Septal Perforation Repair
A patient who had a nasal septum perforation after a nose operation performed at a different clinic was examined (I explain in Turkish in the video)
- Ellipsoid shaped, close to 4 cm in the horizontal axis, 2.5 cm in the vertical axis at its largest
- Red and dry edges
- There are black particles on the back (the patient is working on an iron lathe, it looks like iron dust)
- The left inferior turbinate is seen to have grown towards the hole in order to slow down the rapid airflow passing through it, narrowing the hole.
We performed an open technique septum perforation repair surgery on the patient. Fascia was taken from the patient's temporal region and cartilage graft and parachute-shaped fascia were used. Silicone splints were kept inside the nose for 3 months and the second examination video was recorded after the silicone splints were removed. As seen in the video, the perforation area is completely closed, a pink and thin mucosa covers the cartilage and there are bulges due to fascia pieces protruding from the hole on the back. For a period of 3 months, the patient irrigated the nose with a mixture of rifampin and antibiotic serum.
About the Patient's Story
The patient I am sharing with you here is a metal lathe worker and his complaints that emerged after having a nose surgery in another clinic have gradually increased over time. Perhaps the iron dust and hot environment that the patient came into contact with may have caused the septum perforation in the nose to grow. Unfortunately, since there is accelerated airflow in the nose; the patient has not only complaints about the nose but also various problems in the lower respiratory tract, namely the lungs and larynx. According to the patient's description, the patient has constantly had sticky secretions coming from his nasal passages and has a constant wheezing or coughing complaint in his lungs. Our nose normally purifies, warms and humidifies the external air, ensuring that our air reaches the lungs in a clean, warm, moist and pressurized manner. There is a structure called the nasal septum inside our nose that separates the cavity vertically into two separate cavities. When this structure is pierced, the 2 cavities that should work independently of each other merge and the air currents entering the left and right nostrils accelerate, pass through each other and move towards the nasal passages and lungs. In other words, the dirty, cold and dry air outside can easily reach the lower respiratory tract directly. If you look at the patient's pre-operative video, you can see that the perforation edges were quite dry, bleeding, and even contained black particles due to iron dust. The inferior turbinate, which extends from the left nasal cavity to the perforation hole, slowed down the incoming air while also causing the patient's nose to become increasingly blocked. In fact, this mechanism is very important for the protection of lung health.
Why Does Nasal Septum Perforation Occur During Septoplasty?
Patients with a nasal septum that is deviated to the right or left also experience nasal obstruction at various levels. This condition is called nasal septum deviation and we usually perform the procedure of removing the deviated cartilage areas that narrow the airway in the septum for treatment purposes. This procedure is called septoplasty. Usually, an incision is made on the nasal septum during the procedure and the membrane on the cartilage on both sides, namely the mucoperichondrium, is removed (submucoperichondrial dissection). Then, the deviated cartilage sections are removed and the non-devviated cartilage sections are left untouched. If both sides of the cartilage membrane are damaged at the same level during this procedure and the cartilage in the middle is also surgically removed, a perforation, namely a hole, may occur in the nasal septum that can be easily noticed during surgery.
Which patients are more likely to have septum perforation?
Especially in patients with advanced septum deviation, severe traumatic injuries such as bending, twisting, folding, etc. in the septum that are so severe that they fold over each other, the cartilage membrane on both sides may be punctured during the septoplasty operation and perforation may occur.
Perforation can be closed during the septoplasty operation
If the otolaryngologist notices a puncture or damage in the septum during the septoplasty operation; the perforation can be intervened by simply placing a piece of cartilage in the vertical axis and the hole can be closed. Apart from this, the perforation can be closed by stitching the torn areas in the mucosa from inside the nose. However, if the hole is not noticed during the procedure or if the hole appears after the tampons are removed; then the patient is informed about the hole in the septum and that it may need to be closed in case of growth or if symptoms occur. Sometimes, even if the hole does not appear during the septoplasty operation; After the silicone tampons inside the nose are removed, patients can also cause perforation with their own hands or by inserting tissues, fingers, cotton, sticks, or using various medical products that can cause serious drying of the nasal mucosa. However, perforation that occurs during the septoplasty operation can usually be easily attended.
In large perforations, it may be beneficial to keep the silicone tampons in the nose for a long time after the perforation repair operation!
Especially in patients with serious defects in the nasal septum and a perforation larger than 2 cm, I think that keeping the internal silicone sprints in the nose for 2 months or longer after the perforation repair operation may be beneficial in terms of increasing the success of the procedure. The reason for this is that if the tampons in the nose are removed early after the procedure performed inside the nose, the surgical area where the graft is placed, stitched and repaired will directly come into contact with the dirty, particulate, hot, cold or dry external air. With the contact of the external air inside the nose, which is a dirty environment, infection, perforation and separation may occur in the grafts placed on the edges of the holes that have already become unhealthy, dried and crusted inside the nose. I usually tell my patients with nasal septum perforation - not to use - nasal moisturizers containing sesame oil, olive oil, vaseline or any petroleum product. Because when they use these products, serious mucosal infections can occur in the perforation area. I usually recommend my patients to regularly irrigate the nose with a mixture of rifampicin and isotonic serum. The air entering through the holes of the internal silicone splints placed inside the nose that allow the patient to breathe usually cannot reach the perforation area. In other words, since the patient has protected the graft area from the external air; drying or crusting usually does not occur in the perforation area. I recommend our patients to keep the holes of the silicone that allow breathing clean by washing them regularly. I recommend that they be a little patient about removing the internal silicone splint. I say that the silicones inside the nose are not placed in any tissue, they are only fixed to the front of the nasal septum with threads and can be easily removed by cutting the threads in office conditions.
After the silicone splints are removed from the nose, irrigation with a mixture containing rifampicin and serum containing antibiotics may be beneficial for a few more months
As in the patient I shared with you in the video above; I tell my patients who have a complete successful closure in the perforation and the defect in the nasal septum play is completely closed to be a little more patient and to apply the mixture we recommend consisting of rifampicin and isotonic inside the nose for at least 2 or even 3 months. The reason for this is that the nasal mucosa covering the defect does not come into contact with the external air while the silicone splints are present and the mucosa that comes into contact with dirty, cold or hot, dry air after the silicones are removed can swell and edema can occur and sometimes local mucosal infections can occur. I tell my patients that temporary nasal congestion may occur for a few weeks after the silicones are removed and that this is normal and that the mucosa that comes into contact with the external air can edema. However, within a few weeks, the mucosa usually turns into a healthier mucosa that produces thicker secretions, and patients can notice this as a relief. During this period, I recommend that my patients drink plenty of water orally, consume fruits and vegetables with high water content, reduce their consumption of diuretic tea and coffee, reduce excessive salt consumption, and avoid inserting tissues, fingers, or cotton swabs into the nose.
Search result link where you can find articles prepared by Dr. Murat Enöz about nose tip plasty and published on this website (you can also reach previous articles by clicking "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=septum+perforation
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
Private Office:
Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52
Appointment Phone: +90 212 561 00 52
Fax: +90 212 542 74 47
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