Wednesday, February 25, 2009

Prevention and Management of Complications of Rhinoplasty – an Article Review

This article is a CME (continuing medical education) article.  As such it is a review of complications of rhinoplasty.  It is a good review and worth reading.

Complications of rhinoplasty can be classified into hemorrhagic, infectious, traumatic, functional, or aesthetic problems.  Here is a  summary of the article.

 

Hemorrhagic Complications

Postoperative bleeding is one of the most common
complications following nasal surgery. 

Epistaxis  --  The most common causes of mild epistaxis are bleeding from the incision sites and traumatized
mucosa.

For mild to moderate epistaxis being with

  • 60-degree head elevation
  • gentle nostril pressure for 15 minutes
  • application of topical decongestant nasal sprays such as oxymetazoline or phenylephrine.

If bleeding persists

  • Remove the septal splints and gently suction the nasal passages remove blood clots and crusts.
  • Cauterize focal areas of bleeding with silver nitrate or place a light hemostatic packing made of methylcellulose over the bleeding surface.

Continued bleeding may require a formal nasal pack, either in the form of gauze or a commercially available nasal tampon.

Bleeding that persists despite anterior packing may signify
a posterior bleed from a branch of the sphenopalatine
artery.  If so, a posterior pack may be required. 

  • Patients should be observed for airway compromise while a posterior pack is in place.
  • Antibiotics should be administered while packing is in place to reduce the risk of toxic shock syndrome.

Serious bleeding occurs in less than 1 percent of patients, but warrants operative exploration when conservative measures fail.

 

Septal Hematoma -- is a potentially serious complication of rhinoplasty.  These patients may present with symptoms of nasal obstruction, pain, rhinorrhea, or fever.   The typical finding on physical examination is an ecchymotic nasal septal mass.

Untreated septal hematoma may lead to cartilage necrosis with subsequent loss of dorsal support and a saddle-nose deformity.

Management

  • early recognition with prompt evacuation of the hematoma, either via needle aspiration or incision and drainage.
  • Antimicrobial therapy should be initiated if a secondary nasal septal abscess is suspected.

 

Infectious Complications

Postoperative infections following rhinoplasty can range in severity from mild cellulitis of the soft tissue envelope to life-threatening systemic illness resulting from cavernous sinus thrombosis or toxic shock syndrome.

Local wound infections (such as cellulitis) -- treat with systemic antibiotics and close observation.

Abscesses require prompt surgical drainage in addition to antibiotic therapy. Common sites of abscess formation following
rhinoplasty include the nasal dorsum, nasal tip, and septum.

Cavernous sinus thrombosis,  meningitis, or a brain abscess may result without adequate treatment of a septal abscess.

Toxic shock syndrome is an acute, multisystem disease.  It has been described after nasal surgery with the use of both nasal packing and intranasal splints.   Symptoms occur early and can include nausea or vomiting, rash, fever, tachycardia, and hypotension.  Treatment requires the immediate removal of the offending object (packing or splint), intensive care unit admission, intravenous antibiotics, and supportive care.

 

Traumatic Complications


L-Strut Fractures  -- 
When L-strut fractures occur, they should be repaired immediately to prevent significant deformity.  If it isn’t, the  cartilaginous septal segment will tend to rock posteriorly, resulting in a loss of dorsal support and a saddle-nose deformity.

Depending on the location of the fracture, it may be stabilized with either spread grafts or a combination of spreader grafts and
Kirschner wires.

Intracranial Injury and Cerebrospinal Fluid Leak
Intracranial injury and cerebrospinal fluid leaks are a major complication after rhinoplasty.  They can happen with the cribiform plate it violated by surgical instruments or from excessive bony septum manipulation.  Either can result in a cerebrospinal fluid leak and potential intracranial injury or infection.

Symptoms of a cerebrospinal fluid leak include clear rhinorrhea and positional headache. The diagnosis may be confirmed by testing the fluid for the presence of 2-transferrin, a protein highly specific for cerebrospinal fluid. A

Treatment requires hospitalization, bed rest, and prompt otolaryngologic and neurosurgical evaluations.


Epiphora  --  after rhinoplasty is most commonly occurs due to compression of the lacrimal system by the soft-tissue edema.  It normally resolves after 1 to 2 weeks.


Functional Complications

Septal Perforation -- are most often caused by opposing tears in the elevated septal mucoperichondrial flaps with no  intervening septal cartilage.   They may also result from decreased blood flow to those same flaps from an unrecognized septal hematoma or tissue necrosis from septal stitches.

Symptoms of a nasal septal perforation include crusting, bleeding,
whistling, and nasal airway obstruction due to disruption
of the normal laminar airflow through the nasal passages.

Treatment includes

  • Local hygiene with nasal saline irrigation
  • Obturation with a Silastic septal button
  • For small perforations, local advancement flaps with an interposed connective tissue autograft or an allograft can be
    used to close the perforation.

Intranasal Adhesions  -- (synechiae ) result from cicatrical healing of opposed, abraded mucosal surfaces.

Patients may present with nasal obstruction. Intranasal examination will reveal a “bridge” of mucosa from the septum to the inferior turbinate, middle turbinate, or lateral nasal wall.

Treatment requires division and placement of a barrier between the incised surfaces, such as a Silastic splint, until the surfaces undergo complete re-epithelialization.


Postoperative Septal Deviation  -- whether new or uncorrected, following septorhinoplasty is a source of frustration for both the patient and the surgeon.  Any significant septal deviation that persists and causes cosmetic or functional impairment may require revision surgery.

 

Rhinitis – Atrophic rhinitis is due to atrophy of the nasal mucosa usually due to overresection of intranasal structures such as the middle or inferior turbinate.

Patients often present with subsequent symptoms of dryness, crusting, and nasal obstruction.  These patients will get relief with nasal saline.

Patients may also report a spontaneous clear watery nasal discharge.   This phenomenon is most likely due to  a variant of vasomotor rhinitis caused by abnormal parasympathetic tone to
the intranasal mucosa.  These patients are often effectively treated with topical anticholinergic preparations, such as 0.03% ipratropium bromide  which act locally to decrease the watery rhinorrhea.  The recommended dosing regimen is two sprays in each nostril two to three times a day as needed.

Continued symptoms of watery nasal discharge despite appropriate topical therapy should raise the concern for an occult cerebrospinal fluid leak.

 

Aesthetic Complications

Tip and Dorsal Deformities
Postoperative deformities of the osseocartilaginous framework may be caused by overresection or underresection of the osseocartilaginous framework, incorrectly performed osteotomies, incorrect shaping of grafts and their edges, and migration of grafts due to insufficient or inaccurate fixation.

Persistent tip or dorsal deformities are generally not treated until at least 1 year after the previous rhinoplasty.


Supratip (“Pollybeak”) Deformity -- is a postoperative complication of rhinoplasty in which the nasal supratip assumes a convex shape in relation to the nasal dorsum. The deformity results either from inadequate resection of the lower dorsal septum and upper lateral cartilages or, paradoxically, from overresection of these supratip structures with subsequent scar tissue formation in the resulting dead space.

Patients who develop supratip fullness should be instructed to apply compressive tape onto the supratip area nightly. This is generally effective in treating transient postoperative swelling.  Taping should be discontinued when a permanent depression is obtained.

Steroid injections can improve excessive swelling and reduce scar tissue in the supratip area.  The injections can be used in patients who continue to supratip fullness despite compressive taping.  Triamcinolone acetate,  1 to 2 mg, is injected below the
dermis in the supratip area.  The injections may be repeated at 2-month intervals until an aesthetically pleasing supratip contour is obtained.

Side effects of the steroid injections should be remembered.  The most frequent is dermal atrophy, which may lead to a contraction
deformity of the skin. Other side effects include telangiectasias, depressions, color changes, and eventual visibility of the underlying cartilages or contour imperfections, which may be enhanced by the resulting decrease of skin thickness.

Corrective surgical procedures should not be performed until
at least 1 year after the initial procedure. 

The basic principles include judicious removal of the offending cartilage or scar tissue, adjustment of the osseocartilaginous framework so that the differential between the midvault and the tip is adequate, elimination of dead space by establishing direct contact between the underlying framework and the skin, and application of a dressing with selective compression over the supratip area.


Soft-Tissue Complications

Postrhinoplasty Nasal Cysts  -- are a rare complication
of rhinoplasty. The most common site of occurrence for both types of cysts is the nasal dorsum.  Both may require complete excision.

  • Lipogranulomas or “paraffinomas” are foreign-body inclusion cysts that are thought to arise from the use of petroleum-based
    ointments in conjunction with nasal packing.
  • Mucous cysts are a second type of nasal cyst that can arise after rhinoplasty. They are thought to arise from ectopic or displaced mucosa and ointment extravasation into osteotomy sites.

Contact Dermatitis and Skin Necrosis --

Contact dermatitis may result from irritation of the skin by the topical adhesives, tape, or dorsal splint. It usually resolves without any permanent sequelae.

Treatment of contact dermatitis

  • removal of the offending agent
  • application of topical and potentially systemic steroids,
    depending on the severity of the reaction.

Superficial skin necrosis or epidermolysis can occur secondary to excessive compression of the skin by the taping and dressing.  More problematic is partial-thickness or full-thickness skin necrosis that can occurs when the blood supply of the soft-tissue envelope is severely embarrassed. 

Treatment of minor skin necrosis should initially be conservative.

  • Daily wound care, allow the wound to close by secondary intention
  • Protection from the sun
  • After maturation of the scar, dermabrasion, filler substances, skin care, and laser treatment may be helpful.

 

Telangiectasias -- are small superficial vessels of the skin visible to the human eye and usually measure 0.1 to 1.0 mm in diameter.  Argon and pulsed dye lasers have proven to
be an effective means of treatment.


 

 

REFERENCE

Prevention and Management of Rhinoplasty Complications;  Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 60e-67e; Cochran, C Spencer M.D.; Landecker, Alan M.D.

 

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