Epistaxis

Some amount of bleeding is common following nasal surgery of all kinds. Simple oozing frequently occurs in the immediate postoperative period and is self-limited. However, more extensive bleeding may be encountered, particularly if septorhinoplasty is combined with additional nasal procedures such as turbinate surgery or endoscopic sinus surgery. Patients should be screened for coagulopathies and platelet deficiencies in the preoperative period. They should be instructed to discontinue use of antiplatelet medicines and nonsteroidal antiinflammatory medications at least 1 week before their surgery.

If bleeding beyond simple oozing is encountered in the immediate postoperative period, much of it will resolve with elevation of the head of the patient’s bed and holding of pressure for a minimum of 10 minutes. The patient’s blood pressure should be monitored and treated if necessary. Should these steps fail to control the bleeding, intranasal splints or packing, if present, should be removed and the nasal cavities suctioned free of clots so that the source of the bleeding can be determined. Topical oxymetazoline or phenylephrine can be applied to induce vasoconstriction. If the bleeding area is visible in the anterior nasal cavity, cauterization with silver nitrate or a bipolar electrocautery device can be attempted. It is important not to over-cauterize the septal mucosa, especially at the same location on both sides of the septum, to avoid a permanent perforation. Should these measures fail, packing the affected side with gelatin sponges or nonabsorbable nasal packs will control most bleeding. If patients continue to actively bleed, their airway should be secured and they should be returned to the operating room for nasal endoscopy with control of epistaxis using electrocautery or other means.2

Extensive hemorrhage following osteotomies warrants special consideration. Osteotomies may cause some degree of mucosal tearing that will bleed; this bleeding is usually self-limited. However, if the osteotome is not correctly placed, the angular artery is susceptible to injury. Knowledge of the anatomy and usual location of this vessel is important to avoiding its injury. If the angular artery is disrupted, brisk bleeding will be noted with the formation of a hematoma along the line of the osteotomy. If this occurs, exploration of the wound with identification and ligation of the injured artery is necessary.

Infection

Infection can occur following any invasive procedure including septorhinoplasty. Most cases of postoperative infection are limited to mild cellulitis or vestibulitis. Vestibulitis generally responds to topical treatment with antibiotic ointment and saline, although systemic antibiotics providing coverage for both gram-positive and gram-negative bacteria are warranted for extensive cellulitis.3 ^, 4 If an abscess is present, prompt incision and drainage is required ( Fig. IV.1 ). Any purulent material obtained should be sent to the lab for culture and sensitivities.

The nasal vestibule can serve as a reservoir for methicillin-resistant Staphylococcus aureus (MRSA).5 Patients may be screened for MRSA carriage in several ways, most commonly by taking culture swabs of the anterior nares and either growing the cultures on MRSA-specific plates or through rapid polymerase chain reaction (PCR) testing.6 ^, 7 Fortunately, the MRSA carriage rate remains low among patients undergoing nasal surgery.6 ^, 8 Nasal mupirocin (Bactroban) ointment has been shown to be effective in decreasing the rate of S. aureus complications among patients who are carriers.9 Although the value of screening for MRSA and treating with mupirocin has not been specifically evaluated for rhinoplasty, surgeons may wish to consider it, particularly in patients receiving synthetic implants ( Fig. IV.2 ).

Nasal Septal Perforations

The nasal septum is a three-layered structure consisting of a cartilaginous and bony framework covered on both sides by mucoperichondrium. Postoperative septal perforations occur when opposing injuries to the mucoperichondrium occur, coinciding with surgical removal or loss of the underlying cartilaginous or bony framework. The key to avoiding this problem is to make certain that the septal mucosa is not injured at the same location on both sides. If a very sharp septal spur exists and should be removed, surgeons know it is quite likely they will create a rent in the mucoperichondrium overlying it on the side to which it projects. A prudent step is to first dissect the mucosa off of the other side of the septum at the site of the spur, being very careful to keep it intact. If a hole is then made on the other side while removing the spur, a full-thickness perforation will not result. If a bilateral mucoperichondrial injury is noticed intraoperatively, it should be repaired immediately if possible.

Septal perforations may also result from tightly packing both nasal cavities, which can pinch the septum, causing pressure necrosis. Overtightening of sutures placed to hold splints in position can produce this phenomenon.

Small perforations that do occur are often asymptomatic and can be treated expectantly. Larger perforations can lead to bleeding, nasal obstruction, crusting, and whistling. When symptoms occur, closure is necessary if local measures including nasal saline and emollients fail to control the symptoms. The simplest way of closing a nasal septal perforation is with commercially available silicone buttons. Buttons can be placed in the office setting under local anesthesia. Although they will close the perforation and satisfy some patients, others will complain that the buttons cause crusting and pain, and request surgical repair of the perforation.

Septal perforation repair can be a difficult procedure. Several surgical management strategies have been described, including septal mucosal rotation flaps, pedicled turbinate flaps, and advancement flaps using the mucosa of the remaining nasal septum and nasal cavity, with a connective tissue graft in between the repaired mucoperichondrial layers.10 ^, 11 For extremely large nasal septal perforations, a radial forearm free flap may be necessary. Postoperative care with nasal saline and ointment is essential for optimal wound healing following surgical repair of septal perforations.

Septal Hematomas

Septal hematomas are collections of blood between the septal mucoperichondrium and the underlying cartilage or between the opposing mucoperichondrial flaps in cases where cartilage has been resected. Many surgeons create a small drainage hole in the septal mucosa on one side or place side-to-side mattress or quilting sutures at the end of the septoplasty to prevent hematomas from forming. Patients with septal hematomas present complaining of increasing pain and nasal obstruction. Endonasal examination reveals an erythematous, ballotable mass on the septum. Untreated hematomas can become infected, resulting in septal abscesses. Septal abscesses can lead to cartilage destruction, which ultimately may result in a dramatic reduction in dorsal support, and a saddle-nose deformity (Fig. IV.3). More dire complications such as meningitis and intracranial abscesses can result from untreated septal abscesses.12 Prompt incision and drainage, with placement of a quilting stitch or nasal splints, is necessary to prevent reaccumulation of the hematoma.

Paresthesias

Although some element of numbness is quite common after septorhinoplasty, it almost always resolves within a couple of months. Patients should be counseled about this in the preoperative setting so that they are not alarmed. If they note paresthesias postoperatively, a period of watchful waiting will almost always result in resolution of the complaint.

Sensation to the nasal tip is supplied by the external nasal branch of the anterior ethmoidal nerve. This nerve exits between the junction of the nasal bones and the upper lateral cartilages and runs within the nasal subcutaneous musculoaponeurotic system (SMAS) over the dorsum. It is susceptible to injury if dissection over the dorsum is not kept in the supraperichondrial plane. The sensory supply to the columella and lateral nasal vestibule comes from unnamed branches of the infraorbital nerve.13 Injury to these nerves as they course superiorly through the columella (as in an open rhinoplasty approach) results in paresthesias distal to the injury.

Paresthesias of the palate can also result from septal surgery. The anterior palate is supplied by branches of the naso-palatine nerve. This nerve can be injured during resection of the anterior maxillary crest during septal surgery.14

Cerebrospinal Fluid Leak

Reports of cerebrospinal fluid (CSF) leaks as a complication of septorhinoplasty are rare.15 However, there is a risk of injury to the cribriform plate during instrumentation of the bony vault as well as to the anterior skull base through fractures of the perpendicular plate of the ethmoid bone during septal surgery. CSF leaks should be suspected when patients complain of positional headache with clear rhinorrhea in the postoperative period. If the fluid can be collected, it can be sent for β₂-transferrin testing to confirm the diagnosis.

Once a leak is identified, consultations from neurosurgical and otolaryngologic colleagues should be obtained. Very small leaks frequently resolve with conservative management that consists of bed rest, head elevation, and stool softeners. A lumbar drain may be placed to help further decrease intracranial pressure. If these measures fail, surgical management is necessary. High-resolution computed tomography (CT) scans, magnetic resonance imaging (MRI), and intrathecal fluorescein can aid in identifying small leaks. Surgical management includes both endoscopic transnasal and transcranial approaches. Leaks may be repaired with several materials including turbinate grafts, acellular dermis, fibrin glue, bone grafts, and temporalis fascia.16

Dorsal Nasal Cysts

Postoperative cysts of the nasal dorsum are a rare complication of rhinoplasty. They usually present as widening of the nasal dorsum with a palpable subcutaneous mass. Patients may note that the masses enlarge when they have a cold. The pathogenesis of dorsal nasal cysts is thought to be twofold. Mucosal cysts are thought to result from herniation of the nasal lining through intranasal incisions or osteotomy sites into the subcutaneous tissues. Biopsies show respiratory epithelium.17 Foreign-body cysts containing petroleum ointment have also been reported.18 ^, 19 Also known as lipogranulomas or paraffinomas, these cysts are thought to result from leakage of petroleum-based ointment through intranasal incisions or osteotomy sites during nasal packing.

Dorsal nasal cysts are best prevented through avoidance of nasal packing and meticulous attention to closure of all intranasal incisions. If the upper lateral cartilages are separated from the septum, they should be reattached primarily or in conjunction with a spreader graft, if necessary. Should a cyst occur, surgical excision is curative.