Management of Pediatric Nasal Surgery (Rhinoplasty)

Pediatric Functional Rhinoplasty

Surgery on the growing pediatric nose poses many questions regarding the indications and proper timing. Historically, surgeries on the pediatric nose led to facial growth alterations so many urged caution and waiting until skeletal maturity at the age of 18. However, animal studies showed some promise that facial growth may not be affected. Investigations into effects of pediatric sinus surgery and septal surgery on facial growth showed no issues. The external nose is somewhat different in that minor variations potentially can grow to a cosmetic deformity. However, numerous studies on facial growth show, to date, that it is not affected, and that surgery is safe. The caveat that one uses is the techniques of cartilage sparing and preservation, which have been studied and shown to be safe. There are ways to measure the effectiveness of surgery in relieving nasal airway obstruction both objectively and, more recently, subjectively. It is essential to treat pediatric nasal airway obstruction to avoid other facial growth problems, such as mouth breathing, snoring, malocclusion, and obstructive sleep apnea.

Craniofacial Growth and Development: A Primer for the Facial Trauma Surgeon

Understanding craniofacial growth and development is important in the management of facial trauma in the growing pediatric patient. This manuscript is a review of craniofacial growth and development and clinical implications of pediatric facial fractures.

The Role of Antibiotics in Nasal Fractures after Closed Reduction

Nasal fractures represent the most common fracture in facial trauma. The role of prophylactic antibiotics in these injuries is debated, given low infection rates and demonstrated risks of antibiotics. We studied the isolated effect of prophylactic antibiotics on infection rate in patients with nasal fracture after closed reduction.

Methods

Retrospective cohort study of a prospectively maintained facial trauma database was conducted. Demographics, comorbidities, fracture classifications, and management of patients who received antibiotics at the time of closed nasal reduction were compared against those who did not receive antibiotics. Infection rates between groups were analyzed. Multivariate analysis was conducted to control for confounding variables. Qualitative analysis was performed for patients who experienced infection following nasal fracture.

Results

A total of 282 patients met inclusion criteria (n = 144, antibiotic; n = 138, nonantibiotic). Six patients experienced infection. There was no difference in infection rate between antibiotic and nonantibiotic groups (2.0% versus 2.2%; P = 0.90). On multivariate regression, antibiotics did not significantly decrease odds of infection (OR 1.7 [0.17-13.6]; P = 0.64). Moreover, patients with open nasal fractures did not have significantly higher odds of infection (OR 1.9 [0.08-20.8]; P = 0.64). Similarly, increasing severity of injury based on Rohrich classification did not significantly impact odds of infection (OR 0.68 [0.23-1.9]; P = 0.46). All six infections were managed at the bedside, with zero infections following operating room management (P = 0.32).

Conclusions

Prophylactic antibiotics do not decrease infection rates following nasal fractures managed by closed reduction. Bedside management may be a risk factor for the development of infection; however, this finding requires further evaluation.

OUTCOMES OF SEPTOPLASTY IN CHILDREN

OBJECTIVE

Aim: The aim of the study was to present the experience of a local hospital surgical department where septoplasty is performed on children suffering from its degeneration.

PATIENTS AND METHODS

Materials and methods: A retrospective cohort study with 100 patients aged between 3 and 18 years were taken. Both males and females out of 100 patients were followed up for 7 years. The patients were treated with using septoplasty as well as the related clinical procedures such as cauterization of the inferior turbinate. We performed clinical evaluation and nasal endoscopy of the cases in the postoperative period. The longest observation period was 7 years.

RESULTS

Results: The male and female child enrolled in the study were 60 (60%) and 40 (40%), respectively. Out of this number of patients, 92 (92%) had inferior turbinate cauterization. In all the 100 cases, we did not notice any intraoperative complication. Also, all the cases were evaluated in 15th, 30th, and 60th days of observation.

CONCLUSION

Conclusions: When performed correctly, septoplasty in children is a good clinical intervention as it allows the right growth and development of the crani-ofacial region and prevents abnormalities in psychic and somatic components in young patients. Moreover, this study confirms the previous studies that have demystified the point of view, that the setoplasty should only be recommended when the patients reach the ages of 17 and 18.

The Effects of Septorhinoplasty Techniques and Poly-P-Dioxanone Plate Use on Maxillofacial Growth: An Experimental Study

ABSTRACT

Since the septum plays a key role in maxillofacial growth, the effect of septorhinoplasty maneuvers and the use of poly-p-dioxanone plate during growth on maxillofacial growth was investigated in our study. Thirty-three New Zealand rabbits each with an age of 8 weeks were included in the study. Maxillofacial computed tomography was performed on all 8-weeks old rabbits. Then, the rabbits were divided into 5 groups randomly. No intervention was done on the rabbits in group 1. Nasal dorsum of the rabbits in the 2nd group were opened, and the mucosae were bilaterally elevated. In the third group underwent limited cartilage resection by preserving the nasal dorsum. Removed cartilage was crushed and placed back between the mucoperichondrial flaps for the rabbits in the 4th group. Crushed cartilage with Poly-P-Dioxanone plate was used for the rabbits in the 5th Group. Maxillofacial computed tomography was performed at the end of the 20th week and growth parameters were investigated. When the group 2 was compared with the control group, the nasal bone length was observed to be significantly shorter (P < 0.05). Group 5 compared with group 4, incisive bone volume remained significantly low (P < 0.05) and malocclusion developed. Nasal bone length was affected negatively in the group that underwent osteotomy and mucosa elevation. Although positive results related to poly-p-dioxanone plate use have been reported for adults, incisive bone development retarded in noses that had not yet reached adult size in our study and the maxillofacial development was affected adversely.

Pediatric nasal septoplasty outcomes

BACKGROUND

Corrective nasal surgery has historically been avoided in the pediatric population out of concerns surrounding the potential disruption of nasal growth centers. There is a paucity of data on the rate of complications or revision surgery following septoplasty in this population. As such, the purpose of this study is to review the long-term outcomes of a large cohort of children who underwent nasal septoplasty and to compare outcomes of septoplasty patients under the age of 14 to those 14 years and older.

METHODS

A retrospective review was performed on all patients who received nasal septoplasty at our tertiary care pediatric referral center between October 2009 and September 2016. All patients who underwent septoplasty for a deviated nasal septum and were 0-18 years of age at the time of surgery were included in this analysis. Outcomes were compared between patients under the age of 14 to those 14 years and older. Demographic, surgical, and follow-up data were collected including complications and the need for revision surgery.

RESULTS

A total of 194 pediatric patients were identified as meeting inclusion criteria for the study. Mean age for the total cohort was 14.6 years (0-18 years), with a mean of 15.9 years in the older group and 10.6 years in the younger group. Revision septoplasty was performed more frequently in the younger group. However, no significant difference in the rate of complications was seen between the two groups.

CONCLUSIONS

To the best of our knowledge, this is the largest retrospective study examining outcomes following septoplasty in pediatric patients. We also specifically examine outcomes of very young septoplasty patients, a population for which limited evidence exists. Further retrospective studies are needed to validate the use of nasal septoplasty in the pediatric population.

Comparing plastic surgery and otolaryngology surgical outcomes and cartilage graft preferences in pediatric rhinoplasty: A retrospective cohort study analyzing 1839 patients

ABSTRACT

Rhinoplasty in children has raised concerns about its safety in the pediatric population. There is scarcity of evidence describing outcomes and surgical techniques performed in pediatric rhinoplasty. We analyzed post-operative complications and cartilage preferences between plastic surgeons and otolaryngologists.Data was collected through the Pediatric National Surgical Improvement Program from 2012 to 2017. Current Procedure Terminology codes were used for data extraction. Patients were grouped according to type of rhinoplasty procedures (primary, secondary, and cleft rhinoplasty). A comparison between plastic surgeons and otolaryngologists was made in each group in terms of postoperative complications. Additionally, a sub-group analysis based on cartilage graft preferences was performed.During the study period, a total of 1839 patients underwent rhinoplasty procedures; plastic surgeons performed 1438 (78.2%) cases and otolaryngologists performed 401 (21.8%) cases. After analyzing each group, no significant differences were noted in terms of wound dehiscence, surgical site infection, readmission, or reoperation. Subgroup analysis revealed that plastic surgeons prefer using rib and ear cartilage, while otolaryngologists prefer septal and ear cartilage.The analysis of 1839 pediatric patients undergoing three types of rhinoplasty procedures showed similar postoperative outcomes, but different cartilage graft utilization between plastic surgeons and otolaryngologists.

Does pediatric septoplasty compromise midfacial growth? A systematic review

OBJECTIVE

Septal deviation is an important cause of impaired nasal breathing among pediatric patients. A widespread solution to septal deviation is septoplasty. However, there are certain controversies surrounding the effect of this technique on pediatric patients and its influence on the growth centers of the nose. The objective of this review is to study if there is a strong and valid evidence in the literature that supports a detrimental effect of pediatric septo- and rhinoseptoplasty in facial growth DATA SOURCES: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database.

REVIEW METHODS

The outcome assessed was the midfacial growth after pediatric septoplasty.

RESULTS

Eight publications met the inclusion criteria. None found major disturbances in facial growth. Only minor nasal anomalies were reported by 4 authors.

CONCLUSION

Septoplasty in pediatric patients does not seem to affect midfacial growth according to available evidence. However, due to their design, the degree of recommendation of these studies was not superior to level C.

Craniofacial Growth: Current Theories and Influence on Management

Craniofacial development is a highly coordinated process under a tight genetic control and environmental influence. Understanding the core concepts of growth and development of the craniofacial skeleton and the impact of treatment on growth potential is vital to successful patient management. To maximize outcomes and minimize iatrogenic consequences, proper sequencing and timing of interventions are critical. The development of the craniofacial skeleton occurs as a result of a sequence of normal developmental events: brain growth and development, optic pathway development, speech and swallowing development, airway and pharyngeal development, muscle development, and tooth development and eruption.

The Case of the Missing Nose: Congenital Arhinia Case Presentation and Management Recommendations

OBJECTIVES

To discuss the presentation and management of infants with arhinia or congenital absence of the nose.

METHODS

This case report describes an infant with arhinia that was diagnosed prenatally. In addition to a discussion of the case, a review of the literature was completed to define appropriate postnatal work-up and management.

RESULTS

The patient is a term male infant, diagnosed with arhinia on ultrasound and magnetic resonance imaging (MRI) performed at 21-weeks gestational age. Upon birth, the patient was subsequently intubated, followed by tracheostomy due to complete nasal obstruction. Through a genetics evaluation, the patient was found to be heterozygous for the SMCHD1 gene, with hypomethylation at the D4Z4 locus. Plans for reconstruction will be based on future imaging and the development of any nasal patency, however, the patient's family plans to utilize a prosthetic nose until the patient is older.

CONCLUSION

Arhinia is a rare condition causing respiratory distress in the neonatal period. While stabilization of the airway is the first priority, further management is not clearly defined given the rarity of the malformation. This case discusses stabilization of the airway with a review of treatment and reconstructive options.

Secondary Cleft Rhinoplasty in 1720 Patients: Are National Practices Consistent With Guidelines?

OBJECTIVE

To assess the timing, type, and associated adjunct procedures for secondary cleft rhinoplasty nationally.

DESIGN

Data were extracted from a national database of all secondary cleft rhinoplasty procedures (Current Procedural Terminology [CPT] codes 30460 and 30462). Frequency statistics were utilized to analyze demographics, comorbidities, surgical procedures, and timing. Chi-squared analysis and Fisher exact test were used for analysis.

SETTING

National Surgical Quality Improvement Program-Pediatric Database.

PARTICIPANTS

A total of 1720 patients met inclusion criteria for secondary cleft rhinoplasty repair.

INTERVENTIONS

No relevant intervention.

MAIN OUTCOMES AND MEASURES

Age, demographics, comorbidities, and associated procedures.

RESULTS

Over 5 consecutive years, 1720 patients underwent secondary cleft lip rhinoplasty nationally. Mean patient age was 9.3 ± 5.3 years. Unilateral cleft rhinoplasty patients were older (9.0 years) than bilateral patients (7.8 years; P = .001). Rib grafting was performed in 6.3% of patients at a mean age of 10.6 years with a higher proportion of Asian and female patients. Auricular grafts were more commonly performed by otolaryngology than plastic surgery. The most common adjunct procedures included secondary cleft lip revision (33.1%) and tympanostomy tube placement (10.2%). When subdividing by type of cleft rhinoplasty, tip rhinoplasty was performed at a mean age of 7.3 years compared to rhinoplasty with osteotomies and a major septal component at 12.1 years (P < .001).

CONCLUSIONS

This study reveals that a large proportion of cleft rhinoplasties are performed in skeletally immature patients. Although patients undergoing rib grafting, nasal osteotomies, and a major septal component were older, these procedures are still performed in a large proportion of patients who are younger than expected.

Functional septorhinoplasty in the pediatric and adolescent patient

OBJECTIVES

To describe pediatric and adolescent patients undergoing functional septorhinoplasty and to analyze both subjective and objective outcomes.

METHODS

Retrospective review of prospective cohort study of patients ≤18 years old undergoing functional septorhinoplasty between 2013 and 2016 at a tertiary care center. Patient demographics, nasal exam, procedure, and pre- and postoperative nasal obstruction symptom evaluation (NOSE) score, EuroQOL 5-dimension (EQ5D), and peak nasal inspiratory flow (PNIF) scores were analyzed.

RESULTS

39 patients, 48.7% male, mean age 15.9 years (range 7-18), with nasal obstruction underwent functional septorhinoplasty with mean follow up of 8.5 months. Patients reported a history of allergies (46.5%), nasal fracture (59.0%), and previous nasal surgery (25.6%). Most common exam findings included internal nasal valve narrowing (92.3%), superior/dorsal septal deviation (74.4%), external nasal valve narrowing (43.6%), caudal septal deviation (35.9%), and a narrow middle vault (33.3%). Septal cartilage grafts were placed in 79.5% of patients and PDS plate was used in 28.2%. Most common procedures included spreader grafts (84.6%), columellar strut graft (30.8%), and swinging door (23.1%). Of patients with both baseline and postoperative scores, at last follow up NOSE scores (SD) decreased from 59.0 (23.7) to 21.2 (8.8) (n = 26, p < 0.001), EQ5D VAS scores increased from 76.2 (17.7) to 85.8 (13.5), (n = 19, p = 0.056), and PNIF scores increased from 66.2 (25.3) to 90.8 (46) L/min, (n = 13, p < 0.01); all mean differences met the minimal clinically important difference for each score. 2 patients underwent revision surgery and there was one complication of a nasal abscess.

CONCLUSIONS

Functional septorhinoplasty is safe and effective in select pediatric and adolescent patients with significant nasal obstruction and results in significant improvements in both subjective and objective outcomes measures.