The Journal of Laryngology and Otology October 1992, Vol. 106, pp. 893-895
Tragal cartilage inferior turbinate mucoperiosteal sandwich graft technique for repair of nasal septal perforations A. HUSSAIN, M.D., F.R.C.S., N. KAY, F.R.C.S. (Albany, New York)
Abstract Ten cases of large nasal septal perforation were repaired with a tragal cartilage inferior turbinate mucoperiosteal sandwich graft technique with 70 per cent success rate over a follow-up period of up to 24 months. The technique is described in detail. The results are comparable to other techniques.
Introduction The exact incidence of nasal septal perforation remains unknown, however during the last decade a higher incidence has been reported due to the increase in recreational abuse of cocaine and crack cocaine. The symptoms can vary from being asymptomatic to incapacitating epistaxis. Smaller perforations usually present with whistling, and larger perforations can cause disturbance of air flow with resulting crusting, obstruction, rhinolalia, and epistaxis. All surgical management remains less than satisfactory in spite of a myriad of surgical techniques. Most techniques describe some local pedicle flap. Free grafts have been used before.
tum is injected with normal saline to increase its bulk and injectable vasoconstrictor is avoided. After about a ten minutes wait an incision is made, anterior to the perforation extending from the nasal floor to the dorsum. Bilateral submucoperichondrial flaps are elevated with the Freer's elevator and otological elevators can be used to reduce the trauma. This elevation is carried anteriorly, inferiorly and posteriorly. The superior flap elevation is done with a 15 Bard Parker knife. This part of the septum is usually just two layers of mucoperichondrium/mucoperiosteum which are sharply divided and two flaps created. Blunt dissection, in that area, is avoided because it can cause excessive trauma and tear the flap. Tragal cartilage is now harvested from one or both sides depending on the size of perforation and graft requirement, which is measured before hand. The perichondrium is left attached to the tragal cartilage on both sides. Bilateral free inferior turbinate mucoperiosteal flaps are elevated by making an incision along the anterior border of the inferior turbinate, and dissecting down to the floor of the nose, if necessary, to harvest an adequate graft (Fig. 2). The inferior turbinate is not removed. A sandwich graft is prepared. The middle layer of the sandwich consists of tragal cartilage which is an exact fit for the perforation (Fig. 3). The outer two layers consist of free turbinate mucoperiosteal tissue, which is left 1 cm larger
Materials and methods Ten cases of large septal perforation were repaired with a sandwich graft technique at Stockport Infirmary, Cheshire, England. The sandwich consists of a central layer of tragal cartilage with perichondrium and the outer two layers consist of free inferior turbinate mucoperiostium. There was no history of cocaine abuse, and all cases were thought to be post traumatic. In six cases there was history of surgical trauma in the form of submucous resection and other four cases gave history of previous nasal injury, and had external nasal deformity with deviation of nasal bridge indicative of nasal fracture. All perforations were large (2-4 cm) and were located in the middle part of the septum with loss of both cartilage and bone (Fig. 1). Technique The procedure can be performed under monitored controlled anaesthesia (local anaesthesia with sedation) or general anaesthesia. The approach has been endonasal in all cases. After all appropriate preparation and draping, 1 to 2 per cent lignocaine with 1:100,000 adrenaline is injected submuco-perichondrially, anteriorly, inferiorly, and posteriorly. The superior edge of the perforation is usually rolled over and epithelialized. This part of the sep-
FIG. 1 Showing perforation.
Accepted for publication: 31 July 1992.
893
894
A. HUSSAIN, N. KAY
FIG. 2 Showing the incision and harvesting of graft.
than the cartilage circumferentially, 3 or 4 vicryl mattress sutures are placed through all three layers of the sandwich. The mucoperiosteal side of the free turbinate tissue lies in contact with the perichondrium of the tragal cartilage. The peripheral 1 cm of the mucoperiosteal part of the sandwich is denuded of epithelium by sharp dissection, the graft is inserted through the caudal incision. The cartilage fits the perforation while the mucosal part of the graft is inserted under the septal flaps bilaterally, and the mucoperiosteal part of the graft is sutured with mattress sutures of vicryl both anteriorly and inferiorly to the remaining septum. A layer of Gelfoam is placed on both sides, and bilateral silastic splints are inserted, sutured to the inferior septum; no packing is used, the splints are removed in two weeks, and patient is given a ten day course of oral antibiotics.
De-epithelialized
FIG. 3 A. Showing the sandwich graft. Note central cartilaginous part is 1-2 cm smaller than mucoperiosteal part, also showing central mattress sutures. B. Graft showing peripheral 1-2 cm depithelialized. C. Graft in place with sutures inferiorly.
Results Ten cases of septal perforation were repaired with the tragal cartilage turbinate mucoperiosteal sandwich technique. The follow-up ranges from four months to 24 months. Seven out of 10 cases were repaired successfully with complete closure of perforation and relief of symptoms. Three cases were unsuccessful, in one case the patient removed the graft by blowing his nose; in the other two cases the perforations were smaller than before surgery, but the patients remained symptomatic. Discussion A large number of prosthetic and surgical techniques have been used to repair nasoseptal perforations with variable results. Various approaches has been advocated depending on the size and the site of perforation including alaotomy, (Belmont, 1985), external rhinoplasty (Kridel etal., 1986), sublabial (Karlan et al., 1982) and modified external rhinoplasty (Goodman and Strelzow, 1982). The surgical procedures include nasal septal rotation flaps, inferior turbinate pedicle flaps, nasal labial flaps, and sublabial flap. Temporalis fascia and mastoid periosteum (Fairbanks, 1989) have been used as frequently. This report details a surgical repair of large septal perforations with a 70 per cent success rate. The success rate is comparable with other repair techniques. This report shows that large perforations can be repaired successfully with a free sandwich graft technique with no donor site morbidity. It also shows that no single method is 100 per cent successful as demonstrated by the three failures. This particular technique does, however, have some distinct advantages. The operation is done endonasally, the turbinate mucoperiosteum is easily harvestable with no extra morbidity and the donor site epithelializes in six to eight weeks. The choice of tragal cartilage as graft material is based on the fact that it is easily harvestable with no donor site deformity, and very little morbidity. The graft material
TRAGAL CARTILAGE INFERIOR TURBINATE MUCOPERIOSTEAL SANDWICH GRAFT TECHNIQUE
is thin, pliable, and flat, as apposed to conchal cartilage which can also be used. References Belmont, J. R. (1985) An approach to large nasoseptal perforations and attendant deformity. Archives of Otolaryngology, 111: 45CM55. Fairbanks, D. N. F. (1980) Closure of septal perforations. Archives of Otolaryngology, 106: 509-513. Goodman, W. S., Strelzow, V. V. (1982) The surgical closure of nasoseptal perforations. Laryngoscope, 92: 121-124.
Key words: Nasal septum, perforation.
895
Karlan, M. S., Ossoff, R., Christu, P. (1982) Reconstruction of large septal perforations. Archives of Otolaryngology, 108: 433-436. Kridel, R. W. H., Appling, D. A., Wright, W. K. (1986) Septal perforation closure utilizing the external septorhinoplasty approach. Archives of Otolaryngology, 112: 168-172. Address for correspondence: Akhtar Hussain, M.D., F.R.C.S., Division of Otolaryngology A-41, Albany Medical Center, Albany, New York 12208.
Tragal cartilage inferior turbinate mucoperiosteal sandwich graft technique for repair of nasal septal perforations A. HUSSAIN, M.D., F.R.C.S., N. KAY, F.R.C.S. (Albany, New York)
Abstract Ten cases of large nasal septal perforation were repaired with a tragal cartilage inferior turbinate mucoperiosteal sandwich graft technique with 70 per cent success rate over a follow-up period of up to 24 months. The technique is described in detail. The results are comparable to other techniques.
Introduction The exact incidence of nasal septal perforation remains unknown, however during the last decade a higher incidence has been reported due to the increase in recreational abuse of cocaine and crack cocaine. The symptoms can vary from being asymptomatic to incapacitating epistaxis. Smaller perforations usually present with whistling, and larger perforations can cause disturbance of air flow with resulting crusting, obstruction, rhinolalia, and epistaxis. All surgical management remains less than satisfactory in spite of a myriad of surgical techniques. Most techniques describe some local pedicle flap. Free grafts have been used before.
tum is injected with normal saline to increase its bulk and injectable vasoconstrictor is avoided. After about a ten minutes wait an incision is made, anterior to the perforation extending from the nasal floor to the dorsum. Bilateral submucoperichondrial flaps are elevated with the Freer's elevator and otological elevators can be used to reduce the trauma. This elevation is carried anteriorly, inferiorly and posteriorly. The superior flap elevation is done with a 15 Bard Parker knife. This part of the septum is usually just two layers of mucoperichondrium/mucoperiosteum which are sharply divided and two flaps created. Blunt dissection, in that area, is avoided because it can cause excessive trauma and tear the flap. Tragal cartilage is now harvested from one or both sides depending on the size of perforation and graft requirement, which is measured before hand. The perichondrium is left attached to the tragal cartilage on both sides. Bilateral free inferior turbinate mucoperiosteal flaps are elevated by making an incision along the anterior border of the inferior turbinate, and dissecting down to the floor of the nose, if necessary, to harvest an adequate graft (Fig. 2). The inferior turbinate is not removed. A sandwich graft is prepared. The middle layer of the sandwich consists of tragal cartilage which is an exact fit for the perforation (Fig. 3). The outer two layers consist of free turbinate mucoperiosteal tissue, which is left 1 cm larger
Materials and methods Ten cases of large septal perforation were repaired with a sandwich graft technique at Stockport Infirmary, Cheshire, England. The sandwich consists of a central layer of tragal cartilage with perichondrium and the outer two layers consist of free inferior turbinate mucoperiostium. There was no history of cocaine abuse, and all cases were thought to be post traumatic. In six cases there was history of surgical trauma in the form of submucous resection and other four cases gave history of previous nasal injury, and had external nasal deformity with deviation of nasal bridge indicative of nasal fracture. All perforations were large (2-4 cm) and were located in the middle part of the septum with loss of both cartilage and bone (Fig. 1). Technique The procedure can be performed under monitored controlled anaesthesia (local anaesthesia with sedation) or general anaesthesia. The approach has been endonasal in all cases. After all appropriate preparation and draping, 1 to 2 per cent lignocaine with 1:100,000 adrenaline is injected submuco-perichondrially, anteriorly, inferiorly, and posteriorly. The superior edge of the perforation is usually rolled over and epithelialized. This part of the sep-
FIG. 1 Showing perforation.
Accepted for publication: 31 July 1992.
893
894
A. HUSSAIN, N. KAY
FIG. 2 Showing the incision and harvesting of graft.
than the cartilage circumferentially, 3 or 4 vicryl mattress sutures are placed through all three layers of the sandwich. The mucoperiosteal side of the free turbinate tissue lies in contact with the perichondrium of the tragal cartilage. The peripheral 1 cm of the mucoperiosteal part of the sandwich is denuded of epithelium by sharp dissection, the graft is inserted through the caudal incision. The cartilage fits the perforation while the mucosal part of the graft is inserted under the septal flaps bilaterally, and the mucoperiosteal part of the graft is sutured with mattress sutures of vicryl both anteriorly and inferiorly to the remaining septum. A layer of Gelfoam is placed on both sides, and bilateral silastic splints are inserted, sutured to the inferior septum; no packing is used, the splints are removed in two weeks, and patient is given a ten day course of oral antibiotics.
De-epithelialized
FIG. 3 A. Showing the sandwich graft. Note central cartilaginous part is 1-2 cm smaller than mucoperiosteal part, also showing central mattress sutures. B. Graft showing peripheral 1-2 cm depithelialized. C. Graft in place with sutures inferiorly.
Results Ten cases of septal perforation were repaired with the tragal cartilage turbinate mucoperiosteal sandwich technique. The follow-up ranges from four months to 24 months. Seven out of 10 cases were repaired successfully with complete closure of perforation and relief of symptoms. Three cases were unsuccessful, in one case the patient removed the graft by blowing his nose; in the other two cases the perforations were smaller than before surgery, but the patients remained symptomatic. Discussion A large number of prosthetic and surgical techniques have been used to repair nasoseptal perforations with variable results. Various approaches has been advocated depending on the size and the site of perforation including alaotomy, (Belmont, 1985), external rhinoplasty (Kridel etal., 1986), sublabial (Karlan et al., 1982) and modified external rhinoplasty (Goodman and Strelzow, 1982). The surgical procedures include nasal septal rotation flaps, inferior turbinate pedicle flaps, nasal labial flaps, and sublabial flap. Temporalis fascia and mastoid periosteum (Fairbanks, 1989) have been used as frequently. This report details a surgical repair of large septal perforations with a 70 per cent success rate. The success rate is comparable with other repair techniques. This report shows that large perforations can be repaired successfully with a free sandwich graft technique with no donor site morbidity. It also shows that no single method is 100 per cent successful as demonstrated by the three failures. This particular technique does, however, have some distinct advantages. The operation is done endonasally, the turbinate mucoperiosteum is easily harvestable with no extra morbidity and the donor site epithelializes in six to eight weeks. The choice of tragal cartilage as graft material is based on the fact that it is easily harvestable with no donor site deformity, and very little morbidity. The graft material
TRAGAL CARTILAGE INFERIOR TURBINATE MUCOPERIOSTEAL SANDWICH GRAFT TECHNIQUE
is thin, pliable, and flat, as apposed to conchal cartilage which can also be used. References Belmont, J. R. (1985) An approach to large nasoseptal perforations and attendant deformity. Archives of Otolaryngology, 111: 45CM55. Fairbanks, D. N. F. (1980) Closure of septal perforations. Archives of Otolaryngology, 106: 509-513. Goodman, W. S., Strelzow, V. V. (1982) The surgical closure of nasoseptal perforations. Laryngoscope, 92: 121-124.
Key words: Nasal septum, perforation.
895
Karlan, M. S., Ossoff, R., Christu, P. (1982) Reconstruction of large septal perforations. Archives of Otolaryngology, 108: 433-436. Kridel, R. W. H., Appling, D. A., Wright, W. K. (1986) Septal perforation closure utilizing the external septorhinoplasty approach. Archives of Otolaryngology, 112: 168-172. Address for correspondence: Akhtar Hussain, M.D., F.R.C.S., Division of Otolaryngology A-41, Albany Medical Center, Albany, New York 12208.
