Septoplasty with and without additional sinonasal surgery: postoperative sequelae and the use of prophylactic antibiotics

Deviation of the nasal septum causes increased breathing resistance in the nasal passages creating an uncomfortable feeling of inadequate airflow i.e. nasal obstruction. This may further cause decreased quality of life, disturbed sleep, snoring and/or worsen sleep apnoea [1]. Septoplasty is the surgical correction of a deviated nasal septum. The aim of the surgery is to diminish obstruction and thus improve nasal breathing. It is one of the most common ear-, nose- and throat (ENT) surgeries in adults.

After septoplasty there is a risk of both early and late postoperative complications, such as haemorrhage, infection, saddle nose and septal perforation [2‐4]. A recent large retrospective study found a 3.1% rate of postoperative septoplasty infections [5], while another reported a rate of 3.3% [6]. At our hospital during the last decades the rate of infections and antibiotic prophylaxis in septoplasties has been repeatedly evaluated [4, 7, 8]. The two first studies reported infection rates of 12% for the late 90’s and 4.2% in the early 2000’s and use of orally administered postoperative antibiotic prophylaxis in 21% and 41% of the cases, respectively [4, 7]. However, the prophylaxis did not appear to be useful in these two retrospective analyses. We then performed a double-blind randomised placebo-controlled study to evaluate the effect of single-dose intravenous cefuroxime given prior to surgery [8]. The infection rate was 2.2% in the antibiotic group and 8.3% in the placebo group (p = 0.10). The American Association of Plastic Surgeons has published a recommendation of antibiotic prophylaxis for patients undergoing septoplasty / rhinoplasty [9]. However, the level of evidence in this meta-analysis was low and the grade of recommendation was weak.

The aim of the present study was to investigate the use of antibiotic prophylaxis in every-day clinical practise in septoplasty and septocolumelloplasty with and without additional sinonasal surgery. We were interested in the current indications and implementation of antibiotic prophylaxis at our institution based on the aforementioned studies. Another aim was to assess the effect of antibiotic prophylaxis.

We collected data on all consecutive 302 septoplasty or septocolumelloplasty patients operated during the year 2018. Altogether 115 patients (38.1%) received some kind of additional sinonasal surgery beyond the septoplasty. According to our findings prophylactic antibiotics used in septo(columello)plasties seem to be useful in preventing short-term postoperative complications, such as SSIs or any other reasons resulting in an unplanned visit to the treating surgeon. This especially if patients also require additional surgery, such as RFAIT. More research is required within this field of study to determine our results.

Georgiou et al. [14] reviewed studies on the incidence of postoperative infection in the absence of prophylactic antibiotics and on the effect of prophylactic antibiotic treatment in elective septoplasty. They concluded routine prophylaxis to be unnecessary due to a generally small amount of arising postoperative complications. There are a few other studies that have come to the same conclusion [14‐17]. The majority of the analysed study populations in the review by Georgiou et al. were rather small, varying from groups of 35 to 174 patients. This is often the case in studies examining the effects of prophylactic antibiotics in septoplasty [14‐16, 18], which automatically makes it difficult to reach proper statistical significance to prove their effect. Two of the studies analysed by Georgiou et al. had considerably larger study populations (1040 and 2000 rhinoplasty patients) and both reported only few postoperative infections (0.48% and 0.6%, respectively), whereas our study presented noticeably higher rates, as high as 5.3%. This shows a great variation in the reported number of postoperative infections in septoplasty, which in turn could be explained by differences in criteria and definition of these postoperative infections in rhino- and septoplasties. We explicitly defined postoperative infections according to published international consensus criteria [9‐11]. These same criteria for defining postoperative infection were used by Ariyan et al. [9] who established a consensus statement on evidence-based recommendations for usage of antimicrobial prophylaxis in different types of plastic surgery. They concluded antibiotic prophylaxis to be recommended in clean-contaminated surgery such as septoplasty [9]. They also recognised the difficulties with diagnosing postoperative infections in septoplasty and agreed that this might be a reason for varying rates of infection reported by study groups.

There are a few more studies that have presented low incidences of postoperative complications in septoplasty. In 2005 Caniello et al. reported no postoperative infections within a study population of 35 patients and therefore concluded prophylactic antibiotic treatment to be unnecessary [15]. In another, retrospective study from the 1980’s, Weimert and Yoder presented four postoperative infections (2.3%) in a population of 174 septo- and rhinoplasty patients [14]. In a more recent study Ritter et al. reported no postoperative complications in a study population of 55 septoplasty patients [18]. Whereas, a retrospective study from 2018, as mentioned earlier, reported an incidence of 3.1% of postoperative infection in septoplasty [5], while another study from 2019 presented an infection rate of 3.3% [6]. The rates of SSIs are low but existent, when examining larger study groups.

A previous study at our department on 100 septoplasty patients during the 1990’s reported a postoperative infection rate of 12%, while antibiotic prophylaxis was used in 21% of the cases [7]. Two decades later antibiotic prophylaxis was given to 79.1% of the cases at our centre, and the postoperative infection rate was 5.3%. We can note that usage of antibiotic prophylaxis, especially preoperatively, has increased significantly during these two decades, while the amount of postoperative infections after septoplasty has decreased. In 2011 Lilja et al. [8] reported an infection rate of 5.3% within a study group of 188 patients. Three of these infections were reported as deep incisional SSIs (septal abscesses), all of which occurred within the non-prophylaxis group, whereas, in our current study the postoperative infections consisted of only superficial SSIs. Postoperative infections in septoplasty nowadays seem to be of the milder kind. One reason might be the proper use of antibiotics: a single intravenous dose preoperatively. The total percentage of SSIs, however, has not changed considerably. Could it be that nowadays patients are more sensitive to various postoperative symptoms or any kind of discomfort and therefore, seek medical attention with a lower threshold than before? Even normal postoperative findings can be interpreted as SSIs. These factors, along with different diagnostic criteria, might explain some of the differences in the reported percentage of postoperative infections in septoplasty. Still, we can speculate if our study from 2011 [8] might have been the driving factor for the increased use of prophylactic antibiotics at our department during the last decade.

Even though most of the postoperative infections are indeed mild and only in few cases of the severe kind (abscess, deep incisional or organ based SSI, sepsis, toxic shock syndrome, endocarditis, osteomyelitis, meningitis, cavernous sinus thrombosis), it is important to minimise even these few mild infections that do occur postoperatively. Any arising complications hinder normal healing of the wound and might damage the outcome of the operative treatment and thus it is immensely important to prevent these complications from emerging [19].

In the present study, antibiotic therapy with a prophylactic purpose was used in 79.1% of the cases. We found that usage of antibiotics was statistically significantly more common in septocolumelloplasties, in surgeries of longer duration and if general anaesthesia or silicone splints were used. In general, it seems that surgeons use antibiotic prophylaxis more often in challenging cases as opposed to shorter and simpler ones. All surgeries were performed by a total of 20 surgeons. Therefore, individual variations were possible and even probable, but these were not evaluated any further in this study.

In this study postoperative antibiotic prophylaxis did not turn out to have any statistical significance in diminishing SSIs in septoplasty. A possible contributing factor might be the small number of patients treated with a postoperative antibiotic. According to recent guidelines the prophylactic antibiotic should be administered as a single dose 30–60 min before incision is made to establish the right therapeutic levels at the initiation of the operation, as well as throughout the surgical procedure, but no longer than a few hours after closing the wound [12, 13]. Neither did we find any statistically significant indication that usage of both pre- and postoperative antibiotics should be used to decrease the incidence of SSIs in septoplasty. Usage of both types of antibiotic prophylaxis together would on the other hand possibly and needlessly increase the presence of adverse effects in patients.

When we analysed the material as a whole, we found that an increased rate of UPVs was positively associated with a shorter duration of septoplasty surgery. According to a large systematic review the risk of developing an SSI rises linearly with the duration of the surgery, although notably, the review did not specifically contain any cases of nasal surgery [20]. Our findings seemed to be logically unexpected and further analyses showed that these findings could be explained by a lesser use of antibiotics during shorter surgeries.

In the population of 63 cases without any prophylactic antibiotic, RFAIT as an additional intervention raised statistically significantly rates of UPVs (Table 4). However, the same findings were not observed in the whole material of 302 cases, or in the material of 213 patients all receiving a preoperative single intravenous dose of antibiotic. It appears that the use of antibiotics affected the number of SSIs so strongly that it negated the effect of other variables. Our findings are in line with another study on 5639 patients that concluded turbinectomy, and therefore, RFAIT as additional surgery, to be associated with a higher occurrence of postoperative infection [5]. However, the role of RFAIT as additional surgery should be assessed more. In our study the results may be too biased to allow any further conclusions.

We showed that usage of silicone splints did not increase the rate of SSIs in septoplasty. This is the same outcome as in our previous study [8]. In addition, the use of nasal packing or a stapler was not associated with a higher rate of SSIs. The latter finding correlates with a study by Sainio et al. on 457 patients evaluating the safety of using a stapler in septoplasty [21]. The duration of the use of nasal packing was short in this material, which might explain the absence of any cases of toxic shock syndrome.

The most considerable weakness of this study is its retrospective design. Our study population being rather small with only 302 patients was another limiting factor, although notably many reports on septoplasty have even smaller study populations. On the other hand, a significant strength compared with a prospective trial is the absence of selection bias. Our study group included all septo(columello)plasties performed at our department during the year 2018 and therefore also consisted of patients who had undergone any kind of additional sinonasal surgery beyond the septoplasty itself. This shows a real-world assortment of ENT patients, not a constructed setup as in a prospective study setting. We recognise the bias it generates in regard to the analysis, and this we have taken into account when making our conclusions. We thus believe that the present results are rather generalizable.

The present study showed that the use of preoperative antibiotic prophylaxis in septo(columello)plasty has increased during the past two decades at the Helsinki University Hospital. Most typically antibiotic prophylaxis was given as a single dose of intravenous antibiotic before the beginning of surgery according to recent international recommendations. The use of preoperative antibiotic treatment as a prophylactic measure statistically significantly diminished the rate of SSIs, and more broadly short-term complications in general, in septoplasty when all SSIs, superficial SSIs included, were taken into account, especially in connection to additional sinonasal surgery.