Journal of Otology & RhinologyISSN: 2324-8785

All submissions of the EM system will be redirected to Online Manuscript Submission System. Authors are requested to submit articles directly to Online Manuscript Submission System of respective journal.
bahis siteleri bahis siteleri bahis siteleri casino siteleri

Research Article, J Otol Rhinol Vol: 3 Issue: 2

Endoscopic Repair of Nasal Septal Perforations Using Modified Pedicled Inferior Turbinate Flap

Samy Elwany* and Zeyad Mandour
Department of Otolaryngology, Faculty of Medicine, University of Alexandria, Egypt
Corresponding author : Samy Elwany
Department of Otolaryngology, Faculty of Medicine, University of Alexandria, 4 KafrAbdou Street #605, Alexandria 21925, Egypt
Tel: +20122167222; Fax: +2034831498
E-mail: [email protected]; [email protected]
Received: January 17, 2014 Accepted: February 15, 2014 Published: February 27, 2014
Citation: Elwany S,Mandour Z(2014) Endoscopic Repair of Nasal Septal Perforations Using Modified Pedicled Inferior Turbinate Flap. J Otol Rhinol 3:2. doi:10.4172/2324-8785.1000147

Abstract

Endoscopic Repair of Nasal Septal Perforations Using Modified Pedicled Inferior Turbinate Flap

Background: Septal perforations are usually difficult to treat. Surgery is indicated if the perforation is symptomatic. Our aim is to evaluate endoscopic closure of nasal septal perforation using pedicled inferior turbinate flap.

Patients and Methods: Endoscopic closure of nasal septum perforations were performed in 31 patients using unilateral pedicled inferior turbinate flap.

Results: Twenty-three patients (74%) had complete closure of their perforations. Six other patients (19.5%) had incomplete closure with a small residual perforation< 1cm in diameter posteriorly. Two patients (6.5%), who had previous submucosal diathermy of the inferior turbinate, had flap necrosis with complete failure of the repair. There was a significant inverse relationship between the diameter of the perforation and the success of the repair.

Conclusions: Endoscopic repair of nasal septal perforations, up to 2 cm in diameter, using a modified pedicled inferior turbinate flap, is a feasible technique that offers acceptable success rates due to the remarkable vascularity and thickness of the flap. The use of endoscopes allowed more precise a traumatic elevation of the flap posteriorly. The present technique differs from other previously described flap procedures in that it extends the posterior dissection to include a part of the mucosa of the inferior meatus in order to allow more free un-constrained rotation of the flap, and decrease the thickness of the pedicle so that we may not need to divide it in a second stage. This step would have been more difficult and less precise without the use of the endoscope. Previously operated turbinates are not suitable for this technique. Also the procedure may not be suitable if the perforation is very anterior or larger than 2 cm in diameter.

Keywords: Septum; Perforation; Endoscopic; Inferior turbinate flap

Keywords

Septum; Perforation; Endoscopic; Inferior turbinate flap

Introduction

Septal perforation is one of the difficult problems that the otolaryngologist has to solve. All surgical procedures, aimed at repair of nasal septal perforations, are based on using local mucosal, mucoperichondrial, and/or mucoperiosteal flaps with or without connective tissue autograft, to be interposed between the mucosal flaps.
Septal perforations are commonly classified according to their size. Small perforations refer to those with a diameter of ≤ 0.5 cm; medium perforations with a diameter ranging between 0.5-2 cm; and large perforations with a diameter >2 cm [1-3].
Surgery is indicated in the presence of symptomatic perforations. On the other hand, surgical repair is not usually recommended for perforations not presenting subjective and functional disorders, as well as perforations due to neoplastic and granulomatous conditions [4].
Closure of septal perforations remains a surgical challenge. In fact, most perforations remain unclosed because available closure techniques are technically difficult and require training and experience to master. Many authors have described high success rates with their techniques; but these results are not reproducible by all surgeons [5- 7]. High success rates were usually reported for perforation less than 15 mm in diameter [8].
In 1980 Masing introduced the inferior turbinate flap for closure of septal perforations, and reported an encouraging success rate of about 80% [9]. Other authors, using the same flap, reported much lower success rates of about 30-40% in perforations up to 2 cm in diameter [5]. In this paper we report our experience with endoscopic closure of septal perforations using a modified pedicled inferior turbinate flap.

Patients and Methods

Between January 2008 and June 2013, 31 patients with iatrogenic septal perforations were operated upon using unilateral inferior turbinate pedicled flap. The patients were 10 women and 21 men. Their ages ranged from 16 to 52 years. Eighteen patients had been previously treated elsewhere with different surgical techniques. In 3 more patients silastic prosthesis had been applied unsuccessfully.
IRB approval was obtained from ethical committee of Alexandria Medical School and informed consents were taken from all patients.
Surgical technique
The procedure (Figure 1) was performed under hypotensive general anaesthesia using 0° endoscope. The perforation edges were trimmed with a sickle knife to obtain fresh margins. The turbinate flap, including the mucosa and submucosa of the turbinate, was created starting from the anterior end of the turbinate and proceeding posteriorly taking care to preserve adequate posterior pedicle. It is important to extend the posterior dissection so that to include a part of the mucosa of the inferior meatus. This allows easy and unconstrained rotation of the flap, and decreases the thickness of the pedicle so that we may avoid a second procedure to divide it. Also care is taken to preserve good part of the anterior part of the turbinate in order to avoid postoperative atrophic changes. The turbinate bone is left intact to re-mucosalize later on. The flap was spread to create mucosal surface on one side and raw submucosal surface on the other side. The flap was then rotated along its posterior pedicle, adjusted to fill the perforation, and fixed in place, to all edges of the perforation, using fibrin glue and 4-0 plain catgut. The contralateral side was left bare for closure by secondary intention. Nasal silastic sheath was inserted to support the flap on both sides and to prevent possible postoperative adhesions. The patients were followed up on weekly basis for three months or until complete healing of the perforation. The patients were advised to use frequent saline douches during the follow up period to minimize crust formation. Division of the pedicle, under topical anaesthesia, was done only when it caused nasal obstruction on the side of the flap.
Visual Analog Scale was used to assess the changes in patients’ symptoms following the procedure. We defined the minimum clinically significant difference as 50%-change in the previously recorded VAS value, and thus ended with a three-category scale (Better, Unchanged, Worse) in order to simplify the evaluation.

Results

The preoperative symptoms of the patients are listed in Table 1. All patients complained from crusting and nasal obstruction preoperatively. Mild epistaxis was present in 17 patients (55%), and 13 patients (42%) complained of halitosis. No patients complained from whistling possibly due to the large size of the perforations.
The diameter of the perforations was 5-20 mm in 21 patients (67.7%), and more than 20 mm in 10 patients (32.3%). The average diameter of the perforation was 18.5 mm. Thirteen perforations were totally located anterior to the anterior end of the inferior turbinate. The other 18 perforations were located partially or totally behind the anterior end of the inferior turbinate (area of mid septum).
Twenty-three (74%) patients had complete closure of their perforations. Six patients (19.5%) had incomplete closure with residual perforations, < 1 cm in diameter, posteriorly. Four of these 6 patients had perforations > 20 mm in diameter preoperatively. Two patients (6.5%), who had previous submucosal diathermy of the inferior turbinate, had flap necrosis with complete failure of the repair.
All patients complained of variable degrees of nasal airway obstruction, mainly on the flap side, for the first 3-4 weeks postoperatively, but none of them complained from permanent dryness or developed atrophic changes. Eleven patients (35%) needed a second stage to divide the pedicle of the flap. Adequate incorporation of the flap into the septum with epithelialization of the contralateral raw surface of the flap took place in all successful cases at 4-6 weeks after surgery. Analysis of the procedural results (Table 2) showed that there was a significant relationship between the diameter of the perforation and the success of the repair (Yates’ chi- square = 6.57, Yates’ p-value = 0.010).
Twenty-seven patients (87%) reported improvement of nasal crusting at the end of follow up period. Likewise, 26 patients (83%) reported improvement of nasal breathing. Epistaxis was improved in 16 out of 17 patients, while bad breath improved in 12 out of 13 patients (Table 2). Four patients with incompletely closed perforations reported improvement of some of their nasal symptoms.
Figure 1: 1) Large perforation (2.5 cm) in the mid septum. The arrowheads outline the edges of the perforation. it : inferior turbinate; 2) The initial incision in the inferior turbinate (it); 3) The pedicled inferior turbinate flap (it) is completely elevated; 4) Complete closure of the perforation with the flap(F). The arrowheads outline the edges of the flap. The small arrow points to the pedicle of the flap; 5) The contralateral raw side of the flap (F) at the end of surgery; 6) A well healed perforation (*) 6 weeks after surgery. The arrowheads outline the edges of the healed flap. it: residual inferior turbinate.
Table 1: Preoperative symptoms and postoperative results of the patients.
Table 2: The relationship between the size of the perforation and the postoperative result.

Discussion

The successful management of septal perforations often poses a significant technical challenge. Surgical trauma during septoplasty is still one of the main offenders. Other causes include tight pressure by hemostatic nasal balloons, bilateral cauterization of nosebleeds, repeated nose picking, or inadequately treated septal hematoma with subsequent septal abscess [5,10-12]. The neighbouring cartilage, mucosa, and submucosa may be normal or variably diseased depending on the cause of the perforation.
Treatment is only necessary for symptomatic perforations and may be conservative, prosthetic or surgical as many perforations go unnoticed by the patient. However, some perforations cause significant symptoms of bleeding, crusting, and whistling. Unfortunately, most otolaryngologists probably experience poor overall success rates with repair of septal perforations.
Small perforations are generally treated with local advancement flaps from the remaining septum with or without an underlying connective tissue autograft [13,14]. Many two-stage procedures have been also described for larger perforations [10].
Recently, Kridel et al. [15,16] popularized an external septorhinoplasty approach that achieved good results, with the disadvantage of needing open rhinoplasty incision. Weller et al. [17] described a more conservative open septoplasty transcollumar approach for repair of septal perforations. The external scar, though usually un-noticeable, is the main drawback of these open approaches.
The present study confirmed the concept that the most important predictor of successful surgical perforation closure is the size of the perforation. The location of the perforation is another key element in the decision to perform or not to perform repair and in the type of repair to use. Posterior perforations, for example, are harder to repair with advancement flaps. Also advancement flaps may not suitable for anterior perforations in the nasal valve area because of unavailability of enough tissues anteriorly. An advantage of the pedicled inferior turbinate flap is that it can be used for most perforations, regardless of its location, with the exception of very anterior perforations beyond the limit of the flap. Other key advantages of the inferior turbinate flap are abundant vascularity, wide arc of rotation, thickness of the flap, and ease of development and insertion.
Success rates ranging from 40% to 95% have been reported in some series [17]. In the current study, twenty-three patients (74%) have had complete closure of their perforations. Six other patients (19.5%) had incomplete closure with a small residual perforation posteriorly. Two patients (6.5%), who had previous submucosal diathermy of the inferior turbinate, had flap necrosis with complete failure of the repair.
Ideally, repair would resurface the septum with respiratory mucosa of nasal origin to allow the repaired septum to achieve physiological normalcy. Only advancement and inferior turbinate flaps have this advantage. However, the inferior turbinate flap is more versatile than advancement flaps and is ideally suitable for perforations of the mid septum. Other methods that use skin grafts or buccal mucosa grafts may succeed in closing the perforation but leave the patient with a dry nose that continues to crust because normal respiratory tract mucosa is not present [18,19].
The major disadvantage of the inferior turbinate flap is that one surface is left initially uncovered with epithelium and must heal by secondary in growth of epithelium. However, after 3-4 weeks, almost all flaps are well re-epithelialized. The use of nasal douches and daily application of antibiotic ointment may be helpful to further reduce the crusting during the healing process. However, none of the patients developed permanent atrophic changes. Another disadvantage is that the procedure may not be successful in patients who have had previous turbinate surgery, and those with very anterior perforations reaching the mucocutaneous junction of the septum.
All techniques described for surgical repair of the septal perforation are valuable in selected situations by the right surgeon. Many patients who seek perforation repair have already failed local advancement flaps from the septum; therefore, flaps from other areas are needed. Other patients have had extensive previous septal surgery with removal of cartilage and also are not candidates for local advancement flaps. The inferior turbinate provides easily accessible tissue that, in many cases, has not been previously traumatized.
In conclusion, the modified pedicled inferior turbinate flap allows for more options to correct a difficult problem. The procedure utilizes local nasal highly vascularized tissues, avoids external scars, and is easy to master with reasonable training. The use of endoscopes allowed more precise a traumatic elevation of the flap posteriorly. The present techniques differs from other previously described flap procedures [20] in that it extends the posterior dissection to include a part of the mucosa of the inferior meatus in order to allow more free unrestrained rotation of the flap. This step would have been more difficult and less precise without the use of the endoscope. The described technique achieved acceptable and encouraging results, and is especially useful for perforations, up to 20 mm in diameter, that cannot be dealt with advancement techniques. Larger perforations may have a much lower success rate of 40% and the patients should be appropriately counselled prior to attempting the procedure. The patients should also understand that they might need a second stage to divide the pedicle of the flap in about 35% of cases.

References





















Track Your Manuscript

Media Partners

Associations