31

Nasal Septal Perforations

H. D. Juvk and T. D. Ziflker
Nasal septal perIorations (NSP) may
cause physiologic changes leading to
various symptoms. The management oI
NSP poses a challenge to patients and
otolaryngologists. Most NSP results Irom
iatrogenic trauma. In view oI the possible
Irustrating treatment, prevention is oI
eminent importance. Sympto-matic NSP
may be treated conserva-tively,
prosthetically, or surgically. This chapter
reviews the etiology, prevention,
symptoms, evaluation, and therapy oI
most NSP.
ETIOLOGY
The vast majority oI NSP results Irom
trauma with or without secondary inIec-
tion (Table 1). Most oI these traumas are
iatrogenic,
1
"
3
surgical trauma during sep-
toplasty being one oI the main causes.
Other traumatic causes include nasal
packing, cauterization, and nose picking.
Inadequately treated septal abscess may
lead to NSP. Various disease states that
predispose to NSP include granuloma-
tous diseases, autoimmune disorders with
vasculitis, neoplasms, and rare in-
Iections such as tuberculosis and syphi-
lis. Cocaine abuse may be a growing Iactor
causing NSP in our society. Chronic
exposure to certain industrial inhalants
such as chromic acid has caused NSP as
well.
PREVENTION
Because in all series the most common
cause oI perIoration is nasal septal sur-
gery, the best treatment is prevention.
Surgeons must be vigilant to prevent bi-
lateral mucosal tears in corresponding
areas and must immediately repair those
that do occur. Tight nasal packing and
tight suturing oI septal splints should be
avoided. Septal hematomas must be.
treated adequately. Nasal septal abscess,
which usually Iorms aIter un-treated
septal hematoma, may cause a
perIoration and should be considered an
emergency. II inadequately perIormed,
cryosurgery oI the nasal turbinates may
cause NSP. Cautery Ior epistaxis should
not be perIormed bilaterally and simulta-
neously in corresponding septal areas.
SYMPTOMS
Symptoms associated with NSP are
listcd in Table 2. Probably only one third
oI all NSP causes symptoms.
1
The inci-
dence oI troublesome symptoms de-pends
on the size and location oI the
perIoration. Large perIorations and per-
Iorations located more anteriorly cause
more trouble.' Masing and colleagues
4
suggested that epistaxis, crusting, and
headache are mainly caused by the des-
iccating eIIect oI the inspiratory airIlow
TABLE 1. EtioIogy of NasaI
SeptaI Perforation
Trauma
ntranasal trauma
Nasal septal surgery
Nasal packing
Bilateral cauterization
Nasal gastric intubation
Cryosurgery
Nose picking
Extranasal trauma with septal hematoma
Infection
Septal abscess
Tuberculosis
Syphilis
Wegener's granulomatosis
Lupus erythematosus
Sarcoidosis
Rhinoscleroma
InhaIant irritance
Cocaine abuse
Caustic fumes
NeopIasms
Carcinoma
Lethal midline granuloma
TABLE 2. Main Symptoms of NasaI
SeptaI Perforation*
Crusting 26
Epistaxis 18
Nasal obstruction 18
Whistling 14
Pain 12
Rhinorrhea 10
* Listed in order of frequency (31 sur-
gically treated patients). (Vuyk HD,
Versluys RJJ: The inferior turbinate
flap for closure of septal perforations.
Clin Otolaryngol 13:53, 1988)
residual nasal mucosa is an important
Iactor in the symptoms oI NSP. Crusting
may be worse because oI concomitant
chronic sinusitis, atrophic rhinitis, or
previous radiotherapy Ior a neoplasm.
EVALUATION
AIter analysis oI the symptoms, the
evaluation oI NSP is Iocused on the eti-
ology, size and location, and concomi-
tant deIormities.
Symptoms
Symptoms determine the need Ior
treatment. ThereIore, patients' com-
plaints, especially whistling, headache,
epistaxis, and nasal obstruction, must be
related to the NSP, and other causes must
be ruled out. The status oI the mucosa oI
the nasal cavity may be indica-tive oI
systemic disease or chronic inIec-tion.
However, a clean appearance oI an
anterior septal deIect encompassed by
healthy mucosa is not very suspicious oI
sinister causes such as neoplasms, malig-
nant granuloma, and inIectious disease,
in particular tuberculosis and syphilis. A
biopsy oI the margins may be necessary
in selected cases. Nasal endoscopy and
computed tomographic (CT) scanning can
be helpIul to rule out sinus disease.
Systemic disease should be excluded, iI
suspected.
Size and Location
The size and location oI NSP are im-
portant because they determine the choice
oI treatment. Because oI the oblique view
oI the perIoration, it is diIIi-cult to
evaluate the exact horizontal and vertical
diameter. The size oI NSP may be
determined with the help oI a sheet oI
blotting paper aIter coating the nasal septal
mucosa with dye. Mucous secretions
may, however, cause a spread oI the dye
on the paper.
5
Rettinger and Hosemann
6
suggest a
lateral radiogram aIter coating the bor-
ders oI the septal perIoration with a radi-
opaque medium. A wire Iixed on the nasal
dorsal skin is used as reIerence value.
2 Volume 4
OTOLARYNGOLOGY
on the posterior rim oI the perIoration.
Nasal obstruction associated with NSP is
caused by excessive turbulence in the
inspiratory airIlow. Moreover, patients
with large perIorations oIten lack support
oI the septum, causing saddling oI the
dorsum and nasal valve distortion, which
may contribute to nasal obstruction as
well. Moreover, the state oI the
Symptoms
Number of
patients
NASAL SEPTAL PERFORATIONS
PerIorations in the middle and posterior
part (which rarely cause problems) oI the
septum may be superimposed by Iacial
bones on the lateral view. Modern imag-
ing techniques like CT may be used as
well but are expensive.
7
We suggest directly measuring the
horizontal and vertical diameter oI the
nasal septal perIoration with instruments
originally developed by Grote Ior ear
surgery. This method is easy and without
restrictions (Fig. 1).
AIter taking measurements, the deIect
should be classiIied according to the total
surIace area,
7
not just to the greatest di-
ameter.
4
For evaluation purposes, we suggest
the Iollowing classiIication:
1. 0.25 cm
2
2. 0.25 to l cm
2
3. l to 4 cm
2
4. ~4 cm
2
The location oI NSP may be classiIied
using Cottle's topographical division oI
the nasal septum.
1
Important data regarding location are
the distances oI the edges oI the perIora-
tion to the maxillary crest, columella,
and nasal dorsum. These measurements
may be a Iactor in the successIul retain-
ment oI a prosthesis as well as the width
oI the mucosal Ilaps that may be mobi-
lized locally during surgery.
Concomitant Deformities
NSP may present with concomitant
deIormities. Persistent septal pathology
should be diagnosed and the integrity oI
the septal supporting Iramework as-
sessed. In addition, a routine preopera-
tive rhinoplasty assessment should be
made. The size oI the nose eventually
determines the size oI the perIoration
that may be closed surgically. The
amount oI abundant mucosa obtained by
reduction rhinoplasty and the resulting
size oI the mucosal Ilaps Ireed by wide
undermining will be proportionally larger
in relatively larger noses.
TREATMENT
In general, only symptomatic NSP
needs treatment. Treatment oI neo-
plasms and oI inIectious and systemic
diseases causing NSP is not discussed in
this chapter. II inhalant irritants (co-
caine, chromic acid) or nose picking is
the cause, the patient should deIinitely
stop this exposure or practice. Concomi-
tant chronic sinusitis (which may have
been the reason Ior the primary oIIend-
ing septal surgery) should be adequately
treated beIore treatment oI NSP itselI is
considered. The available choices oI
treatment include conservative, pros-
thetic, and surgical approaches.
Conservative Treatment
The mainstay oI conservative manage-
ment has been humidiIication to relieve
crusting and epistaxis. As with other
crusting types oI intranasal pathology
moisturizing ointments and nasal saline
irrigations may be used. In addition, the
nose may be "put to rest" by plugging
the nasal vestibules with impregnated
cotton Ior 3 hours a day to soIten and
dissolve the crusts.
8
However, these
measures must be continued indeIinitely
and have limited success.
Prosthetic Treatment
Prosthetic closure oI NSP using cus-
tom-made prostheses was Iirst proposed
by Meyer in 1951.
9
Most oI the nasal septal
obturators used today are preIabri-cated
and commercially available. In Figure 2,
a prosthesis and its introduc-tion
technique are depicted. The major-ity oI
these prostheses may be intro-
Chapter 31 3
. Grote ear instruments Ior measuring NSP.
O-9I
Fig. 2. Nasal septal prosthesis and insertion techniques schematically depicted. Note that to
Iacilitate introduction a suture is placed through one oI the Ilanges oI the prosthesis. (Reproduced by
permission Irom Kern EB: Non-surgical closure oI nasal septal perIorations. In Rees TD |ed|:
Rhinoplasty, pp 262-268. St. Louis, CV Mosby, 1988)
duced as an oIIice procedure using local
anesthesia. In approximately 15 oI the
patients reported by Pallanch and col-
leagues,
2
the nasal septal prostheses were
introduced in association with other nasal
surgery in the operating room. Some
patients probably needed correction oI
concomitant septal deIorm-ity Ior better
retainment oI the prosthesis as described
by Haye.
I0
An external inci-sion was used
in cases oI very large perIorations,
warranting a custom-made prosthesis.
BeneIits reported by patients most
commonly include reduced epi-staxis,
reduced crusting, and improved
breathing. Some crusting can sometimes
still occur over the sides oI the obtura-
tor, although these crusts are usually
much less adherent and can be more eas-
ily removed by douching. The main
problems are spontaneous loss oI the
prosthesis or patients' discomIort war-
ranting removal oI their prosthesis.
In the largest series oI 203 patients re-
ported in the literature, 50 oI the pros-
theses used as primary treatment have
been retained aIter Iollow-up oI l to 13
years.
11
The success rate oI the pros-
thetic treatment seems largely dependent
on the size oI the deIect.
1
'
10
The worst
results are generally obtained in patients
with the largest perIorations. Prosthetic
closure oI NSP is certainly a reasonable
and economical treatment possibility. It
should be considered in symptomatic pa-
tients who are poor operative candi-
4 Volume 4

B
NASAL SEPTAL PERFORATIONS
dates, or patients whose perIorations are
caused by active granulomatous or vas-
cular disease, or patients who have re-
cently undergone treatment Ior nasal
Iossa carcinoma.
Some clinicians use a prosthesis as pri-
mary treatment in all cases.
1
*
7
They only
consider surgical closure as a secondary
treatment, when the obturator Iails to re-
duce the symptoms dramatically. How-
ever, many patients, when oIIered the
hope Ior a more deIinite solution, have
welcomed the suggestion oI operative
correction.
8
'
12
'
13
Reconstruction oI the cartilage Irame-
work with cartilage is in Iact not strictly
necessary Ior closure oI NSP. However, it
should be considered iI dorsal support is
to be obtained. From the consider-ations
regarding the blood supply men-tioned
earlier, it Iollows that Ilaps are
preIerable to Iree graIts Ior reconstruc-
tion. Free graIts have been applied mainly
in the Iorm oI composite skin cartilage
graIts Irom the ear.
17J8
Results in terms oI
closure and mucosal Iunctional
restoration could not be duplicated by
other investigators.
14
SurgicaI Treatment
The literature describes many meth-
ods Ior closure oI NSP. GraIts oI various
types and both local and regional Ilaps
have been suggested. However, the
plethora oI operations described testiIies
to the diIIiculties involved. Younger and
Blokmanis
14
published an excellent his-
torical review. It is oI interest to note that
surgical treatment at Iirst involved
enlargement oI the perIoration to make it
less symptomatic.
15
In view oI the surgical
possibilities today, this strategy should
be regarded with extreme reser-vation.
Closure oI NSP involves the re-
construction oI a strictly two-dimen-
sional deIect.
For a complete Iunctional reconstruc-
tion, the missing mucosa on both sides
and the cartilage in between should be
substituted. Skin as graIting material is
not ideal, because it may lead to more
crusting in the nose.
16
ThereIore, mucosal
graIts (not essentially rcspiratory mucosa)
are preIerable. CareIul consider-ation oI
the blood supply oI any material uscd Ior
reconstruction is oI eminent im-portance.
Free graIts depend solely on the blood
supply oI the ingrowing vessels Irom the
edges oI the perIoration. Flaps have the
advantage oI carrying thcir own blood
supply.
It has been shown that some Iorm oI
autogenous supportive graIt should be
placed in between reconstructed mucosal
layers as scaIIolding Ior epitheliali-
zation.
13
0-91
MUCOSAL FLAPS. Mucosal Ilaps with
an interposed graIt, advocated by Fair-
banks,
12
'
19
are the mainstay oI surgical
reconstruction today. The basic princi-
ple oI mucosal Ilap design is preservation
oI maximal blood supply. Gollom
20
pro-
posed that mucosal Ilaps should lie in the
same axis as the blood supply to mini-
mize the random portion oI any Ilap
used. In general, Ilaps should be broadly
based; however, a balance between broad
undermining Ior relieI oI tension and the
decrease in cartilage blood supply must
always be weighed.
Understanding the anatomy oI the
blood supply to the nasal cavityespe-
cially the nasal septum, Iloor, and lateral
nasal wallis essential. The anterior and
posterior ethmoidal arteries and the
sphcnopalatine artery arise Irom the su-
perior and posterior area oI the septum.
There are anastomoses between the pal-
atine artery through the incisor Ioramen,
the dcscending palatine artery, and the
scptal branch oI the superior labial ar-
tery.
Maximum use oI the available tissue in
the nasal cavity requires imagination.
Flaps Irequcntly require movement, thrce
dimensionally Irom the Iloor oI the nose
up to the septum, Irom the side to the
center. A thicker mucoperiosteal Ilap is
intrinsically stronger than a thjn peri-
chondrial Ilap. Another principle in NSP
closure is tcnsionless suturing oI the mu-
cosal Ilaps.
The Iollowing mucosal Ilaps will be re-
viewed according to their donor site:
Chapter 31
1. Septum
2. Nasal Iloor/lateral nasal wall
3. InIerior turbinate
4. Buccal sulcus
Then Iollows a discussion on the use oI
autogenous graIts supporting these Ilaps.
Various options Ior surgical exposure
will be considered.
Septal Flaps. Muchoperichondrial Ilaps oI
the septum have gained wide use in the
closure oI mainly small types oI septal
perIorations.
1
'
20
'
21
Advancement and ro-
tation oI Ilaps Irom both sides oI the sep-
tum should be asymmetrie to provide
nonopposing suture lines. A broad-based
Ilap
16
(Fig. 3) incorporating axial blood
supply proved versatile Ior reconstruc-
tion oI smaller NSP. The posterior inci-
sion should lie l cm below the skull base
to protect olIactory Iunctional mucosa,
ending above the level oI the bottom oI
the sphenoidal sinus to include branches
oI the sphenopalatine artery.
InIeriorly or superiorly based biped-
icled Ilaps (Fig. 4) have the advantage oI
ood blood supply, compared with ante-
riorly and posteriorly based bipedicle
Ilaps. Furthermore, mobilization, and es-
pecially possible extension oI the anteri-
orly and posteriorly based bipedicled
Ilaps, is limited compared with inIeriorly
and superiorly based bipedicled Ilaps.
Note that the amount oI septal mucosa
available Ior closure is inversely propor-
tioned to the diameter oI the NSP.
Floor and Lateral Wall Flaps. Septal muco-
perichondrial Ilaps may be extended in
continuity along the Iloor and lateral nasal
wall (Figs. 5 and 6). The included mu-
coperiosteum oI the Iloor and lateral
nasal wall is strong and substantial in
comparison with a Ilap attenuated Irom
the septum alone. These Ilaps may be
based anteriorly on the branches Irom the
superior labial artery that originates Irom
the Iacial artery.
22
Posteriorly based Ilaps
may contain the posterior septal branch
oI the sphenopalatine artery but also the
posterior lateral' nasal wall arteries also
derived Irom the sphenopalatine artery.
23
For large perIorations, these extended
septal/Iloor/lat-
Fig. 3 A and B. Broad posterior-based mucoperi-
chondrial advancement and rotation Ilap Irom the
septum. (Karlan MS, OssoI RH, Sisson GA: A
compendium oI intranasal Ilaps. Laryngoscope
82:774, 1982)
eral wall Ilaps may be leIt bipedicled an-
teriorly and posteriorly. An advantage oI
anteriorly based Ilaps is that iI they
should Iail, the reperIoration will likely
occur posteriorly and not be associated
with symptoms.
These extended Ilaps do not have to be
conIined to the lining oI the maxillary
crest, the Iloor oI the nose, and the lateral
nasal wall under the inIerior turbinate.
Belmont
23
described the extension oI the
mucoperiosteal Ilap oI septum, Iloor, and
lateral nasal wall onto the under surIace
and even the upper surIace oI
6 Volume 4
B
NASAL SEPTAL PERFORATIONS
Fig. 4. InIeriorly and superiorly based mucoperi-
chondrial bipedicled Ilap Irom the septum. (Karlan
MS, OssoI RH, Sisson GA: A compendium oI in-
tranasal Ilaps. Laryngoscope 82:774, 1982)
the inIerior turbinate, thus making possi-
ble a Ilap as wide as 3.5 cm. The bare
areas oI the nasal cavities along the Iloor
oI the nose and in the vault seem to heal
without any deIormity.
Septal Ilaps may be extended superi-
orly as well. Mucosa may be mobilized
Irom the dorsal portion oI the perIoration
to the under surIace oI the upper lateral
cartilage and nasal bones. A bipedicled
Ilap may be created with a relaxing inci-
sion approximately 10 to 15 mm lateral to
the junction oI the septum and the nasal
dorsum. This Ilap is ad vaneed medially
to cover the dorsal portion oI the perIo-
ration.
The amount oI mucosal lining avail-
able Ior reconstruction is not only re-
lated to the diameter oI the perIoration
but also to the size oI the nose. Addi-
tional mucosa Ior perIoration closure can
be gained by lowering the nasal proIile iI
indicated.
8
The amount oI extra mucosa
obtained by reduction rhinoplasty and
the size oI the mobilized mucosal Ilaps
will be proportionally larger in a rela-
tively larger nose (Fig. 7).
Inferior Turbinate Flaps. The technique
consists oI the transposition oI a mucosal
skin Ilap centered around the inIerior tur-
binate head, including some vestibulum
skin into the perIoration.
4
The Ilap ob-
tains its blood supply Irom the posterior
extended superior
septal flap raised
mucoperiosteal
flap raised
Fig. 5. Development oI mucoperiosteal Ilaps Irom the nasal Iloor and lateral nasal wall in continuit y with
the mucoperichondrium oI the nasal septum.
Chapter 31
Fig. 6. Advancement oI inIeriorly
and superiorly developed Ilaps Irom
the nasal septum, nasal Iloor, and
lateral nasal w all.
base. Two stages Ior reconstruction are
necessary. The Iirst includes raising the
Ilap with transposition and Iixation to the
anterior, inIerior, and superior edges oI
the perIoration. In the second stage, the
predicle oI the Ilap is sectioned poste-
riorly, rotated into the posterior rim to
close the deIect (Fig. 8). This technique
has the advantage oI not disturbing the
cartilaginous blood supply oI the septum,
but the width oI the Ilap is limited.
Moreover, the Iailure rate is high, with
some severe complications such as ste-
nosis oI the nasal passage causing ob-
struction and alar asymmetry.
3
This
technique has been disregarded in Iavor
oI mucosal advancement and rotation
Ilaps.
16
Buccal Sulcus Flaps. The buccal sulcus Ilap
(Fig. 9), as described by Tipton
24
and
popularized by Tardy,
25
is a regional mu-
cosal Ilap that provides good potential
Ior repair oI septal deIects. The Ilap car-
ries its own blood supply. It may be com-
bined with the transoral-premaxillary ap-
proach or lateral alotomy, providing
immediate regional access to the nose.
The donor-side deIect may be leIt unre-
paired and heals uneventIully. The
Fig. 7. Extra mucosa can be obtained by reduction rhinoplasty. (Goodman WS,
Strelzow W: The closure oI nasoseptal perIorations. Laryngoscope 92:121, 1982)
8 Volume 4
exposed bone
Amount dorsum
lowered
Final site of
nasal skeleton
Mucosal
'sleeve'
Nasal cavity
Mucosal flaps
NASAL SEPTAL PERFORATIONS

Fig. 8. Development oI an inIerior turbinate Ilap. Alotomy is outlined Ior demonstration pur-
poses. InIerior turbinate Ilap is sutured to the mucosa on the opposite site oI the septum anteriorly,
inIeriorly, and superiorly. Division oI the pedicle oI the Ilap posteriorly requires a second stage.
(Masing H, Gammert CH, Jaumann MP: Laryngol Rhinol Otol |Stuttg| 59:50, 1980)
bridge oI the Ilap does not need second-
ary division in all cases. However, to
reach the septum the Ilap must be rotated
on its base, thereby potentially compro-
mising its blood supply. Furthermore, the
width oI the harvested Ilap is limited. One
should also take into account shrinkage oI
the distal end oI the Ilap aI-ter
mobilization, which probably makes the
buccal sulcus Ilap unsuited Ior clos-ing
any perIoration with a diameter larger
than 1.5 cm.
1
AUTOGENOUS GRAFTS. The interposi-
tion oI some Iorm oI autogenous sup-
porting graIt in between the recon-structed
mucosal lining is regarded as the probable
key Iactor Ior improvement in the
survival rate oI the surgical repair.
12
This
material should maintain closure oI the
perIoration until epithelialization is
complete and should lend strength and
durability to the closure. Moreover, the
graIt should have a low metabolic re-
quirement because it is placed in areas oI
vascular compromise. Temporalis Iascia
or cranial periosteum has been pro-
posed.
12
'
26
The residual septal bone or
cartilage has been used by others.
8
From
studies oI tissues used in tympanic mem-
brane graIting, we know that Iascia or
periosteal graIts have become adherent
within 24 hours and that revasculariza-
tion quickly Iollows. Periosteum has an
advantage over Iascia in that it does not
curl and is thereIore easier to manage.
The graIt should be placed between the
mucosal Ilaps with a generous overlap-
ping area. The placement oI graIts on
each side oI the septal remnants with
overlap may be advantageous.
26
An addi-
tional advantage oI connective tissue
graIt is that the mucosal Ilaps need not
completely cover the graIts on both
sides.
II every part oI the connective tissue
graIt has a mucosal Ilap blood supply on
one side, the perIorated mucosa on the
opposite side will migrate over the raw
surIace oI the graIt and epithelialize.
This may not occur as readily when bone
or cartilage is used.
SURGICAL EXPOSURE. A prerequisite
to successIul surgery is adequate expo-
sure oI the perIoration. Good exposure is
usually diIIicult, iI not impossible, with
the usual endonasal approach. A Iew
techniques have been suggested to in-
crease exposure Ior NSP reconstruction.
A lateral alotomy provides lateral ac-
cess to the anterior septum and nasal
Iloor only. Extension oI the lateral alo-
tomy to a lateral rhinotomy incision oI-
Iers more exposure on the dorsal aspect
oI the septum. However, manipulation is
still perIormed tangentially, with limited
view on the posterior and basal parts oI
the septum and nasal Iloor.
The transoral-premaxillary approach
21
Chapter 31
Fig. 9 A and B. Principle oI buccal sulcus Ilap
outlined. A mucosal and submucosal Ilap Irom the
buccal sulcus passes through a separate stab inci-
sion into the nose. (Karlan MS, OssoI RH, Sisson
GA: A compendium oI intranasal Ilaps. Laryngo-
scope 92:774, 1982)
provides enhanced visibility oI intransal
structures but Irom a diIIerent perspec-
tive than normal. A gingivolabial incision
is used. The main advantage is the crea-
tion and rotation oI Ilaps unmanageable
Irom the endonasal approach with or
without lateral alotomy.
The open approach Ior rhinoplasty
propagated by Brain,
1
Goodman and
Strelzow,
8
Meyer and Berghaus,
27
Kridel
and colleagues,
13
and Arnstein
26
provides
excellent exposure Ior NSP recon-
struction (Fig. 10). The open technique
has the advantage oI approaching the su-
perior and posterior area oI the septum
Irom an area oI relatively easy access
(superiorly). Binocular vision and the
opportunity to use both hands Iacilitates
surgical dissection, and mucosal Ilap mo-
bilization enhances ability to primarily
close NSP. To Iurther enhance exposure,
the lower lateral cartilage and the
vestibular skin can be divided at the
dome.
13
All the mucosal Ilaps previously
described can be used in combination
with the external approach. Interposition
oI an autologous tissue graIt and Iorma-
tion oI the Ilaps are easier than with the
closed approach. Moreover, instruction
oI residents in NSP closure technique is
enhanced in the open approach.
26
The
open approach oIIers an opportunity Ior a
limited concurrent rhinoplasty.
The midIace degloving procedure has
been adopted by Romo
28
to repair larger
NSP. The main drawback is the com-
plete interruption oI the blood supply oI
the anterior nasal Iloor mucoperiosteum.
Moreover, the potential exists Ior injury
to the inIraorbital nerves and Ior vestibular
stenosis and asymmetry. The exposure is
not superior to the open approach.
Open septorhinoplasty approach used Ior closure oI NSP. Excellent binocular exposure to
the entire septal space, premaxilla, pyriIorm openings, and Iloor oI the nose is obtained. The medial crura
are spread until the premaxilla is exposed. The upper lateral cartilages are divided Irom the septum,
and the leIt and right septal Ilaps are elevated. LeIt septal Ilap perIoration is shown. Mucosal
perIoration is sutured Irom inside the septum. A periosteal graIt is then sutured in place to separate the
closed septal Ilap perIorations. (Kridel RWH, Appling WD, Wright WK: Septal perIoration closure
utilizing the external septorhinoplasty approach. Aren Otolaryngol Head Neck Surg 112:168, 1986.
Copyright 1986 American Medical Association.)
10 Volume 4

NASAL SEPTAL PERFORATIONS
B
Mastoid Periosteum
Perforated Mucosa Closed
Chapter 31 11
Septal Cartilage
Upper Lateral
Cartiiage
Perforated
Mucosal Flap
Medial Crus
Septal Septal Flap
Medial Crus
O-9I
SUMMARY
NSP can be a troublesome problem; it
should be prevented iI possible. Thor-
ough evaluation is a prerequisite Ior suc-
cessIul treatment. Prosthetic treatment
is a reasonable and economical alterna-
tive.
Surgical treatment should not be taken
lightly but oIIers a deIinitive solution.
Mucoperichondrial-periosteal Ilaps Irom
the septum, Iloor oI the nose, and lateral
nasal wall with interposed autogenous
Iree graIts are the mainstay oI surgical
treatment today. The external rhino-
plasty approach oIIers the best surgical
exposure Ior NSP closure.
REFERENCES
1. Brain DJ: Septo-rhinoplasty: The closure oI
septal perIorations. J Laryngol Otol 94:495,
1980
2. Pallanch JF, Facer GW, Kern EB et al: Pros-
thetic closure oI nasal septal perIorations.
Otolaryngol Head Neck Surg 94:448, 1982
3. Vuyk HD, Versluys RJJ: The inIerior turbi-
nate Ilap Ior closure oI septal perIorations.
Clin Otolaryngol 13:53, 1988
4. Masing H, Gammert CH, Jaumann MP: Un-
ser Konzept zur operativen Behandlung von
SeptumperIorationen. Laryngol Rhinol Otol
(Stuttg) 59:50, 1980
5. Facer GW, Kern EB: Nonsurgical closure oI
nasal septal perIorations. Arch Otolaryngol
105:6, 1979
6. Rettinger G, Hosemann W: Measuring the size
oI nasal septal perIorations: A simple ra-
diological method. Rhinology 26:157, 1988
7. Kern EB: Nonsurgical closure oI nasal septal
perIorations. In Rees TD (ed): Rhinoplasty, p
226. St. Louis, CV Mosby, 1988
8. Goodman WS, Strelzow W: The surgical
closure oI nasoseptal perIorations. Laryngo-
scope 92:121, 1982
9. Meyer R: Neurungen in der nasenplastik.
Practica Otolaryngol 13:373, 1951
10. Haye R: Septal perIorations. Prosthetic and
surgical treatment. Rhinology 27:11, 1989
11. Facer GW: Nasal septal perIorations: An up-
date 1988. Presented at 12th Congress oI the
European Rhinologic Society, Amsterdam,
June 19, 1988
12. Fairbanks DNF: Closure oI nasal septal per-
Iorations. Arch Otolaryngol 106:509, 1980
13. Kridel RWH, Appling WD, Wright WK: Septal
perIoration closure utilizing the external
septorhinoplasty approach. Arch Otolaryngol
Head Neck Surg 112:168, 1986
14. Younger R, Blokmanis A: Nasal septal perIo-
rations. J Otolaryngol 14:125, 1985
15. Jackson C, Coates GM: The Nose, Throat,
and Ear and Their Diseases, p 79. Philadel-
phia, WB Saunders, 1929
16. Rettinger G, Masing H, Heinl W: Versorgung
von SeptumperIorationen durch eine Rota-
tionsplastik der Septumschleimhaut. HNO
34:461, 1986
17. Walter CD: Composite graIts in nasal sur-
gery. Arch Otolaryngol 90:106, 1969
18. McCollough EG: An approach to repair septal
perIorations. ORL Dig 38:11, 1976
19. Fairbanks DNF, Fairbanks GR: Surgical
management oI large nasal septum perIora-
tions. Br J Plast Surg 24:382, 1971
20. Gollom J: PerIoration oI the nasal septum.
Arch Otolaryngol 88:84, 1968
21. Karlan MS, OssoI RH, Sisson GA: A com-
pendium oI intranasal Ilaps. Laryngoscope
92:774, 1982
22. Karlan MS, OssoI RH, Christu P: Recon-
struction Ior large septal perIorations. Arch
Otolaryngol 108:433, 1982
23. Belmont JR: An approach to large nasoseptal
perIorations and attendant deIormity. Arch
Otolaryngol 111:450, 1985
24. Tipton JB: Closure oI large septal perIoration
with a labial-buccal Ilap. Plast Recontr Surg
46:514, 1970
25. Tardy ME: Septal perIorations. Otolaryngol
Clin North Am 6:711, 1973
26. Arnstein DP: Surgical considerations in t he
open rhinoplasty approach to closure oI septal
perIorations. Arch Otolaryngol Head Neck
Surg 115:435, 1989
27. Meyer R, Berghaus A: Closure oI perIorations
oI the septum including a single session
method Ior large deIects. Head Neck Surg
5:390, 1983
28. Romo TR, Foster CA, Korovin GS et al: Re-
pair oI nasal septal perIoration ut ili si ng the
midIace degloving technique. Arch Otolar-
yngol Head Neck Surg 114:739, 1988
12 Volume 4 OTOLARYNGOLOGY