Endoscopic Repair of Nasal Septal Perforation

PROGRAM DESCRIPTION: Nasal septal perforation can result from multiple etiologies, including trauma, intranasal drug use, and prior septal surgery. Repair of nasal septal perforations can be challenging, particularly for large diameter defects. This video will demonstrate endoscopic repair of a nasal septal perforation that resulted from cautery and packing after a severe nosebleed. The patient had a history of prior pituitary surgery with nasoseptal flap reconstruction 4 years prior, and this may have increased her risk for a nasal septal perforation. The surgery begins with elevation of bilateral superior and inferior mucosal flaps, taken from the superior septum and nasal floor mucosa respectively. Incisions are made anteriorly, superiorly and infero-laterally, around the septal perforation. The flaps are elevated off the underlying cartilage and bone, then divided anteriorly, to allow mobilization and rotation of the flaps. Flaps are elevated on both right and left sides of the septum and mobilized so that they cover the perforation. A piece of Biodesign® Sinonasal Repair Graft (Cook Medical, Bloomington, IN) is trimmed to be slightly larger than the septal perforation and placed in the perforation. This provides a scaffolding for the healing and re-epithelialization process to take place. The 4 mucosal flaps are then rotated so that they cover the majority of the graft. No sutures are necessary for the mucosal flaps. A thin silicone sheet is then trimmed to fit along the septum and nasal floor, and one piece is placed on each side of the septum, to hold the mucosal flaps against the graft securely on each side. A mattress suture is placed through all layers of the septum and sheets using a 4-0 Prolene. The sheets were removed after 3 weeks. The patient’s perforation had healed completely, and she continued to do well at 2 years follow-up.