Complications Following Surgery of the Septum and Turbinates
Septoplasty and inferior turbinate reduction are very commonly performed procedures,1 usually for the surgical treatment of nasal obstruction. Although major complications are rare, minor complications are not infrequent. This chapter will outline these complications, their management, and strategies to reduce the risk of them occurring.
When treating a patient with nasal obstruction secondary to deviation of the septum, it is common practice to perform a procedure to reduce the size of the inferior turbinates, which serves to increase the cross-sectional area at the region of the nasal valve and to improve airflow. When the inferior turbinates are large but the nasal septum is in the midline, inferior turbinate surgery may be performed alone. In this chapter, these two procedures will be discussed separately.
Some degree of nasal septal deviation is extremely common.2 Septoplasty is most commonly performed for those deviations that are severe enough to cause obstruction of nasal airflow.3 If there is significant associated deviation of the external nose, a septorhinoplasty is usually performed.4
The role played by deviation of the nasal septum in causing nasal symptoms is not easily measured objectively because there is poor correlation between physical measurements of nasal airflow and a patient′s subjective appreciation of the severity of obstruction.5 Nonetheless, most patients with septal deviation sufficiently severe to warrant septoplasty report an improvement in both nasal symptoms and quality of life after the procedure.6,7
Many cases of septal deviation are congenital, and may be related to birth trauma.8 Any retrospective study would be expected to be subject to significant recall bias but a proportion of septal deviations are acquired, being clearly related, by patients, to external trauma.9
Any part of the septum may be deviated from the midline. The three most common patterns of septal deviation seen in rhinology practice are a convex deviation away from the sagittal plane, which is usually maximal in the region of the osseochondral junction, septal spurs, which are usually formed by the vomer, and very caudal cartilaginous deflections.10 The nature of the deviation (and there are often several in combination) alters the surgical approach and consequently the potential for complications to occur. The septum is most commonly approached endonasally via hemitransfixion or Killian incisions. Visualization can be facilitated by a speculum and headlight, or a nasal endoscope.
Septal deviation and rhinitis are both very common, and when a patient presents with nasal obstruction it is not easy to assess the relative contributions of these two factors toward the patient′s symptoms. When coexistent rhinitis is suspected, a trial of medical therapy (including at least several weeks treatment with a topical nasal corticosteroid spray) is indicated. Many patients will have sufficient relief from medical therapy alone so that septoplasty is no longer required.14
If chronic rhinosinusitis is suspected on clinical grounds, a computed tomography scan of the sinuses is indicated. It is not uncommon for patients with chronic rhinosinusitis to have a septoplasty and inferior turbinate reduction procedure performed without adequate investigation to exclude chronic rhinosinusitis, only to return postoperatively with inadequate relief of symptoms due to persisting sinusitis.
The majority of cases of septoplasty are performed under general anesthesia. The general health status of the patient needs to be assessed preoperatively because it may impact on the safety of general anesthesia. Although nasal obstruction may have a significant impact on quality of life, septal surgery indications are nearly always relative, and septoplasty should be undertaken circumspectly in patients with significant cardiovascular risk factors. Anticoagulant or antiplatelet medication and possibly nonsteroidal anti-inflammatories should be stopped an appropriate numbers of days before surgery.15 If the risk of stopping anticoagulant and antiplatelet medication outweighs the perceived benefit of the surgery we would advocate postponing surgery until the medication is no longer required.
The risk of general anesthesia can be avoided by performing a septoplasty under local anesthesia. There is evidence to suggest that the use of local anesthesia reduces overall operating time.19 However, it is our experience that the procedure is better tolerated under general anesthetic than under local anesthetic.
Optimizing operating conditions improves visualization and so reduces the possibility of intraoperative complications occurring. Preparing the nasal mucosa by the application of topical vasoconstrictors such as epinephrine, oxymetazoline, or cocaine reduces intraoperative bleeding. Injecting the septal mucosa with a combination of topical anesthetic and epinephrine reduces mucosal blood flow further, and injection into the subperichondral plane may facilitate dissection of the mucosal flaps. There is however a lack of consensus on the most appropriate regimen for topical preparation of the nose before surgery.20,21
General anesthetic conditions affect intraoperative blood flow. Placing the patient in a reverse Trendelenburg position facilitates venous return, and induction of relative hypotension and bradycardia reduces bleeding further.22
Obstacles and Complications
Because septoplasty is largely performed within avascular planes, there is usually little associated blood loss. Most of the bleeding that occurs comes from the initial mucosal incision or from fractured or incised bone edges. Accordingly, persistent epistaxis after septoplasty alone is uncommon and rarely severe.23 However, small volumes of blood can collect in the potential space between the mucosal flaps to form a septal hematoma. This can cause nasal obstruction, but a far more serious complication occurs if the hematoma becomes infected.24 The septal abscess can break down the septal cartilage, and a saddle defect can result.25
The risk of a septal hematoma forming may be reduced by placing a posterior incision in one of the intact flaps (assuming no mucosal tears occur during the raising of the flaps). Preventing or limiting the collection of blood in the space between the two flaps can be achieved by placing septal quilting sutures.26 Bilateral packing can achieve the same result, but packing universally causes obstruction until its removal. In some patients this can cause systemic effects, the most significant of which is compromising of oxygen saturation in the early postoperative period.27 There is some evidence that thin Silastic sheets (Dow Corning, Midland, MI, USA) placed against the nasal septum may improve postoperative healing ( Fig. 7.1 )28 but routine packing of the nose for hemostasis following septal surgery appears to be unnecessary.29
A saddle deformity presents both cosmetic and functional problems and arises because of destabilization of the septal cartilage ( Fig. 7.2 ).30 The mid-third of the nasal dorsum is depressed and widened. In more severe cases the lack of support causes the nasal tip to become over-rotated and there is columellar retraction. It can result from the inadvertent division of the attachment of the quadrangular cartilage from the perpendicular plate of the ethmoid bone at its superior end. At least 1 cm of superior attachment of the cartilage to the perpendicular plate needs to be left intact to prevent this cosmetically displeasing deformity from developing. It is safer to start the incision made at the osseochondral junction at its superior extent, ensuring at least a 1-cm margin of safety above the tip of the Freer elevator, and then continue it inferiorly toward the maxillary crest ( Fig. 7.3 ).
Another way in which the bony support can be disrupted is by fracturing the anterior end of the perpendicular plate of the ethmoid from its attachment to the nasal bones. This usually occurs as a consequence of twisting the superior part of the perpendicular plate. It is possible to control the site of fracture of the ethmoid plate by making a cut with turbinectomy scissors from the superior extent of the osseochondral incision, in a direction parallel to the nasal bones. This bony incision reduces the possibility of twisting the superior attachment of the ethmoid plate from the nasal bones and so reduces the risk of both saddle deformity and cerebrospinal fluid (CSF) leak30 ( Fig. 7.4 ).
Should a saddle deformity occur, the defect can be concealed using techniques such as the placement of camouflage cartilage grafts over the depression. This procedure requires an external rhinoplasty approach and is usually performed some time after the septoplasty.31
Cerebrospinal Fluid Leak
This is a very rare but significant complication of septoplasty.32 It results from either the instruments used to elevate the periosteal flap being driven inadvertently through the cribriform plate or alternatively the cribriform plate being cracked by the use of excessive twisting force while removing the perpendicular plate of the ethmoid. Patients with low cribriform plates are more at risk of this complication.33 It is noted however that if required, the septal cartilage can be safely removed anterior to the middle turbinate without threatening the skull base.34
A CSF leak may be recognized intraoperatively by the flow of clear fluid from the region of the cribriform plate, or postoperatively by the persistence of clear rhinorrhea that is positive for the presence of β2-transferrin protein.35 If a CSF leak is suspected, then a thin-slice computed tomography scan is required to delineate the extent of the disruption of the cribriform plate. Intraoperative identification of the site of the leak may be facilitated by the intrathecal administration of a small quantity of fluorescein via a lumbar puncture performed immediately preoperatively. The majority of traumatic leaks are amenable to endoscopic multilayer closure.36
Septal perforation is the most common of the significant complications that follow septoplasty. Although septal perforation may occur as a late and consequently unrecorded complication, reported prevalence rates after septoplasty range from 1 to 6.7%.30 The severity of the symptoms caused by a septal perforation are a function of both its size and site. Paradoxically, small perforations are often more problematic than larger ones because the velocity and turbulence of airflow through smaller perforations is greater ( Fig. 7.5 ). Small perforations can produce a whistling sound that can be particularly disturbing at night. Anterior and inferior perforations tend to be more symptomatic than posterior or superior perforations. This is because there is physiologic turbulence in the posterior nose but anteriorly the abnormal turbulent air flow caused by a perforation desiccates nasal mucosa, leading to crusting, local infection, mucosal granulation and bleeding.37
Septal perforation occurs when the mucosal blood flow to adjacent sides of the septal mucosa is disrupted. This may result from local tears in the mucosa of both septal flaps. This situation is best managed by avoidance and an intraoperative injury to the mucosa on one side of the septum should prompt a particularly cautious and conservative approach to the remaining dissection. It is common practice to elevate the mucosal flap on the concave side of the septal deviation to improve the chance of raising this flap intact.4 Septal tears are very easily created around sharp vomerine spurs ( Figs. 7.6 and 7.7 ). Fortunately, should a perforation occur it is likely to be sufficiently posterior that symptoms are unlikely to result.
The risk of septal perforation is increased if the plane of dissection is superficial to the deepest layer, the perichondrium. The perichondrium is the strongest component of the septal flap, and its disruption increases the possibility of the flap breaking down.38