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Alternate Sliding Technique for Repairing a Nasal Septum Perforation

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Alternate Sliding Technique for Repairing a Nasal Septum Perforation AlternateAlternate slidingsliding techniquetechnique forfor repairingrepairing aa nasalnasal septumseptum perforaperforationtion Munetaka Ushio1), Kenji Kondo1), Shintaro Baba1), Kaori Kanaya1), Naoya Egami1), Noriko Tamaruya2), Maho Nagai3), Tsutomu Nomura2), Kenji Ino4), Tatsuya Yamasoba1) 1) Dpt. of Otolaryngology, The Univ. of Tokyo; 2) Dpt. of Otolaryngology, NTT Medical Center Tokyo; 3) Dpt. of Otolaryngology, JR Tokyo General Hospital; 4) Dpt. of Radiology, The Univ. of Tokyo ABSTRACTABSTRACT INTRODUCTION SURGICAL TECHNIQUE 2 RESULTS 2 DISCUSSION Objective: A critical point for successful Some patients with nasal septum perforation suffer from recurrent Elevation of the flap is extended to the nasal floor on one side of Representative Case Reports For repairing nasal septum perforation, a variety of surgical surgical closure of the perforation of a epistaxis, nasal obstruction, crusting, pain and whistling. Possible the nasal cavity (side A) (Fig. 2A, 3A) and to the lateral portion of Case 1: A 52-year-old female visited with the complaints of nasal techniques have been developed, including the endonasal nasal septum is the simultaneous etiological factors are aggressive cauterization of the nasal the upper lateral cartilage on the other side of the nasal cavity obstruction, recurrent epistaxis and crusting. On presentation, a nasal approach, the external rhinoplasty approach, and local and free achievement of both sufficient blood supply mucosa for epistaxis, external or self-induced trauma, Wegener’s (side B) (Fig. 2B, 3A). Elevation should be performed carefully so septum perforation having a longer axis of 20 mm with unknown flap reconstruction1,2. Our experience suggests that the endonasal to the closure site and reduced tension of granuloma, cocaine use, organic solvent inhalation, or iatrogenic as not to extend the perforation. reason was noted (Fig. 4A). The perforation was closed using the approach is adequate for exposing septal perforation, flap the flaps. We describe a modified surgical perforation secondary to surgical procedures such as septoplasty alternate sliding technique. No interpositional graft was placed. dissection and suturing, because the use of an endoscope technique, the “alternate sliding technique”, or deviatomy. Complete closure of the perforation was observed, and symptomatic facilitates precise surgical manipulation at each step. to manage this difficulty. Symptomatic septal perforations often require surgical improvement was noted. In the postoperative follow-up period of 18 Our technique resolves, at least partially, the difficulty of months, reperforation was not observed (Fig. 4B). The axial view of Methods: The procedure starts with the treatment because conservative treatments do not improve simultaneously achieving sufficient blood supply to the closure site computational fluid dynamic studies revealed vortex airflow around the elevation of bilateral mucosal flaps under symptoms significantly. Surgical closure of a perforated nasal and reduced tension in the flaps. Poor blood flow to the closure perforation before surgery (Fig. 5A, red arrows) that resolved an endoscopic view. A releasing incision is septum is one of the most difficult challenges in rhinology. A completely after the procedure (Fig. 5B). site can result in flap defects. In this technique, alternate flaps are made across the nasal floor on one side variety of surgical methods have been developed, including the used for closing the septal perforation. Thus, the blood flow to the and across the lateral cartilage on the other endonasal approach, the external rhinoplasty approach, and both upper half of the mucosa on one side and the lower half on the side. The flaps are slid up- and downward, local and free flap reconstruction1,2. other side can remain almost intact, although the blood flow to the respectively. The perforation is then The endonasal approach has the advantage over other sliding portions may be comparatively poor. In addition, since sutured. methods in that it is less invasive and does not require an external blood flow around the edges of the perforation is usually poor, Results: Nasal septum perforation was incision. Although in the past it had the disadvantage of offering placing opposing suture lines at the same level can result in successfully fixed with the first surgery in an insufficient surgical view, the recent introduction of endoscopy Figure 2. Endoscopic view during surgery 2 dehiscence, and thus suture lines can become necrotic after 10 of the 13 patients. Among them, re- has nearly eliminated this problem.In the endonasal approach, the Once the bilateral flaps are completely elevated, a posterior-to- Figure 4. 3D CT findings before and after surgery (case 1) surgery. Using our technique, the levels of opposing suture lines perforation was not observed during post- mucoperichondrial and mucoperiosteal flaps (or inferior turbinates) anterior longitudinal mucosal-releasing incision is made across the are different because the left- and right-side flaps are advanced operative follow-up of 3-28 months. The are most commonly used as donor tissues for reconstruction of nasal floor of side A (Fig. 3A, blue arrow head). A similar alternately. Thus, areas of mucosal weakness are not piled up on symptoms complained of before surgery the septal mucosa. A critically important but often difficult issue for longitudinal mucosal-releasing incision is made on the lateral either the left or right side. Furthermore, these alternating, fully resolved. A patient who had taken successful surgical wound closure is simultaneously achieving a portion of the upper lateral cartilage, parallel to the nasal dorsum “bipedal,” flaps prevent perfect alignment of suture lines, which corticosteroids for several years, a patient sufficient blood supply to and reduced tension on the flaps. superiorly and anteriorly, on side B (Fig. 3A, red arrow head). The facilitates healing and allows non-perfect technique. who had had multiple perforations and A modified surgical technique, the “alternate sliding technique,” flaps are then slid upward and downward on sides A and B, A patient who had taken corticosteroids for several years, a another required the additional closure of a for managing this difficulty is described here. respectively (Fig. 3A, blue and red arrows). This procedure Figure 5. Fluid dynamic studies in case 1 patient who had multiple perforations (having a total longer axis of Case 2: A 24-year-old male visited with the complaints of recurrent small perforation in our clinic. enables the surgeon to make adjustments to effect optimal left 40 mm) and another required an additional closure for a epistaxis and nose pain. He had a history of several surgeries for cleft Conclusion: Our alternate sliding and right suture line orientations. The perforation is then sutured lip and palate and nasal septal deviation. On examination, multiple subsequent small reperforation. Multiple or large perforations and technique facilitates a better blood supply from posterior to anterior in each flap using 5-0 nylon sutures nasal septum perforations covering a longer axis totaling 40 mm were corticosteroid use may be risk factors for reperforation. from the bipedicled attachment. Each SURGICAL TECHNIQUE 1 (Figs. 2D, 3B, red arrow). The reconstructed septal mucosae are identified (Fig. 6A). On surgery, all the perforations were connected suture is lined by a mucosal flap of the covered and protected during the healing period by silicone because the nasal mucosa between them was extremely thin and other side. These minimize the risk of re- This intervention is accomplished exclusively through an sheets. weak (Fig. 6B). The perforations were closed using the alternate perforation. Our technique is applicable for endoscopic endonasal approach. We usually use our modified sliding technique. Temporal fascia was placed between the left and CONCLUSIONS small to medium perforations. nasal speculum to facilitate manipulation of the anterior septum3. right nasal septal mucosa as an interpositional graft (Fig. 6B, red The procedure begins with a hemitransfixion incision of the circles). Complete closure of all perforations was observed and Alternate sliding technique does not require particularly advanced septal mucosa (Fig. 1A). After the anterior end of the quadrant symptomatic improvement was noted. However, 3 months after surgical expertise. Any surgeon having adequate experience with cartilage is exposed (Fig. 1B, white arrow), the mucoperichondrial surgery, a small reperforation was observed (Fig. 6C), and a second endoscopic septoplasty or deviatomy can perform this operation. and mucoperiosteal flap is elevated bilaterally from the septum procedure was required (Fig. 6D). We believe that our technique is applicable for repair of small to (Fig. 1C, D, white arrow heads). medium perforations, and that its use can reduce the risk of Figure 3. Illustration of alternate sliding technique reperforation. CONTACTCONTACT RESULTS 1 REFERENCES The average major axis was 21.8 mm (8-40 mm) in length. Munetaka Ushio nasal septum perforation repair was successful with the first 1. Goh AY, Hussain SS. Different surgical treatments for nasal septal Dpt. of Otolaryngology, The Univ. of Tokyo surgery in 10 of the 13 patients. Among these, reperforation was perforation and their outcomes. J Laryngol Otol. 2007;121:419-26. Email: [email protected] not observed during the post-operative follow-up period of 3-28 2. Watson D, Barkdull G. Surgical management of the septal perforation. Phone: +81-3-5800-8665 months, and presenting symptoms resolved fully. A patient who Otolaryngol Clin North Am. 2009;42:483-93. had taken corticosteroids for several years, a patient who had 3. Ushio M, Nakaya M, Kondo K, Suzuki M, Yamasoba T. Modified nasal multiple perforations (representative case 2) and another required specula and flexible holder for endoscopic nasal surgery. Figure 1. Endoscopic view during surgery 1 additional surgical closure of a small reperforation. Figure 6. 3D CT findings before and after surgery (case 2) Laryngoscope. 2008;118:1293-4. Poster Design & Printing by Genigraphics® - 800.790.4001.
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