What are the risks of not removing a deep nasal suture that is hard to see?

Retained Deep Nasal Sutures: Risk Assessment

If you fail to remove a deep nasal suture that is difficult to visualize, you are unlikely to encounter serious complications, as retained sutures in the nasal cavity typically cause manageable problems rather than catastrophic outcomes.

Primary Risks of Retained Nasal Sutures

Infection and Inflammatory Response

• Retained sutures can serve as a nidus for bacterial colonization, potentially leading to localized infection or chronic inflammation 1
• Non-absorbable sutures left in place indefinitely carry risk of suture erosion, which can introduce bacteria and cause secondary infection 1
• The risk of infection appears relatively low but increases with prolonged retention, particularly with multifilament sutures that harbor bacteria more readily than monofilament 2

Foreign Body Reaction

• Permanent sutures may trigger chronic foreign body reactions, leading to granulation tissue formation and persistent nasal symptoms 1
• Patients may experience ongoing nasal irritation, discharge, or sensation of obstruction from the retained suture material 1

Structural Complications

• Synechiae formation (bridging scar tissue) is a significant concern, as sutures can serve as scaffolding for scar bands between the septum and lateral nasal wall or turbinates 1
• These adhesions may obstruct the nasal airway or middle meatus, potentially requiring revision surgery 1

When Retained Sutures Are More Problematic

Location-Specific Concerns

• Sutures in the middle meatus or near sinus ostia pose higher risk of obstructing drainage pathways and causing recurrent sinusitis 1
• Deep sutures near the frontal recess are particularly concerning due to the small caliber of this area and difficulty with subsequent removal 1

Material Considerations

• Non-absorbable sutures (nylon, polypropylene) will remain indefinitely and carry ongoing risk 1
• Absorbable sutures will eventually dissolve, though this process may take months and can still cause temporary inflammatory reactions 2

Practical Management Approach

Immediate Assessment

• Document the suture location, type, and reason for incomplete removal in the medical record 3
• Inform the patient about the retained suture and potential symptoms to monitor 3

Follow-Up Strategy

• Schedule endoscopic re-evaluation in 2-4 weeks when post-operative edema has resolved, which may improve visualization 1
• Consider referral to an otolaryngologist with experience in nasal endoscopy if you cannot adequately visualize the area 1
• Image-guided techniques may facilitate removal of deeply placed sutures in complex anatomy 1

Conservative Monitoring

• If the suture is absorbable and the patient remains asymptomatic, observation is reasonable 2
• Instruct patients to report new symptoms including purulent discharge, facial pain, fever, or worsening nasal obstruction 1

Key Clinical Pitfalls

The most important caveat is that retained sutures near the frontal sinus or ethmoid sinuses carry higher morbidity due to the confined spaces and critical drainage pathways in these areas 1. Simple deep nasal sutures in the septum or inferior portions of the nasal cavity are generally well-tolerated if left in place 1.

Attempting aggressive removal of a poorly visualized suture risks more tissue trauma than leaving it in place, particularly if adequate anesthesia and visualization cannot be achieved 1. When in doubt, refer to a specialist with appropriate endoscopic equipment rather than causing iatrogenic injury 1.