Complications in septoplasty based on a large group of 5639 patients

Excessive bleeding was most frequent complication in our study, what is similar to other studies [7, 11]. There is one report of lethal bleeding from the internal carotid artery after fracturing the vomer by force [12].

Septal perforations, second most common complication in our study, may not be readily apparent at first follow up, or are asymptomatic so are probably underreported overall [5]. The rate of nasal septal perforation after septoplasty ranges from 1.6 to 6.7% [6, 7, 11]. Most commonly, perforations result from traumatic elevation of the mucosal flaps with opposing tears in the flap on either side. Careful and meticulous elevation of the mucosal flaps is the key to prevention as is making an effort to close any mucosal tears at the end of surgery. Small perforations with well-mucosalized edges may not require any suturing at all, and may not have any impact on the nasal airway per se. Yet another reason for septal perforation involves the placement of quilting sutures or sutures to maintain septal splint placement. If the suture is tight enough to cause ischemia and necrosis of the surrounding area, a perforation may result; we have seen it twice. In some patients, local mucosal trauma caused by intranasal steroid and nasal saline sprays is enough to cause a perforation. Another reason they could be caused is by healing complications due to infection, typically Staphylococcus aureus. We prevent this by advising our patients application of antibiotic ointment (Mupirocin) and irrigation with a saline solution 4–6 times daily to keep the splints clear and minimize potential crusting in post-op period. Surgical repair of a septal perforation, if indicated or desired, is delayed well beyond the initial healing period (6–12 months at a minimum).

Adhesions or spikes mostly occur between septum and inferior turbinate if a tear in the septal mucosa is opposite to a mucosal defect of the turbinate, especially after simultaneous interventions at the turbinate. Septal splints can prevent the formation of the adhesions. We observed this complication more often in allergic rhinitis patients; adhesions were not observed as long as the splints were in place, but usually were noticed on the second or third post-op visit.

Although turbinate reduction was done with RF, which is known to be less traumatic than laser ablation, we believe that prolonged healing, adhesions and hyposmia, more often observed, were due to impaired mucociliary function.

Infections after septoplasty and/or turbinoplasty are rare complications. The rate of local infection and septal abscess after septoplasty ranges from 0.4 to 12.0% [7]. Other infectious complications such as meningitis, brain abscess, cavernous sinus thrombosis [13] and endocarditis [14] are extremely rare. Transient bacteremia, however, is not infrequent. Bacteria were found in venous blood samples obtained immediately after the operation in 15% and after removal of packing even in 16.9% [15]. This may explain why some patients have a body temperature increase postoperatively without evidence of local infection. This raises the question of whether prophylactic antibiotics are mandatory. In a survey, 66% of the surgeons used antibiotics routinely after septoplasty because of the fear of postoperative infection [8]. From the authors’ point of view, prophylactic antibiotics are necessary as long as the splints are kept (usually 7 days post-op). There are case reports of toxic shock syndrome (TSS) after use of nasal packing and intranasal splints, the estimated rate is 0.0165%.

Changes in the external appearance of the nose are nowadays uncommon, but can occur [8, 16]. We present such a complication (Fig. 1), but the patient was operated elsewhere. The overall rate of significant change in the cosmetic appearance of the nose after septoplasty has been reported between 0.4–3.4% [7, 8]. However, some surgeons [17] suggest that this is underestimated complication and aesthetic changes have been noted in up to 21% of the patients. Often this is as a result of inadequate fixation of the septal cartilage when it has been mobilized leading to its posterior inferior rotation and slight settling of the dorsal septum reflecting a loss of tip support and sometimes collumellar retraction [18, 19]. This usually has more a cosmetic than functional implication and can be corrected if the patient is bothered by it, with cartilaginous dorsal onlay grafting through an endonasal approach.

Anosmia or hyposmia is most often temporary and is due to edema. Permanent anosmia resulting from nasal surgery, as reported in the literature [20, 21] is uncommon (0.3–2.9%). Persistent symptomatic septal deviation (nasal obstruction) may be apparent early or may present later. The surgeon should reexamine the nasal airway with particular attention paid to the nasal valve areas. Revision surgery, if needed, should be done by a surgeon well experienced in such cases and typically not before 6 months after the initial surgery.

Cerebrospinal fluid (CSF) rhinorrhea after septoplasty is a rare, but serious complication [22]. Prevention is most important with care when resecting high deviations. Limited studies have been done to investigate the rate of dental anesthesia of the upper incisors after septoplasty surgery, but it is a potential complication [11]. Ocular complication, including blindness, are very rare, but do occur [23, 24]. The theory for complete visual loss after septoplasty is that when epinephrine is injected under pressure into the mucosa of the septum or tissue surrounding the inferior turbinate there is a risk of a retrograde flow through the anterior ethmoidal artery into the ophthalmic artery, which can cause vasospasm of the end arteries to the optic nerve and retina. This hypo perfusion can induce optic nerve neuropathy and unfortunately there is no treatment available in the late stages with corticosteroids and vasodilators.

Atrophic rhinitis has been attributed to overly aggressive turbinate resection with chronic symptoms of nasal crusting, mucosal atrophy and nasal congestion. Empty nose syndrome is a similar condition more specifically referring to the symptoms of paradoxical nasal congestion. Despite many possible complications we should encourage our patients to undergo septoplasty. Recent studies show significant improvement in disease-specific quality of life, high patient satisfaction and decreased medication use [25].

There was a group of patients “not satisfied” with the surgery, meaning they did not notice any difference post operatively. When thinking about contraindications, we should also think about patients whose goals and expectations regarding surgical outcomes are completely discordant with the measurable objective of the surgical procedure (e.g., those seeking resolution of postnasal drip, cure of headache in the absence of any symptomatic nasal obstruction, or elimination of chronic cough) so they are not good candidates for surgery.

In conclusion, most frequent complications after septoplasty were excessive bleeding. More severe complications like hyposmia or inadequate vision were very rare and transient. Meticulous attention to detail in identifying the appropriate anatomy and maintaining good visualization is the key to a safe and effective septoplasty, enabling for very low complication rate. Commitment to proper postoperative care must be stressed to the patient and is crucial for the healing process.