What is the incidence of septal perforation after septoplasty?

Incidence of Septal Perforation After Septoplasty

The incidence of septal perforation after septoplasty is approximately 1-3%, with the septum most commonly damaged during the septoplasty procedure itself. 1

Risk Factors and Mechanisms

Septal perforation following septoplasty occurs primarily through several mechanisms:

• Direct surgical trauma during the procedure
• Bilateral mucosal tears at corresponding areas of the nasal septum
• Inadequate postoperative care
• Postoperative infections (rare but significant)

The risk of perforation increases with:

• Bilateral mucosal tears during surgery
• Narrow sinus morphology, particularly in the second premolar area 1
• Thin maxillary lateral wall (less than 1.25 mm) 1
• Smoking history 1
• Pre-existing sinus pathology 1
• Presence of septa in the surgical field 1
• Residual alveolar ridge height of 4mm or less 1

Prevention Strategies

Several techniques have been shown to reduce the risk of septal perforation:

• Interposition grafting: Placing materials between mucosal flaps at sites of tears significantly reduces perforation risk

  • TnR Nasal Mesh has shown a 57.1% complete bilateral healing rate compared to 36.4% with septal cartilage when used for bilateral mucosal tears 2
  • Complete healing rates are significantly higher with TnR Nasal Mesh than with septal cartilage insertion (p=0.022) 2

• Quilting sutures: Associated with less postoperative pain compared to nasal packing and septal splints, potentially reducing patient manipulation of the surgical site 3

• Careful surgical technique: The septum is potentially vulnerable to injury both during surgery and during postoperative debridement 1

Perforation Size and Repair Success

When perforations do occur, the size affects repair success rates:

• Small perforations (0.5-2.0 cm): 92.9% closure rate using extended external rhinoplasty approach with bilateral posteriorly based mucosal flaps 4
• Larger perforations (2.0-4.5 cm): 81.8% closure rate using two-staged technique with midfacial degloving approach 4
• Perforations under 1.5 cm in height: 96.7% closure rate 5
• Perforations 1.5 cm or taller: 71.4% closure rate 5

Clinical Implications

Septal perforation can lead to significant symptoms including:

• Disruption of normal laminar airflow
• Crusting
• Bleeding
• Parosmia
• Neuralgia

Unusual Complications

While rare, infectious complications can lead to more severe outcomes:

• Enterobacter cloacae infection has been documented as causing septal mucosal necrosis and subsequent perforation 6

Prevention Best Practices

To minimize the risk of septal perforation:

1. Careful surgical technique to avoid bilateral mucosal tears
2. When tears occur, immediate placement of interposition grafts (preferably TnR Nasal Mesh) between the injured mucoperichondrial flaps
3. Confirm proper positioning of grafts under nasal endoscope
4. Consider quilting sutures rather than nasal packing for postoperative management
5. Careful postoperative monitoring for early signs of infection or necrosis

The vertical dimension of a septal perforation and presence of mucosa above and below a perforation are important considerations for successful repair when perforation does occur 5.