Keywords
nasal septal perforation - septal reconstruction - PDS plate - polydioxanone plate
Nasal septal perforations are a relatively uncommon pathology that can occur due to
trauma, iatrogenic causes, and inhalation drug use among others.[1]
[2] Perforations can cause symptoms of chronic epistaxis, nasal crusting, congestion,
and whistling when breathing.[2] These symptoms can significantly impact patient quality of life.
Repair of septal perforations poses a challenge for the surgeon. From a conservative
perspective, perforations can be managed with a septal button.[3] However, septal buttons can be uncomfortable and hard to fit.[3]
[4] For larger perforations, a local rotational/advancement/free flap reconstruction
approach can be used.[2] These flap reconstructions can be technically challenging with high complication
and failure rates.[2] Hence, innovative techniques have been described aiming at improving reconstruction
of septal perforations. In the last decade, there have been a limited number of articles
published on the use of a polydioxanone (PDS) plate to aid with reconstruction of
septal perforations.[5]
[6]
[7]
[8]
[9]
[10]
[11] PDS is a resorbable polymer that is completely metabolized by the body.[12] The PDS plate itself is not actually the material that closes septal perforations.
Rather, PDS plates act as the scaffold that supports the recipient's tissue to regenerate
over the perforated septum.[12] In a systematic review that evaluated 49 clinical trials and 104 articles, PDS sutures,
plates, and mesh were found to have low rates of inflammatory reactions, foreign body
responses, surgical site infections, and postoperative fevers. For example, PDS plates
had a surgical site infection rate below 10%.[13] Hence, early research has shown that PDS plates may be a safe and effective way
to provide a template for the attachment of tissue grafts to facilitate septal perforation
reconstruction without the long-term complications of synthetic grafts.[12] The results of these studies have been promising, showing successful closure of
septal perforations with PDS plates.
Despite this aforementioned literature, there is no published collective report on
the use of PDS plates in septal reconstruction. Hence, the purpose of this article
was to review the literature on PDS plates for nasal septal perforation reconstruction.
With such a unified understanding of this technique, surgeons may be able to provide
up-to-date, evidence-based care for their patients.
Materials and Methods
The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines
were adhered to for this systematic review.[14]
Search
PubMed, OVID Medline, and OVID Embase databases were searched on June 20, 2021. Search
terms included nasal septal perforation, polydioxanone, septal perforation, septal
repair, nasal septum, and PDS plate. These terms were combined with Boolean search
terms, AND or OR.
Inclusion/Exclusion Criteria
Prospective and retrospective articles that met inclusion criteria focused on the
use of PDS plate for reconstruction of a nasal septum perforation. Articles that used
PDS plates for reconstruction of septal deviations (septoplasty) and/or cosmetic rhinoplasty/septorhinoplasty
were excluded. Articles that were not in English, had not undergone peer-review, and/or
those that did not report original data, such as editorials, letters to the editor,
review articles and conference abstracts, were excluded.
Article Selection/Data Extraction and Analysis
Two independent reviewers (M.L. and H.Z.) engaged in article title/abstract screening,
and full-text screening according to the inclusion and exclusion criteria. This review
was completed using Covidence (Covidence systematic review software; Veritas Health
Innovation, Melbourne, Australia). A third reviewer (M.G.R.) was introduced if consensus
regarding an article's inclusion could not be agreed upon.
Data were then extracted from the articles that met inclusion criteria. Such data
included the following: study demographic information, included patient symptoms,
type of repair completed, materials other than PDS used in repair, results, and complications.
Pooled analysis was completed across all included studies regarding patient symptoms,
perforation etiology, and closure rates.
The data were organized on a Microsoft Excel worksheet and then analyzed using R software.
Descriptive statistics was completed.
Results
Article Inclusion
From the initial search which yielded 80 articles, 11 were selected after title and
abstract screening. Following full-text screening, seven articles were selected for
final inclusion and data extraction ([Fig. 1]). The majority of the included articles were from the United States of America (n = 4).[6]
[8]
[10]
[11] Most articles were published in the last decade (six or seven published in or after
2011).[5]
[6]
[7]
[8]
[10]
[11] A detailed description of the included studies can be found in [Table 1].
Table 1
Included studies' demographics
|
Study
|
Year published
|
Country published
|
Number of patients
|
Number of females
n (%)
|
Number of males
n (%)
|
Age of patients (y)
|
Number of centers
|
Number of surgeons
|
Type of injury
|
Patient symptoms
|
|
Morse et al[6]
|
2019
|
The United States
|
17
|
12 (70.59)
|
5 (29.41)
|
45
|
1
|
1
|
Unknown/idiopathic (35%), rheumatologic (12%), prior septoplasty (53%)
|
Nasal crusting, whistling, nasal obstruction, epistaxis
|
|
Epprecht et al[7]
|
2017
|
Switzerland
|
20
|
13 (65)
|
7 (35)
|
33
|
1
|
N/R
|
Previous operation (45%), posttraumatic (25%), cocaine (10%), infection (5%), idiopathic
(15%)
|
Nasal crusting, obstruction, bleeding, whistling
|
|
Hughes and Paun[5]
|
2012
|
The United Kingdom
|
10
|
1 (10)
|
9 (90)
|
27–58
|
1
|
1
|
Cocaine (50%), postseptoplasty (30%), cauterization (10%), idiopathic (10%)
|
N/R
|
|
Sand et al[10]
|
2015
|
The United States
|
7
|
15 (60)
|
10 (40)
|
21–61
|
1
|
1
|
N/R
|
N/R
|
|
Mirzai et al[11]
|
2021
|
The United States
|
5
|
3 (60)
|
2 (40)
|
22–56
|
1
|
1
|
Previous septoplasty (80%), nasal decongestant use (60%), Nasal trauma (60%)
|
Nasal obstruction, whistling, epistaxis, crusting, malodor
|
|
Menger et al[9]
|
2008
|
The Netherlands
|
6
|
1 (16.67)
|
5 (83.33)
|
3–11
|
1
|
1
|
Septal abscess (100%)
|
Obstruction
|
|
Flavill and Gilmore[8]
|
2014
|
The United States
|
9
|
N/A
|
N/A
|
N/A
|
1
|
1
|
Trauma (33%), surgery (23%), cocaine (11%), oxymetazoline (22%), gunshot wound (11%)
|
Nasal crusting, discomfort, obstruction, epistaxis, whistling
|
Abbreviations: N/A, not available; N/R, not reported.
Fig. 1 The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow
diagram.
Patient Demographics
A total of 74 patients were included in this review. The age of included patients
ranged from 3 to 61 years. Overall, ages were reported for 65 of 74 (87.8%) patients
across all seven studies. The mean age across all patients was 37 years. The pooled
distribution of the included patients' etiologies of septal perforation were as follows:
27 of 74 (36.5%) patients received prior surgery or septoplasty, 12of 74 (16.2%) patients
had trauma-related septal perforation (including one patient from a gunshot wound),
8 of 74 (10.8%) patients had septal perforations related to cocaine use, 7 of 74 (9.5%)
patients had a septal infection or abscess, 5 of 74 (6.8%) patients had septal perforations
related to nasal decongestant use, 2 of 74 (2.7%) patients had septal perforations
secondary to rheumatologic conditions, 1 of 74 (1.4%) patient suffered a perforation
due to cauterization of the nasal septum, 10 of 74 (13.5%) patients had an idiopathic
cause of septal perforation and no etiology was reported for 7 of 74 (9.5%) patients.
Certain patients were reported to have greater than one etiology for their nasal septal
perforation.
The presence or absence of symptoms for patients included in this review were pooled
and reported for 51 of 74 (68.9%) individual patients in the included studies. Of
these, 37 of 51 (72.5%) patients experienced crusting, 33 of 51 (65%) patients experienced
obstruction, 18 of 51 (35.3%) patients experienced bleeding or epistaxis, 17 of 51
(33.3%) patients experienced whistling, and 4 of 51 (8%) patients experienced malodor.
Some patients included in this review presented with a combination of the aforementioned
symptoms.
Reconstruction Trends
All included studies used a PDS plate for their nasal septum perforation reconstruction.
All studies reported using other materials in addition to the PDS plate for their
repair. Four of seven studies also used a temporalis fascia graft, 2 of 7 studies
used autologous cartilage grafts and 3 of 7 studies used a variety of other reconstruction
materials, including acellular dermal matrices with tissue and mucoperichondrial rotation
flaps ([Table 2]). Twenty-two of 74 (29.7%) patients, in three of seven studies, underwent surgery
involving both a PDS plate and local rotation flaps. One study reported the use of
nasal septal flaps on five patients.[11] Another two studies involved a technique that used mucoperichondrial flaps over
PDS plates on a total of 17 patients.[5]
[10]
Table 2
Included studies' reconstruction techniques and outcomes
|
Study
|
Year published
|
Perforation size range (mm)
|
Plate sizes used
|
Other materials for reconstruction
|
Follow-up time (mo)
|
Outcome (% of closures)
|
Outcome (no. of closures)
|
Complications
|
|
Mirzai et al[11]
|
2021
|
10 × 25–20 × 25
|
1-cm larger than nasal septal perforation
|
Inferior turbinate flap, acellular dermal matrix
|
6
|
100
|
5
|
None
|
|
Morse et al[6]
|
2019
|
2 × 2–14 × 30
|
0.15-mm thick
|
Temporoparietal fascia graft
|
8.7
|
88
|
15
|
Temporal pain (6%), scalp seroma (6%)
|
|
Epprecht et al[7]
|
2017
|
5 × 5–40 × 30
|
0.25-mm thick
|
Plate enveloped by temporoparietal fascia
|
12
|
90
|
18
|
Temporal pain (5%), Infection (5%)
|
|
Sand et al[10]
|
2015
|
5 × 20– > 20
|
0.15 , 0.25, and 0.55 mm
|
Temporalis fascia, mucoperichondrial rotation flaps.
|
6.6
|
86
|
6
|
N/R
|
|
Flavill and Gilmore[8]
|
2014
|
8 × 10–20 × 25
|
0.25-mm thick
|
Deep temporal fascia, temporoparietal fascia, acellular dermal matrix
|
6–50
|
100
|
9
|
None
|
|
Hughes and Paun[5]
|
2012
|
7–16
|
0.15-, 0.25-, and 0.5-mm thick
|
Autologous cartilage interpositional grafts
|
10–68
|
80
|
8
|
Mild postoperative inflammation (10%)
|
|
Menger et al[9]
|
2008
|
15 × 23–25 × 36
|
0.15 mm × 50 mm × 40 mm plates
|
Autologous cartilage graft of auricle or rib
|
4–17
|
100
|
6
|
None
|
Abbreviation: N/R, not reported.
Patient Outcomes
The majority of patients were followed-up around the 4 to 6 months postoperatively.
The maximum time for follow-up was 5 years and 8 months postoperatively.[5] All included studies reported septal perforation closure rates greater than 80%
with the PDS plate repair. Three of seven studies reported 100% septal perforation
closure rates.[5]
[8]
[11] Pooled analysis of the reconstruction trends across all included patients demonstrating
closure rates of 91% (48/53) for temporalis fascia and PDS, 88% (14/16) for autologous
cartilage grafts and PDS, 100% (6/6) for acellular dermal matrix with tissue (via
inferior turbinate flap or temporalis fascia) and PDS, and 86% (6/7) for mucoperichondrial
rotation flaps with tissue (via temporalis fascia) and PDS. Four of seven studies
reported that no patients had any complications following surgery.[5]
[8]
[9]
[10] Three of seven studies reported complications, including temporal scalp seroma,
temporal pain, and local infection.[6]
[7]
[11]
Discussion
All studies in this review reported septal perforation closure rates of at least 80%.
The different materials used in conjunction with PDS plates in the included studies,
all contributed to high rates of successful nasal septum perforation closure. The
majority (four of seven) of studies did not report any complications following nasal
septal repair with PDS plate.[5]
[8]
[9]
[10] In total, 67 of 74 (90.5%) patients in the included studies reported closure of
their septal perforation. As an innovative technique for repairing nasal septal perforations,
these results are promising. However, due to the sparse literature on the role of
PDS plates in nasal septal perforation reconstruction, further research is needed
to demonstrate its utility and to suggest its routine use.
In most reconstructive surgeries, the use of autologous tissue is preferred. However,
due to factors, such as the limited amount of suitable, high-quality cartilage available
at donor sites, synthetic materials are often used in septal reconstructive surgeries.[15] As has been shown, PDS plates appear to be a useful material for reconstructing
nasal septal perforations. From a physiologic perspective, PDS plates aid septal perforation
closure by acting as a scaffold to support other human tissue (cartilage, fascia,
etc.) which encourages structural stability and remucosalization of the nasal septum.[15] Hence, PDS plates may act as an important cartilage replacement in the context of
nasal septum perforations. They degrade spontaneously without impacting the surrounding
tissue, and they serve to guide regenerating chondrocytes over the perforation to
avoid the formation of deviated cartilage.[16]
[17] Furthermore, when cartilage and PDS plate are used simultaneously, the regenerated
tissue has been shown to be stronger than had the perforation been repaired solely
with cartilage.[18]
Notably, three studies included the use of temporoparietal fascia (TPF) grafting in
addition to PDS plates for reconstruction of the nasal septum.[6]
[8]
[10] TPF grafts have demonstrated a high success rate for other reconstructive procedures.[6]
[19] The histological properties of the TPF are thought to contribute to the successful
use of PDS plates as a scaffold/cartilage replacement to enhance cellular regeneration,
migration, and mucosalization.[6]
[20]
Other techniques of nasal septal reconstruction have been shown to have significantly
more complications than the use of PDS plates.[2] For example, while rotational and advancement flaps have been shown to be efficacious
in nasal septal repair, the pooled data on PDS plates presented in this review report
lower complication rates compared with similar studies pertaining to rotational or
advancement flaps.[21]
[22] Further, using free flaps for nasal septal reconstruction have also been shown to
have a higher failure rate than alternative techniques.[2]
[23] This reconstructive method can also cause morbidity at the donor site. One study
reported a successful closure rate of 78% which is lower than all PDS studies included
in this review.[24] Another study using interpositional auricular cartilage grafting via a mucosal regeneration
technique to repair nasal septal perforations demonstrated symptom relief in 83.3%
of patients, notably lower than the pooled results for our included studies.[25] Septal buttons have also been used to treat nasal septal perforations. However,
they are only suitable for small perforations.[3] Patients who received treatment with buttons have reported that they do not fit
well and can be painful.[3] Further, 50% of patients reported that they poorly tolerate septal buttons.[4] However, PDS products are not without their own risks. Despite the efficacy of PDS
plates, mesh, and screws, PDS clips and staples have higher rates of migration from
site of injury and related adverse reactions.[13] Furthermore, when PDS plates have sharp cutting edges, particularly at the nasal
tip and anterior columella, they can become palpable or exposed.[15] Care should be taken to ensure PDS plates have rounded-off edges before being used
in septal reconstruction.
Limitations and Future Directions
Limitations and Future Directions
There are several limitations associated with this review. First, the scant number
of studies on the topic negates a meta-analysis or the ability to draw definitive
conclusions on the usefulness of PDS plates for repairing nasal septum perforations.
The included studies involved cohorts with a relatively small number of patients.
Further, each study evaluated participants from a single site, and six studies reported
that all operations were performed by a single surgeon, weakening the external validity
of the results. Only one study contained patient-reported outcomes, which reduces
the understanding of how patients perceive the benefit of reconstruction with PDS
plates.[6]
Future research could incorporate larger cohorts of patients from various centers.
Further, longitudinal studies that evaluate the long-term safety and outcomes for
patients receiving nasal septal perforation reconstruction with PDS plates is warranted.
Future studies could also investigate what types of perforations, in terms of characteristics,
such as etiology or size, are most suitable to be reconstructed with PDS plates. Patient-reported
outcomes should also be included in future studies.[26] Given that PDS plates and materials required for alternative procedures have varying
associated costs, future studies could also include cost-benefit analyses or cost-utility
analyses of using PDS plates compared with other strategies for individuals with nasal
septum perforations.[27] PDS plates are reported to cost $299 per sheet.[12] Finally, future research should also focus on innovations to improve PDS plates
with the use of other biomaterials.
Conclusion
This systematic review ultimately included seven studies representing 74 patients
who received nasal septal perforation reconstruction with a PDS plate. All included
studies reported closure rates of at least 80%. The use of PDS plates is an innovative
and promising approach to repairing septal perforations that has demonstrated positive
outcomes. Future studies should continue to evaluate the long-term safety and outcomes
of using PDS plates on larger cohorts of patients with nasal septum perforations.
