Repair of Large Nasal Septal Perforations Using the Upper Lateral Cartilage Mucosal Flap

Abstract

Objectives/Hypothesis To describe the surgical technique and closure outcomes of larger septal perforation repair incorporating mucosa from the undersurface of the upper lateral cartilage into a superiorly positioned advancement flap. Study Design Retrospective case series. Methods A chart review was performed for patients who underwent perforation repair utilizing bilateral nasal mucosal flaps which incorporated mucosa from the undersurface of the upper lateral cartilage into the superior flap between January 2009 and December 2020. Results Sixty‐six patients met study criteria. Prior septal surgery was the most common (28.8%) etiology. Mean perforation length and height were 18.9 and 14.4 mm, respectively. Complete perforation closure was noted in 91.2% of patients followed for a minimum of 6 months (mean follow‐up time 32.1 months). Twelve patients underwent secondary surgery for persistent nasal obstruction. Postoperative loss of dorsal height was noted in seven patients. The NOSE‐perf scores were available for the last 15 repairs and demonstrated significant symptom improvement from a mean score of 26.4 (95% confidence interval [CI], 5.2) to 14.5 (95% CI, 5.2) (P < .0001). Conclusion The ventral surface of the upper lateral cartilage can provide additional mucosa for incorporation into a superior advancement flap to achieve successful closure for larger septal perforations. Optimization of surgical outcomes for this challenging condition may require secondary functional or aesthetic procedures. Level of Evidence 4 Laryngoscope, 132:973–979, 2022

Nasal Swell Body Characteristics in Patients With Septal Perforation

“…The superior flap, which can be extended to incorporate mucosa from the undersurface of the upper lateral cartilage, is the most consequential flap in our larger perforation repairs. 21 The nasal obstruction noted postoperatively in a prior study using a unilateral, superior longitudinally‐oriented superior flap was noted to occur on the side of the superior flap. 13 A secondary study interest analyzed the relationship between superior septal deviations and NSB thickness in the control cohort.…”

“…Unilateral superior mucosal incision and inferior flap advancement mitigate against the possibility of bilateral superior cartilage exposure and devascularization with subsequent necrosis and reperforation. The superior flap, which can be extended to incorporate mucosa from the undersurface of the upper lateral cartilage, is the most consequential flap in our larger perforation repairs 21 . The nasal obstruction noted postoperatively in a prior study using a unilateral, superior longitudinally‐oriented superior flap was noted to occur on the side of the superior flap 13 .…”

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

“…The senior author’s repair technique has been published. 15,16 Perforation size was determined through direct measurement at surgery. Each of the 18 GBI items were scored from −2 to +2.…”

Presenting Symptomatology for Patients With Nasal Septal Perforation: Application of the NOSE‐Perf Scale

“…Surgical experience and innovation in varied nasal mucosal advancement/rotation flap, mucosal pedicled flap, and substrate scaffolding graft techniques are driving much of this interest. Closure success rates exceeding 90% are frequently reported using these varied procedures 1–8 . For perforations not amendable to attempted closure, the endoscopic skull base surgery experience has provided insight to support surgical modification of the posterior perforation margin for symptom relief 9,10 .…”

“…Closure success rates exceeding 90% are frequently reported using these varied procedures. [1][2][3][4][5][6][7][8] For perforations not amendable to attempted closure, the endoscopic skull base surgery experience has provided insight to support surgical modification of the posterior perforation margin for symptom relief. 9,10 Customized silastic prostheses may improve fit and tolerance over standard septal buttons.…”