Septoplasty is a common procedure in otolaryngology used to address nasal obstruction caused by a deviated nasal septum. It is often accompanied by inferior turbinate reduction. Complications that may arise from this procedure include excessive bleeding; cerebrospinal fluid rhinorrhea; extraocular muscle damage; wound infection; septal abscess; toxic shock syndrome; septal perforation; saddle nose deformity; nasal tip depression; and sensory changes, such as anosmia or dental anesthesia. Local and general anesthetics have been used to successfully perform septoplasty and the operation may be done either endoscopically or open. Overall, good intraoperative visualization is a key factor in preventing complications and achieving a functional nasal airway.
Septoplasty is one of the most common and earliest-learned otolaryngologic operations. A deviated nasal septum requiring septoplasty to improve the nasal airway may result from traumatic injury, iatrogenic injury, congenital deformation, or as a complication of a severe nasal infection. In many cases, patients have no obvious cause for their septal deviation. Other reasons to perform septoplasty include the treatment of facial pain caused by contact of the septum with the lateral nasal wall and improvement of intraoperative visualization during distribution of topical nasal sprays after endoscopic sinus surgery (ESS). Given the number of people affected by nasal obstruction caused by septal deviation, continued evaluation of the effectiveness, complications, management, and modifications of modern septoplasty is warranted.
Generally, nasal airflow is not only decreased on the side of the septal deviation but also on the contralateral side. The reason for this phenomenon is compensatory inferior turbinate hypertrophy. As a result, inferior turbinate reduction is frequently performed at the same time as septoplasty to maximize improvement in nasal airflow. Some complications from inferior turbinate reduction are reviewed in this article.
Septoplasty has traditionally been performed as an open procedure working through hemitransfixion incisions just caudal to the septum. Mucoperichondrial flaps are raised bilaterally and the offending cartilage and bone is selectively removed. Historically, maximal resection of the bony and cartilaginous septum has been performed to ensure a midline septum after septoplasty. Maximal excision, however, prevents septal cartilage use in future procedures and may also be associated with an increased incidence of postoperative cosmetic deformities. As a result, other techniques, such as scarification remodeling, have arisen to preserve as much of the septum as possible while still straightening it. In this procedure, Doyle splints may be placed to provide support during the postoperative period while the perichondrium reattaches to the nasal septal cartilage in its new straightened position.
Pain and postoperative discomfort
Some have advocated postoperative use of decongestant nasal sprays, such as xylometazoline hydrochloride, in hopes that these sprays would aid in pain control and decrease postoperative congestion, rhinorrhea, and hyposmia. Unfortunately, Humphreys and colleagues found that this decongestant actually increased pain and had no advantages over nasal saline irrigation. Measures, such as cold compresses, elevation of the head of the bed, and avoidance of straining, may help decrease postoperative swelling, congestion, and discomfort in the immediate postoperative period.
Bleeding
Intraoperative bleeding and postoperative epistaxis are of particular concern in septoplasty given the high vascularity of the intranasal mucosa. Surgically speaking, one should make every attempt to dissect in the avascular submucoperichondrial and submucoperiosteal plans. The addition of low concentrations of epinephrine to the local anesthetic used in hydrodissection of the mucoperichondrial flaps during preparation for surgery appears to effectively induce vasoconstriction of the mucosa; it also greatly aids in prevention of a bloody surgical field. Although using epinephrine in this manner has been found to raise systolic blood pressure significantly in some patients, in the authors’ experience epinephrine may be used safely and effectively in many patients during septoplasty. Intraoperative bleeding may also be decreased by the anesthesiologist’s careful attention to the blood pressure parameters. This topic is addressed in detail by Timperly and Harvey elsewhere in this issue.
Topical vasoconstrictors can be used to minimize or even arrest intraoperative bleeding. Oxymetazoline may be effective in some cases and its risk profile is minimal. However, some patients may require more vasoconstriction than oxymetazoline can provide. Topical 1:2000 epinephrine and topical 4% cocaine may be used with greater effect. These agents may cause cardiac complications if improperly used. A systematic literature review by Higgins and colleagues addresses the issue of the safety and efficacy of topical vasoconstrictors in nasal procedures. Although oxymetazoline is the safest agent, it also appears to be the least effective. Cocaine and epinephrine both yield good vasoconstriction but are associated with case reports of cardiac complications, including myocardial infarction and cardiogenic shock. Use of halothane as an anesthetic in combination with cocaine and epinephrine should be avoided. Topical cocaine and epinephrine should be used judiciously in patients with a known history of cardiac disease.
Nasal packing has been traditionally used to prevent significant postoperative epistaxis and septal hematomas. Given the patient discomfort and minor complications associated with packing and its removal, many have sought alternatives. One randomized, controlled trial showed no difference in postoperative bleeding between nasal packing and fibrin sealant without packing. Another randomized, controlled trial found that placing septal quilting sutures and performing routine postoperative nasal care was associated with the same rate of postoperative bleeding, septal hematomas, adhesions, and infections as in patients with nasal packing. In other words, packing not only failed to decrease the rate of complications it was intended to prevent but it was also associated with increased postoperative pain and discomfort. For this reason, many surgeons have either abandoned or significantly modified their use of postoperative packing.
Quilting sutures have been used in lieu of nasal packing since 1984. The sutures help to re-approximate the mucoperichondrial flaps and prevent a dead space where blood can accumulate. Typically, absorbable sutures, such as chromic or Vicryl, are used for this purpose. Using a curved needle instead of the traditional straight needle may also decrease mucosal trauma. Many recommend placing small stab incisions in the septal mucosa to create drainage ports for any blood that may collect. Still others support the application of fibrin sealant to aid in hemostasis and prevent postoperative epistaxis. After considering the previously mentioned techniques for acquiring hemostasis and preventing postoperative bleeding, the standard recommendations still remain true: patients should avoid aspirin, nonsteroidal antiinflammatory drugs, anticoagulants, and strenuous activity for 2 weeks after surgery, whenever possible.
Bleeding
Intraoperative bleeding and postoperative epistaxis are of particular concern in septoplasty given the high vascularity of the intranasal mucosa. Surgically speaking, one should make every attempt to dissect in the avascular submucoperichondrial and submucoperiosteal plans. The addition of low concentrations of epinephrine to the local anesthetic used in hydrodissection of the mucoperichondrial flaps during preparation for surgery appears to effectively induce vasoconstriction of the mucosa; it also greatly aids in prevention of a bloody surgical field. Although using epinephrine in this manner has been found to raise systolic blood pressure significantly in some patients, in the authors’ experience epinephrine may be used safely and effectively in many patients during septoplasty. Intraoperative bleeding may also be decreased by the anesthesiologist’s careful attention to the blood pressure parameters. This topic is addressed in detail by Timperly and Harvey elsewhere in this issue.
Topical vasoconstrictors can be used to minimize or even arrest intraoperative bleeding. Oxymetazoline may be effective in some cases and its risk profile is minimal. However, some patients may require more vasoconstriction than oxymetazoline can provide. Topical 1:2000 epinephrine and topical 4% cocaine may be used with greater effect. These agents may cause cardiac complications if improperly used. A systematic literature review by Higgins and colleagues addresses the issue of the safety and efficacy of topical vasoconstrictors in nasal procedures. Although oxymetazoline is the safest agent, it also appears to be the least effective. Cocaine and epinephrine both yield good vasoconstriction but are associated with case reports of cardiac complications, including myocardial infarction and cardiogenic shock. Use of halothane as an anesthetic in combination with cocaine and epinephrine should be avoided. Topical cocaine and epinephrine should be used judiciously in patients with a known history of cardiac disease.
Nasal packing has been traditionally used to prevent significant postoperative epistaxis and septal hematomas. Given the patient discomfort and minor complications associated with packing and its removal, many have sought alternatives. One randomized, controlled trial showed no difference in postoperative bleeding between nasal packing and fibrin sealant without packing. Another randomized, controlled trial found that placing septal quilting sutures and performing routine postoperative nasal care was associated with the same rate of postoperative bleeding, septal hematomas, adhesions, and infections as in patients with nasal packing. In other words, packing not only failed to decrease the rate of complications it was intended to prevent but it was also associated with increased postoperative pain and discomfort. For this reason, many surgeons have either abandoned or significantly modified their use of postoperative packing.
Quilting sutures have been used in lieu of nasal packing since 1984. The sutures help to re-approximate the mucoperichondrial flaps and prevent a dead space where blood can accumulate. Typically, absorbable sutures, such as chromic or Vicryl, are used for this purpose. Using a curved needle instead of the traditional straight needle may also decrease mucosal trauma. Many recommend placing small stab incisions in the septal mucosa to create drainage ports for any blood that may collect. Still others support the application of fibrin sealant to aid in hemostasis and prevent postoperative epistaxis. After considering the previously mentioned techniques for acquiring hemostasis and preventing postoperative bleeding, the standard recommendations still remain true: patients should avoid aspirin, nonsteroidal antiinflammatory drugs, anticoagulants, and strenuous activity for 2 weeks after surgery, whenever possible.
Cerebrospinal fluid rhinorrhea
In rare cases, a defect in the cribriform plate caused during septoplasty may lead to a cerebrospinal fluid (CSF) leak. Such defects may be created by angling dissecting forceps more superiorly than posteriorly during submucoperiosteal elevation. Another etiology may be multidirectional forces exerted on the perpendicular plate of the ethmoid during attempts to grasp and remove part of the bony ethmoid plate. Either error will be exacerbated by a variation in anatomy that brings the cribriform plate closer to the ethmoid air cells. To prevent this major complication, detailed knowledge of patients’ anatomy and the proper use of dissection technique with sharp removal of the septum and elimination of multidirectional forces are required. Preoperative CT scans can be helpful in delineating the anatomy at risk. Generally speaking, it is prudent to pay particularly careful attention to any septal bone removal posterior to the anterior attachment of the middle turbinate. In the event that a CSF leak is created, it may be repaired endoscopically with a fascial graft and fibrin glue. In some cases, simple application of fibrin glue over the bony disruption and approximation of the nonporous mucosal flaps by the fracture site with quilting sutures is sufficient to repair the CSF leak.
Ocular complications
In rare instances, ocular complications may occur secondary to the inferior turbinate reduction that is often performed along with septoplasty. Typically these complications are associated with violation of the medial orbital wall or orbital floor. There is, however, one case report involving medial rectus palsy caused by inferior turbinate radiofrequency ablation in which the orbit remained completely intact. In this case, the damage was likely caused by improper distribution of radiofrequency. Close intraoperative attention to patients’ anatomy will help prevent such complications.
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