Repair of Traumatic Nasal Septal Perforation Using Temporalis Fascia and Interpositional Auricular Cartilage Graft

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1 Med. J. Cairo Univ., Vol. 83, No. 1, March: , Repair of Traumatic Nasal Septal Perforation Using Temporalis Fascia and Interpositional Auricular Cartilage Graft NASSER A. FAGEEH, M.D., F.R.C.S.C., F.A.C.S. The Department of Otolaryngology, College of Medicine, King Khalid University, KSA Abstract Objectives: To review our experience in the surgical repair of medium size symptomatic posttraumatic nasal septal perforation using conchal cartilage and temporalis fascia grafts. Patients and Methods: A retrospective study patients' records-based design was followed. The study was conducted at Asser Central Hospital and Abha Private Hospital. It comprised the study of medical records of 19 patients (15 males, 4 females) diagnosed and treated for nasal septal perforation between January 2008 and June Patients who presented with symptomatic post-traumatic nasal septal perforation were included in the study. All other patients, including asymptomatic patients, patients who had septal perforation less than 1cm or larger than 3cm, patients suspected to have active inflammatory process, drug abuse and patients who were followed-up for less than 6 months were excluded from the study. One surgeon (the researcher) operated all patients and the surgical technique using temporalis fascia and auricular cartilage grafts was used in all patients. Results: Sixteen (84.21%) patients had septal perforation as a complication of septoplasty procedure and 3 (15.78%) patients following facial trauma. The mean size of the operated perforations was 15.68mm (range 10-25mm). Presenting symptoms included nasal dryness and crusting in 11 ( %) patients, nasal pain in 10 (52.63%) patients, nasal obstruction in 8 (42.10%) patients and epistaxis in 7 (36.84%) patients. Five (26.31%) patients experienced three or more symptoms. Seventeen (89.47%) had complete closure and 2 (10.53%) had incomplete closure. One (5.26%) patient of those who had incomplete closure remained symptomatic and declined a second trial of surgical repair. Conclusion: Closure of nasal septal perforations using temporalis fascia with interpositional auricular cartilage graft is very useful and has high successful rate, especially for the medium sized septal perforations. Key Words: Nasal septum Perforation Conchal cartilage Temporalis fascia Auricular. Introduction NASAL septal perforation is an anatomical defect of the nasal septum that results secondary to ne- Correspondence to: Dr. Nasser A. Fageeh, The Department of Otolaryngology, College of Medicine, King Khalid University crosis or loss of the bone or the cartilage and its mucosal covering [1]. The etiology of nasal septum includes excessive resection of the septal cartilage and tearing of its mucosal covering during septoplasty, blunt trauma, chronic nasal picking, nasal packing resulting in pressure necrosis, septal electrical cauterization for treating epistaxis, substance abuse, T-cell lymphoma and some inflammatory diseases [2-4]. Patients having septal perforation can be symptomatic or asymptomatic. The symptomatic perforation is classified according to it size into small perforation (less than 1.0cm), medium size (1-2cm) and large perforation (greater than 2.0cm). The usual symptoms may include epistaxis, nasal obstruction, discharge, dryness and crusting, nasal pain, whistling and bad odor (halitosis) [5,6]. Small symptomatic perforations continued to be the best for surgical repair using local nasal flaps [4,6,7]. However, the success rate in closing large perforations remains challenging and suboptimal in achieving complete closure for all operated cases. Other factors that may contribute to the success of repair may include presence or absence of fibrosis and previous scar formation, presence or absences of inflammation and, most important of all, is the surgeon's experience. Patients with asymptomatic perforations usually do not require closure [5,7]. The technical challenge of the perforation repair arises from the fact that it has three distinct tissue layers: Two septal mucoperichondrial flaps and the absent intervening cartilage. Both mucoperichondrial flaps, which are usually adherent to each other, must be distinctly separated and repaired individually, and the space in between should be filled with a connective tissue graft [5,6]. The aim of this study was to review our experience in closing symptomatic nasal septum perfo- 181

2 182 Repair of Traumatic Nasal Septal Perforation Using Temporalis Fascia rations that cannot be closed solely by local mucoperichondrial or mucoperiosteal flaps. Material and Methods Patients with medium sized perforation less than 3cm only were included in study. Nineteen patients (15 men, 4 females) with traumatic nasal septal perforation were surgically treated using auricular cartilage interpositional grafts and temporalis fascia in Aseer Central Hospital and Abha Private Hospital, Abha City, Kingdom of Saudi Arabia, between January 2008 and June The patients' records were reviewed retrospectively for age at the time of the surgery, gender, etiology of the perforation, preoperative and postoperative symptoms, operative notes, and the success in achieving complete closure and the follow-up period for all patients. Exclusion criteria included perforation less than 1cm or larger than 3cm and follow-up period less than 6 months. Patients with other possible causes apart from trauma were also excluded from the study. The researcher operated all study patients and the surgical technique was identical in all cases. The procedure was done under general anesthesia and only after adequate prepping and draping of the right auricle and the area for harvesting temporalis fascia. The temporalis fascia was taken using a C-incision starting in the right post-auricular area, extending up in the temporal area, no hair shaving was done. A minimum of 8cm 2 fascia was taken, adequate enough to cover both surfaces of the harvested cartilage. The auricular cartilage was harvested from the conchal part of the cartilage through a C-incision on the anterior border of the anti-helix. The skin was dissected a way to expose the cartilage. The cartilage was then incised and dissected with its perichondrial covering on the anterior surface and in the subperichondrial level posteriorly. This was to allow future regrowth of cartilage in the donor area. The donor area was then closed using 5-0 Nylon sutures. A mastoid dressing was applied at the end of the procedure and removed on the second postoperative day. The dried fascia was used to cover both sides of the harvested cartilage and sutured in place using 4-0 Vicryl suture. The composite graft (the cartilage and the temporalis fascia) was then kept in saline-wet 4x4 gauze. The septal perforation was prepared where bilateral elevation of septal mucoperichondrial was raised on both sides of the septum including the area of the perforation. The prepared graft was then inserted in between the two-mucoperichondrial flaps to close the perforation area. The graft was fixed in place in all four directions using throughand-through 4-0 Vicryl suture. Antibiotic ointment (sodium fusidate) was applied on the graft from both sides. A silastic nasal septal splint was applied and sutured in place using 3-0 Nylon suture. Great care was taken to avoid mobilizing the graft when applying the splint final suture. All patients were given oral antibiotics for a period of 10 days. The splint was removed on the second postoperative week in all patients. All patients were given the antibiotic ointment to use for a period of two weeks and they were then booked for one month, 6 months visits respectively. Results Nineteen patients (15 males, 4 females) diagnosed to have traumatic perforation were selected for surgical repair. The cause of the perforation was found to be iatrogenic in16 (84.21%) patients. Facial trauma was the cause in 3 (15.78%) patients; two of them after motor vehicle accidents and the third one was as a result of football injury. The mean size of the septal perforation was 15.68mm (range 10-25mm). Seventeen patients (89.47%) had anterior perforation while 2 (10.53%) had posterior perforation (Table 1). The most common complaint was nasal dryness and crusting that was reported in 11 patients ( %). Nasal pain and discomfort was bothersome in 10 patients (52.63%). Nasal obstruction was the main complaint in 8 patients (42.10%), disturbing nasal bleed in 7 patients (36.84%), whistling in 5 patients (26.32%) and halitosis in 3 patients (15.79%). Five patients (26.32%) experienced three or more symptoms. (Table 2). Table (3) shows that complete closure was achieved in 17 patients (89.47%) and the remaining 2 patients (10.53%) had incomplete closure. Only 1 (5.26%) of those two patients remained symptomatic. All successful 17 cases were done through endonasal approach. The other 2 cases that had incomplete closure were done through open rhinoplasty approach and both had posteriorly located perforation with perforation size above 2cm. The mean follow-up period was 8.37 months. All patients had their postoperative visits at the second week, where their septal splint was removed. All patients showed healthy looking septum but 1

3 Nasser A. Fageeh 183 patient (5.26%) had purulent discharge at the site of the graft and eventually had incomplete closure of his perforation. Table (1): Personal characteristics of study sample. Characteristics Age (Mean±SD) Values 36.74±7.74 years Sex: Male (No., %) 15 (78.9%) Female (No., %) 4 (21.1%) Cause of septal perforation: Complication of septoplasty (No., %) 16 (84.21%) Facial trauma (No., %) 3 (15.79%) Size of septal perforation (Mean±SD) 15.68±4.70mm Site of perforation: Anterior 17 (89.5%) Posterior 2 (10.5%) Table (2): Patient's preoperative symptoms. Symptoms No. & Percentage Dryness & crusting 11 ( ) Nasal pain 10 (52.63) Nasal obstruction 8 (42.10) Epistaxis 7 (36.84) Whistling 5 (26.32) More than one symptom 5 (26.32) Halitosis 3 (15.79) Table (3): Operative and postoperative results. Characteristics Values Surgical approach: Close 17 (89.47%) Open 2 (10.53%) Outcome: Incomplete closure 2 (10.53%) Complete closure 17 (89.47%) Postoperative symptoms: Asymptomatic 18 (94.74%) Symptomatic 1 (5.26%) Follow-up period (Mean±SD) Discussion 8.37±2.39 months Iatrogenic septal perforation remains to be a common cause of septal perforation [6,7]. Sixteen of our patients had their septal perforation after septoplasty operation. This complication usually occurs when there is excessive cartilage removal and/or mucosal flaps tears that were ignored and were not repaired during surgery. Three patients had history of severe nasal trauma; two after motor vehicle accident and the third one were after football injury. These three patients had cartilage and mucosal covering loss that was not repaired immediately after trauma and was left till necrosis resulted in septal perforation. Repair of nasal septal perforation remains a challenge for both the surgeon and patient, with the primary goal of restoring aesthetic aspects and recovering anatomical and functional integrity of the nasal airway. There are multiple factors that play a major role in achieving success in closing a nasal septum perforation. These factors include the size of the perforation, presence of active inflammatory process, habitual nasal piking, and continuous substance abuse, active granulomatous disease and immune compromising diseases like diabetes mellitus. One of the most important of all is the size of the perforation. Perforations larger than 3cm, in general, produce unsatisfactory results [7-9]. In the two study hospitals, it has been our trend to select only symptomatic patients presenting with perforation less than 3cm in diameter for surgical repair. Large perforations more often reperforate and may require a different approach and a different type of closure. Two of our patients had incomplete closure of their perforation. They both had perforations of 23mm and 25mm. Many approaches have been used for surgical therapy of septal perforation. The endonasal approach was found adequate for surgical exposure of most of septal perforations, nasal flap dissection, and suturing especially for small and medium size anterior perforations. The endonasal approach also has the advantage of the absence of external scars. On the other hand open rhinoplasty approach is good for large and posteriorly located perorations [5,9]. Endoscopic repair of septal perforation was also reported to be successful in some reports [9]. We used endonasal approach for all cases except in two cases where their perforations were larger than 2cm and posteriorly located. Different types of flaps and grafts were described in septal perforation repair. Local nasal flaps whether mono-pedicled, bi-pedicled mucoperichondrial nasal or inferior turbinate flaps are mostly used to close small (smaller than 1cm) perforations [10,11]. Oral mucosal, forearm free flaps have been described for repairing large (greater than 3cm)

4 184 Repair of Traumatic Nasal Septal Perforation Using Temporalis Fascia septal perforation [12-14]. In case of medium sized perforations, the local mucoperichondrial mucosa flaps are usually insufficient, especially suturing a limited upper and inferior mucosa margins. Closure using local flaps in such wide perforations ends in tension and eventually breakdown of sutures and reperforation [2,4,7]. Therefore, autografts including fascia and cartilage were found useful for repairing medium sized perforations. The most commonly used autograft cartilage for nasal septal peroration repair is either extraction-reposition of the quadrangular cartilage or conchal cartilage [13]. We preferred to use the conchal cartilage and temporalis fascia in all patients because it is close to the operative site and has limited donor site morbidity. The use of the fascia has other advantages that may include prevention of dryness and crusting of the cartilage and helping to provide blood supply and therefore helps in preventing its reperforation. In conclusion, traumatic septal perforation can be minimized by meticulous surgical repair of the mucosal tears that occur during septoplasty procedure and there should be an immediate attention to the nasal septum in case of nasal injuries. Local nasal flaps are the best for repairing small perforations. Conchal cartilage covered with temporalis fascia is useful in repairing medium sized perforation that cannot be repaired by local nasal flaps. Oral mucosal flaps, free forearm flaps that require more operative time and cause donor site morbidity should be reserved for large perforations. References 1- TASCA I. and COMPADRETTI G.C.: Closure of nasal septal perforation via endonasal approach. Otolaryngol. Head Neck Surg., 135: 922-7, FRIEDMAN M., IBRAHIM H. and RAMAKRISHNAN V.: Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope, 113: , HIER M.P., YOSKOVITCH A. and PANJE W.R.: Endoscopic repair of a nasal septal perforation. J. Otolaryngol., 31: 323-6, RE M., PAOLUCCI L., ROMEO R. and MALLARDI V.: Surgical treatment of nasal septal perforations. Our experience. Acta Otorhinolaryngol. Ital., 26 (2): 102-9, AYSHFORD C.A., SHYKHON M., UPPAL H.S. and WAKE M.: Endoscopic repair of nasal septal perforation with a cellular human dermal allograft and an inferior turbinate flap. Clin. Otolaryngol. Allied Sci., 28: 29-33, PEDROZA F., PATROCINIO L.G. and AREVALO O.: A Review of 25-Year Experience of Nasal Septal Perforation Repair. Arch. Facial. Plast. Surg., 9 (1): 12-8, BRYAN T.A., ZIMMERMAN J., ROSENTHAL M. and PRIBITKIN E.A.: Nasal septal repair with porcine small intestinal submucosa. Arch. Facial. Plast. Surg., 5: 528-9, HELLER J.B., GABBAY J.S., et al.: Repair of Large Nasal Septal Perforations Using Facial Artery Musculomucosal (FAMM) Flap. Ann. Plast. Surg., 55: 456-9, PRESUTTI L., M.A. CIUFELLI, et al.: Nasal septal perforations: Our surgical technique. Otolaryngol. Head Neck Surg., 136, , KRIDEL R. W.H.: Considerations in the etiology, treatment, and repair of septal perforations. Facial. Plast. Surg. Clin. North Am., 12: , ENG S.P., NILSSEN E.L.K., RANTA M., et al.: Surgical management of septal perforation: An alternative to closure of perforation. J. Laryngol. Otol., 115: 194-7, STOOR P. and GRENMAN R.: Bioactive glass and turbinate flaps in the repair of nasal septal perforations. Ann. Otol. Rhinol. Laryngol., 113: , MOBLEY S.R., BOYD J.B. and ASTOR F.C.: Repair of a large septal perforation with a radial forearm flap: Brief report of a case. Ear. Nose Throat. J., 80 (8): 512, PALOMA V., SAMPER A. and CERNERA-PAZ F.J.: Surgical technique for the reconstruction of the nasal septum: The pericranial flap. Head Neck, 22: 90-4, 2000.

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