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Nasal septal adhesions — Clinical Guidelines

Overview

Nasal septal adhesions occur when scar tissue forms between the nasal septum and adjacent mucosal surfaces following trauma, surgery, or inflammation, leading to impaired nasal breathing and potential functional and aesthetic complications. This condition is particularly significant in pediatric patients due to its impact on growth, development, and quality of life, affecting areas such as sleep patterns and respiratory health. Adults also suffer from these adhesions, often as a complication post-septal surgery or due to chronic nasal conditions. Early recognition and management are crucial in day-to-day practice to prevent long-term sequelae and ensure optimal patient outcomes 1 2.

Pathophysiology

Nasal septal adhesions develop as a consequence of healing processes following injury or surgical intervention. Inflammation and tissue damage trigger the release of cytokines and growth factors, promoting fibroblast proliferation and collagen deposition. These processes lead to the formation of fibrous bands that bind the septal cartilage or bone to the nasal mucosa, effectively occluding nasal passages. The healing environment, influenced by factors such as postoperative care, presence of infection, and the use of packing materials, significantly affects the likelihood of adhesion formation. In pediatric patients, the delicate balance between allowing growth and preventing adhesions is particularly challenging, as excessive scarring can impede normal facial development 1 4 5.

Epidemiology

The incidence of nasal septal adhesions is not extensively documented in large population studies, but they are commonly encountered complications following nasal surgeries and chronic inflammatory conditions. Pediatric populations exhibit septal deviations in approximately 29% of nonsyndromic children presenting with nasal obstruction, with higher incidences noted in some general population studies reaching up to 55% 1. Age distribution shows that significant nasal obstruction due to septal deviation often becomes established by around 7 years of age, suggesting early intervention might be necessary 6. There is no clear sex predilection noted in the literature, but geographic and environmental factors influencing nasal health may play roles in varying incidences 1 2.

Clinical Presentation

Patients with nasal septal adhesions typically present with symptoms of nasal obstruction, including difficulty breathing through the nose, nasal congestion, and recurrent nasal blockage. Additional symptoms may include epistaxis (nosebleeds), crusting, and a sensation of nasal fullness or pressure. In pediatric patients, these symptoms can manifest as mouth breathing, sleep disturbances, and developmental concerns such as midfacial growth abnormalities. Red-flag features include persistent bleeding, severe facial deformity changes, and significant impairment in daily activities, which warrant prompt evaluation and intervention 1 3.

Diagnosis

The diagnosis of nasal septal adhesions involves a thorough clinical evaluation complemented by endoscopic examination and imaging when necessary. Specific diagnostic criteria include:

Clinical History: Detailed history of nasal trauma, surgery, or chronic nasal conditions.

Physical Examination: Anterior rhinoscopy and flexible nasal endoscopy to visualize adhesions and assess septal anatomy.

Imaging: Radiographic studies (CT scans) may be used to evaluate the extent of septal deviation and structural changes 1 6.

Differential Diagnosis:

- Nasal Polyps: Typically present with unilateral obstruction and visible polypoid masses. - Allergic Rhinitis: Characterized by seasonal symptoms, sneezing, and clear rhinorrhea. - Deviated Septum without Adhesions: Obstruction without visible or palpable adhesions 1 3.

Management

Initial Management

Medical Management:

- Saline Irrigation: Regular nasal irrigation to reduce mucosal irritation and promote healing. - Topical Steroids: Application of topical corticosteroids to reduce inflammation and prevent adhesion formation 2.

Surgical Interventions:

- Septorhinoplasty: For significant anatomical deformities, functional septorhinoplasty can address both structural issues and adhesions. Techniques include open or closed approaches with cartilage-sparing methods to minimize complications 1 7. - Adhesion Release: Endoscopic or open surgical procedures to manually separate adhesions and reposition the septum 2 7.

Advanced Management

Use of Antiadhesive Agents:

- Sodium Hyaluronate-Based Hydrogels: Application of SH-CMC-COL1 hydrogels post-surgery to reduce bleeding time and promote healing without adhesions 2. - Bioglue: Utilization of albumin-glutaraldehyde-based tissue adhesives as an alternative to traditional nasal packing to stabilize the septum and prevent complications 5.

Custom Septal Splints: Implementation of 3D-printed septal splints for precise fit and stabilization, reducing the risk of synechiae formation 3.

Contraindications

Active Infections: Surgical interventions are contraindicated in the presence of active nasal infections.

Severe Bleeding Disorders: Patients with significant coagulopathies may require alternative management strategies to prevent excessive bleeding 1 5.

Complications

Acute Complications:

- Postoperative Bleeding: Increased risk immediately following surgery, especially if antiadhesive measures are not properly implemented. - Synechiae Formation: Recurrent adhesions leading to persistent nasal obstruction.

Long-term Complications:

- Midfacial Deformity: In pediatric patients, uncorrected or improperly managed adhesions can affect facial growth. - Chronic Nasal Obstruction: Persistent symptoms impacting quality of life and sleep patterns. - Referral Indicators: Persistent symptoms despite initial management, significant facial deformity changes, or recurrent bleeding should prompt referral to a specialist 1 4 6.

Prognosis & Follow-up

The prognosis for patients with nasal septal adhesions is generally good with appropriate management, particularly when interventions are timely and comprehensive. Key prognostic indicators include:

Early Intervention: Prompt surgical or medical intervention significantly improves outcomes.

Patient Compliance: Adherence to postoperative care instructions and follow-up visits is crucial.

Follow-up Intervals: Regular follow-ups at 1 week, 1 month, 3 months, 6 months, and annually to monitor healing and address any recurrence 1 8.

Special Populations

Pediatrics

Growth Considerations: Early surgical interventions must balance the need for correction with preservation of growth centers.

Quality of Life: Significant improvements in quality of life metrics following septoplasty have been documented, emphasizing the importance of timely surgical intervention 1 8.

Adults

Functional Outcomes: Pack-free septoplasty techniques have shown effective functional outcomes with reduced complications like synechiae and minor hemorrhage 8.

Key Recommendations

Early Surgical Intervention for Symptomatic Patients: Perform septoplasty or septorhinoplasty in symptomatic children aged 14 years and older to prevent long-term developmental issues (Evidence: Strong 1 7).

Use of Antiadhesive Agents: Apply sodium hyaluronate-based hydrogels post-surgery to reduce bleeding and promote healing without adhesions (Evidence: Moderate 2).

Custom Septal Splints: Utilize 3D-printed septal splints for precise fit and stabilization to minimize synechiae formation (Evidence: Moderate 3).

Comprehensive Postoperative Care: Ensure regular follow-up visits at 1 week, 1 month, 3 months, 6 months, and annually to monitor healing and address complications (Evidence: Expert opinion).

Avoid Nasal Packs When Possible: Opt for pack-free techniques or alternative stabilization methods like Bioglue to reduce complications such as synechiae (Evidence: Moderate 5 6).

Evaluate for Midfacial Growth in Pediatric Patients: Regular radiographic assessments to monitor facial development post-surgery (Evidence: Expert opinion).

Address Chronic Inflammation: Use topical corticosteroids preoperatively to reduce inflammation and prevent adhesion formation (Evidence: Moderate 2).

Consider Patient Compliance: Educate patients on the importance of postoperative care and follow-up to ensure optimal outcomes (Evidence: Expert opinion).

Refer Complex Cases: Refer patients with persistent symptoms, significant deformities, or recurrent complications to specialists for further evaluation (Evidence: Expert opinion).

Monitor Quality of Life: Utilize validated questionnaires like NOSE and SN-5 to assess and document improvements in quality of life post-intervention (Evidence: Strong 8).

References

1 Frank E, Osowski C, Good R, Leuin SC. Durability of Quality-of-Life Improvements Following Pediatric Septorhinoplasty. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2026. link 2 Padalhin A, Ryu HS, Yoo SH, Abueva C, Seo HH, Park SY et al.. Evaluation of sodium hyaluronate-based composite hydrogels for prevention of nasal adhesions. Biomedical materials (Bristol, England) 2024. link 3 Sakellaris NI, Sakellari EI, Kanaan Y, Khalil H, Stavrakas M. Added value of 3D printing technology in the manufacturing of customised septal buttons: A scoping review of the literature. American journal of otolaryngology 2023. link 4 Topal K, Kars A, Atalay F, Kılıc K. Evaluation of effect of septoplasty on nasal mucosal dryness using intranasal Schirmer test. Acta oto-laryngologica 2022. link 5 Subasi B, Guclu E. The Effects of Using Bioglue in Nasal Septal Surgery. Ear, nose, & throat journal 2021. link 6 Kim SJ, Chang DS, Choi MS, Lee HY, Pyo JS. Efficacy of nasal septal splints for preventing complications after septoplasty: A meta-analysis. American journal of otolaryngology 2021. link 7 Furbish N, Kühnel TS. Nasal septum configuration as a basis for novel septal splints. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2017. link 8 Eşki E, Yılmaz İ. Pack free septoplasty: functional outcomes and complications. Kulak burun bogaz ihtisas dergisi : KBB = Journal of ear, nose, and throat 2015. link 9 Aksoy F, Yilmaz F, Yildirim YS, Gideroglu K, Tatar Z. Use of N-butyl cyanoacrylate in nasal septoplasty: histopathological evaluation using rabbit nasal septum model. The Journal of laryngology and otology 2010. link 10 Doğru H, Uygur K, Tüz M. Nasal septal clip (Ciğdem clip). The Journal of laryngology and otology 2002. link

Nasal septal adhesions