstruction 53% and bleeding 29%.

Rests on: Joo and Jang · Cheung et al. · Morse et al., fascia and plate repair.

Size is the strongest predictor of whether it closes

A systematic review of predictive factors found size the most significant factor, with failure more frequent above 2 cm than at or below 2 cm. In the 84-patient series the perforations that stayed open measured 12.21 mm against 8.04 mm for those that closed. Smoking and a combined rhinoplasty raised the odds of incomplete closure, and an interposition graft raised the odds of success with an odds ratio of 6.752.

Rests on: Kim and Rhee, predictive factors · Joo and Jang.

Reported closure rates run from about two-thirds to about nine in ten

Pooled endoscopic repair closed 296 of 329 perforations, 90.0%, at a mean follow-up of 16.3 months. An anterior ethmoidal artery flap closed 17 of 18. A two-institution series using the same flap closed 73.2%, with active smoking, intranasal drug use and diabetes each associated with failure. Bilateral rotational flaps with a periosteal graft closed 87.5% of 104 perforations at six months. One single-surgeon series reports 64.3%. For perforations of 20 mm or more the pooled rate was 84.4%.

Rests on: Gravina et al. · Almahbub et al., tunnel technique · Tumlin et al., two-institution outcome · Wang et al., bilateral rotational flaps · Joo and Jang · Cheung et al..

Symptoms improve more reliably than the hole closes

In one hundred and seventeen patients repaired with bilateral mucosal flaps and an interposition graft, repair failed in seven, 6.0%, while the NOSE-Perf score fell from 25.3 to 7.9 and more than 91% cleared the minimal clinically important difference. In another series 15 of 17 patients, 88%, had complete resolution of their symptoms, with NOSE falling from 62.78 to 17.78. Resolution of symptoms is the endpoint the authors treat as clinically meaningful, ahead of the closure rate.

Rests on: Taylor et al., NOSE-Perf outcomes · Morse et al. · Taylor et al., Glasgow Benefit Inventory.

By how the hole is closed

One defect, several reconstructions.

Bilateral mucosal flaps with a graft between them

Lining is advanced from both sides and a graft is laid between the two layers. This is the technique behind the largest validated symptom series, with its 6.0% failure rate, and behind the quality-of-life series of 98 patients where the highest scores fell in the quality of life factor followed by self-confidence and social involvement.

Rests on: Taylor et al. · Taylor et al..

A flap carried on the anterior ethmoidal artery

A named artery keeps the flap alive, which is why pedicled septal flaps carry the higher success rates in the technique review. The tunnel modification closed 17 of 18 perforations averaging 1.5 cm with no complications. A two-institution series of forty-one patients with a mean perforation of 2.2 cm closed 73.2%.

Rests on: Garaycochea et al., septal perforation repair · Almahbub et al. · Tumlin et al..

Temporoparietal fascia wrapped around a polydioxanone plate

Fascia from above the ear is wrapped around an absorbable plate and placed as the middle layer. In one two-centre series of 17 patients all perforations were closed with overlying mucosa at last follow-up, mean perforation area 0.99 cm2. A later series of 31 patients, mean area 1.49 cm2, reports an overall success rate of 90%.

Rests on: Morse et al. · Rossi Meyer et al., Iowa series.

A silicone button that plugs the hole rather than closing it

A button seals the defect without restoring the lining. Over a mean observation of 13 years, 67% of 45 buttons had been removed, symptom score improvement was 55% across all symptoms and 70% for the main nasal symptoms, and only 11% of patients considered a prosthesis the best answer. A custom button made from an intranasal cast was still in place in 75% of 57 patients, who rated overall improvement at 83%.

Rests on: Døsen and Haye, long-term button · Federspil and Schneider, custom button.

A 3D-printed prosthesis fitted to the defect

Thirty-five patients were compared, 23 repaired surgically and 12 fitted with a printed prosthesis. Both improved on the NOSE-Perf scale, from 24 to 8 after surgery and from 17 to 9.5 with the prosthesis, and the reduction was greater after surgery. The prosthesis group had the larger perforations, 25 mm by 17 mm against 12 mm by 10 mm.

Rests on: Gomes et al., surgery versus printed prosthesis · Sapmaz et al., classification and quality of life.

What to ask about a septal perforation

Questions the evidence supports asking.

How big is mine, and where does it sit

Size drives the odds. Above 2 cm the failure rate rises, and the pooled series for perforations at or over 20 mm reports 84.4% closure with results that vary by technique: 88.2% for mucosal advancement, 86.6% for interposition grafts, 72.7% for graft and flap combinations.

Rests on: Kim and Rhee · Cheung et al..

What has to change before surgery

Smoking, intranasal drug use and diabetes were each associated with failure in the endoscopic series, and smoking raised the odds of incomplete closure in the single-surgeon series. Where cocaine is the cause, only abstinence interrupts the process, and one team declined repair for patients screening positive for cocaine or antineutrophil cytoplasmic antibodies.

Rests on: Tumlin et al. · Joo and Jang · Trimarchi et al., cocaine induced midline destructive lesions · Wang et al..

Repair or a prosthesis

A prosthesis is fitted in clinic and can be removed. Repair is an operation. In the direct comparison, symptom reduction was greater after surgery, and in the long-term button series two thirds of the buttons had been removed by 13 years.

Rests on: Gomes et al. · Døsen and Haye · Sapmaz et al..

What counts as success

Closure and symptom relief are different endpoints and are reported separately. Ask the surgeon for both, and ask which questionnaire they use.

Rests on: Taylor et al. · Morse et al..

The terms, defined

The words used about this problem.

• Nasal septal perforation: a hole through the septum where both mucoperichondrial layers and the cartilage or bone between them are lost. [30057254]
• Iatrogenic: caused by a previous operation, the commonest cause in every series here. [35676865]
• Interposition graft: tissue placed between the two mucosal layers to support the repair. [37357889]
• Mucosal advancement flap: lining moved across the defect from adjacent septum or floor. [41466067]
• Anterior ethmoidal artery flap: a flap carried on a named artery, which keeps it perfused. [36729895]
• Temporoparietal fascia: a thin sheet of tissue from above the ear used as a graft layer. [30973580]
• Polydioxanone plate: an absorbable plate used as the stiff middle layer of a repair. [38161289]
• Septal button: a silicone prosthesis that plugs the perforation. [19146004]
• NOSE-Perf scale: the questionnaire developed and validated for perforation symptoms. [38334159]
• Glasgow Benefit Inventory: a general health questionnaire used after ear, nose and throat procedures, revised into 15 items with 5 sub-scales. [37157824]
• Cocaine induced midline destructive lesions: progressive destruction of septum, sinus walls and palate from intranasal cocaine, with a reported prevalence around 4.8% among cocaine users. [24932619]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology publishes a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. Septal perforation is one of the surgical complications it asks clinicians to counsel patients about and to document.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries a Septal Surgery section with three chapters covering the hole and its repair. They are written for surgeons and go further into technique than a patient page should.

• Septal Perforation
• Repair of Septal Perforations in Revision Septoplasty
• Septoplasty and Turbinate Surgery

The reference summaries

Three StatPearls chapters on the National Library of Medicine's Bookshelf cover the septum, the operation that most often makes the hole and the flap used to close defects in nasal lining, in full text at no charge.

• Anatomy, Head and Neck, Nose.
• Septoplasty, where perforation is listed among the complications.
• Nasoseptal Flap.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

Two registered trials test new ways to close the hole.

• New Method to Close Nasal Septal Perforation, recruiting, 23 participants.
• Nasal Septum Perforation Treatment Using Tissue Engineered Cartilage Graft, completed, 5 participants.

What is not settled

• There is no standard approach and no single technique. The recommendation is built around where the defect sits and what bone and cartilage support remains. [36729895]
• Reported success ranges from 64.3% in one single-surgeon series to 90.0% pooled across endoscopic series, and the series are not comparable in case mix. [37357889] [35676865]
• The number of layers used in the repair did not separate outcomes: 92.9% for single-layer, 88.3% for two-layer, 91.9% for three-layer. [35676865]
• In one series the bilaterality of flap coverage, the surgical approach, the flap type and the shape of the perforation were all unrelated to success while the interposition graft was. [37357889]
• Surgery and a printed prosthesis have been compared once, in 35 patients, with unequal perforation sizes in the two arms. [41844333]
• In children the literature is a single series of 20 patients, with iatrogenic causes at 40% and button batteries at 20%, and closure in half of those operated on. [30578990]