Septoplasty Part 3 - Complications & Approaches

⚠️ Complications of Septoplasty

This post covers:

• Classification of complications of septoplasty
• Intraoperative complications
• Immediate postoperative complications
• Delayed postoperative complications
• Approaches to septoplasty

📋 Classification of Complications of Septoplasty

1️⃣ Intraoperative Complications

• Anaesthetic complications
• Complications due to surgery

2️⃣ Postoperative Complications

• Immediate postoperative complications
• Delayed postoperative complications

🚨 Intraoperative Complications of Septoplasty

💉 1- Anaesthetic Complications

• Hypotension from adrenaline used in the local anaesthetic
• Drug allergy to anaesthetic gases
• Cardiac arrest from anaesthesia

Management

• Managed by the anaesthetist intraoperatively

Prevention

• Good pre operative assessment before surgery

What are the things to check during Preoperative assessment for a case of Septoplasty?

🩸 2- Primary Hemorrhage

Hemorrhage occurring at the time of surgery.

Management

• Nasal packing
• Cauterization of the bleeding point

Bleeding from the Bone in the Floor

• Bone wax
• Packing
• Bone hemostat

What are the arteries at risk of injury during Septoplasty?

✂️ 3- Damage to Surrounding Structures

Tear of the Mucoperichondrial Flap

• Tear limited to one side → Not a concern
• Tears on both sides at identical points → Leads to Septal perforation (delayed complication)

⚠️ Elevation of the mucoperichondrial and periosteal flaps is a crucial step in septoplasty.

⏳ Immediate Postoperative Complications of Septoplasty

🩸 1- Reactionary Hemorrhage

Hemorrhage occurring within 24 hours of surgery.

Causes

• Adrenaline wearing off
• Rise in blood pressure postoperatively

How do you manage Reactionary Hemorrhage in Septoplasty?

🤕 2- Headache

Cause

Tight nasal packing pressing on the turbinates and septum

Management

• Loosen the nasal packing
• Early removal of the pack
• Analgesics, if required

👁️ 3- Eyelid Edema

Cause

Tight nasal packing → Pressure transmitted via the thin lamina papyracea to the periorbital tissue

Management

• Self limiting
• Resolves on removal of the pack

🦠 4- Infection

Nasal packing may result in infection of:

• Nose
• Paranasal sinuses
• Middle ear

🕰️ Delayed Postoperative Complications of Septoplasty

⭐ Most of these complications occur more often in SMR than in septoplasty, as SMR is a radical procedure and septoplasty is a conservative one.

What are the differences between SMR and Septoplasty?

🩸 1- Secondary Hemorrhage

Cause

• Infection

Management

• Antibiotics
• Repacking of the nose, if required

🩸 2- Septal Hematoma

Features

• Smooth fluctuant swelling
• Blocks both sides of the nose

Management

Drain immediately by:

• Aspiration, OR
• Incision and drainage

What is Septal Hematoma? When does it form in Septoplasty?

🦠 3- Septal Abscess

Occurs when an undrained septal hematoma gets infected, with pus collecting between the flaps.

Features

• Fever
• Fluctuant swelling on both sides
• Severe nasal pain

How will you manage a case of Septal abscess in a post operative case of Septoplasty?

🕳️ 4- Septal Perforation

Causes

• Untreated septal abscess → Necrosis of cartilage → Perforation
• Tear of the mucoperichondrial flap at identical sites on both sides

How will you manage a case of Septal Perforation in a post operative case of Septoplasty?

🔗 5- Synechiae (Adhesions)

Cause

Injury to the septal flap and the turbinates on the lateral wall at identical sites → Raw mucosal surfaces on both sides join together

Prevention

• Avoid injury to the mucosal surfaces
• Proper postoperative packing

Management

• Asymptomatic → No treatment required
• Nasal obstruction → Release the adhesions and keep the raw edges apart using a silastic sheet for 10–14 days

👃 6- Columellar Retraction

Cause

Removal of too much caudal cartilage, with loss of caudal support

Which Septoplasty incision has a higher rate of Columellar Retraction?

Features

• Columella appears pulled upwards
• Nostrils appear exposed

Management

• Reconstructive rhinoplasty

🐴 7- Saddle Nose Deformity

Cause

Loss of dorsal strut support due to excessive cartilage removal → Collapse of the dorsum

Management

• Dorsal augmentation with a cartilage or bone graft

Name the causes of Saddle nose deformity?

🔻 8- Supratip Depression

Cause

Disruption of the attachment of the upper lateral cartilage to the dorsal septum → Loss of support just above the tip of the nose

Management

• Grafting

🚫 9- Persistent or Recurrent Nasal Obstruction

Management

Examine the nose to determine the cause, then:

• Revision septoplasty
• Turbinate reduction
• Anti-allergic treatment

What are the causes of Persistent or Recurrent Nasal Obstruction in a post operative case of Septoplasty?

💧 10- CSF Rhinorrhea

⭐ Very rare but serious complication.

Cause

Damage or avulsion of the perpendicular plate of the ethmoid

Management

• Bed rest
• Head elevation
• Surgical repair if no improvement

☠️ 11- Toxic Shock Syndrome

⭐ Very rare complication.

Cause

Nasal packing left for too long → Release of staphylococcal exotoxin

Features

• High fever
• Diffuse rash
• Hypotension

Management (Medical Emergency)

• Remove the pack
• IV antibiotics
• ICU management

🔍 Approaches to Septoplasty

1- Conventional Technique

• Performed using a headlight
• Most widely practised technique

2- Endoscopic Septoplasty

• Performed using a 0° 4 mm telescope
• Gaining popularity in recent times

What are the Advantages of Endoscopic Septoplasty over conventional technique?

3- External (Open) Approach Septoplasty

Steps

• Bilateral marginal and transcolumellar incision
• Elevation of the nasal skin after decortication
• Nasal septum approached between the medial crura
• Elevation of the mucoperichondrium
• Reconstruction of the septum

What are the indications of External (Open) Approach Septoplasty?

4- Extracorporeal Septoplasty

The entire septal cartilage is removed, reshaped on the table and reinserted.

⚠️ Risks

• Septal perforation
• Saddle nose deformity

What is the indications of Extracorporeal Septoplasty?

What are the Advantages of Septoplasty over SMR?

⭐ Exam Pearls

• Primary hemorrhage → Intraoperative
• Reactionary hemorrhage → Within 24 hours
• Secondary hemorrhage → Due to infection
• Eyelid edema → Pressure transmitted via the lamina papyracea
• Septal hematoma → Drain immediately
• Untreated septal hematoma → Septal abscess → Septal perforation
• Synechiae → Keep raw edges apart with a silastic sheet for 10–14 days
• Columellar retraction → Most common after a transfixion incision
• Saddle nose deformity → Loss of dorsal strut support
• CSF rhinorrhea → Damage to the perpendicular plate of ethmoid
• Toxic shock syndrome → Staphylococcal exotoxin from prolonged packing
• Endoscopic septoplasty → 0° 4 mm telescope

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