Complications of Septal Surgeries (Septoplasty / SMR)

1. Intraoperative Complications

Mucosal (Flap) Tear / Perforation

• The mucoperichondrial/mucoperiosteal flap can tear during elevation, especially over large spurs or severely deviated segments. This is the most important intraoperative event.
• If bilateral membrane tears occur simultaneously, a permanent septal perforation is highly likely. Management: repair each tear with 5-0 plain suture AND place an interposition graft of crushed cartilage between the flaps to significantly reduce the risk of permanent perforation.
• Cummings Otolaryngology, p. 578

Excessive Hemorrhage

• Bleeding from mucosal vessels and septal vasculature. Quilting mattress sutures of the septal flaps postoperatively prevent hematomas and hemorrhage while eliminating the need for rigid internal splints in most patients.
• Cummings Otolaryngology, p. 578

CSF Leak

• Injury near the cribriform plate during aggressive posterior dissection can cause a CSF leak. Rare but serious.

2. Early Postoperative Complications

Septal Hematoma

• Collection of blood beneath the mucoperichondrial flap(s). Presents as nasal obstruction, fluctuant midline mass.
• Must be drained promptly - nasal packing applied after drainage to obliterate dead space.
• If untreated, leads to infection, abscess formation, cartilage destruction, and ultimately saddle nose deformity.
• K.J. Lee's Essential Otolaryngology; Scott-Brown's Vol 1

Septal Abscess

• Follows an untreated or inadequately treated hematoma.
• Suppurative destruction of cartilage leads to saddle nose deformity.
• Intracranial spread (meningitis, cavernous sinus thrombosis) is a rare but life-threatening complication.

Epistaxis (Postoperative Bleeding)

• Can occur early (within 24-48 hours) due to inadequate hemostasis or mucosal disruption.

Infection

• Wound site infection or sinusitis. Rare with modern antibiotic prophylaxis.

3. Late / Long-term Complications

Septal Perforation

• Most common serious late complication, particularly after SMR. Occurs more frequently after SMR than septoplasty because SMR removes more supporting cartilage.
• Presents with: whistling on inspiration, nasal crusting, epistaxis, nasal obstruction, paradoxical obstruction.
• The presence of a perforation does not automatically imply substandard technique; it is more likely to be an indicator of a severely fractured nasal septum or another disease (atrophic rhinitis, granulomatous disease, Wegener's granulomatosis).
• Scott-Brown's Otorhinolaryngology Vol 1, p. 479

Saddle Nose Deformity (Supratip Depression)

• Results from excessive cartilage removal (the classic complication of SMR when too much cartilage is resected, especially the L-strut).
• Can also follow septal abscess that destroys cartilage.
• The surgeon must preserve at least 1 cm dorsal and 1 cm caudal strut (the "L-strut") to prevent this.
• Disorders such as Wegener's granulomatosis, sarcoidosis, and relapsing polychondritis should be excluded if unexpected saddle deformity occurs.
• Scott-Brown's Otorhinolaryngology Vol 1, p. 479; Cummings Otolaryngology, p. 575

Persistent / Recurrent Deviation

• Approximately 20-30% of patients may find symptoms are not adequately corrected; this falls to <10% with optimal technique and appropriate diagnosis.
• Due to cartilage memory (inherent spring), inadequate resection, or failure to identify all contributing deformities (maxillary crest, turbinate, nasal valve).
• Cummings Otolaryngology, p. 578

Nasal Valve Compromise

• Removal of too much septal cartilage narrows the internal nasal valve angle (normally 10-15 degrees).
• Scarring between the septal mucosa and lateral nasal wall forms adhesions (synechiae) that create fixed obstruction.
• In patients with a previous rhinoplasty, ULCs displaced inferiorly produce an "inverted V" sign with nasal collapse.
• Cummings Otolaryngology, pp. 568-569

Anosmia / Olfactory Disturbance

• Damage to olfactory epithelium at the roof of the nasal cavity, or prolonged mucosal edema, can impair smell. Usually transient; permanent anosmia is rare.

Cosmetic Deformities (particularly after septorhinoplasty)

• Bossa formation - knuckling of cartilage edges after lower lateral cartilage surgery; not evident early (appears as swelling settles).
• Alar pinching - over-excision of lower lateral cartilage causing external nasal valve collapse.
• Columellar retraction - due to over-excision; treated with composite/cartilage graft.
• Widened columella - from caudal septal deviation pushing medial crura into the airway.
• Subdermal hematoma - after septorhinoplasty, collecting under external dressings; requires prompt evacuation.
• Scott-Brown's Otorhinolaryngology Vol 1, pp. 50-53; Cummings Otolaryngology

Non-healing Fissure at Nostril Apex

• Can result from suture rubbing against the skin while tying intranasal knots.
• Cummings Otolaryngology, p. 578

4. Special Considerations

Summary Table

Complications of Mastoid Surgeries

1. Facial Nerve Injury

• The key to safe mastoid surgery is identification of the facial nerve, not avoidance. The facial nerve monitor is an adjunct - not a substitute for anatomical knowledge.
• Injury is rarely due to an anomalous nerve course. It is usually caused by:
  • Excessive manipulation of a disease-exposed or congenitally dehiscent tympanic segment
  • Misadventure with the drill at the second genu or the mastoid portion of the nerve

• In 416 consecutive cholesteatoma surgeries, facial nerve dehiscence was found in ~20% of cases.
• 80% of dehiscences were just superior or adjacent to the oval window (tympanic segment).
• Only 1% involved the mastoid segment.
• 7% were in the anterior epitympanic space.
• Patients ≥19 years had a 3.6× greater likelihood of dehiscence than those ≤18 years.

• Immediate paralysis (surgeon recognized injury): decompressed nerve, periodic electrical testing.
• Immediate paralysis (unrecognized intraoperatively): re-exploration within 1-2 days; identify nerve in unaffected area (distal mastoid or proximal tympanic segments) and trace to injury.
• Delayed paralysis (days post-op): usually treated expectantly with steroids; good recovery expected if paresis only.
• Electrical testing: Loss of excitability >90% degeneration by electroneurography within 2 weeks of mastoid surgery = indication for nerve exploration.

2. Dural Injury and CSF Leak

• Exposure of a small area of tegmen dura without abrasion is common and usually inconsequential.
• A dural tear or significant abrasion with arachnoid herniation (with or without CSF leak) requires repair.
• Repair technique: Layered closure using soft tissue (fascia or perichondrium) + rigid support material (bone or cartilage). If actual dural tear, part of packing placed intradurally into subarachnoid space. Gelfoam ± fibrin glue for support.
• Antibiotics: Broad-spectrum agent with CSF penetration should be considered.

3. Labyrinthine / Horizontal Semicircular Canal (HSCC) Fistula

• A fistula of the HSCC must always be considered in chronic ear surgery regardless of preoperative history or CT findings.
• Incidence: 6.5% in 416 consecutive cholesteatoma surgeries. Rate was more than twice as high in patients with facial nerve dehiscence.
• Recognition: A flattened HSCC dome suggests labyrinthine erosion; palpate matrix slowly - if endosteum only exposed ("blue-lined") without penetrating perilymphatic space, overlying disease can be safely removed.
• If canal erosion is suspected: Leave cholesteatoma matrix in place until all other disease removed; then options are:
  1. Remove matrix + cover defect with soft tissue or bone wax
  2. Canal wall-down procedure + leave matrix as mastoid cavity lining
  3. Intact canal wall + leave matrix for second-stage removal when ear is sterile
• Iatrogenic HSCC injury: Close immediately with bone wax; broad-spectrum antibiotic + steroids.
• Risk of untreated HSCC injury: Bacterial labyrinthitis → severe sensorineural hearing loss + vertigo. If recognized and treated immediately, sequelae can be minimized (dizziness may be transient without permanent sensorineural loss).

4. Sigmoid Sinus and Jugular Bulb Injury

• The sigmoid sinus and jugular bulb have variable anatomy - unlike most fixed mastoid structures.
• In poorly pneumatized mastoids, the sigmoid sinus may be very superficial and anterior, just beneath the mastoid cortex and <1 cm from the posterior canal wall.
• The jugular bulb can be high in the mastoid just inferior to the posterior semicircular canal ("high-riding jugular bulb").

• A significant sinus injury can result in thrombosis → otitic hydrocephalus (via decreased CSF absorption from arachnoid villi due to increased venous pressure).
• Postoperative warning signs: Persistent headache, visual changes → require MRI/MR venography + fundoscopy by ophthalmologist.

5. Sensorineural Hearing Loss (SNHL)

• Can result from:
  • Drill vibration transmitted to the cochlea via ossicles or otic capsule
  • Direct labyrinthine fistula (see above)
  • Acoustic trauma from high-speed drilling
  • Suction applied near the oval/round window
• SNHL may be partial or total (dead ear).
• Risk is higher in canal wall-down procedures and when disease directly overlies the labyrinth.

6. Conductive Hearing Loss

• Injury to the ossicular chain (incus long process most vulnerable, especially eroded by disease preoperatively).
• Displaced ossicles, dislodged prosthesis, or failure of tympanoplasty all contribute.

7. Chorda Tympani Injury

• The chorda tympani (branch of CN VII carrying taste from the anterior 2/3 tongue) is at risk when opening the facial recess.
• Sacrifice may be necessary to improve inferior exposure; this causes taste disturbance (dysgeusia / ageusia) ipsilaterally, which is usually tolerated but can persist.
• Sacrificing it allows extension of posterior tympanotomy inferiorly.

8. Residual and Recurrent Cholesteatoma

• Residual cholesteatoma: Incompletely removed disease left at primary surgery (especially in canal wall-up technique where access is limited).
• Recurrent cholesteatoma: New formation from retraction pocket of reconstructed tympanic membrane.
• Canal wall-up technique has higher risk of residual/recurrent disease, requiring planned second-look surgery.
• Canal wall-down technique reduces this risk but creates a mastoid cavity requiring lifelong care.
• 10-year recurrence rates with retrograde mastoidectomy (canal reconstruction technique): 5-10%.

9. Mastoid Cavity Problems (Canal Wall-Down)

• Cavity disease: Accumulation of keratin debris, wax, and crusts in the mastoid bowl.
• Patients require regular aural toilet (microsuction/cleaning) for life.
• Inadequate meatoplasty leads to poor ventilation and pooling → recurrent otorrhea and infection.
• Ear must be kept dry; swimming and water sports are restricted.

10. Intracranial Complications

11. Other Complications

Summary by Anatomical Structure at Risk

Dura           → CSF leak, meningitis, epidural abscess
Facial nerve   → Facial palsy (intraop / delayed), dehiscence (20% in cholesteatoma)
HSCC / Labyrinth → Perilymph fistula, SNHL, vertigo, labyrinthitis
Sigmoid sinus  → Haemorrhage, thrombosis, otitic hydrocephalus
Jugular bulb   → Haemorrhage (variable anatomy)
Chorda tympani → Dysgeusia / ageusia
Ossicular chain → Conductive hearing loss
Cholesteatoma  → Residual / recurrent disease