September 2019 HSC Section 1 Congenital and Pediatric Problems

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A. Manteghi et al.

of-life (QOL) outcomes of septoplasty and FSR in pediatric patients using the Nasal Obstruction Symptom Evaluation (NOSE) Scale. It is a brief, simple, and easily administered QOL instrument speci fi c to nasal obstruction developed by Stewart et al. [ 20 ]. Additionally, we sought to evaluate whether gender, age, nasal trauma, prior nasal surgery, al- lergic rhinitis, or additional surgeries at the time of procedure con- tributed to postoperative NOSE scores.

2. Methods

2.1. Study design and procedures

This study is a prospective cohort study of pediatric patients that underwent septoplasty or FSR from January 2013 to January 2017 at Rady Children's Hospital San Diego, a tertiary care pediatric hospital. It was approved by the Institutional Review Board (IRB) of the University of California San Diego and Rady Children's Hospital. Patients 18 years of age and younger were seen in consultation for nasal obstruction after failing medical management. A careful history and complete head and neck evaluation, including anterior rhinoscopy and/or fl exible nasal endoscopy, were carried out in all patients with nasal obstruction to identify an anatomic cause such as septal deviation, internal/external valve collapse, external nasal deformity, and/or turbinate hypertrophy. Computed tomography (CT) of the sinuses without contrast was ob- tained in a subpopulation of patients when clinically indicated to evaluate for pathology such as chronic sinusitis, nasal polyposis, concha bullosa, or other sinonasal abnormalities. Consecutive patients underwent either septoplasty or open FSR by the senior author (SL) based on their physical exam fi ndings and symptom burden. Cartilage-sparing techniques were implemented for both procedures whenever possible. FSR was de fi ned as open surgical management of the bony/cartilaginous nasal framework and/or soft tissues of the nose targeting the internal and/or external nasal valve. Septoplasty is generally considered to be a necessary step in FSR and was performed in each case. Additional techniques such as inferior turbinate reduction, adenoidectomy, concha bullosa excision, or max- illary antrostomy were performed as indicated and recorded. Demographics (age and sex), history of nasal trauma, prior nasal sur- gery, or allergic rhinitis history were documented. Patients were trialed on a nasal steroid and an oral antihistamine if found to have allergic rhinitis. A history of previous rhinoplasty or septoplasty did not exclude patients from consideration. Pre- and post-operative photographs were taken in all FSR patients and the NOSE score was collected. Patients were followed postoperatively on a schedule of 1 month, 3 months, 6 months, 9 months, and 1 year, although patient compliance with that schedule did vary. Subjective evaluation of patient nasal obstruction symptoms was obtained using the NOSE Scale ( Fig. 1 ) preoperatively and at each subsequent postoperative visit. The NOSE Scale consists of fi ve items, each scored using a 5-point symptom speci fi c Likert scale, with 0 meaning ‘ not a problem ’ and 4 meaning ‘ severe problem ’ . The answers are then summed and multiplied by 5 for a fi nal score out of a 100. Higher scores indicate worse nasal obstruction. Patients were categor- ized as having mild (5 – 25), moderate (30 – 50), severe (55 – 75), or ex- treme (80 – 100) nasal obstruction depending on responses to the NOSE Scale [ 21 ]. We also performed a reliability analysis of the NOSE Scale in our study population. 2.2. Outcome data

Fig. 1. Nasal obstruction symptoms evaluation (NOSE) scale.

post-operative NOSE scores were obtained and compared for both septoplasty and FSR groups using a Wilcoxon signed-rank test. A Mann- Whitney U test was used to determine if the change in NOSE scores was signi fi cantly di ff erent between septoplasty and FSR patients. A multi- regression analysis was used to evaluate whether gender, age, nasal trauma, prior nasal surgery, or allergic rhinitis in fl uenced NOSE score changes. Given the possibility of confounding from additional surgeries (at time of procedure), a one-way ANCOVA was conducted to de- termine interaction e ff ects on NOSE score changes by surgery type. A total of 136 patients with nasal obstruction with a mean age of 15.7 ± 2.1 years were included in the study. There were 94 males (69.1%) and 42 females (30.8%). 52 patients underwent septoplasty (38.2%) while 84 underwent FSR (61.8%). Table 1 summarizes patient demographics. Mean follow-up time was 3.6 ± 5.1 months for all surgeries with a range of 1 month – 2.7 years ( Table 2 ). There was a statistically signi fi cant decrease in NOSE scores from pre- (median = 75) to post-operative (median =20) in the septoplasty group (z = − 5.9, p < 0.001) ( Fig. 2 ). There was also a statistically signi fi cant decrease in NOSE scores from pre- (median = 75) to post- operative (median = 15) in the FSR group (z = − 7.9 p < 0.001) ( Fig. 2 ). The mean change in NOSE score was − 40.9 (SD: 25.3) in the septoplasty group and − 52.0 (SD: 23.7) in the FSR group. Patients who underwent FSR had a greater median change in NOSE score compared to septoplasty patients (U=1521, Z = − 2.4, p =0.02). Gender, nasal trauma, prior nasal surgery, and allergic rhinitis did not have a statis- tically signi fi cant e ff ect on post-operative NOSE scores for septoplasty ( Table 3 ) or FSR patients ( Table 4 ). Among FSR patients, turbinate reduction (8.3%) was the only additional procedure at the time of surgery. Among septoplasty patients additional procedures included turbinate reduction (35.8%), concha bullosa excision (13.5%), ade- noidectomy (19.2%), and maxillary antrostomy (5.8%). Results of a one-way ANCOVA test indicated additional surgeries at time of proce- dure were not a confounding variable in the relationship between surgery type and change in NOSE score for either FSR or septoplasty patients (p = 0.3). Subgroup analysis was done comparing septoplasty patients 13 years of age and younger (Group A) and 14 years of age and older (Group B) ( Table 5 ). Younger patients (Group A) were more likely to have allergic rhinitis (p = 0.03). A Wilcoxon signed-rank test de- termined an overall statistically signi fi cant decrease in NOSE scores in both group A and B post-surgery ( Table 6 ). Subgroup analysis by age was not done for FSR patients as there were only 2 patients ≤ 13 years of age versus 76 patients ≥ 14 years of age. A NOSE Scale reliability analysis was also performed. The NOSE Scale showed high internal consistency with Cronbach's α of 0.83 across 3. Results

2.3. Statistical analysis

Statistical analyses were performed using Statistical Package for Social Sciences Software (SPSS) (IBM Corp. Released 2016. IBM SPSS Statistics for Macintosh, Version 23.0. Armonk, NY: IBM Corp.) Pre- and

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