September 2019 HSC Section 1 Congenital and Pediatric Problems

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A. Manteghi et al.

septoplasty and FSR patients.

adults [ 20 ]. This presents one limitation of our study where although the NOSE Scale is disease-speci fi c, it is not yet validated in children. Thus, we performed a reliability analysis of the NOSE Scale in our study. We found a high internal consistency across both septoplasty and FSR patients indicating excellent reliability. Other limitations to our study include the heterogeneity in follow- up periods and shorter average follow-up duration. Future studies will be performed to observe whether QOL outcomes sustain over time, ideally with a one-year minimum follow-up. Also, there was no control group of patients undergoing non-surgical intervention. Both septo- plasty and FSR patients had additional procedures performed as needed. However, our study found that these surgeries did not sig- ni fi cantly a ff ect NOSE score changes. There were signi fi cant di ff erences in the number of patients in the septoplasty and FSR ≤ 13 years of age groups, especially the FSR group which contained only two patients. This precludes us from making any de fi nitive conclusions regarding QOL outcomes in the ≤ 13 years of age FSR group. We attribute this to making every attempt to delay nasal surgery during the patient's growth spurt. This of course must be ba- lanced with the degree of obstruction and comorbidities such as ob- structive sleep apnea. In the future, more data will need to be collected from patients in this group in order to make more substantial conclu- sions. The confounding issues and key di ffi culties in measuring the out- come of FSR on nasal obstruction are the multiple methods employed in the surgical modi fi cation of nasal valve compromise. The umbrella term “ functional septorhinoplasty ” is by no means exact, and a certain level of heterogeneity is to be expected unless di ff erent maneuvers are stu- died in isolation. However, our aim was simply to deliver insight into the outcomes of FSR on nasal obstruction symptomatology as assessed by the NOSE Scale. Septoplasty and FSR are very e ff ective in treating nasal obstruction and improving nasal airway function in pediatric patients. Both sur- geries provide signi fi cant improvement in disease-speci fi c QOL as measured by the NOSE Scale. Gender, nasal trauma, nasal surgery, and allergic rhinitis history had no signi fi cant e ff ect on postoperative NOSE score change. The NOSE Scale did demonstrate high reliability ana- lyzing nasal obstruction in our patient population, and it remains a promising tool in evaluating pediatric nasal obstruction. 5. Conclusion

4. Discussion

Our results demonstrate a signi fi cant improvement in disease-spe- ci fi c QOL in patients undergoing either septoplasty or FSR. This is the fi rst prospective study of septoplasty or FSR QOL outcomes in a purely pediatric study population. It is the largest study to date examining disease-speci fi c QOL markers in pediatric patients undergoing either septoplasty or FSR, and it is the fi rst to show statistically signi fi cant disease-speci fi c QOL improvement in pediatric FSR patients. Septoplasty and FSR are accepted procedures to treat nasal ob- struction. In patients with nasal trauma and/or external nasal defor- mity, the goal is to relieve nasal obstruction and reestablish the ap- pearance and function of the nose by straightening the dorsum and septum. Some maintain that nasal surgery should be avoided due to the potential impact on nasal and midface growth, while others argue that delaying surgery may have functional, aesthetic, and social con- sequences. There have been a number of recent studies showing no adverse e ff ects on nasal and facial growth post-septoplasty or FSR [ 2 – 7 ]. Trans-septal skull base surgery literature shows that septal sur- gery is safe in children 4 years and older [ 22 – 25 ]. In addition, D'As- canio et al. [ 6 ] showed that children with uncorrected nasal septal deviations and obligate mouth-breathing demonstrate facial and dental anomalies in comparison to controls. Gray [ 26 ] demonstrated infants with “ unilateral bending or kinking at the vomerine junction ” had a higher chance of developing dental abnormalities and malocclusion, palatal asymmetry, upper respiratory tract infections, and ear disease. QOL studies in only pediatric patients undergoing rhinoplasty are sparse with one study demonstrating improvement in health-related QOL in 30 patients undergoing aesthetic rhinoplasty [ 27 ] and another study demonstrating variable QOL improvement in 64 patients who had undergone rhinoplasty, as measured with a telephone interview [ 28 ]. Floyd et al. [ 29 ] performed a systematic review and meta-analysis of patients ≥ 15 years age (including adults) regarding the ability of FSR to improve nasal obstruction as measured by the NOSE Scale. They found nasal obstruction was substantially reduced with a mean change of 43 – 50 points (out of 100) for 12 months after FSR. There have been three studies to examine QOL measures in pediatric patients undergoing septoplasty alone. These studies corroborate our fi ndings of improved QOL post-septoplasty. Yilmaz et al. [ 30 ] per- formed a retrospective study of 35 septoplasty patients and examined QOL measures pre- and post-operatively using the NOSE Scale and Visual Analog Scale (VAS). There was a signi fi cant improvement in the NOSE and VAS score at 3 months and 12 months post-septoplasty. Anderson et al. [ 31 ] demonstrated improvement in health -related QOL in 29 pediatric septoplasty patients. Lee et al. [ 32 ] performed a retro- spective review of 28 pediatric septoplasty patients and examined QOL measures pre- and 30 days post-operatively using the pediatric-vali- dated Sinus and Nasal Quality of Life Survey (SN-5) and VAS. SN-5 and VAS scores signi fi cantly improved post-operatively, with females re- porting a greater overall change compared to males. In our study, gender did not have a signi fi cant e ff ect on NOSE score change in sep- toplasty patients. Furthermore, age, nasal trauma, prior nasal surgery, and allergic rhinitis had no signi fi cant e ff ect on NOSE score changes. The SN-5 and NOSE Scale each have advantages and disadvantages for measuring QOL outcomes. The SN-5 is a pediatric validated measure of health-related QOL for children with persistent sinonasal symptoms and is measured via fi ve di ff erent domains: sinus infection, nasal ob- struction, allergy symptoms, emotional distress, and activity limitations [ 33 ]. Although health-related QOL instruments are an integral part of the health assessment, for many conditions the changes in health status are too subtle or disease speci fi c to be assessed using the content of a global instrument. In future studies we plan to measure the SN-5 scale in addition to the NOSE scale. The NOSE Scale is a disease-speci fi c QOL instrument designed to assess nasal obstruction, but is validated only in

Con fl icts of interest

There are no con fl icts of interest to disclose among the four authors.

Funding

This research did not receive any speci fi c grant from funding agencies in the public, commercial, or not-for-pro fi t sectors.

References

[1] J.J. Christophel, C.W. Gross, Pediatric septoplasty, Otolaryngol. Clin. North Am. 42 (2) (2009 Apr) 287 – 294 ix . [2] H. El-Hakim, W.S. Crysdale, M. Abdollel, L.G. Farkas, A study of anthropometric measures before and after external septoplasty in children: a preliminary study, Arch. Otolaryngol. Head Neck Surg. 127 (11) (2001 Nov) 1362 – 1366 . [3] I. Béjar, L.G. Farkas, A.H. Messner, W.S. Crysdale, Nasal growth after external septoplasty in children, Arch. Otolaryngol. Head Neck Surg. 122 (8) (1996 Aug) 816 – 821 . [4] I. Tasca, G.C. Compadretti, Nasal growth after pediatric septoplasty at long-term follow-up, Am J Rhinol Allergy 25 (1) (2011 Jan-Feb) e7 – 12 . [5] P.J. Walker, W.S. Crysdale, L.G. Farkas, External septorhinoplasty in children: outcome and e ff ect on growth of septal excision and reimplantation, Arch. Otolaryngol. Head Neck Surg. 119 (9) (1993 Sep) 984 – 989 . [6] L. D'Ascanio, C. Lancione, G. Pompa, et al., Craniofacial growth in children with nasal septum deviation: a cephalometric comparative study, Int. J. Pediatr.

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