Endoscopic Techniques for Nasal Septal Perforation Repair: A Systematic Review

Abstract

Objectives: Surgical repair of nasal septal perforations (NSPs) is technically challenging. Advantages associated with endoscopic NSP repair (ENSPR) include enhanced visualization and its minimally invasive nature. Purely endoscopic techniques have successful outcomes with low morbidity. This study provides a review of clinical features, surgical techniques, and outcomes in patients who underwent ENSPR. Methods: A systematic review was conducted using PubMed/MEDLINE, Cochrane library, and Embase databases. Manual bibliography search produced additional articles. Studies reporting purely endoscopic approaches for NSP repair were included. Patient demographics, NSP size, etiology, repair strategy, incidence of closure, and follow-up were analyzed. Results: A total of 329 cases from 20 studies were included. The mean age was 37.2 years (range, 12.3-51 years) and 55.0% were male. Common etiologies were iatrogenic (n = 180, 60.0%), trauma (n = 66, 22.0%), and idiopathic (n = 36, 12.0%). The mean NSP size was 17.1 mm (range, 4-23). Repair techniques included unilateral random pattern flaps (n = 205, 62.3%), interposition grafts (n = 137, 41.6%), and unilateral axial pedicled local flaps (n = 81, 24.6%). 222 patients (67.5%) underwent a 2-layered repair, while 70 (21.3%) and 37 (11.2%) patients underwent single and 3-layered repairs, respectively. Successful closure was achieved in 296 patients (90.0%). When stratified by layers of repair, 65 single-layered (92.9%), 196 2-layered (88.3%), and 34 3-layered repairs (91.9%) were successful at a mean follow-up of 16.3 months (range, 3-31 months). Conclusions: ENSPR generally achieves NSP closure with high rates of success among varying types of repairs. Further studies may determine how clinical factors and surgical methods impact the likelihood of obtaining successful closure.

State-of-the-art: septal perforation repair

“…Currently, success closure rates exceeding 90% are now commonly reported [3 ▪▪ ], however, there is no standard approach or single technique. The different techniques described include unilateral random pattern flaps, interposition grafts, unilateral pedicle septal local flaps, free mucosal grafts and bilateral random patter flaps [3 ▪▪ ,4,17,18].…”

“…Currently, success closure rates exceeding 90% are now commonly reported [3 ▪▪ ], however, there is no standard approach or single technique. The different techniques described include unilateral random pattern flaps, interposition grafts, unilateral pedicle septal local flaps, free mucosal grafts and bilateral random patter flaps [3 ▪▪ ,4,17,18]. A systematic review performed in 2007 concluded that each technique had its own advantages and drawbacks, however, the authors were not able to conclude anything categorical because the results reported were rarely statistically significant [18].…”

“…Although all the techniques that we describe bellow can be complemented with interposition grafts, we do not recommend their use since the surgical success with or without them is similar, prolonging the surgical time, and adding morbidity to the procedure. The only exception that has been shown to increase the success rate is the use of free mucosal grafts or interposition grafts associated to pediculated septal flap combined [3 ▪▪ ,17,18]. Regardless of the technique used, silicone nasal splints are fixed between 3 and 6 weeks.…”

“…Early 2022, a systematic review and meta-analysis concluded that the closure success was not associated with the surgical technique [17]. Recently, another systematic review concluded that the overall incidence of success was higher in pediculated septal flaps combined with additional techniques (92.6%), is probably because of the additional surface area provided by free mucosal grafts or interposition grafts, the coverage of the exposed perichondrium, and the reduction of the wound closure tension [3 ▪▪ ].…”

“…In patients undergoing facial bone CT in an emergent setting, the prevalence of NSP was found to be 2.05% [2]. Although anterior perforation is the most frequent (92%) location of NSP, <10% are either posterior or superior [3 ▪▪ ]…”