DRUG/DEVICE CAPSULES WILLIAM J. RICHTSMEIER, MD, PhD Drug/Device Capsule Editor
Improved nasal septal prosthetic button ISAAC ELIACHAR,MD, and NICHOLASP. MASTROS,MD, Cleveland, Ohio
N a s a l septal perforations can be caused by several factors, such as cocaine abuse, trauma, nasal surgery, chemical irritants, neoplasms, infections, or inflammatory diseases. Some perforations, especially those in the deeper, osseous segment of the septum, are commonly asymptomatic. However, the majority of perforations involve the cartilaginous or caudal segment of the septum. These perforations are usually associated with underlying nasal deformities, such as septal deviation, nasal fractures, and other underlying diseases, such as allergy and vasomotor rhinitis. Anterior perforations, especially when they are first seen in conjunction with other aggravating conditions, often become disturbing to the patient. 1 Epistaxis, crusting, secondary infection, and inflammation, as well as whistling and nasal obstruction, are common. In general, surgical closure of septal perforations is considered difficult and is associated with wide variation in rates of complications and failures. ~-5 The surgeon and the patient must decide whether a particular perforation should be managed surgically. In some instances, surgery may be contraindicated because of the patient's age, general medical condition, or underlying pathology. The application of a nasal septal prosthesis, or "button," may be a temporary or even long-term alternative treatment until the patient's general or local condition allows definitive surgical closure of the perforation.
From the Department of Otolaryngology,the Cleveland Clinic Foundation. Received for publication Feb. 11, 1994; accepted July 29, 1994. Reprint requests: Isaac Eliachar, MD, Department of Otnlaryngology,A71, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195. OTOtaRYr~OOLHEAONECXSURe1995;112:347-9. Copyright© 1995by the AmericanAcademyof OtolaryngologyHead and Neck SurgeryFoundation, Inc. 0194-5998/95/$3.00 + 0. 23/75/59515
Several nasal septal prostheses made of acrylic, plastic, and silicone have been described. 6-1° The most commonly applied septal button (model no. XO-1400; Xomed-Treace, Jacksonville, Fla~) 8 is composed of two fiat silicone disks 3 cm in diameter, connected by a solid, narrow hub 5 mm in diameter and 3 mm wide. Experience with the silicone button 7-1° has been marked by difficulties in insertion, followed by patient intolerance as a result of local irritation, nasal obstruction, accumulation of inspissated secretions, crust formations, and secondary infections. 8,9 The relatively rigid disks do not adhere to the nasal septum as a result of the underlying curvatures of the septurn. The flange act as flap-like valves that obstruct the airway and tend to accumulate secretions and crusts. Septal deviations are stated in the manufacturer's instruction manual to be contraindications for application of Xomed buttons. This article describes a new nasal septal button design that overcomes the deficiencies of earlier designs. THE NEW SEPTAL BUTTON
The new septal button (catalog no. NSB-30; Hood Laboratories, Pembroke, Mass.) is a modification of earlier septal buttons. It too consists of two parallel disks 3 cm in diameter connected by central hub. However, the disks consist of a more pliable, softer, medical-grade silicone with a conical profile. Furthermore, the disks taper toward the periphery, thus ensuring adherence and adaptability to the underlying curvatures and irregularities of the septum (Fig. 1). The connecting hub is flexible (hinge-like), which adapts the button better to the varied anatomic nasal deformities by allowing the disks to be positioned diagonally if needed, as opposed to being rigidly fixed to each other in a perpendicular plane (Fig. 2). 347
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Fig. 1. Artist rendition demonstrating the flexibility of the new septal prosthesis allowing it to a d h e r e to the curves and irregularities of the perforated septum.
The nasal cavity must be topically decongested and anesthetized. A headlight, lubricating jelly, hemostats, and scissors should be available. The size of the perforation in the horizontal and vertical planes is determined. These dimensions can be visually assessed or measured with a strip of white paper introduced through one nostril and measured with a marking pen through the other nostril. The septal button may be trimmed, especially in cases where the perforation is close to the nasal floor or the dome or toward the caudal end of the septum. The disks should be larger than the perforation to overlap its margins. INSERTION
In most cases it is preferable to introduce the well-lubricated button into the narrower nasal passage until the anterior-most free margin of the disk, intended to be passed through the perforation, pre-
sents itself in the middle of the perforation. The free margin is then grasped with a curved hemostat and pulled through the septum toward the contralateral, wider side. Rotating the button along its central axis will allow it to optimally adapt to the contours and surfaces of the septum. LONG-TERM CARE
The septal button is a foreign body and should be managed as such. The patient should be instructed to irrigate the nose at least three times a day with normal saline spray. Appropriate humidification and moisturization should be maintained, particularly during dry summers and more so during the cold winters when indoor humidity is substantially below normal. A non-petroleum-based nasal cream should be applied at least twice a day. A follow-up appointment should be scheduled within 10 days of insertion and thereafter as needed. However, time between appointments should not exceed 3 months
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to avoid neglect and potential complications. The patient should be instructed to report any signs of intolerance, such as pain, throbbing, erythema, and discharge. Treatment of the patient's underlying condition-be it allergy, vasomotor rhinitis, or any local and systemic disease-must be continued. CLINICAL EXPERIENCE
This n e w s e p t a l b u t t o n has b e e n in r o u t i n e u s e at the Department of Otolaryngology and Communicative D i s o r d e r s at t h e C l e v e l a n d Clinic F o u n d a t i o n for t h e p a s t 2 years. A full clinical r e p o r t is p e n d i n g . T o date, its applicability, m a n a g e m e n t , a n d p a t i e n t t o l e r a n c e have b e e n s u p e r i o r to t h o s e o f convent i o n a l b u t t o n s . W e have n o t h a d any difficulties in insertion, m a i n t e n a n c e , or t o l e r a n c e o f t h e b u t t o n s d u r i n g t h e p a s t 2 years. F o l l o w - u p has r a n g e d b e t w e e n 2 a n d 24 m o n t h s , a n d 10 p a t i e n t s have b e e n f o l l o w e d u p for m o r e t h a n 6 m o n t h s . SUMMARY
Nasal septal button prostheses are useful alternatives to surgical management of symptomatic nasal septal perforations. The new modified button appears to be superior to the conventional button in several ways. It can be trimmed or ordered with larger or asymmetric disks if needed. The two new features of this button are (1) its flexible hub, giving it plasticity and adaptability; and (2) the tapered dome or umbrella-shaped, flexible disks, which allow for greater conformity to the septum. REFERENCES
1. Kuriloff DB. Nasal septal perforations and nasal obstruction. Otolaryngol Clin North Am 1989;22:333-49. 2. Fairbanks DN. Closure of nasal septal perforations. Arch Otolaryngol 1980;106:509-13. 3. Kriedel W, Appling D, Wright W. Septal perforation closure utilizing the external rhinoplasty approach. Arch Otolaryngol 1986;112:168-72. 4. Vuyk HD, Versluis JJ. The inferior turbinate flap for closure of septal perforations. Clin Otolaryngol 1988;13(1):53-7.
Fig. 2. The specially designed, flexible, hinge-like hub allows the disks to be positioned diagonally if needed for optimal adherence to the septum.
5. Papay FA, Eliachar I, Risica R, Carroll M. Large septal perforations. Repair using inferior turbinate sliding advancement flap. Am J Rhinology 1989;3:185-9. 6. McKinstry RE, Johnson JT. Acrylic nasal septal obturators for nasal septal perforations. Laryngoscope 1989;99:560-3. 7. Facer GW, Kern EB. Nonsurgical closure of nasal septal perforations. Arch Otolaryngol 1979;105:6-8. 8. AI-Khabori M. Simple method of insertion of Xomed one piece septal button. J Laryngol Otol 1992;106;358-60. 9. Pallanch J, Facer G, Kern E, Westwood W. Prosthetic closure of nasal septal perforations. OTOLARYNGOLHEADNECKSURG 1982;90:448-52. 10. Kern EB, Facer GW. McDonald TJ, et al. Closure of nasal septal perforations with a Silastic button: results in 45 patients. ORL Digest 1977;39:9-17.