[Numerical simulation of intranasal airflow in nasal numerical models with nasal septum perforations of different locations and sizes].

Objective: To investigate the effect of nasal septum perforation (SP) with different locations and sizes on nasal airflow by means of numerical simulation. Methods: Two healthy persons with normal nasal anatomy were enrolled in this study, including a 45 years old male (case 1) and a 36 years old female (case 2). Nasal CT data was used as the basis to create nasal airway numerical models of nasal SP with different locations (anterior caudal, central caudal, posterior caudal and anterior cranial) and sizes (diameter of 10 mm and 5 mm respectively). The inspiratory airflow characteristics (nasal cavity volume, nasal cavity wall area, pressure, nasal resistance, temperature, airflow velocity, wall shear stress, airflow-rate partitioning and vortex) of these nasal airway numerical models were simulated and analyzed. Pearson correlation analysis was performed between nasal resistances, airflow temperature and nasal cavity wall area. Results: In terms of pressure and nose resistance, the anterior caudal and larger size SP lead to more obvious variation of pressure distribution, and increased nasal resistance was especially found in the nasal cavity with anterior and medium caudal SP. In terms of temperature, the anterior (caudal and cranial) and larger size SP had significant effect on local temperature gradient as same as the anterior cranial and smaller size SP. Nasal heating efficiency was lower in nasal model with the anterior and larger size SP than that in the normal model. The temperature difference from the nostril to the end of nasal septum had positive correlation with nasal cavity wall area (R(2) value of case 1 and case 2 was 0.69, 0.41, respectively, all P<0.01). In terms of airflow velocity, the anterior caudal and cranial SP had more significant effect on the average airflow velocity in the nasal cavity. The anterior and medium caudal SP could make the airflow distribution in the asymmetric bilateral nasal cavity more unbalanced compared to the bilateral symmetrical nasal models. The anterior and medium SP resulted in a more pronounced vortex distribution than the posterior SP. Conclusions: The effect of SP on nasal cavity is related to its location and size. The anterior and larger size SP shows more negative influence on intranasal pressure, nasal resistance, heat transmission efficiency, airflow-rate partitioning than the posterior and smaller size SP.

Approach to Correction of Septal Perforation.

Iatrogenic septal perforation is a complication of nasal surgery. Small or posterior perforations cause few symptoms, and need only conservative treatment. Larger and anterior perforations contribute to nasal airflow disturbances and external nasal deformities. When considering surgical candidacy, one should consider the severity of symptoms, location and size of the perforation, and need for revsional rhinoplasty. We repair perforations using intranasal mucosal advancement flaps augmented by an interposition connective tissue graft. Septal perforation repairs are tedious and technically challenging. We review key points to minimize unintended perforation formation following nasal surgery.

Nasoseptal Perforation: from Etiology to Treatment.

PURPOSE OF REVIEW: Nasal septum perforation (NSP) is a communication between the two nasal cavities. This review contributes to the better knowledge of NSP causes, diagnosis, and treatment. RECENT FINDINGS: NSP prevalence is about 1%. Clinical presentation may range from absence of symptoms to the presence of bothersome sinonasal symptoms. NSP is more frequently caused by trauma or post-surgery, inflammatory diseases, and abuse substances. Conservative management (nasal irrigation, topical use of antibiotic or lubricant ointments, or placement of prosthesis) is considered the first-line treatment. Symptomatic NSP not improving with local therapies usually requires surgical approach. Selection of the technique for the endoscopic septal repair depends on perforation characteristics and surgeon experience. When NSP is diagnosed, its cause has to be promptly determined. Most of them can be controlled with conservative measures. Surgical/endoscopic approaches are usually needed in refractory cases, and new repair techniques have to be considered.

Total septal perforation repair with a pericranial flap: Radio-anatomical and clinical findings.

OBJECTIVES/HYPOTHESIS: Endonasal surgeries are the primary cause of septal perforation (SP). However, trauma, inflammation, infections, neoplasms, or abuse of inhaled drugs can also cause SP. Septal repair is indicated in patients who experience nasal obstruction, crusting, intermittent epistaxis, purulent discharge, or nasal whistling and in those who fail conservative treatment. Multiple approaches have been suggested to repair the SP; however, none has been universally adopted. This study explores the feasibility of repairing a total SP using the pericranial flap (PCF). STUDY DESIGN: Anatomical cadaver and radiological study plus case study. METHODS: Total nasal septectomy and endoscopic reconstruction with a PCF was performed in 12 injected cadaveric specimens. Maximum length and area of the nasal septum and the PCF were measured in 75 computed tomography scans. Based on the anatomical study and the radiological measurements of the cadavers, one patient underwent total nasal septum repair. RESULTS: Anatomic measurements showed that the nasal septum has a mean length of 5.8 ± 0.7 cm, whereas the PCF was on average 18.4 ± 1.3 cm long (mean surface area 121.6 ± 17.7 cm2 ). Radiological measurements revealed that the PCF should provide a surface area of 40.9 ± 4.2 cm2 to account for the total septal area and an additional 30% to account range for potential scar retraction. For total septum repair, the distal edge of the PCF had to be placed 0.8 ± 2.0 cm (3.4 ± 8.7°) from the adopted reference point (vertical projection of the external ear canal). Total septal reconstruction was performed successfully in one patient without complications. CONCLUSIONS: Radio-anatomical data and a case study demonstrate that a PCF allows complete endoscopic repair of the nasal septum. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1320-1327, 2018.

Deconstructing IgG4-related disease involvement of midline structures: Comparison to common mimickers.

OBJECTIVE: A series of destructive and tumefactive lesions of the midline structures have been recently added to the spectrum of IgG4-related disease (IgG4-RD). We examined the clinical, serological, endoscopic, radiological, and histological features that might be of utility in distinguishing IgG4-RD from other forms of inflammatory conditions with the potential to involve the sinonasal area and the oral cavity. METHODS: We studied 11 consecutive patients with erosive and/or tumefactive lesions of the midline structures referred to our tertiary care center. All patients underwent serum IgG4 measurement, flow cytometry for circulating plasmablast counts, nasal endoscopy, radiological studies, and histological evaluation of tissue specimens. The histological studies included immunostaining studies to assess the number of IgG4 + plasma cells/HPF for calculation of the IgG4+/IgG + plasma cell ratio. RESULTS: Five patients with granulomatosis with polyangiitis (GPA), three with cocaine-induced midline destructive lesions (CIMDL), and three with IgG4-RD were studied. We found no clinical, endoscopic, or radiological findings specific for IgG4-RD. Increased serum IgG4 and plasmablasts levels were not specific for IgG4-RD. Rather, all 11 patients had elevated blood plasmablast concentrations, and several patients with GPA and CIMDL had elevated serum IgG4 levels. Storiform fibrosis and an IgG4+/IgG + plasma cell ratio >20% on histological examination, however, were observed only in patients with IgG4-RD. CONCLUSIONS: Histological examination of bioptic samples from the sinonasal area and oral cavity represents the mainstay for the diagnosis of IgG4-RD involvement of the midline structures.

Three-dimensional printing of large nasal septal perforations for optimal prosthetic closure.

BACKGROUND: Since 1972, patients with large nasal perforations, who were symptomatic, and who were not candidates for surgery, had the option of custom prosthetic closure at Mayo Clinic. Although septal prostheses have helped many patients, 27% of pre-1982 patients chose not to keep the prosthesis in place. Two-dimensional computed tomography (CT) sizing resulted in more of the patients choosing to retain the prosthesis. The introduction of three-dimensional (3-D) printing to the sizing process offered the potential of further improved retention by refinement in prosthesis fit. OBJECTIVE: To describe the fabrication of nasal septal prostheses by using 3-D printing for sizing and to compare the retention rate of 3-D-sized prostheses with those that used previous sizing methods. METHODS: Twenty-one consecutive patients who had placement of septal prostheses sized by using 3-D printed templates were studied. CT image data were used to print 3-D templates of the exact shape of the patient's septal perforation, and medical-grade silastic prostheses were fabricated to fit. In four cases, the 3-D printed template allowed preoperative surgical simulation. Metrics collected included prosthesis retention; symptoms, including intranasal crusting and epistaxis; and previous prosthetic closure failures. RESULTS: Twenty of the twenty-one patients had improvement in symptoms. The mean diameter of the perforations was 2.4 cm; the mean closure time by the end of the study period was 2.2 years. All but two patients chose to keep their prosthesis in place, for a retention rate of 90%. Seven patients with successful closure had failed previously with prior prosthesis sized without the current 3-D printing methodology. This 90% retention rate exceeded the previous rates before the introduction of 3-D sizing. CONCLUSION: Sizing done by 3-D printing for prosthetic closure of nasal septal perforations resulted in a higher retention rate in helping patients with these most-challenging nasal septal perforations.

Multiple mucocutaneous ulcers associated with cocaine-induced midline destructive lesions.

Cocaine-induced midline destructive lesions (CIMDL) occur in a small subset of cocaine users, who clinically present with inflammation and necrosis of facial midline structures such as the palate, nasal septum, turbinates, and sinuses. We present a patient with CIMDL occurring concomitantly with ulcers on the cheek and upper trunk. Multiple biopsy specimens from the cutaneous and mucosal lesions consistently showed a dense dermal/submucosal infiltrate of neutrophils and plasma cells, without vasculitis or thrombosis. The ulcers resolved following cessation of cocaine use.

Pedicled lateral nasal wall flap for the reconstruction of the nasal septum perforation. A radio-anatomical study.

INTRODUCTION: The aim of this radio-anatomical study is to ensure that the potential donor area of the pedicled lateral nasal wall flap (PLNW) is adequate to reconstruct nasal perforation. MATERIAL AND METHODS: Analysis was conducted on 40 de-identified CT angiographies. The area and length of the PLNW, the septum, and the nasal floor were measured. In a cadaver study, 20 hemi-cranial sagittal sections were also analyzed. The anterior-posterior length of the PLNW flap and the distance between the sphenopalatine foramen and piriform aperture were measured. A clinical study with endoscopic closure of a large perforation was conducted in three patients. RESULTS: The CT angiographies demonstrated an average PLNW area of 10.80±1.13 cm2 and a nasal floor area of 3.78±0.58 cm2. The septal area (22.54±21.32 cm2) was significantly larger than the total PLNW flap area (14.59±1.21 cm2). The average length of the flap was 5.58±0.39 cm, while the septum was 6.66±0.42 cm; therefore the PLNW flap is insufficient to reconstruct the entire septum. The cadaver study showed that the length of the PLNW flap was 5.28±0.40 cm. These results demonstrate that measurements obtained from CT scans are reliable data and similar to those found in the radiological study. Complete closure was achieved in all three patients. CONCLUSION: The PLNW flap does not render enough tissue to reconstruct a total septal perforation; however, up to 84% of the septum could be repaired with a PLNW. The potential donor area obtained by CT scan and clinical practice support the approachability of PLNW to repair large septal perforation.

Repair of nasal septal perforation using middle turbinate flap (monopedicled superiory based bone included conchal flap): a new unilateral middle turbinate mucosal flap technique.

UNLABELLED: The purpose of this study is to present a new approach for treatment of nasal septal perforation using middle turbinate flap. A consecutive study with follow-up of 31 patients with nasal septal perforation treated using middle turbinate flap. All patients underwent an endoscopic repair of nasal septal perforation using middle turbinate flap. All patients were followed for 18-24 months. Complete closure of the perforation was achieved in 29 of the 31 patients. Complete failure of the repair was observed in two patients. All patients showed nasal crusting in varying degrees for a period of 2-4 weeks. None of the patients showed nasal obstruction or atrophic rhinitis symptoms (stuffy nose, purulent postnasal drip, nasal crusting, epistaxis and anosmia) in postoperative follow-up. This technique provides a new method with many advantages compared to other techniques for closure of septal perforations. LEVEL OF EVIDENCE: IV.

Effects of nasal septum perforation repair surgery on three-dimensional airflow: an evaluation using computational fluid dynamics.

The purpose of this research is to determine the cause of nasal perforation symptoms and to predict post-operative function after nasal perforation repair surgery. A realistic three-dimensional (3D) model of the nose with a septal perforation was reconstructed using a computed tomography (CT) scan from a patient with nasal septal defect. The numerical simulation was carried out using ANSYS CFX V13.0. Pre- and post-operative models were compared by their velocity, pressure gradient (PG), wall shear (WS), shear strain rate (SSR) and turbulence kinetic energy in three plains. In the post-operative state, the crossflows had disappeared, and stream lines bound to the olfactory cleft area had appeared. After surgery, almost all of high-shear stress areas were disappeared comparing pre-operative model. In conclusion, the effects of surgery to correct nasal septal perforation were evaluated using a three-dimensional airflow evaluation. Following the surgery, crossflows disappeared, and WS, PG and SSR rate were decreased. A high WS.PG and SSR were suspected as causes of nasal perforation symptoms.

Nasal septal ulceration.

Nasal septal ulceration can have multiple etiologies. Determining the exact cause depends on who the consulting specialist is, who could either be the ENT surgeon or the dermatologist. The common causes are infections (tuberculosis, leprosy, leishmaniasis), vasculitis (Wegener's granulomatosis and Churg-Strauss syndrome), and lupus erythematosus. Traumatic causes and malignancy can also be seen in tertiary referral centers. The diagnosis often requires thorough investigations and multiple tissue specimens from various sites, and in chronic cases, a suspicion of lymphoma should be considered. Apart from disease-specific therapy, a multidisciplinary approach is required in most cases to tackle the cosmetic disfigurement.

Closure of nasal septal perforations using bilateral intranasal advancement/rotation flaps.

OBJECTIVES: This study aims to report our experience on surgical repair of nasal septal perforations (NSP) using bilateral intranasal advancement/rotation flaps with open septoplasty technique. PATIENTS AND METHODS: Medical records of 28 consecutive patients who were operated for NSP in our clinic between January 2009 and February 2013 were retrospectively analyzed. Demographic features of the patients and surgical results were evaluated. RESULTS: The most common cause of NSP was previous septal surgery in 18 (64%) of the patients. Nasal crusting was the most common symptom in 21 patients (75%). Perforation size ranged from 10 to 30 mm in diameter. Septoplasty was performed in five patients, while septorhinoplasty was performed in three patients simultaneously to the NSP repair. Nasal septal cartilage and auricular chonchal cartilage were used to support the nasoseptal skeleton, if required. There were no major intra- or postoperative complications. The mean postoperative follow-up period was 23 months. During follow-up, there was mild columellar retraction in five patients (18%). Nasal septal perforation was closed successfully in 24 patients (86%). Pinpoint perforation remained in two patients and perforation size was smaller than 5 mm in two patients. CONCLUSION: Closing the NSP with bilateral intranasal advancement/rotation flaps has a comparable high success rate. Therefore, this technique can be easily applied to small-medium sized septal perforations.

Squamous cell carcinoma originating from the nasal septal perforation: a rare nasal tumor.

Primary squamous cell carcinoma of the nasal septum is an extremely rare malignancy. In this article, we report a case of 52-year-old female with a complaint of nasal obstruction along with occasional nasal bleeding for one year. Endoscopy showed a 2.5x2 cm perforation originating from the anterior nasal septum. Incisional biopsy result was reported as squamous cell carcinoma. The tumor was removed by functional endoscopic surgery. Histopathological examination revealed squamous cell carcinoma with safe surgery borders. No recurrence and complications were noticed after one year of follow-up. The functional impact of the treatment with high mortality rates highlights the importance of early diagnosis. We recommend the differential diagnosis of septal perforation and early wide surgical excision for such cases.

Perforation of the nasal septum as the first sign of histoplasmosis associated with AIDS and review of published literature.

Disseminated histoplasmosis in South America is associated with AIDS in 70-90 % of cases. It is visceral and cutaneous, compromising the oral, pharynx, and laryngeal mucous membranes. The involvement of the nasal mucosa is unusual. Two patients with perforation of the nasal septum as the only sign of their disease were clinically and histopathologically diagnosed as leishmaniasis. The revision of the biopsies and the culture of nasal discharge secretions showed that the pathogens seen were not amastigotes but Histoplasma capsulatum. Other mycotic lesions were not detected, nor there was history of cutaneous leishmaniasis. The leishmanin skin test, available only for the male patient, was negative. The PCR and immunofluorescence antibody titers for Leishmania were negative in both patients. They were HIV positive; in the male, his CD4+ T cell count was 60/mm(3) and in the female 133/mm(3). The nasal ulcer was the only manifestation of histoplasmosis and the first of AIDS in both patients. The male patient recovered with amphotericin B and itraconazole treatment. The female has improved with itraconazole. Both patients received antiretroviral treatment. Nasal mucous membrane ulcers should include histoplasmosis among the differential diagnosis. In conclusion, two patients had perforation of their nasal septum as the only manifestation of histoplasmosis, a diagnosis confirmed by nasal mucosa biopsy and by culture of H. capsulatum, findings which demonstrated that both patients had AIDS.

Nasal septal perforation repair using intranasal rotation and advancement flaps.

BACKGROUND: We aimed to present our experience with and algorithm for septal perforation repair using advancement and rotation flaps. METHODS: A retrospective chart review was performed on 14 patients who underwent septal perforation repair. Etiology, perforation size, presenting symptoms, reconstruction methods, combined operation, surgical results, and complications were evaluated. RESULTS: The mean postoperative follow-up duration was 36 ± 18 months. Among 14 cases, 9 had previous septoplasty or septorhinoplasty and 5 cases suffered from nasal trauma. The perforation sizes varied from 5 to 27 mm, with a 14-mm average. Two cases had multiple perforations. The main symptoms included nasal obstruction, crusting, epistaxis, and whistling. Perforations were repaired using advancement flaps in seven cases or combination of advancement and rotation flaps in seven cases, with or without an interposition graft. Bilateral mucosal closure was accomplished in all cases. Conchal cartilage, remnant septal cartilage, or septal bone was used for an interposition graft. Nine patients had a concurrent rhinoplasty with septal perforation repair. At last follow-up, complete perforation closure was achieved in 12 cases (85.7%). Septal perforation recurred in 2 large perforation cases, which were repaired without interposition grafts. Nasal symptoms disappeared or improved in 13 cases (92.9%). There were no serious complications after surgery. CONCLUSION: Combined use of intranasal advancement and rotation flaps is a safe and promising option for surgical repair of moderate to large septal perforation. Bilateral tension-free mucosal closure with an interposition graft is important for the surgical success.

Nasal septal perforation repair: predictive factors and systematic review of the literature.

PURPOSE OF REVIEW: Although numerous surgical techniques have been introduced thus far in order to achieve the surgical closure of nasal septal perforation, the repair of nasal septal perforation is still challenging for surgeons and operative techniques are not standardized. Furthermore, predictive factors for successful closure have not been elucidated. This review aimed to investigate predictive factors for complete closure of nasal septal perforation. RECENT FINDINGS: The size of perforation was the most significant factor for complete closure. Surgical failure occurred more frequently in patients with large perforation (>2 cm) than those with small-to-moderate perforation (≤2 cm). The bilateral coverage over the perforation with vascularized mucosal flap also helped complete closure. Interposition of grafts appeared to assist complete closure, although it was statistically insignificant. SUMMARY: This review provides information for surgeons on how to predict surgical outcomes of the repair of nasal septal perforation and which surgical techniques to choose in order to obtain better results.