September 2019 HSC Section 1 Congenital and Pediatric Problems

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

Table 7 Complications.

Type (n, %)

Complication (n,%)

Aesthetic (39, 15.4%)

Unspec fi ed aesthetic dissatisfaction (17, 11.8%), nasal deviation (6, 4.2%), tip depression (5, 3.5%), wide dorsum (3, 2.1%), short nose (2, 1.4%), hanging columella (2, 1.4%), nostril asymmetry (2, 1.4%), pincushioning of alar skin (1, 0.7%), broad nasal bones (1, 0.7%) Postoperative dif fi culty breathing through the nose (8, 5.6%), symptomatic postoperative septal deviation (2, 1.4%), restenosis of choanal atresia (2, 1.4%)

Obstructive (12, 4.7%)

Pain (2, 0.8%) Other (4, 1.6%)

Transient nasal pain (2, 1.4%)

Swelling around suture (1, 0.7%), Residual cyst in skin of nose requiring re-operation (1, 0.7%), Mild supratip deformity (1, 0.7%), Epistaxis on POD6 after splint removal that self-resolved (1, 0.7%)

Unknown (109, 43.1%)

Not speci fi ed (109, 43.1%) [15,16]

comment on why a speci fi c grafting material was used in prefer- ence to another. One author [18] , however, did specify that septal cartilage harvest was avoided in younger children due to concerns of affecting skeletal growth and that auricular cartilage was used as an alternative. Surgical outcomes were presented in six of the seven studies reviewed. The largest study reviewed contained 106 patients and was the one which did not report outcomes. Four studies noted that there were positive outcomes in 100% of patients with ability to address the underlying pathology successfully in every case [15,17 e 19] . In one study, when physicians analyzed patient photos they noted good results but there was low patient aesthetic satis- faction [1] . Another study in which negative outcomes were re- ported noted that 5 of 15 (33.3%) of patients had fair or poor results. Interestingly, 4 out of 5 (80%) of these patients had inadequate septal tissue at the time of surgery. While many authors may be hesitant to report negative outcomes, especially in small case se- ries, preoperative factors which may increase the risk of negative outcomes such as inadequate septal tissue should be identi fi ed and assessed by the surgeon. Five studies presented information on surgical complications. Of the patients in these studies, approximately 40% had identi fi ed complications, the most common of which were aesthetic dissat- isfaction (17 patients, 11.8%) and postoperative nasal obstruction (8 patients, 5.6%). Many other surgical complications were noted with less frequency but no mention of nasal or midfacial growth disturbance was noted in any of the studies reviewed. The com- plications, in general, tended to coincide with the speci fi c indica- tion for which the surgical procedure was performed. As there are virtually no large-scale analyses in the literature evaluating this topic and reporting complication rates, these rates have potential utility for inclusion in the pre-operative patient counseling process. The revision rate was reported in four studies and totaled 27 out of 200 patients (13.5%). Importantly, these revision rates are largely greater than comparable values among adult series [34 e 36] . Un- fortunately, most of the studies in the current analysis did not provide information on why revisions were being undertaken. In fact, only in 1 patient (0.5%) was a speci fi c reason for revision noted - cyst recurrence in the nasal tip skin. Good data is not available comparing outcomes of pediatric rhinoplasty performed by pedi- atric otolaryngologists versus facial plastic surgeons. Perhaps the number of rhinoplasty procedures a surgeon performs per year has a bearing on outcomes. Clearly, further study needs to be done in this area which can provide guidance to surgeons who are per- forming pediatric rhinoplasty. In addition to the considerations outlined above, another issue our analysis brings forth is a void in inquiry focusing on the psy- chological readiness and sequelae of rhinoplasty in this population. We have discussed some of the background considerations and controversies relating to the impact of open surgical procedures on growth. Nonetheless, appearance-altering surgery certainly has psychological rami fi cations, which have been widely evaluated in

Table 8 Revision rate and indications.

Study

Revision rate (%)

Indication for revision

Pierce et al.

Not speci fi ed

Not speci fi ed Not speci fi ed Not speci fi ed Not speci fi ed Not speci fi ed

Bae et al.

6 patients (9.4%)

Koltai et al.

Not speci fi ed

Crysdale et al. Chung et al.

2 patients (13.3%) Not speci fi ed 1 patient (6.7%) 18 patients (17%)

Locke et al.

Nasal tip skin cyst recurrence

Shandilya et al.

Not speci fi ed

inadequate informed consent as a factor in medicolegal litigation in a variety of analyses encompassing craniofacial, aesthetic, and pe- diatric surgical procedures [23 e 27] . Particularly as health literacy and reasonable expectations have been closely associated with patient satisfaction, one potential strategy facilitate comprehension could be to make available appropriately written patient education materials [28 e 30] . In the articles included in our analysis, review of patient char- acteristics revealed that rhinoplasty had been performed in a wide age range of patients (7 months e 19 years) and showed a male preponderance (67%). It is likely that children with congenital le- sions amenable to excision via an external rhinoplasty approach were the ones most likely to undergo rhinoplasty earlier in life. Many studies did not provide demographic data speci fi cally for patients based on indication for surgery. However, in our analysis of the article by Locke et al., [19] all 15 children that were retrospec- tively analyzed had a congenital lesion excised via external rhino- plasty with a mean age of 25 months (range 1 e 5 years). In addition, approximately 70% of children who underwent rhinoplasty were male. This may perhaps coincide with the high percentage (41.7%) of children with antecedent trauma prior to rhinoplasty. For example, boys may be more likely to engage in contact sports in which nasal trauma may be sustained [31 e 33] . The two most common indications for rhinoplasty in this pa- tient population were “ functional aesthetic ” (62 patients, 24.5%) followed by cleft lip nasal deformity (40 patients, 15.8%). One theme noted in our evaluation was that factors were not presented in a standardized way in between different studies. The largest study reviewed, which contained 106 patients, only noted indications for surgery as “ fuctional aesthetic ” , “ functional ” , or “ cleft lip ” and did not provide further explanation regarding these terms [16] . Other studies provided more speci fi c disease entities that were being addressed such as nasal tip dermoid cyst [15] or choanal atresia [17] . Approximately 79% of patients underwent open rhinoplasty and concomitant septal intervention was undertaken in approxi- mately 71%. This demonstrates that the majority of pediatric rhi- noplasties involved extensive manipulation of major components of the nose. Septal cartilage, as expected, was the most commonly used graft (52.8%) and interestingly the second most common was processed fascia lata (19.3%). Most studies unfortunately did not

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