Complications of Septal Surgeries

1. Intraoperative Complications

Hemorrhage

• Most common immediate complication. Mild oozing is expected, not a true complication.
• Significant bleeding is more likely when septoplasty is combined with inferior turbinate resection.
• Controlled with vasoconstrictors (lidocaine + epinephrine), bipolar cautery, or packing.

Mucosal Tears / Bilateral Fenestrations

• Unrepaired contiguous mucoperichondrial tears on both sides of the septum are a primary cause of septal perforation.
• Placing crushed cartilage back into the mucoperichondrial envelope at the end of the procedure creates a barrier against perforation development.

2. Early Postoperative Complications

Septal Hematoma

• Occurs when a quilting suture is not placed at closure, allowing blood to collect between the mucoperichondrial flaps.
• Presents with bilateral nasal obstruction and a boggy, bluish swelling on examination.
• Must be drained promptly - untreated hematoma leads to:
  • Cartilage necrosis (avascular necrosis from pressure)
  • Septal abscess
  • Septal perforation
  • Saddle nose deformity

Septal Abscess

• Secondary infection of an untreated or inadequately drained hematoma.
• Presents with nasal obstruction, pain, swelling, and fever.
• Leads to rapid cartilage destruction; requires urgent surgical drainage and antibiotics.
• Complications of septal abscess include perforation, saddle nose, and columellar retraction.

Infection / Rhinosinusitis

• True infection is rare after septoplasty.
• Rhinorrhea may persist for several months postoperatively and is not always indicative of infection.

3. Late / Long-term Complications

Septal Perforation

• Results from:
  • Unrepaired bilateral (contiguous) mucoperichondrial tears
  • Failure to re-skeletonize the mucoperichondrial envelope at completion of resection
  • Avascular necrosis following untreated hematoma
• Manifests as whistling on inspiration, crusting, epistaxis, and persistent obstruction.

Saddle Nose Deformity

• Over-resection of the dorsal strut removes the structural support of the nasal bridge, causing collapse.
• Also results from cartilage destruction secondary to hematoma or abscess.
• Principle: always preserve an L-strut of at least 10-15 mm of dorsal and caudal cartilage.

Nasal Tip Ptosis / Columellar Retraction

• Caused by over-resection of the caudal septum, which provides tip projection and support.
• Loss of medial crural support leads to tip drooping and/or columellar retraction.

Nasal Dorsal Collapse / Inverted-V Deformity

• Occurs with loss of dorsal nasal support from aggressive resection.

Persistent Nasal Obstruction (Most Common Overall Complication)

• The single most frequent complaint after septoplasty.
• Often due to inadequate resection of the posterior bony spur - a common pitfall when only the anterior deviated cartilage is addressed with a swivel knife.
• The remaining posterior spur creates ongoing obstruction AND makes revision surgery technically harder (difficult anterior dissection due to scarring).

Synechiae (Adhesions)

• Fibrous bands form between the septum and the inferior turbinate or lateral nasal wall.
• More common with traumatic suturing technique, especially when straight septal needles are used.
• Cause nasal obstruction and are managed by division + placement of a silastic sheet spacer.

4. Sensory / Neurological Complications

Upper Dental Anesthesia / Numbness

• The nasopalatine nerve and anterior superior alveolar nerve can be stretched or damaged during dissection, causing numbness of the upper incisors and anterior palate.
• Usually transient; rarely permanent.

Tooth Discoloration

• Upper incisor teeth discoloration has been reported, attributed to nerve/vascular disruption to the teeth during septal surgery.

5. Aesthetic Complications

6. Special Considerations

SMR vs. Septoplasty

• SMR (classic Killian's operation) is less preferred today because it removes too much cartilage, risking saddle nose and tip ptosis. Septoplasty with conservative cartilage preservation is now standard.
• In pediatric patients, resection must be especially conservative to avoid disrupting endochondral ossification plates, which would impair nasal growth.

Revision Surgery

• Posterior septal spurs left untreated at primary surgery make revision dissection difficult due to anterior scarring.
• Revision septoplasty is technically harder and carries higher risk of perforation.

• Cummings Otolaryngology Head and Neck Surgery (9780323612173), p. 582
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol. 1 (9781138094611), p. 1195

Complications of Septal Surgeries

1. Persistent Nasal Obstruction (Most Common)

• Usually caused by inadequate resection of the posterior bony spur - a pitfall when only the anterior deviated cartilage is removed (e.g., with a swivel knife) without addressing the full septum including its posterior bony component.
• The residual spur causes ongoing obstruction, and the resulting anterior scarring makes revision septoplasty technically harder - the revision surgeon faces difficult dissection anteriorly to reach and address the posterior spur.

2. Hemorrhage

• Mild postoperative oozing is expected and is not a true complication in the early phase.
• Significant postoperative bleeding is more likely when septoplasty is combined with inferior turbinate resection.
• Controlled intraoperatively with vasoconstrictors (lidocaine + epinephrine), bipolar cautery, and nasal packing.

3. Septal Hematoma

• Occurs when a quilting (through-and-through) suture is not placed at closure, allowing blood to accumulate between the two mucoperichondrial flaps.
• Presents with bilateral nasal obstruction and a boggy, blue-red swelling of the septum.
• Must be drained urgently - untreated hematoma leads to:
  • Avascular necrosis of septal cartilage (cartilage has no blood supply of its own; it depends entirely on the perichondrium)
  • Septal abscess
  • Septal perforation
  • Saddle nose deformity
  • Columellar retraction and nasal base widening

4. Septal Abscess

• Secondary infection of an incompletely drained or untreated hematoma.
• Presents with nasal obstruction, pain, fever, and a tender fluctuant swelling.
• Causative organisms: Streptococcus pneumoniae and group A beta-hemolytic streptococci.
• Leads rapidly to cartilage lysis and saddle nose deformity.
• Management: surgical drainage + nasal packing + systemic antibiotics.
• Note: In children under 2 years with septal abscess, child abuse should be considered.

5. Septal Perforation

• Unrepaired bilateral (contiguous) mucoperichondrial tears on both sides of the septum at the same location - the most direct cause.
• Failure to re-skeletonize (replace crushed cartilage into) the mucoperichondrial envelope at the end of resection - the envelope without a cartilage scaffold is vulnerable.
• Avascular necrosis secondary to untreated hematoma.
• Over-tight internal nasal splints compressing the septal membrane.

6. Structural / Aesthetic Deformities

Key principle: A minimum L-strut of ~10-15 mm of both dorsal and caudal cartilage must be preserved to maintain structural integrity.

7. Synechiae (Adhesions)

• Fibrous bands between the septum and inferior turbinate or lateral nasal wall.
• More common with traumatic suturing technique, especially when straight septal needles are used instead of curved ones.
• Result in nasal obstruction; managed by division and placement of a silastic sheet spacer to prevent re-adhesion.

8. Infection / Rhinosinusitis

• True infection after septoplasty is rare.
• Rhinorrhea may persist for several months postoperatively - this is a side effect, not strictly a complication, and should be discussed with patients preoperatively.

9. Sensory / Neurological Complications

• Upper dental anesthesia / numbness of upper incisors - from stretch or injury to the nasopalatine nerve during dissection; usually transient, rarely permanent.
• Upper incisor tooth discoloration - reported from disruption of nerve and vascular supply to the teeth.

10. Aesthetic Changes from Nasal Valve Surgery

• Rigidity of the nose can result from bone grafting techniques.
• Visible aesthetic changes to the nasal contour are an anticipated side effect that must be discussed with the patient preoperatively.
• When patients decline major nasal valve surgery due to aesthetic concerns, a combination of septal surgery, turbinate surgery, and minor nasal valve procedures can achieve comparable functional results with minimal visible change.

Summary Table

• Cummings Otolaryngology Head and Neck Surgery, p. 582 - "Complications of Septoplasty"
• K.J. Lee's Essential Otolaryngology, p. 1011 - Septal hematoma and abscess
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol. 1, p. 1195 - Complications of Septal Surgery

Modified Wullstein Classification of Tympanoplasty

Classic Diagram (Shambaugh's Surgery of the Ear)

Type I - Myringoplasty / Tympanoplasty

Distinction: Myringoplasty = repair of TM alone without middle ear exploration. Tympanoplasty Type I = repair + middle ear inspection confirming intact mobile ossicles.

Type II - Ossicular Reconstruction with Lever Mechanism Preserved

Not commonly performed in its original form today; most lenticular process erosions are now handled with PORP-type reconstructions (subsumed into Type III).

Type III - Columella Reconstruction (MOST COMMON)

IIIa - Stapes Columella (Myringostapediopexy)

• TM graft is placed directly onto the stapes capitulum (head)
• No prosthesis used; the stapes itself acts as the columella
• Creates a shallow middle ear with a columella effect
• Requires an intact stapes superstructure

IIIb - Minor Columella (PORP)

• An ossicular or synthetic strut is placed between the stapes capitulum and the tympanic membrane / manubrium
• Uses a Partial Ossicular Replacement Prosthesis (PORP)
• Stapes superstructure must be intact

IIIc - Major Columella (TORP)

• Performed when the stapes crura are also missing - only the footplate remains
• A graft or prosthesis extends from the stapes footplate to the TM/manubrium
• Uses a Total Ossicular Replacement Prosthesis (TORP)
• A cartilage interposition graft is placed between the prosthesis head and the TM to prevent extrusion

Type IV - Cavum Minor / Round Window Protection

This creates a "small middle ear" (cavum minor). Hearing results are modest but functional.

Type V - Fixed Stapes Footplate / Fenestration

Va (Original Wullstein Type V) - Lateral Semicircular Canal Fenestration

• A new window (fenestra novovalis) is created in the lateral (horizontal) semicircular canal
• TM graft placed over this fenestra transmits sound directly to the perilymph
• Round window protected with tissue seal
• Rarely performed today; largely replaced by Type Vb and stapedectomy

Vb (Modified Type V) - Oval Window Stapedectomy / Footplate Removal

• The stapes footplate is removed and the oval window is sealed with a tissue graft
• Similar concept to a Type IV but adapted for a fixed footplate situation
• This is essentially the modern stapedectomy / stapedotomy approach
• Now the standard method; has supplanted Type Va

Summary Table

Key Physiological Principle

1. Sound transformer function - restoring efficient sound conduction to the oval window
2. Round window protection - ensuring the round window membrane does not receive the same sound pressure as the oval window simultaneously (which would cancel out the pressure differential needed for perilymph flow)

• Shambaugh's Surgery of the Ear (9781607950264), pp. 490, Chapter 28-29 - Wullstein classification diagram and modified descriptions
• Ossiculoplasty and Tympanoplasty in Chronic Otitis Media (Ento Key / Cummings-affiliated source) - Modified Wullstein types with PORP/TORP taxonomy

TORP - Total Ossicular Replacement Prosthesis

Definition

• PORP (Partial Ossicular Replacement Prosthesis) = used when stapes superstructure (head + crura) is intact - bridges stapes head to TM
• TORP = used when stapes superstructure is absent - bridges stapes footplate to TM

Indications

• Chronic otitis media with total ossicular chain erosion/destruction
• Cholesteatoma with absent superstructure
• Traumatic ossicular disruption with absent crura
• Previous failed ossiculoplasty with complete ossicular loss
• Congenital ossicular anomalies

Anatomy of the TORP

TORP in situ - Diagrams

Materials Used

Historical (now less favored)

Current Standard

Key: Multiple RCTs and a meta-analysis of 12 studies (1388 patients) found no significant difference in stability or hearing outcomes between titanium and non-titanium prostheses. The underlying middle ear pathology has more influence on outcome than prosthesis material.

Surgical Technique - Key Principles (TRACS Mnemonic)

1. T - Tension: The prosthesis must be placed under appropriate minimal tension from the TM. Too lax = sound energy loss. Too tight = TM erosion and extrusion. The prosthesis should spontaneously return to position when displaced with gentle pressure.
2. R - Rigidity: Higher rigidity = better high-frequency transmission. Titanium is optimal.
3. A - Angulation: The TORP must be placed as close to perpendicular to the stapes footplate as possible. Angulation reduces efficiency of piston motion.
4. C - Contact: The base must maintain secure stable contact with the footplate center.
5. S - Surface (Cartilage interposition): A 0.5-0.7 mm conchal or tragal cartilage graft is always interposed between the TORP headplate and the TM undersurface. This:
   • Prevents direct TM-prosthesis contact
   • Reduces TM erosion and implant extrusion
   • Has minimal acoustic transmission effect when matched to prosthesis head diameter (shown in cadaver studies)

Placement Requirements for TORP

• Mobile footplate preferred - TORP on a fixed footplate gives worse results
• Healthy, well-aerated middle ear mucosa
• Normal middle ear pressure / functional Eustachian tube
• Stable tympanic membrane graft (second-stage TORP placement recommended if TM graft done simultaneously to reduce displacement risk)

Outcomes

• Longer column = less stable; more likely to displace
• No stapes superstructure to provide medial support
• Greater distance to bridge = harder to achieve optimal tension
• Relies entirely on the footplate as the medial anchor

Factors Affecting TORP Success

• Eustachian tube dysfunction (major risk for displacement)
• Chronic infection / mucosal adhesions
• Atelectasis of the middle ear
• Intraoperative stability at time of surgery
• Open vs. closed mastoidectomy technique
• Cartilage cap size and placement

• Cummings Otolaryngology Head and Neck Surgery (9780323612173), pp. 2733-2773 - Materials and TORP outcomes
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol. 2 (9781138094634), p. 1076 - TORP terminology and technique