[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.

"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.

Validated Symptom Outcomes Following Septal Perforation Repair: Application of the NOSE-Perf Scale.

OBJECTIVE: The Nasal Obstruction Symptom Evaluation (NOSE)-Perf scale was developed and validated to measure symptoms associated with nasal septal perforations. This study reports the application of the NOSE-Perf scale to evaluate symptom change following septal perforation repair. METHODS: Patients with NOSE-Perf evaluations ≥6 months following attempted perforation closure from July 2018 to December 2021 utilizing bilateral nasal mucosal flaps with an interposition graft were eligible for study inclusion. Change in NOSE-Perf scores were noted. Patient demographics, perforation size, and concurrent functional procedures were analyzed for impact on symptom outcomes. RESULTS: One-hundred and seventeen patients met the study criteria. Seventy-nine (67.5%) of the patients were female and the mean (range) age at surgery was 47.3 (14-78) years. Repair failure was noted in 7 (6.0%) patients. Mean (SD) preoperative NOSE-Perf score was 25.3 (95% CI, 23.5-27.1) and postoperative score was 7.9 (95% CI, 6.5-9.3). Minimal clinically important difference (MCID) was estimated and greater than 91% of patients had improvement above this threshold. Patient age, perforation size, or concurrent functional procedures did not impact outcomes. Postoperative scores at short (2-4 months), intermediate (5-8 months), and long-term (≥9 months) time periods showed significant improvement (all p < 0.001) compared to preoperative NOSE-Perf scores. CONCLUSION: Significant reduction in nasal symptoms as measured by the NOSE-Perf scale is noted following bilateral mucosal flap repair. Although the nose does not completely normalize following repair, clinically important improvement was noted in at least 91% of patients. The NOSE-Perf scale is positioned to play a role in the standardization of septal perforation evaluation and outcomes assessment. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3067-3072, 2024.

Posterior Septal Artery Flap for Endoscopic Repair of Large Nasal Septal Perforation: How I Do It.

Endoscopic repair of large nasal septal perforation (SP) remains a rather challenging procedure. The presented modification of vascularized flap, which is supplied with branches of posterior septal artery, has proven to be convenient and effective in closure of SPs larger than 2 cm. Laryngoscope, 134:3485-3488, 2024.

Impact of nasal septal perforation on the airflow and air-conditioning characteristics of the nasal cavity.

We investigated (1) how nasal septal perforations (NSPs) modify nasal airflow and air-conditioning characteristics and (2) how the modifications of nasal airflow are influenced by the size and location of the NSP. Computed tomography scans of 14 subjects with NSPs were used to generate nasal cavity models. Virtual repair of NSPs was conducted to examine the sole effect of NSPs on airflow. The computational fluid dynamics technique was used to assess geometric and airflow parameters around the NSPs and in the nasopharynx. The net crossover airflow rate, the increased wall shear stress (WSS) and the surface water-vapor flux on the posterior surface of the NSPs were not correlated with the size of the perforation. After the virtual closure of the NSPs, the levels in relative humidity (RH), air temperature (AT) and nasal resistance did not improve significantly both in the choanae and nasopharynx. A geometric parameter associated with turbinate volume, the surface area-to-volume ratio (SAVR), was shown to be an important factor in the determination of the RH and AT, even in the presence of NSPs. The levels of RH and AT in the choanae and nasopharynx were more influenced by SAVR than the size and location of the NSPs.

Fascia Lata-Fat Island Graft in Septal Perforation Repair.

Objective: To measure the success of the fascia lata-fat island graft technique in septal perforation repair as measured by nasal endoscopic examination. Background: This study presents the results of using fascia lata-fat island, a different graft technique, for the repair of septal perforations, offering an alternative to this challenging procedure. Methods: This retrospective study assesses nasal septal perforation repair using the fascia lata-fat island graft technique performed by a single surgeon. Inclusion criteria involved completing 12-month follow-ups within a 3-year review period. Success rates were calculated and evaluated alongside patient characteristics. Results: The median (range) age of the 25 patients included in the study was 34 (25-45) years and 72.0% were men. The septal perforation size of all patients was >2 cm and the etiological cause in all of them was previous septal surgery. All patients were followed for 12 months. The perforation was completely closed in 23 of 25 patients (92%). Conclusion: Using a different graft with an open rhinoplasty approach, we achieved a high success rate in patients with large septal perforations, followed for 1 month with nasal stenting and an average follow-up duration of 12 months.

Assessment of a Novel Tool for the Clinical Grading of Nasal Septal Perforation.

BACKGROUND: Nasal septal perforations (NSP) can have a heterogeneous appearance on endoscopic examination with varying degrees of crusting, inflammatory change, and associated septal deviation. The clinical applicability of these findings as contributors to patient symptoms may be enhanced by use of a standardized assessment. METHODS: Video nasal endoscopy recordings were obtained from 40 patients with NSP. Five raters with varied levels of training ranging from a senior resident to an experienced septal perforation surgeon independently reviewed the videos for the following exam findings: crusting, scarring, granulation tissue, septal deviation, and edema. Scoring for each item was reported on a 3-point (0-2) scale, and each reviewer repeated scoring at a 14-day interval. Interrater and intrarater agreement were calculated using Fleiss kappa for each item and the total scores. Additionally, endoscopy scores were correlated with patient-reported NOSE-Perf symptom scores. RESULTS: Interrater agreement for the overall instrument was in the "fair-to-moderate" range with the following interrater agreement for each item: crusting (0.458-0.575), scarring (0.286-0.308), granulation (0.403-0.406), deviation (0.487-0.494), and edema (0.253-0.406). Intrarater agreement was generally "substantial" for individual items as well as the overall instrument (0.688). The NSP endoscopy scores were moderately correlated with NOSE-Perf scores (r = 0.44, p = 0.008). CONCLUSIONS: An endoscopic evaluation of NSP comprising five exam findings has acceptable interrater and intrarater reliability and correlates with patient-reported outcomes. NSP endoscopy may be applied to future clinical studies for characterization of NSP and assessment of treatment outcomes. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:3049-3053, 2024.

Temporoparietal Fascia Graft and Polydioxanone Plate Repair of Nasal Septal Perforation.

BACKGROUND: Surgical repair of septal perforations has been historically cumbersome. Recently described techniques utilizing interposition grafting with polydioxanone (PDS) plates wrapped in a temporoparietal fascia (TPF) graft have reported successful closure in 90% to 100% of cases. Our objective is to expand the investigation into the use of interposition grafts of polydioxanone plates combined with a temporoparietal fascia graft for nasal septal perforation repair. METHODS: Retrospective review of the medical record was performed for all septal perforation repairs using the TPF-PDS plate interposition graft technique from August 1, 2017 to March 1, 2021 at the University of Iowa. Minimum post-operative follow-up was 1 month. RESULTS: Our series included 31 patients with symptomatic nasal septal perforations. Thirteen patients underwent open while 18 patients underwent endonasal graft placement. The mean perforation size was 1.49 cm2. The mean post-operative follow-up was 11.5 months. CONCLUSIONS: Repair of symptomatic nasal septal perforations using an interposition graft of polydioxanone plate wrapped in temporoparietal fascia demonstrated an overall success rate of 90%.

Combined endoscopic sinus surgery and endonasal septal perforation repair: Symptom outcomes and perforation closure rates.

KEY POINTS: Combined endoscopic sinus surgery and nasal septal perforation repair is technically feasible. NOSE-Perf is a recently developed patient-reported outcome measure for nasal septal perforation. The decision to perform combined ESS and NSP repair should be made on a case-by-case basis.

Nasal Septal Perforation and Widespread Skin Lesions Caused by Mycobacterium chelonae Infection Mimicking Granulomatosis with Polyangiitis.

Mycobacterium chelonae, a rapidly growing mycobacterium found in the natural environment, is known to cause localized lesions in the skin, soft tissue, and bone through traumatic inoculation, but widespread lesions are uncommon. We herein report an immunocompromised 79-year-old man suspected of having polyangiitis granulomatosis due to weight loss, epistaxis, and nasal crusts with impending septal perforation who was subsequently diagnosed with mucocutaneous and bone disease caused by widespread M. chelonae infection. Given these findings, clinicians should be aware of the tendency to develop unusual widespread lesions in immunocompromised patients, which can present a clinical picture similar to systemic vasculitides, such as granulomatosis with polyangiitis.

Endoscopic "Racket-on-Donut" Technique for Large Anterior Nasoseptal Perforations.

Endoscopic Racket-on-Donut technique is a combination of a modified greater palatine artery and inverted edges flaps. Endoscopic Racket-on-Donut technique is very useful for anterior NSP repair. Laryngoscope, 134:143-147, 2024.

Factors Affecting the Surgical Outcome in Nasal Septal Perforation Repair.

OBJECTIVE: Nasal septal perforation (NSP) repair is challenging surgery considered in patients with symptomatic NSP intractable to conservative treatments. This study aimed to assess the success rate and identify factors affecting the surgical outcome of NSP by analyzing consecutive series of NSP repairs by a single surgeon. METHODS: We enrolled 84 patients diagnosed with NSP and who underwent surgical repair of NSP by a single surgeon (Y.J.J.) between November 2007 and July 2022. Medical records were retrospectively reviewed regarding variables involving preoperative symptoms, rhinologic history, etiology, surgical techniques, and the outcome of surgery. In addition, features of NSP were objectively evaluated using computed tomography scans. RESULTS: The overall success rate of NSP repair was 64.3% (54 of 84). Nasal obstruction (79.8%), crusting (34.5%), and epistaxis (27.4%) were frequent preoperative symptoms. Iatrogenic injury from previous nasal surgery (70.2%) was the most common cause. The average size of NSP on preoperative CT was 9.53 ± 6.68 mm. Patients with incomplete NSP closure had significantly larger perforations (12.21 ± 7.92 mm) than those with successful closure (8.04 ± 5.41 mm) preoperatively (P = .005). Patients with smoking history (OR = 2.971, 95% CI 1.170-7.548, P = .020) and NSP repair with combined rhinoplasty (OR = 3.811, 95% CI 1.401-10.370, P = .007) were more likely to experience incomplete closure. Patients whose perforations were reinforced with interposition graft were more likely to result in successful repair (OR = 6.752, 95% CI 2.496-18.262, P < .001). The bilaterality of mucosal flap coverage, surgical approach, types of mucosal flap and interposition graft, perforation shape, mucosal thickness around perforation, and distance from the nasal floor were not significantly related to the surgical outcome. CONCLUSIONS: Significant factors affecting the outcome of NSP repair were patient's smoking status, combined rhinoplasty, application of interposition graft, and perforation size.

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.

Predictors of Success of Endonasal Septal Perforation Repair: A 10-Year Experience.

Background: There is no consensus on optimal repair technique for nasal septal perforations (NSPs). Objective: To measure success rate and evaluate predictors of success for NSP repair. Methods: Medical records of patients who underwent NSP repair from 2010 to 2020 were reviewed. Included patients had at least 60 days of postsurgical follow-up. Surgical technique involves an endonasal approach; subperichondrial dissection with local flap mobilization; and multilayer closure using cartilage interposition graft, fascia graft, and mucoperichondrial flaps. A chi-squared test or Fisher exact test was used for statistical analysis. Results: Eighty-one repairs were performed with a closure rate of 86%. The median patient age was 46 years (range 13-77); 34.6% of perforations were ≥2 cm. Conchal (77.8%), rib (7.4%), or septal (7.4%) cartilage was used as graft material. A complication rate of 8.6% was reported. Perforation size or graft material had no impact on successful closure rate. Of patients with failed repairs, 55% had perioperative complications or conditions associated with poor healing. Conclusion: An endonasal approach for NSP repair showed a high success rate across diverse presentations; however, NSP repair was significantly more likely to be successful in patients without perioperative complications or pre-existing conditions associated with poor wound healing.

The Use of Platelet-Rich Fibrin and Polypropylene Mesh in Repair of Nasal Septal Perforation.

OBJECTIVE: In this study, we aimed to investigate the effectiveness of the use of polypropylene mesh and platelet-rich fibrin (PRF) in nasal septal perforation (NSP) repair. STUDY DESIGN: Prospective experimental study. SETTING: Laboratory. METHODS: Twenty-four adult male New Zealand rabbits were used in our study. In all subjects, a 10 × 10 mm perforation was created in the septum. The subjects were divided into 3 equal groups according to the different methods used in perforation closure. The bilateral mucosal flap was used in the control group, polypropylene mesh + bilateral mucosal flap in the mesh group, and polypropylene mesh + bilateral mucosal flap + PRF in the mesh + PRF group. RESULTS: NSP treatment success rate was found to be significantly higher in the mesh (4/6, 66.7%) and mesh + PRF (6/6, 100%) groups compared to the control group (0/6, 0%). Re-epithelialization score was higher in the mesh + PRF group and the control group compared to the mesh group. While the necrosis, neutrophil, and abscess scores were highest in the mesh group, they were similar to the control group in the mesh + PRF group. CONCLUSIONS: While polypropylene mesh significantly increases the success rate in NSP repair, it causes severe inflammatory responses. However, when polypropylene mesh is combined with PRF, it both increases the rate of perforation closure and significantly reduces the complications associated with the use of mesh.

Autologous Interposition Grafts for Mucosal Flap Septal Perforation Repair.

Background: Nasal septal perforation repair is commonly attempted utilizing bilateral nasal mucosal flaps supported with an interposition graft. Objectives: To compare the failure rates for bilateral flap repairs utilizing four different autologous interposition grafts. Methods: This is a retrospective review of a single surgeon's bilateral flap perforation repairs supported with an autologous interposition graft. Study inclusion over the 18-year review period required at least one examination 1 month after surgery. Repair failure rates were calculated and compared for each graft type, and logistic regression was performed for multivariate analysis. Results: For the 356 study patients, median (range) age was 51 years (14-81) and 63.0% were women. Mean (range) perforation length was 13.9 mm (1-45). Median (range) at last follow-up was 11.2 months (1-192). Graft types used (percentage of patients and failure rate) were temporalis fascia (58.7/4.4), septal cartilage (23.3/7.3), auricular perichondrium (13.8/4.1), and septal bone (4.2/6.7) (p > 0.05). Conclusion: There was no significant difference in bilateral mucosal flap perforation repair failure rate when either a temporalis fascia, septal cartilage, auricular perichondrium, or septal bone interposition graft was used.

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.

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.

Septal Perforation Repair Quality of Life Outcomes Using the Revised 15-item Glasgow Benefit Inventory.

BACKGROUND: The 18-item Glasgow Benefit Inventory (GBI) has been widely used to measure patient general health response to otorhinolaryngologic and facial plastic interventions. The GBI was recently reorganized into 15 questions with 5 sub-scale factors (GBI-5F) to improve its utility. Application of the GBI-5F to septal perforation treatments may improve our understanding of quality of life outcomes. METHODOLOGY/PRINCIPAL: The GBI was given to patients seen from August 2018 through October 2021 who were at least 6 months postoperative attempted perforation surgical closure using bilateral nasal mucosal flaps with an interposition graft. Original GBI and GBI-5F scores were computed and subgroup analysis performed in this retrospective medical record review. RESULTS: Of the 98 patients (mean age 45.5 years) who met study criteria, 65 were female. Mean perforation length was 12.9, and height 9.7 mm. The mean postoperative time to GBI completion was 12.7 months. Highest GBI-5F scores were noted in the Quality of Life factor, followed by Self-confidence and Social Involvement. Females reported significantly higher scores than men. Total GBI scores were similar to those recorded for other rhinologic procedures. CONCLUSIONS: The GBI-5F provides measurable insight into patient quality of life benefit following septal perforation repair.

Outcome of Endoscopic Repair of Nasal Septal Perforation.

INTRODUCTION: The anterior ethmoidal artery (AEA) flap has been demonstrated to be a reliable option for endoscopic repair of symptomatic nasal septal perforations. The purpose of this study is to study the outcome of this technique. METHODS: A retrospective case series of all consecutive patients who underwent repair of nasal septal perforation utilizing the AEA flap among 2 institutions from August 2020 to July of 2022 was conducted. Demographics and comorbidities were collected preoperatively and postoperatively. The main outcome of this study was to identify the risk factors for surgical failure. RESULTS: Forty-one patients were included. Mean perforation size was 2.2 cm (range 0.5-4.5 cm). Mean age was 42.5 years (range 14-65 years), 53.6% were female, 39% were active smokers, mean body-mass-index (BMI) was 31.9 (range 19.1-45.5), 20% with history of CRS and 31.7% had diabetes mellitus (DM). Etiologies of the perforation included idiopathic (n = 12), iatrogenic (n = 13), intranasal drug use (n = 7), trauma (n = 6), and secondary to tumor resection (n = 3). Overall success rate for complete closure was 73.2%. Active smoking, history of intranasal drug use, and DM were significantly associated with surgical failure (72.7%vs 26.7%, P = .007; 36.4%vs 10%, P = .047; and 63.6%vs 20%, P = .008 respectively). CONCLUSION: The endoscopic AEA flap is a reliable technique for closure of nasal septal perforation. It may not work when the etiology is intranasal drug use. Close attention to diabetes and smoking status is also needed.