Bansberg, Stephen F.

Abstract Objective To describe and illustrate septal perforation shape through the documentation and analysis of length and height measurements. A secondary objective is to correlate perforation size to surgical and nonsurgical etiologies. Stuy Design Retrospective case series. Setting Tertiary academic medical center. Methods Length and height of consecutively treated perforations over a 3‐year period were measured directly or through computed tomography. Mean differences in length and height measurements were compared and regression analysis used to determine perforation shape and the effect of etiology on perforation size. Perforations were classified by length into small (1‐5 mm), medium (6‐15 mm), and large (>15 mm) and correlated to shape and etiology. Results One hundred twenty‐four patients (mean age 50.4 years, 60.5% female) met study inclusion criteria. Height was less than length in 93% of perforations 5 mm or greater in length. Mean perforation height was significantly less than length for medium and large perforations ( P < .001). Mean length and height measurements of nonsurgical perforations were greater than those for surgical perforations ( P < .001). Conclusion Height is less than length in over 90% of septal perforations. Most perforations assume an elliptical shape as they enlarge. Accurate measurement and presentation of length and height is relevant information to perforation management decisions and for the evaluation of treatment outcomes.

ObjectiveThe Nasal Obstruction Symptom Evaluation (NOSE)‐Perf scale was developed and validated to measure symptoms associated with nasal septal perforations. This study reports the application of the NOSE‐Perf scale to evaluate symptom change following septal perforation repair.MethodsPatients with NOSE‐Perf evaluations ≥6 months following attempted perforation closure from July 2018 to December 2021 utilizing bilateral nasal mucosal flaps with an interposition graft were eligible for study inclusion. Change in NOSE‐Perf scores were noted. Patient demographics, perforation size, and concurrent functional procedures were analyzed for impact on symptom outcomes.ResultsOne‐hundred and seventeen patients met the study criteria. Seventy‐nine (67.5%) of the patients were female and the mean (range) age at surgery was 47.3 (14–78) years. Repair failure was noted in 7 (6.0%) patients. Mean (SD) preoperative NOSE‐Perf score was 25.3 (95% CI, 23.5–27.1) and postoperative score was 7.9 (95% CI, 6.5–9.3). Minimal clinically important difference (MCID) was estimated and greater than 91% of patients had improvement above this threshold. Patient age, perforation size, or concurrent functional procedures did not impact outcomes. Postoperative scores at short (2–4 months), intermediate (5–8 months), and long‐term (≥9 months) time periods showed significant improvement (all p < 0.001) compared to preoperative NOSE‐Perf scores.ConclusionSignificant reduction in nasal symptoms as measured by the NOSE‐Perf scale is noted following bilateral mucosal flap repair. Although the nose does not completely normalize following repair, clinically important improvement was noted in at least 91% of patients. The NOSE‐Perf scale is positioned to play a role in the standardization of septal perforation evaluation and outcomes assessment.Level of Evidence4 Laryngoscope, 134:3067–3072, 2024

BackgroundNasal septal perforations (NSP) can have a heterogeneous appearance on endoscopic examination with varying degrees of crusting, inflammatory change, and associated septal deviation. The clinical applicability of these findings as contributors to patient symptoms may be enhanced by use of a standardized assessment.MethodsVideo nasal endoscopy recordings were obtained from 40 patients with NSP. Five raters with varied levels of training ranging from a senior resident to an experienced septal perforation surgeon independently reviewed the videos for the following exam findings: crusting, scarring, granulation tissue, septal deviation, and edema. Scoring for each item was reported on a 3‐point (0–2) scale, and each reviewer repeated scoring at a 14‐day interval. Interrater and intrarater agreement were calculated using Fleiss kappa for each item and the total scores. Additionally, endoscopy scores were correlated with patient‐reported NOSE‐Perf symptom scores.ResultsInterrater agreement for the overall instrument was in the “fair‐to‐moderate” range with the following interrater agreement for each item: crusting (0.458–0.575), scarring (0.286–0.308), granulation (0.403–0.406), deviation (0.487–0.494), and edema (0.253–0.406). Intrarater agreement was generally “substantial” for individual items as well as the overall instrument (0.688). The NSP endoscopy scores were moderately correlated with NOSE‐Perf scores (r = 0.44, p = 0.008).ConclusionsAn endoscopic evaluation of NSP comprising five exam findings has acceptable interrater and intrarater reliability and correlates with patient‐reported outcomes. NSP endoscopy may be applied to future clinical studies for characterization of NSP and assessment of treatment outcomes.Level of Evidence3 Laryngoscope, 134:3049–3053, 2024

Key Points Combined endoscopic sinus surgery and nasal septal perforation repair is technically feasible. NOSE‐Perf is a recently developed patient‐reported outcome measure for nasal septal perforation. The decision to perform combined ESS and NSP repair should be made on a case‐by‐case basis.

Background: Nasal septal perforation repair is commonly attempted utilizing bilateral nasal mucosal flaps supported with an interposition graft. Objectives: To compare the failure rates for bilateral flap repairs utilizing four different autologous interposition grafts. Methods: This is a retrospective review of a single surgeon's bilateral flap perforation repairs supported with an autologous interposition graft. Study inclusion over the 18-year review period required at least one examination 1 month after surgery. Repair failure rates were calculated and compared for each graft type, and logistic regression was performed for multivariate analysis. Results: For the 356 study patients, median (range) age was 51 years (14–81) and 63.0% were women. Mean (range) perforation length was 13.9 mm (1–45). Median (range) at last follow-up was 11.2 months (1–192). Graft types used (percentage of patients and failure rate) were temporalis fascia (58.7/4.4), septal cartilage (23.3/7.3), auricular perichondrium (13.8/4.1), and septal bone (4.2/6.7) ( p > 0.05). Conclusion: There was no significant difference in bilateral mucosal flap perforation repair failure rate when either a temporalis fascia, septal cartilage, auricular perichondrium, or septal bone interposition graft was used.

Background: The 18-item Glasgow Benefit Inventory (GBI) has been widely used to measure patient general health response to otorhinolaryngologic and facial plastic interventions. The GBI was recently reorganized into 15 questions with 5 sub-scale factors ( GBI-5F) to improve its utility. Application of the GBI-5F to septal perforation treatments may improve our understanding of quality of life outcomes. Methodology/Principal: The GBI was given to patients seen from August 2018 through October 2021 who were at least 6 months postoperative attempted perforation surgical closure using bilateral nasal mucosal flaps with an interposition graft. Original GBI and GBI-5F scores were computed and subgroup analysis performed in this retrospective medical record review. Results: Of the 98 patients (mean age 45.5 years) who met study criteria, 65 were female. Mean perforation length was 12.9, and height 9.7 mm. The mean postoperative time to GBI completion was 12.7 months. Highest GBI-5F scores were noted in the Quality of Life factor, followed by Self-confidence and Social Involvement. Females reported significantly higher scores than men. Total GBI scores were similar to those recorded for other rhinologic procedures. Conclusions: The GBI-5F provides measurable insight into patient quality of life benefit following septal perforation repair.

AbstractObjectiveTo determine whether septal perforations have an effect on nasal swell body (NSB) size.Study DesignRetrospective cohort study.SettingTwo tertiary academic medical centers.MethodsComputed tomography maxillofacial scans of 126 patients with septal perforation and 140 control patients from November 2010 to December 2020 were evaluated. Perforation etiology was determined. Measurements included perforation length and height and swell body width, height, and length. Swell body volume was calculated.ResultsThe width and volume of the NSB are significantly smaller in perforation patients when compared to controls. The swell body is significantly smaller and thinner in perforations exceeding 14 mm in height compared to small perforations. Perforation etiology groupings into prior septal surgery, septal trauma, septal inflammatory, and mucosal vasoconstriction categories all demonstrated decreased swell body volume and width compared to controls. Inflammatory etiology had the greatest decrease in swell body size. The hemi‐swell body on the contralateral side of a septal deviation is significantly thicker than the ipsilateral side.ConclusionThe NSB is smaller in patients with septal perforation regardless of perforation size or etiology.

AbstractObjectivesThis study aims to analyze the impact of age and sex on botulinum neurotoxin (BoNT‐A) dosing and outcomes in adductor spasmodic dysphonia (AdSD).MethodsA database review of all spasmodic dysphonia patients treated with BoNT from 1989 to 2018 at the Mayo Clinic in Arizona was performed. Only patients who had received ≥4 injections of BoNT‐A for AdSD were included. Patients were divided into two cohorts to analyze age, with an age of first treatment cutoff of 60 years. Patients were divided into male and female cohorts to analyze sex.ResultsThe final analysis included 398 patients. The mean dose of BoNT‐A per treatment was significantly higher in the younger cohort (4.4 vs. 3.9 units, p = 0.048). The mean maximal benefit was similar (72% vs. 70%, p = 0.48); however, the mean length of benefit was significantly shorter in younger patients (3.0 vs. 3.6 months, p < 0.01). The mean BoNT‐A dose was significantly higher in the female cohort (4.2 vs. 3.6 units, p = 0.02). The mean maximal benefit was similar (69% vs. 75%, p = 0.58), as was the mean length of benefit (3.2 vs. 3.5 months, p = 0.11).ConclusionsThis study suggests that age and sex influence BoNT‐A dosing and outcomes in AdSD.

ObjectiveTo objectively identify and quantitate presenting nasal symptoms in patients with a septal perforation using the validated NOSE‐Perf scale.Study DesignCase series retrospective review.MethodsThe medical records from August 2018 through January 2022 of patients at a tertiary care academic center with a septal perforation, and who completed the NOSE‐Perf questionnaire, were reviewed. Perforation symptoms were identified and quantified using the 12‐item NOSE‐Perf scale (score range 0–48). NOSE‐Perf findings were correlated to patient demographics, perforation etiology, and perforation length. NOSE‐Perf scores of patients who pursued treatment were compared with those who did not.ResultsNOSE‐Perf data were collected from 202 patients. Nasal crusting was noted in 94.1% of patients and was the most severe symptom reported (mean 2.9 of 4.0). Nasal congestion, difficulty breathing, and nasal obstruction followed in prevalence and severity. The mean total NOSE‐Perf score was 23.7. Linear regression analysis demonstrated a weakly negative association of NOSE‐Perf score with patient age and weakly positive association with increasing perforation length. NOSE‐Perf scores were significantly higher in women and in patients pursuing treatment.ConclusionThis is the first study to use the validated NOSE‐Perf scale to objectively characterize and establish baseline septal perforation symptomatology. The NOSE‐Perf scale can play a role in the standardization of perforation evaluation and treatment outcomes assessment. Laryngoscope, 133:1315–1320, 2023

Objectives/HypothesisTo describe the surgical technique and closure outcomes of larger septal perforation repair incorporating mucosa from the undersurface of the upper lateral cartilage into a superiorly positioned advancement flap.Study DesignRetrospective case series.MethodsA chart review was performed for patients who underwent perforation repair utilizing bilateral nasal mucosal flaps which incorporated mucosa from the undersurface of the upper lateral cartilage into the superior flap between January 2009 and December 2020.ResultsSixty‐six patients met study criteria. Prior septal surgery was the most common (28.8%) etiology. Mean perforation length and height were 18.9 and 14.4 mm, respectively. Complete perforation closure was noted in 91.2% of patients followed for a minimum of 6 months (mean follow‐up time 32.1 months). Twelve patients underwent secondary surgery for persistent nasal obstruction. Postoperative loss of dorsal height was noted in seven patients. The NOSE‐perf scores were available for the last 15 repairs and demonstrated significant symptom improvement from a mean score of 26.4 (95% confidence interval [CI], 5.2) to 14.5 (95% CI, 5.2) (P < .0001).ConclusionThe ventral surface of the upper lateral cartilage can provide additional mucosa for incorporation into a superior advancement flap to achieve successful closure for larger septal perforations. Optimization of surgical outcomes for this challenging condition may require secondary functional or aesthetic procedures.Level of Evidence4 Laryngoscope, 132:973–979, 2022