"Boot-on-Donut" procedure for anterior and large septal perforation.

BACKGROUND: Surgical closure of large nasoseptal perforation (NSP) is challenging. The use of an extended anterior ethmoidal artery (eAEA) flap to reconstruct NSP may present with difficulties for NSPs which have their upper edge in a high position. METHOD: We propose adding a "donut-shape" flap from surrounding septal tissue to the eAEA flap. Thus, the inverted edges of this flap allow to cover the uppermost aspect of the NSP. A series of 18 patients with complete closure of NSPs was included. CONCLUSION: This novel "Boot-on-Donut" technique consisting of the eAEA flap (Boot) and inverted edges (Donut) is a feasible procedure that allows to reconstruct large NSP located superiorly.

Effect of Locally Administered Estradiol on Wound Healing in a Nasal Septal Perforation Animal Model.

We aimed to investigate the effect of estradiol on wound healing in an experimental nasal septal perforation (NSP) model created in rats. Twenty-two Sprague Dawley healthy male rats were separated into two groups. NSP, approximately 2 mm in diameter, was created in each animal. The 0.1 mL 0.12% estradiol (12 g/L) (study group) and 0.1 mL 0.9% saline (9 g/L) (control group) were applied topically once a day for 14 days. The rats were sacrificed on the 14th day and the cartilage nasal septum of each animal was excised for histopathological examination. The nasal mucosal epithelial regeneration and degeneration, acute inflammatory cell count, fibroblast number, vascularization, granulation tissue formation, giant cell number, eosinophil number, degeneration and regeneration of the nasal cartilage, and collagen density were examined. The macroscopic closure rate of the perforations and histopathological parameters were evaluated statistically. In this study, the epithelial regeneration, the fibroblast count, the granulation tissue formation, and the amount of collagen were significantly higher in the study group than in the saline group (p < 0.05). The acute inflammatory activity was lower in the estradiol group than in the saline group (p < 0.05). There was no statistically significant difference in the closure rate of perforation between the two groups (p = 0.163). No significant difference was found in other comparisons (p > 0.05). The locally administered estradiol may improve wound healing of the nasal septum in an experimental NSP animal model. LEVEL OF EVIDENCE: Not applicable.

[Closing of nasal septum perforation using adipose stromal vascular fraction: an experimental study]. / Zakrytie perforatsii peregorodki nosa s primeneniem stromal'no-vaskulyarnoi zhirovoi fraktsii: eksperimental'noe issledovanie.

Nasal septal perforation (NSP) is a complex problem in otorhinolaryngology, which leads to impaired nasal breathing and dryness in the nose. This reduces the patient's quality of life and leads to psychological discomfort. The treatment of nasal septum perforation is selected taking into account the clinical manifestations, perforation parameters and general condition of the patient. Currently, a large number of different surgical methods have been described in order to closing the defect of nasal septum. To date, there is no universally accepted method for closing NSP, which stimulates the search and development of new treatment options. OBJECTIVE: Under experimental conditions, to study a new method for closing nasal septum perforation using a collagen scaffold together with adipose stromal vascular fraction containing multipotent mesenchymal stromal cells. MATERIAL AND METHODS: The experiment was carried out on a model of nasal septum perforation in 24 male rabbits divided into four groups, depending on the construct, implanted into the defect zone: the 1st group was the control group - without the introduction of implantation material; the 2nd group - collagen scaffold without adipose stromal vascular fraction; the 3rd group - collagen scaffold with xenogenic adipose stromal vascular fraction; the 4th group - collagen scaffold with allogeneic adipose stromal vascular fraction with further dynamic evaluation of endoscopic control on day 14, after 1 month, 3 months, and 6 months. At month 6, the animals were removed from the experiment, followed by morphological examination in color with hematoxylin and eosin, as well as safranin and methyl green. RESULTS: As a result of the experiment using adipose stromal vascular fraction of allogeneic and xenogenic origin, closing of perforation of the nasal septum of a rabbit for 3 months of dynamic endoscopic control, as well as according to morphological research, was demonstrated. CONCLUSION: Our study showed that the use of adipose stromal vascular fraction containing not only endothelial cells and pericytes, but also multipotent mesenchymal stromal cells in combination with a collagen scaffold closes the perforation of the nasal septum in a rabbit, without increasing the risk of violations of habitual vital activity.

Added value of 3D printing technology in the manufacturing of customised septal buttons: A scoping review of the literature.

BACKGROUND: In recent years, Three-dimensional printing (3-DP) technology, has had several applications in many fields of medicine, including rhinology. The aim of this review is to evaluate the use of 3-DP buttons as a treatment option for nasal septal perforations (NSP). METHODS: We conducted a scoping review of the literature until June 07, 2022, on the online databases PubMed, Mendeley, and Cochrane Library. All articles referred to treatment of NSP with custom made buttons created by 3-DP technology were included in this study. RESULTS: A total of 197 articles were generated by the search. Six articles met the inclusion criteria. 3 of the articles referred to clinical cases or clinical series. A total of 35 patients used the 3-DP custom made button as a treatment for NSP. The retention rate of this buttons ranged from 90.5 % to 100 %. An overall decrease in NSP symptoms was also observed in the majority of patients, especially regarding the most common complaints such as nasal bleeding and crusting. CONCLUSION: The manufacturing of 3-DP buttons is a complex, time consuming process that requires both special laboratory equipment and trained staff. This method has the advantage of reducing the NSP related symptoms and an improving the retention rate. This could make the 3-DP custom made button a first-choice treatment for patients with NSP. However, as a new treatment option, it needs studies with more patients to determine its superiority over conventional buttons and its long-lasting therapeutic effects.

Trilayer temporalis fascia interposition graft: A reliable technique for nasal septal perforation repair.

PURPOSE: Nasal septal perforation (NSP) repair is a complex procedure with variable techniques and success rates. In this study we describe NSP repair using a trilayer interposition graft of temporalis fascia and thin polydioxanone (PDS) plate without intranasal flaps and report outcomes in our patient population. MATERIALS AND METHODS: IRB-approved retrospective review of 20 consecutive patients presenting to a tertiary medical center with NSP from September 2018 to December 2020 and who underwent NSP repair via our trilayer temporalis fascia interposition graft. De-identified patient data was obtained from the medical record and stored on an encrypted secure server. Descriptive statistics were examined for each variable. RESULTS: All 20 NSP repairs demonstrated durable repair with complete mucosal coverage at last follow-up (average 7 months). Complete resolution of preoperative symptoms was achieved in 85 % of patients, with partial resolution in the remaining 15 %. Of the 20 perforations 25 % were small (<1 cm), 50 % medium (1-2 cm), and 25 % large (>2 cm). The only surgical complication was a single intranasal synechiae. No graft harvest site complications were noted. CONCLUSION: The application of a trilayer temporalis fascia - PDS plate interposition graft without intranasal flaps is highly effective for repair of NSP.

Nasal Septal Perforation Secondary to Graft-Versus-Host Disease.

Nasal septal perforation is a full-thickness defect of the nasal septum. There are many described etiologies of nasal septal perforation, including trauma, infectious, neoplastic, iatrogenic, and autoimmune. Graft-versus-host disease (GVHD) is a common and potentially life-threatening complication that can occur after an allogenic transplant. GVHD can result in the development of autoantibodies that lead to granulomatous inflammation with necrotizing vasculitis, causing perforation of the nasal septum. In this report, we describe a patient with nasal septal perforation secondary to GVHD and hope to provide novel insights into the association of GVHD and nasal septal perforation.

The Efficacy of Topical Lactoferrin on Wound Healing in an Experimental Animal Model of Nasal Septum Perforation.

The aim of the present experimental animal study was to investigate the efficacy of bovine lactoferrin (LF) on wound healing in an animal model of nasal septum perforation (NSP).Twenty-two, 8 to 10 weeks of age, male Sprague-Dawley rats were separated into two groups. Nasal septum perforation was created in each rat. The saline (control) and 0.05 mg LF (study) groups were delivered locally for 14 days. On the 14th day of the study, after the sacrifice, the cartilage nasal septa of the animals were excised. The degeneration and regeneration observed in the nasal septum epithelium and cartilage, the number of acute inflammatory cells, the number of eosinophils, the amount of new vessel formation, the amount of granulation, and the collagen density were examined microscopically. The microscopic parameters and macroscopic healing of NSPs were analyzed. The epithelium regeneration, the fibroblast number, the granulation tissue formation, the collagen density, and the macroscopic healing were significantly higher in the LF group (p < 0.05). Besides, the acute inflammatory cell count was lower in the LF group (p = 0.034). In conclusion, the topically delivered LF can improve wound healing in an experimental rat model of NSP.

Rhinoplasty with Concurrent Repair of Septal Perforation.

Concurrently performing septal perforation repair and rhinoplasty is challenging. Successful management of patients who require or desire these procedures performed simultaneously can be achieved with appropriate preoperative workup and optimization, thoughtful surgical planning, masterful execution, and diligent postoperative care. Consideration of perforation etiology and status of the perforation along with overall nasal health are the foundation upon which surgery may be planned. Preoperative evaluation to determine locations of obstruction, aesthetic goals, and feasibility of procedure is required. Rhinoplasty techniques and perforation closure techniques may share common maneuvers making concurrent surgery possible. Surgical techniques to achieve perforation closure often influence rhinoplasty considerations, and vice versa. Care must be taken to account and possibly even to capitalize on these influences. Perforation closure techniques that may be readily combined with rhinoplasty include interposition grafting and intranasal mucosal rotational advancement flaps, which may exert forces upon the nose with aesthetic or functional consequences. Rhinoplasty techniques targeting any third of the nose also can impact tension or available mucosa for perforation closure techniques. Combining these procedures can be very rewarding for the patient and provider but should be considered responsibly and thoughtfully.

The Effect of Melatonin on Nasal Septal Wound Healing in an Experimental Animal Model.

The purpose of our study was to examine the effect of melatonin (MLT) on wound healing in the nasal septum. Twenty-two Sprague-Dawley rats of the male sex were included in this experimental study. Nasal septal perforation (NSP), about 2 mm in diameter, was formed in each rat. MLT was applied topically to the subjects in the study group and saline was applied topically to the subjects in the control group once a day for 14 days. On day 14, the rats were sacrificed and the nasal septums of the subjects were resected for pathological evaluation. In the NSP area, degeneration and regeneration of nasal septal epithelium; degeneration and regeneration of the septal cartilage; number of cells involved in wound healing such as acute inflammatory cells (leukocytes), fibroblast, eosinophil, and giant cell; capillary vessel intensity; granulation tissue formation; and collagen intensity parameters were evaluated histopathologically. The macroscopic size and histopathologic examination results of NSPs were statistically analyzed. In the MLT group, the epithelium regeneration, cartilage regeneration, fibroblast number, collagen density, vascularity, and granulation formation were significantly higher, and the epithelial degeneration and acute inflammatory cells density were significantly lower, in the NSP area (p < 0.05). In addition, macroscopic healing was significantly higher in the MLT group (p = 0.044 and <0.05). Local application of MLT accelerates nasal septal wound healing. With this feature, the usage of MLT can be promising to prevent the formation of NSP.

The effect of locally administered phenytoin on wound healing in an experimental nasal septal perforation animal model.

PURPOSE: In the present study, we aimed to investigate the effect of phenytoin (PHT) on wound healing in an experimental nasal septal perforation (NSP) model created in rats. METHODS: Twenty-two Sprague Dawley male rats were randomized into two groups. NSP, approximately 2 mm in diameter, was created in each subject. The 1% PHT cream (Study group) and saline (Control group) were applied topically once a day for 14 days. The subjects were sacrificed at the end of 14th day and the nasal septum of each animal was excised for histopathological examination. The epithelial regeneration and degeneration of the nasal mucosa, acute inflammatory cells number, fibroblast number, collagen density, vascularization, eosinophil number, granulation tissue formation, giant cell number, degeneration and regeneration of the nasal cartilage were examined. The macroscopic closure rate of NPSs and histopathological parameters were analyzed statistically. RESULTS: In this study, the epithelial regeneration, the fibroblast count, the collagen density, the vascularization and the amount of granulation tissue and the macroscopic clouse rate of NSPs were significantly higher in the PHT group than in the saline group (p < .05). There was no significant difference was in other comparisons (p > .05). CONCLUSION: The locally administered phenytoin may accelerate wound healing of nasal septum in an experimental NSP model. Consequently, phenytoin might be used as an effective substance to prevent the formation of NSP.

Repair of postoperative and recurrent nasal septal perforations using L-strut overlay flap.

BACKGROUND: Despite the many described techniques, surgical repair of iatrogenic nasal septal perforations is still challenging. The authors present a novel technique for endoscopic closure of postoperative and recurrent nasal septal perforations. METHOD: The technique is based on the elevation of a vascularized flap from the L-strut area and the creation of the bed site without dissection of the surrounding septum. Seven patients were operated using "L-strut overlay" flap from June 2018 to October 2020. All patients had their perforations closed 12 months after surgery. CONCLUSION: Early results of our surgical technique have proven its simplicity and high effectiveness.

Evaluation of septal perforation size using a novel measuring device.

BACKGROUND: Nasal septal perforations can be managed with a septal button prosthesis. While they do not restore the physiological function of the septal mucosa, they are able to improve laminar nasal airflow. With the development of septal buttons sized specifically to perforations, accurate measurement of perforations has become more important for patient satisfaction and comfort. This task can be difficult to accomplish in the clinical setting. In this study, 2 new instruments developed to measure septal perforations were evaluated for accuracy and ease of use. METHODS: Two types of measuring devices ("sizers") were created via 3D printing. One type included six serial, progressively sized instruments (serial sizers) and the other included two instruments with several size gradations (graded sizers). Septal perforations of varying sizes were surgically created in five fresh-frozen cadaver heads. Using a headlight and nasal speculum, 15 otolaryngology trainees and consultants were asked to measure the perforations (length × height) via four different methods: "eyeball" estimation, a ruler, the serial sizers, and the graded sizers. They were also asked to evaluate the methods themselves. An accurate measurement was defined as ± 1 mm of the true measurement. A combination of Chi-square analysis and ANOVA was used to assess the accuracy and ease of use of the four methods. RESULTS: Chi-square analysis showed that the sizers were more accurate than the two traditional methods (eyeball and ruler) for measuring perforation length (73% vs. 44%, p = 4.8 × 10-7) and height (71% vs. 50%, p = 0.0003). ANOVA showed that the eyeball method overestimated perforation length significantly more than the other three methods (p = 0.002), and was also significantly less accurate than the other three methods (p < 0.001). Chi-square analysis did not show any correlation between participant training experience and measurement accuracy for any of the three methods. Participant comments and scores demonstrated a clear preference for the two sizers over the traditional methods. CONCLUSIONS: The two novel sizers studied here were significantly more accurate and easier to use than traditional methods for measuring nasal septal perforations. With broader implementation and study of these devices, there is potential to improve patient care surrounding septal perforations.

Analysis of patient- and procedure-related risk factors for nasal septal perforations following septoplasty.

OBJECTIVES: To assess the possible relationship between various predictive factors (patient or surgery related) and the development of nasal septal perforations (NSP) with the help of a large study group. METHODS: One hundred and forty-three patients were included in the study. The presence of the following factors was evaluated and compared between the NSP and healthy group: types of surgeries, presence of unilateral or bilateral mucosal tears, concomitant inferior turbinate interventions, smoking, accompanying diabetes mellitus (DM) or allergic rhinitis (AR), types of nasal packings, duration of the surgery (minutes), and the experience of the surgeon (senior/junior). Nasal septal deviations were grouped into two: simple cartilage crests at the septum base and other-more complicated-deviations. RESULTS: NSP was detected in six (4.2%) patients after a mean follow-up of 9.3 ± 3.7 (min: 6 max: 14) months. None of these patients suffered from (AR) or DM. Four of these patients had unilateral and one patient had bilateral mucosal tears during the surgeries. None of the above-mentioned factors-including mucosal tears, type of the deviation or experience of the surgeon-had a significant effect on NSP. CONCLUSION: Untreated bilateral corresponding mucosal tears are the main cause of NSP. When immediately repaired, unilateral or bilateral tears do not affect the development of NSP significantly. Patient-related factors such as age, DM, smoking, AR, and procedure-related factors such as duration, the complexity of the septal deviation, type of the nasal packing, and experience of the surgeon also do not have a significant effect on NSP.

Repair of Septal Perforations.

Nasal septal perforations have varied etiologies, clinical presentations, and methods of management. Some patients may be asymptomatic, while others may complain of nasal obstruction, crusting, epistaxis, and whistling. Management of nasal septal perforations is guided by the patient's symptoms and characteristics of the perforation. Some lesions can be managed conservatively or with minimally invasive procedures, while others require surgery. Surgical repair of perforations can be challenging and many techniques have been described without a standardized method of management. This article aims to provide a comprehensive review of options for repair of nasal septal perforations.

Nasal Septal Perforation Reconstruction with Polydioxanone Plate: A Systematic Review.

Nasal septal perforation is an uncommon pathology that is difficult to surgically repair and may significantly impact patients' quality of life. Existing treatments have high complication and failure rates. The use of polydioxanone (PDS) plates to repair septal perforations is an innovative approach that has demonstrated superior outcomes to the conventional techniques. This study aimed to review the literature on PDS plates for nasal septal perforation reconstruction. PubMed, OVID Medline, and OVID Embase databases were searched for relevant articles in June 2021. Search terms included nasal septal perforation, polydioxanone, septal perforation, septal repair, nasal septum, and PDS plate. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were adhered to for this systematic review. Database searches yielded 80 articles. Seven articles were included representing 74 patients. All studies reported the use of PDS plates in addition to other materials. They all reported closure rates of at least 80%. The majority of studies reported no postoperative complications. Nasal septal perforation reconstruction with PDS plates is a promising approach that has demonstrated positive outcomes. Further larger studies are required to evaluate the long-term efficacy of using PDS plates on patients with septal perforations.

Nasal Septal Perforation Closure by "Sandwich Grafts": Technique, Initial Results.

Nasal septal perforation closure represents a considerable surgical challenge. Many techniques rely on the implantation of foreign materials that pose a persisting threat of infection. The authors have identified a reliable technique closing septal perforations by an autologous "sandwich graft." It is layered around a piece of auricular cartilage, covered with temporal fascia, thus emulating the physiological layers of the nasal septum. Finally, the prepared graft is then sewn into the perforation in an underlay technique and kept in place by septal splints for 4 weeks. The technique is easily feasible and strives to reconstruct the nasal as physiological as possible. The data obtained from a case series of 11 patients highlights the efficacy of the technique.

Endoscopic measurement of nasal septum perforations.

BACKGROUND: Nasal septum perforations (NSP) have many uncomfortable symptoms for the patient and a highly negative impact on quality of life. NSPs are closed using patient-specific implants or surgery. Implants are created either under anesthesia using silicone impressions or using 3D models from CT data. Disadvantages for patient safety are the increased risk of morbidity or radiation exposure. MATERIALS AND METHODS: In the context of otorhinolaryngologic surgery, we present a gentle approach to treating NSP with a new image-based, contactless, and radiation-free measurement method using a 3D endoscope. The method relies on image information only and makes use of real-time capable computer vision algorithms to compute 3D information. This endoscopic method can be repeated as often as desired in the clinical course and has already proven its accuracy and robustness for robotic-assisted surgery (RAS) and surgical microscopy. We expand our method for nasal surgery, as there are additional spatial and stereoperspective challenges. RESULTS: After measuring 3 relevant parameters (NSP extension: axial, coronal, and NSP circumference) of 6 patients and comparing the results of 2 stereoendoscopes with CT data, it was shown that the image-based measurements can achieve comparable accuracies to CT data. One patient could be only partially evaluated because the NSP was larger than the endoscopic field of view. CONCLUSION: Based on the very good measurements, we outline a therapeutic procedure which should enable the production of patient-specific NSP implants based on endoscopic data only.

[Endoscopic measurement of nasal septum perforations. German version]. / Endoskopische Vermessung von Nasenseptumdefekten.

BACKGROUND: Nasal septum perforations (NSP) have many uncomfortable symptoms for the patient and a highly negative impact on quality of life. NSPs are closed using patient-specific implants or surgery. Implants are created either under anesthesia using silicone impressions or using 3D models from CT data. Disadvantages for patient safety are the increased risk of morbidity or radiation exposure. MATERIALS AND METHODS: In the context of otorhinolaryngologic surgery, we present a gentle approach to treating NSP with a new image-based, contactless, and radiation-free measurement method using a 3D endoscope. The method relies on image information only and makes use of real-time capable computer vision algorithms to compute 3D information. This endoscopic method can be repeated as often as desired in the clinical course and has already proven its accuracy and robustness for robotic-assisted surgery (RAS) and surgical microscopy. We expand our method for nasal surgery, as there are additional spatial and stereoperspective challenges. RESULTS: After measuring 3 relevant parameters (NSP extension: axial, coronal, and NSP circumference) of 6 patients and comparing the results of 2 stereoendoscopes with CT data, it was shown that the image-based measurements can achieve comparable accuracies to CT data. One patient could be only partially evaluated because the NSP was larger than the endoscopic field of view. CONCLUSION: Based on the very good measurements, we outline a therapeutic procedure which should enable the production of patient-specific NSP implants based on endoscopic data only.

Bcl11b is required for proper odorant receptor expression in the mouse septal organ.

Individual olfactory sensory neurons (OSNs) in the mouse main olfactory epithelium express a single odorant receptor (OR) gene from the repertoire of either class I or class II ORs. The transcription factor Bcl11b determines the OR class to be expressed in OSNs. The septal organ (SO), a small neuroepithelium located at the ventral base of the nasal septum, is considered as an olfactory subsystem because it expresses a specific subset of ORs. However, the mechanisms underlying the generation and differentiation of SO-OSN remain unknown. In the present study, we show that the generation and differentiation of SO-OSN employ the same genetic pathway as in the OSN lineage, which is initiated by the neuronal fate determinant factor Ascl1. Additionally, the key role of Bcl11b in the SO is demonstrated by the abnormal phenotypes of Bcl11b-deficient mice: significant reduction in the expression of OR genes and in the number of mature SO-OSNs. Although SO-OSNs are specified to express a subset of class II OR genes in wild-type mice, the Bcl11b deletion led to the expression of class I OR genes, while the expression of class II OR genes was significantly decreased, with one exception of Olfr15. These results indicate that Bcl11b is necessary for proper OR expression in SO-OSNs.

Innovative Surgical Techniques for Nasal Septal Perforations: Management and Treatment.

PURPOSE OF REVIEW: The aim of this study was to review and describe the main innovative surgical techniques for nasal septal perforation (NSP) repair that have been published in recent years. RECENT FINDINGS: Several techniques for NSP repair have been developed recently. The anterior ethmoidal artery (AEA) flap is a versatile technique for middle-size perforations in different locations. The greater palatine artery (GPA) flap is an excellent option for anterior-most NSPs. The lateral nasal wall flap and the pericranial flap are the most appropriate techniques for large perforations. The advent of these techniques has changed the management and has expanded the therapeutic arsenal to treat all types of NSPs according to the size, location, and osteo-cartilaginous support. However, no technique has been accepted as the gold standard. Extensive knowledge of different techniques is important to individualize the treatment, selecting the most appropriate in each case.