Surgical repair of large nasal septal perforation: a systematic review and meta-analysis

Large nasal septal perforations (NSP) pose significant surgical challenges due to limited tissue availability, increased mucosal tension, and reduced vascularity. This systematic review and meta-analysis (SRMA) evaluates closure outcomes across surgical techniques for large NSP (≥ 20 mm) and answer in patients with large nasal septal perforations, how do different surgical approaches compare in terms of successful closure and failures?

A SRMA were performed on studies employing surgical repair of large NSP (≥ 20 mm). Meta-analyses of continuous measures and proportions and comparison of weighted proportion were performed for demographic and outcomes.

Thirty-eight studies comprising 408 patients with large NSP were included. The mean perforation dimensions were 22.5 mm (length), 21.3 mm (width), and 24.4 mm (diameter). Common etiologies were iatrogenic (61.2%), idiopathic (36.5%), trauma (31.4%), and drug use (28.4%). Symptoms included nasal obstruction (62.0%), crusting (49.9%), and epistaxis (45.7%). Overall surgical closure rate was 84.4% (95% CI, 80.7-87.6). By technique, success rates were 88.2% for mucosal advancement, 86.6% for interpositional grafts, 72.7% for graft-flap combinations, and 91.8% for other approaches (pedicled/composite flaps, implants). Failures with mucosal advancement were predominantly reperforations, whereas interpositional and combination repairs more often failed due to inability to achieve initial closure.

Surgical repair of large NSP achieves high success rates, though outcomes vary by technique. Mucosal advancement and interpositional grafts demonstrate comparable effectiveness, while graft-flap combinations perform less reliably. Larger defects remain the strongest predictor of failure, underscoring the importance of tailored surgical planning and careful technique selection.