“Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?”—A Systematic Review of the Literature

Abstract Corrective septal surgery for children with nasal obstruction has historically been avoided due to concern about the impact on the growing nose, with disruption of midfacial growth. However, there is a paucity of data evaluating complication and revision rates post-nasal septal surgery in the pediatric population. In addition, there is evidence to suggest that failure to treat nasal obstruction in children may itself result in facial deformity and/or developmental delay. The aim of this systematic review is to evaluate the efficacy and safety of septal surgery in pediatric patients with nasal obstruction. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. MEDLINE, Embase, and the Cochrane Library were searched. Original studies in pediatric patients (<18 years of age) with nasal obstruction were eligible for inclusion. Patients with cleft lip or palate as their primary diagnosis were excluded. Our primary outcomes were patient-reported outcome measures (PROMs), postsurgical complications, and revision rates. Secondary outcomes included surgical technique, anatomical considerations, and anthropometric measurements. Eighteen studies were included (1,080 patients). Patients underwent septoplasty, septorhinoplasty, rhinoplasty, or a combination of procedures for nasal obstruction. Obstruction was commonly reported secondary to trauma, nasal septal deviation, or congenital deformity. The mean age of the patients was 13.04 years with an average follow-up of 41.8 months. In all, 5.6% patients required revision surgery and there was an overall complication rate of 7.8%. Septal surgery for nasal obstruction in children has low revision and complication rates. However, a pediatric-specific outcome measure is yet to be determined. Larger prospective studies with long-term follow-up periods are needed to determine the optimal timing of nasal surgery for nasal obstruction in the pediatric population.

Correction of nasal septal deformity before or during adolescence has been a well-established concern in the literature due to the possible adverse impact on midfacial growth and long-term functional and/or aesthetic outcomes. 1asal maturation occurs from designated growth centers and with specific periods of accelerated growth, the two most significant of which are in the first 2 years of life and during puberty. 2 Animal studies dating back to the mid-20th century have supported this notion 3 as well as early descriptions of pediatric septal surgery, in which aggressive techniques such as submucosal resection were employed. 4,5Gilbert and Segal referred to the quadrangular cartilage as a "keystone in [the] development of the cartilaginous vault," warning against its resection prior to completion of nasal growth. 6,7This in turn led to apprehension toward performing nasal surgery before completion of midface development. 6owever, knowledge of the nasal and midfacial growth has advanced over recent decades through animal-based experiments and longitudinal observational studies in children. 3 Later animal studies adopting more conservative techniques describe minimal or no compromise to midfacial growth. 8,9In addition, recent works conclude that nasal surgery can be safely performed in the pediatric patient using conservative techniques that avoid disruption of key structures such as the sphenodorsal and sphenospinal zones of thick cartilage, growth centers driving craniofacial development 10,11 (►Fig.1).Yet controversy remains, with uncertainty surrounding if and when nasal septal surgery should be performed in children/adolescents with nasal obstruction (NO). 12asal septum deformity in pediatric patients ranges from 0.93 to 55% depending on the age and type of deformity reported. 13Most pediatric septal surgeries to date have been performed following destructive pathologies such as nasal abscess, hematoma, or malignancy, as well as in the cleft patient cohort whereby nasal surgery is often completed alongside cleft lip or palate repairs. 11,14][5][6] We aimed to conduct a systematic review to investigate the safety and efficacy of septal surgery in pediatric patients with NO.

Methods
A systematic review was undertaken in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines 15 (►Fig.2).All cohort studies and case series were included.Case reports were excluded.The following databases were searched, and abstracts exported to Covidence (Covidence.org;Melbourne) within which initial screening was performed.PUBMED (OVID Medline), EMBASE, the Cochrane Library, and PROSPERO (University of York) were searched from conception to May 1, 2022 to identify any ongoing research studies.A population, intervention, comparison, and outcome (PICO) framework was used to critically assess papers.
To be eligible for inclusion, studies had to include pediatric patients (<18 years old) who had undergone septal surgery (septoplasty, septorhinoplasty [SRP], and rhinoplasty) for treatment of NO.For studies that had a combination of pediatric and adult articles, data were extracted where possible to allow for the inclusion of pediatric patients only.Where pediatric data could not be isolated, the authors were contacted.Studies where the primary pathology was cleft lip and palate were excluded.Primary outcomes included patientreported outcome measures (PROMs), complication, and revision rates.Secondary outcomes included demographic characteristics and surgical approach/procedure(s).
Two primary researchers (T.H. and I.W.) screened the titles and abstracts independently using Covidence. 16Disagreements were resolved by discussion and a third author (A.N.) was consulted where necessary.All articles that met the inclusion criteria were obtained in full text for further assessment.Data extraction was performed by both primary reviewers independently using a comprehensive, standardized, and piloted extraction template.The authors were emailed when either data were missing or if pediatric patients could not be isolated from the adult patients.Quality assessment was conducted on all included articles following the initial screening and extraction process using the Critical Appraisal Skills Program (CASP) scoring system. 17Bias assessment was completed using the Risk of Bias in Nonrandomized Studies of interventions (ROBINS-I) tool developed by Cochrane. 18,19ata were handled and analyzed using Microsoft Excel version 14.2 for Windows.

Results
In total, 1,043 studies were screened and 18 studies met the inclusion criteria (►Fig. 2).The years of publication ranged from 1993 to 2021.Data were extracted from these articles from both lead authors.From these studies, 1,112 patients were included, 1,080 underwent surgical intervention with 32 patients having nonoperative management, thus acting as controls.There were 7 prospective cohort studies, 1 validation study, and 10 retrospective reviews.No randomized control trials (RCTs) were identified to date.The patients were followed up for an average of 41.8 days (standard deviation [SD] AE 6 months; range: 44 days-10 years; ►Table 1).

Assessment of Bias
Studies were assessed using the ROBINS-I.Overall no RCTs were identified and therefore most of the studies demonstrated a moderate level of bias (see ►Fig. 3).Kawai et al's 32 validation studies and Din et al's 31 high-quality prospective cohort study had lower degrees of bias.Béjar et al, 42 Dispenza et al, 48 and Bae et al 21 were classified as "critical" risk due to issues arising from missing data, cofounding analysis, and selection of participants, respectively (►Fig.3).
In total, 343 (63.4%) and 198 (36.6%) patients had surgery via an open and a closed approach, respectively.Six hundred and forty patients (62.6%) had septoplasty and 268 patients had SRP (26.2%).Sixteen patients had a "Metzenbaum" septoplasty (2.5% of those receiving septoplasty), a surgery that involves removing deviated portions of the anterior quadrangular cartilage.In one study, 111 patients (17.3%) had "quick" septoplasty via a single tunnel on the left side of the septal cartilage, preserving the mucoperichondrium on one side. 20Thirty-eight patients (5.9%) had septoplasty in conjunction with bilateral inferior turbinate reduction surgery.In only one study, 64 patients (6.3%) had rhinoplasty, of which 57 (89.1%) had adjuvant septal reconstruction.In two studies, the surgical procedure was not specified (►Tables 1 and 2).

Outcomes and Complications
Eleven studies reported complications and seven studies reported revision rates.Of the studies reporting complications, epistaxis was the most reported complication (27/  Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al.
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Discussion
The growing cartilaginous septum of the nose is a significant organizer of the developing facial skeleton 22 and thus surgical treatment for NO secondary to NSD in pediatric patients has historically been delayed until adulthood.However, there have been reports that children with uncorrected NSD and obligate mouth breathing can develop facial and dental anomalies in comparison to controls, 23 with such deformities becoming heightened with growth, increasing the incidence of sinonasal disease in later life. 24hile absolute indications for pediatric nasal surgery include malignancy, septal hematoma, and abscess formation, to date NO has been seen as a relative indication for surgical management, despite its impact upon sleep, development, and schooling, all of which affect later physical, social, and mental health. 25The paucity of well-designed clinical studies looking at the long-term outcomes of pediatric septal surgery may deter clinicians from undertaking the procedure in children, even in cases of severe NO.

Improvement in Patient Symptoms
Objective assessments of pediatric septoplasty have rarely been reported in the literature.In this review, nasal airflow studies (head-out volume displacement body plethysmograph), PNIF rates, and active anterior rhinometry [26][27][28] were used to demonstrate clinically significant  Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al.
This document was downloaded for personal use only.Unauthorized distribution is strictly prohibited.Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al.
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improvements in NO postseptoplasty 29 (►Table 3).One study (not meeting inclusion criteria) assessed the minimal cross-sectional areas (MCSA) and total volume (TV) in patients who had either anterior or posterior obstruction or both (following previous septoplasty) against a control group, demonstrating significant postoperative benefit (p < 0.005, paired t-test and analysis of variance [ANOVA]). 30ssessment of surgical outcomes has shifted from objective mortality and morbidity measures toward the use of PROMs.Tools such as the NOSE scale have been validated for use in pediatric patients 31,32 and Manteghi et al demonstrate improvements in disease-specific quality of life in pediatric patients who had either septoplasty or functional SRP. 33oreover, Lee et al show improvement in the SN-5 and VAS scores for pediatric patients after septoplasty 34 (►Table 4).
These findings strengthen support for the rationale that nasal surgery in pediatric populations is effective and safe.However, there lacks a uniform measure to assess outcomes in children with NO undergoing septal surgery; this review highlights the need for a pediatric-specific PROM that is both valid and reliable.

Safety
Eleven of 18 studies in this review commented on postoperative complications and 7/18 reported revision rates.The authors find an epistaxis rate of 4.2%, similar to the rate of 6% reported in the adult population. 35,36Yet epistaxis is more significant in children due to their smaller circulating volumes.Indeed, a study of 175 children with epistaxis found that 20.6% of 131 pediatric patients who had laboratory testing were anemic, with the median age being statistically younger (p ¼ 0.001) when compared with those with normal laboratory results and to those with abnormal coagulation studies. 37Similar trends are noted by Elden et al. 38 Our review illustrates lower infection (1/650) and perforation (1/650) rates in children in comparison to those reported post-nasal septal surgery in adult populations 35,36 (►Table 1) and a revision rate of 5.6%.While not included in this review, in their large retrospective cohort analysis, Spataro et al quote a revision rate of 3.3% of 842 patients undergoing SRP. 39The authors found that patients aged 13 to 18 years were more likely to undergo revision surgery (5.9%) in comparison to their adult counterparts, which corresponds to our overall revision rate.Corroborating these findings, Bishop et al find that septoplasty performed in patients under the age of 14 years is associated with higher revision rates. 40This contrasts with findings from Adil et al whereby no patient (<16 years) required a revision procedure. 41It is important to note that some of these patients will require further surgery, which can be more complex and have greater complications.

Impact on Midfacial Growth
The seven anthropometric studies included in this review do not report significant distortion in midfacial growth as a result of pediatric septal surgery for NO.There are conflicting findings regarding the impact of pediatric septoplasty on the Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al.
This document was downloaded for personal use only.Unauthorized distribution is strictly prohibited.Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al.Costa et al 44 highlighted that in most cases, anthropometric measures were within normal range and patient satisfaction was high 44 (►Table 5).It is difficult to compare the anthropometric studies given the variation in the exact measures used, the time points pre-and postoperatively, as well as surgical approach (open vs. endonasal).Moreover, some studies did not perform statistical analysis on their data 44 (►Fig. 4).
This review theorizes that by respecting the structures guiding nasal and midfacial growth, pediatric septal surgery can be performed safely via either external or endonasal approaches.However, the significance of anthropometric variation on midfacial growth and later development remains to be elucidated.

Surgical Technique to Minimize Risk
It has been theorized that the long-lasting impact of pediatric septoplasty on midfacial growth has a lot to do with surgical technique, including cartilage preservation with its sphenospinal and sphenodorsal growth zones 10,45,46 as well as dorsal preservation and protection of the septospinal ligament. 10iven the small internal and external dimensions of the pediatric nose, an open approach offers maximal exposure to the nasal tip as well as cartilaginous and bony vaults. 21owever, Tasca and Compadretti, 47 Costa et al, 44 and Ori et al 29 all support a closed, conservative approach.Indeed Ori et al favor a "quick septoplasty" technique (a conservative endonasal procedure), reporting excellent outcomes with improvement in nasal breathing and cephalometric parameters on follow-up at the age of 18 years. 29In addition, Dispenza et al 48 and Yilmaz et al 27 advocate for the use of the hemitransfixation incision approach, another conservative approach, maintaining mucoperichondrium integrity.
0][51] Future work must be directed at understanding the genetic and environmental factors that affect nasal growth to develop a safe surgical technique for pediatric septoplasty.

Limitations
Despite rigorous assessment of the literature, significant heterogeneity between studies in this review in terms of patient population, age, surgical indication, technique, and outcome measures made comparison between cohorts challenging.In addition, data were lacking regarding the age of the patients at the time of surgery, observed deformities, and surgical procedure(s) performed.
This review highlights the need for prospective trials with long-term follow-up periods to gain consensus on whether surgical intervention for pediatric NO is safe and effective.Seven of the 18 studies in this review use anthropometric indices as outcome measures.However, standardization of the anthropometric methods is needed to facilitate direct comparison. 52In addition, studies used North American White (NAW) data to draw conclusions despite demographic variations in their cohorts.It remains to be elucidated if normative NAW anthropometric data can be universally applied across patient groups, irrespective of the ethnic or demic heritage of patient populations.
Another methodological limitation was the use of callipers as well as two-dimensional (2D) photogrammetry to obtain facial data, assessment of which is subjective and fraught with human error. 53More recently, 3D laser and digital scanning has been used to measure body composition. 46,54Such technology could be utilized in future to offer precise, individualized measurements of craniofacial indices or even predict growth and facial development.
While revision rates are reportedly low in this review, this may well be in part due to short follow-up periods.For example, the Lee et al study had a follow-up period of only 44 days 34 and Tasca and Compadretti report a revision rate of 0%, despite four patients being referred for revision surgery at the time of publication. 47ROMs are now routinely used in the assessment of surgical interventions, evaluating the patient experience as well as providing objective evidence of benefit to incentivize policymakers.Despite increasing used of PROMs in pediatric surgery, validated and individualized tools are absent. 55hile the NOSE score was utilized in 6/18 studies, answers may be influenced by the children's maturity and psychological development.

Conclusion
This review provides tentative evidence that nasal septal surgery for pediatric NO can be performed safely and effectively, highlighting the need to weigh up the risks of surgery with the benefit of early treatment of pediatric NO.Large prospective studies with long follow-up of nasal form and function, at least till after the adolescent growth spurt, will be paramount in corroborating our findings.
In addition, further studies evaluating child self-reporting with inclusion of patients and families in PROM development and selection are needed to develop a gold standard outcome measure for use in the pediatric population.

Fig. 2
Fig. 2 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) flowchart.

Fig. 3
Fig. 3 Risk of Bias in Non-randomized Studies of interventions ((ROBINS-I) tool demonstrating the risk of bias for included studies.

Fig. 4
Fig. 4 Anthropometric and cephalometric measurements used in the included studies.

Table 1
All studies included in this systematic review with patient demographics and type of study (mean age of 13.04 years, with a total of 1,080 patients undergoing septal surgery) Facial Plastic Surgery © 2024.Thieme.All rights reserved.Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al.This document was downloaded for personal use only.Unauthorized distribution is strictly prohibited.

Table 1 (
Continued) Abbreviations: A, position of deepest concavity on the anterior profile of the maxilla; al, alar rim; AAR, anterior active rhinomanometry; B, position of deepest cavity on the anterior profile of the mandibular symphysis; c', apex of the columella; GCBI, Glasgow children's benefit inventory; gn, gnathion (menton; most inferior soft-tissue contour point of the chin); Me, menton; n/N, nasion (midpoint of the nasofrontal suture line); NO, nasal obstruction; NS, not stated; NSD, nasal septal deviation; Percent NH, (N-palatal plane)/(N-Me); PedsQL, Pediatric Quality of Life Inventory; Pg, pogonion; prn, pronasale (most protruding point of the nasal tip); S, sella; sn, subnasale (midpoint of the base of the columella); sn', columella edge; SN-5, Sinus and Nasal Quality of Life Survey; SRP, septorhinoplasty; sto, stomion; VAS, visual analog scale; zy, zygion.Facial Plastic Surgery © 2024.Thieme.All rights reserved.Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al.This document was downloaded for personal use only.Unauthorized distribution is strictly prohibited.

Table 2
Patient-reported outcome measures from six selected studies, indicating the different outcome measures used and the NOSE score comparisons Abbreviations: NOSE, Nasal Obstruction Symptom Evaluation; VAS, visual analog scale.Facial Plastic Surgery © 2024.Thieme.All rights reserved.

Table 3
Anthropometry measures from relevant studies included in this review reporting the pre-and postoperative means and standard deviations (SDs) with p-values Facial Plastic Surgery © 2024.Thieme.All rights reserved.Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al.This document was downloaded for personal use only.Unauthorized distribution is strictly prohibited.

Table 3 (
Continued) Facial Plastic Surgery © 2024.Thieme.All rights reserved.Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al.This document was downloaded for personal use only.Unauthorized distribution is strictly prohibited.

Table 3 (
Continued) Abbreviations: A, position of deepest concavity on the anterior profile of the maxilla; al, alar rim; B, position of deepest cavity on the anterior profile of the mandibular symphysis; c', apex of the columella; gn, gnathion (menton; the most inferior soft-tissue contour point of the chin); Me, menton; n/N, nasion (midpoint of the nasofrontal suture line); NS, not stated; percent NH, (N-palatal plane)/(N-Me); Pg, pogonion; prn, pronasale (most protruding point of the nasal tip); S, sella; sn, subnasale (midpoint of the base of the columella); sn', columella edge; sto, stomion; zy, zygion.Ã results where statistical significance was demonstrated.Facial Plastic Surgery © 2024.Thieme.All rights reserved.

Table 4
Comparison between the different objective outcome measure used.Three different measures were used in the different included studies with one study demonstrating significance(Ori et al 29 Facial Plastic Surgery © 2024.Thieme.All rights reserved.

Table 5
Surgical indications, approach, and technique(s)Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al. document was downloaded for personal use only.Unauthorized distribution is strictly prohibited.

Table 5 (
Continued)Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?Howard et al.
Abbreviations: NO, nasal obstruction; NS, not specified; NSD, nasal septal deviation; OM, otitis media; SRP, septorhinoplasty.Facial Plastic Surgery © 2024.Thieme.All rights reserved.This document was downloaded for personal use only.Unauthorized distribution is strictly prohibited.
21,47document was downloaded for personal use only.Unauthorized distribution is strictly prohibited.nasaldorsallength, with Béjar et al42and El-Hakim et al43reporting an overall reduction, while Tasca and Compadretti and Bae et al do not replicate this trend.21,47