September 2019 HSC Section 1 Congenital and Pediatric Problems

A. Gupta et al. / International Journal of Pediatric Otorhinolaryngology 92 (2017) 11 e 16

Table 4 Surgical approaches and procedures performed.

Surgical approach (n)

Area addressed (n)

Speci fi c procedure (n)

Open rhinoplasty (200) Closed rhinoplasty (53)

Bony Vault (174) Middle Third (13)

Micro-osteotomies (74), hump reduction (59), Osteotomy (41)

Spreader grafting (13)

Lobule (86)

Tip suturing (45), cephalic resection (32), batten grafting (4), reconstruction of the tip with interdomal sutures and fat grafting from abdomen (3), alar rim grafts (1), hooding correction (1)

Septum (177) Other (125)

Not speci fi ed

Unspeci fi ed open rhinoplasty (61), z-plasty (24), external rhinoplasty with resection of mass and overlying ellipse of skin if tract extended to skin (15), wedge resection (10), sphenoid sinus approached (5), choanal atresia repair (5) lateral rhinotomy (3), nasolabial stitch (2)

Table 5 Grafting materials utilized.

Type

Speci fi c graft (n, %)

Septum Concha

Septal cartilage (115, 52.8%) Conchal cartilage (36, 16.5%)

Rib

Homologous rib cartilage (10, 4.6%), autogenous rib cartilage (1, 0.5%)

Other

Processed fascia lata (42, 19.3%), perforated PDS foil (17, 7.8%), composite graft (4, 1.8%), gore-tex (4, 1.8%), temporalis fascia with free temporal muscle graft (4, 1.8%), Abdominal Fat (3, 1.4%), temporalis fascia (2, 0.9%), tissue engineering (2, 0.9%), tragal cartilage (1, 0.5%)

Unknown

Not speci fi ed (35, 13.8%)

deviation, and 5 (3.5%) had tip depression These represented the most common complications. Other less common complications were wide dorsum (4 patients, 2.8%), short nose (2 patients, 1.4%), hanging columella (2 patients, 1.4%) and multiple others as iden- ti fi ed in Table 6 . Four out of the 7 studies provided information regarding rates of revision surgery. The total revision rate reported in this group was 27 out of 200 patients (13.5%). Speci fi c indication for revision was reported in only 1 patient (0.5%), who had a revision to address cyst recurrence in the skin of the nasal tip. Due to lack of such data in the identi fi ed studies, the authors were unable to differentiate revision rates between the cleft and non-cleft patient population (see Tables 7 and 8 ). This comprehensive analysis represents the largest pooled se- ries of pediatric patients undergoing rhinoplasty. To the best of our knowledge, no controlled trials or other such reviews are present in the literature. Nasal surgery among pediatric patients engenders controversy relating to surgical indications, approaches, speci fi c techniques, optimal timing, and extent of operative intervention [4] . The major concern is that surgical intervention on a developing nose can lead to growth inhibition and abnormalities that may not be fully manifest until the child reaches adult age. Previous studies 4. Discussion

have reviewed the external and internal nasal anatomy of children and have noted signi fi cant differences compared to the adult nose. Externally, the pediatric nose tends to have a larger nasolabial angle with less projection of both the dorsum and nasal tip [1] . Cranio- facial studies have revealed that infants have a greater nasal cartilage-to-bone ratio compared to adults. Newborn septal carti- lage extends from the nasal tip to the skull base and bony structures are relatively underdeveloped. The perpendicular ethmoid plate is absent and vomer rudimentary at birth and ossi fi cation occurs with age with formation of the perpendicular plate which fuses with the vomer between 6 and 8 years of age [20,21] . Early in life, similarly, the upper lateral cartilages extend under the complete length of the nasal bones and regress caudally with age [22] . These anatomic differences are important to recognize for the surgeon performing rhinoplasty on pediatric patients. The dearth of large-scale analyses focusing on pediatric rhino- plasty presents several challenges impacting patient counseling. Importantly, an absence of prospective or population-based data makes it dif fi cult to quote complication and revision rates to pa- tients and parents in a pre-operative informed consent process. The physician-patient relationship and pre-operative counseling play an outsize role in setting expectations; our analysis reinforces the importance of understanding expectations, as dissatisfaction with aesthetic outcome was a signi fi cant consideration (11.8% of pa- tients). Furthermore, we have previously noted allegedly

Table 6 Surgical outcomes.

Type

Speci fi c outcome (n) and corresponding study

Patient satisfaction and aesthetic outcome

100% of the patients expressed satisfaction with the level of improvement of their nasal obstructive symptoms at their 90 day follow-up visit (15) [18] . 100% of the parents/guardians noted satisfaction with the appearance of the postoperative nose (15) [19] . 1/3 patients with fair or poor results (5) [14] . No postop complications, no long term problems (35) [17] . Positive results when judged by surgeons but low patient aesthetic satisfaction, high rate of revision surgery. Assessment by 2 independent otolaryngologists revealed 18 excellent results (29.2%), 37 good (60.8%), 6 (10%) fair, and no poor outcomes, 4 patients did not have postop photographs so were not assessed. Subjective satisfaction was judged for 45 patients who agreed to a telephone interview, 17 (37.8%) excellent, 15 (33.3%) good, 5 (11.1%) fair, and 8 (17.8%) poor outcomes [1] . All lesions were able to be removed via the external rhinoplasty incision.There were no postoperative CSF leaks and there were no delays to discharge as a result of postoperative infection (15) [19] .

Mass excision

Facial growth

No effects on facial growth noted over the follow up time of the study (15) [19] .

Unknown

Not Speci fi ed (106) [16] .

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