Complications of Septal Surgery (Septoplasty / SMR)

1. Intraoperative Complications

2. Early Postoperative Complications

Septal Hematoma

• Most feared early complication
• Blood accumulates between cartilage and mucoperichondrium, stripping the perichondrial blood supply
• Presents as bilateral nasal obstruction with a smooth, bluish, fluctuant bulge
• Prevention: quilting (through-and-through mattress) sutures
• Untreated consequences: cartilage necrosis → septal abscess → saddle nose deformity or septal perforation

Septal Abscess

• May arise from an infected hematoma
• Features: nasal obstruction, pain, fever, fluctuant swelling
• Organisms: S. pneumoniae, group A beta-haemolytic streptococci
• Management: drainage + nasal packing + antibiotics; carries risk of intracranial spread (cavernous sinus thrombosis, meningitis)

Postoperative Bleeding

• Mild oozing is expected and not truly a complication
• Significant haemorrhage more common when inferior turbinate resection is performed concurrently
• Management: nasal packing; rarely requires return to theatre

Infection / Rhinorrhea

• Frank infection is rare
• Rhinorrhea may persist for several months postoperatively

3. Late / Long-Term Complications

Persistent Nasal Obstruction (most common complication overall)

• The most frequent complaint after septoplasty
• Causes:
  • Inadequate surgery — failure to address the entire septum; the posterior bony spur is commonly missed when only the deviated cartilage is resected (e.g., with a swivel knife alone)
  • Persistent inferior turbinate hypertrophy
  • Mucosal oedema

Septal Perforation

• Caused by unrepaired contiguous (bilateral opposing) mucoperichondrial fenestrations
• Also occurs from failure to re-skeletonise the mucoperichondrial envelope at completion of resection
• Symptoms: whistling, crusting, epistaxis, paradoxical obstruction
• Small perforations whistle; large perforations may be asymptomatic or cause saddle nose collapse

Nasal Shape Deformity

• Tip ptosis (drooping nasal tip): overresection of caudal septum removes tip support
• Dorsal saddling (saddle nose deformity): loss of dorsal strut support from overresection; classic complication of old-style aggressive SMR
• Supratip depression
• All reflect violation of the Cottle L-strut principle — preservation of ≥10–15 mm of caudal and dorsal cartilage is mandatory

Synechiae (Adhesions / Intranasal Adhesions)

• Form between the septum and the turbinate/lateral nasal wall
• More common with traumatic suturing, especially when straight septal needles are used
• Cause nasal obstruction and altered airflow

Nasal Valve Collapse

• If the upper lateral cartilages are detached from the dorsal septum and not resuspended, internal nasal valve collapse results
• Presents as inspiratory nasal obstruction

CSF Rhinorrhea (Rare)

• High cranial dissection → cribriform plate injury → CSF leak
• Risk is low in experienced hands but must be recognised promptly

4. Complications Specific to Old-Style SMR (Submucous Resection)

• Saddle nose deformity — hallmark late complication; due to loss of dorsal cartilaginous support
• Columellar retraction — loss of caudal support
• Flail/floppy septum — no structural support remains
• Atrophic rhinitis — secondary to excessive mucosal disruption (particularly with concurrent turbinate destruction)
• Higher rate of septal perforation than modern septoplasty

Summary Table

1. Use quilting sutures to prevent hematoma
2. Repair contiguous mucosal tears to prevent perforation
3. Preserve the L-strut (≥10–15 mm dorsal + caudal strut) to prevent cosmetic deformity
4. Address the entire septum including the posterior bony spur — not just the anterior cartilage — to prevent the #1 complication of persistent obstruction
5. Use curved needles (not straight) for septal suturing to reduce synechiae risk

Cummings Otolaryngology Head and Neck Surgery, p. 582 | KJ Lee's Essential Otolaryngology, p. 1011