Pediatric septoplasty

What repeats

Five findings that hold across the literature.

The fear came from animal work, and it was about how much was taken

Controversy has surrounded the operation since the 1950s. In growing rabbits, Killian-type partial resections of the cartilaginous septum were compared: larger resections in young animals produced a shorter, lower nose in the adult animal, while partial resection of the basal rim had no effect on growth of the nasal dorsum. The dorsum grows from a thick band of cartilage running from the sphenoid to the dorsum, which is the band a conservative operation leaves alone.

Rests on: Lawrence, review of the literature · Meeuwis et al., rabbit model.

The human reviews do not find growth harmed

A systematic review of midfacial growth after pediatric septoplasty found eight publications and none reported major disturbances in facial growth, with minor nasal anomalies noted by four authors. Three long-term follow-up studies using anthropometric measurement concluded the operation does not interfere with normal nasal or facial development. A 1981 series of 44 patients operated on between 8 and 12 years of age and followed for five to eight years found nasal and facial growth unaltered.

Rests on: Calvo-Henríquez et al., systematic review · Lawrence · Ortiz-Monasterio and Olmedo, long-term follow-up.

Complications and revisions are uncommon after septoplasty in children

Eighteen studies covering 1080 children with a mean age of 13.04 years and mean follow-up of 41.8 months reported a revision rate of 5.6% and an overall complication rate of 7.8%. A larger meta-analysis of 23 studies and 27,840 patients separated the three operations: septoplasty had the highest age at surgery and low complication and revision rates, septorhinoplasty had the youngest age at surgery with high complication and revision rates, and rhinoplasty had high complications with low revision rates.

Rests on: Howard et al., systematic review · Patel et al., meta-analysis.

Symptom scores improve and hold through the first year

In 136 patients with a mean age of 15.7 years, the median NOSE score fell from 75 before surgery to 20 after septoplasty and to 15 after functional septorhinoplasty. Sex, age, nasal trauma, prior nasal surgery and allergic rhinitis did not change the size of the gain. Four hundred and twenty-two patients were surveyed in a second series. NOSE fell from 67 before surgery to 16, 13, 16 and 23 at one, three, six and twelve months, and the Sinonasal-5 Likert score from 3.4 to 1.9, 1.6, 1.6 and 2.0 over the same period. The only statistically significant predictor of a poorer outcome was previous nasal surgery.

Rests on: Manteghi et al., quality of life study · Frank et al., durability · Din et al., NOSE psychometrics.

Not operating has consequences of its own

Children with a symptomatic uncorrected deviated septum had a statistically significant increase in facial and dental anomalies compared with age and sex matched controls. Failure to correct a significant nasal deformity may itself cause dysmorphic facial growth through obligate mouth breathing. On that reading, delaying an indicated septoplasty carries a growth risk rather than avoiding one.

Rests on: Lawrence · Gary, timing and technique.

By age and by what is being corrected

The same operation is a different decision at four, at ten and at sixteen.

The septum is straighter in the youngest children

Computed tomography and magnetic resonance scans from 81 patients were divided into four age groups and the septum measured for tortuosity. Children under five years old had significantly less tortuosity than older children and adults, which points away from a purely congenital cause and toward deviation developing as the septum grows.

Rests on: Reitzen et al., pediatric and adult deviation.

A caudal deviation in a child

Twenty-nine children aged four and older had batten grafts placed for caudal septal deviation. The mean NOSE score fell from 86.03 before surgery to 12.76 at six months, and the visual analogue score rose from a median of 3 to 9 at one month and held at six. No complications occurred in 75.9%, with nasal crusting and residual deviation the reported minor effects.

Rests on: Alshehri, batten grafts in children · and the caudal septum.

A severe deviation with a crooked nose

Fifty-four children aged 6 to 15 with severe anterior deviation and external nasal deformity were treated with an endonasal dorsum-preserving extracorporeal technique. Mean follow-up was 24 months, all patients and parents reported functional and aesthetic satisfaction, there were no major complications and no patient needed revision surgery.

Rests on: Guliyev and Erbek, pediatric extracorporeal technique · and extracorporeal septoplasty.

Rhinoplasty rather than septoplasty

Sixty-four Korean children aged 4 to 17 followed for a mean of 59 months had rhinoplasty for a deviated nose, nasal bone fracture, a flat nose, a mass and other reasons. Seventeen, 26.6%, were dissatisfied with the appearance, eight, 12.5%, had difficulty breathing afterwards, six, 9.4%, had revision surgery and four, 6.3%, were considering one. The authors conclude that surgeons should be conservative and apply strict indications.

Rests on: Bae et al., pediatric rhinoplasty · Johnson, management of pediatric nasal surgery.

Cleft lip and palate

Primary septoplasty at cleft lip repair was excluded for decades over the same growth concern. A scoping review of 23 articles finds that primary septoplasty improves nasal function and preserves midfacial growth, and traces the shift in opinion through competing anatomical theories of the septum's role in growth.

Rests on: Lam et al., septoplasty at primary cleft lip repair.

What to ask about septoplasty in a child

Questions the evidence supports asking.

Does this have to happen now

Timing is the open question in every review, and no optimal age has been established. Ask what changes if the operation waits, and whether the child is mouth breathing.

Rests on: Patel et al. · Gary.

How much cartilage is coming out

The animal work separates a large resection from a conservative one, and the conservative one left dorsal growth alone. Ask what will be removed, what will be repositioned, and whether the dorsal strut is being kept.

Rests on: Meeuwis et al. · Guliyev and Erbek.

Is this a septoplasty or a septorhinoplasty

The pooled data separate them. Septoplasty carried low complication and revision rates, septorhinoplasty was performed at the youngest ages with high complication and revision rates.

Rests on: Patel et al. · Bae et al. · and open versus closed rhinoplasty.

How will the result be measured

The NOSE scale has been tested in children aged 8 to 18 and shows high internal consistency, with a Cronbach's alpha of 0.83. The Sinonasal-5 is used alongside it. Ask for a score before surgery and at each visit afterwards.

Rests on: Din et al. · Frank et al..

Are the turbinates being touched as well

The evidence for turbinate reduction in children is weaker than for the septum. Eleven studies covering 730 cases used outcome measures that could not be compared, and the long-term effects on nasal airflow and physiology remain unstudied.

Rests on: Leong et al., turbinate surgery in children · and turbinate surgery.

The terms, defined

The words used about this operation.

• Pediatric septoplasty: straightening the septum in a patient under 18. [38035612]
• Septorhinoplasty: septal surgery combined with reshaping the outside of the nose, done at the youngest ages in the pooled data and carrying the highest complication and revision rates. [40763773]
• Midfacial growth: growth of the middle third of the face, the outcome the systematic reviews set out to measure. [32200434]
• Submucous resection: removing cartilage from under the lining, the Killian-type operation tested in the rabbit model. [8517143]
• Anthropometric measurement: measuring the face directly or from standardised photographs, the method behind the long-term growth studies. [22595463]
• Tortuosity: the ratio of the actual length of the septum to a straight line from top to bottom, used to grade deviation on scans. [21412740]
• Obligate mouth breathing: breathing through the mouth because the nose will not pass air, named as a cause of dysmorphic facial growth. [28509670]
• NOSE scale: the Nasal Obstruction Symptom Evaluation, validated for children aged 8 to 18. [31818184]
• Sinonasal-5: a five-item pediatric sinonasal questionnaire reported alongside NOSE. [41085051]
• Batten graft: a stiff strip fixed alongside the caudal septum, used in children as in adults. [40126620]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what the surgeon should assess and record before operating, at any age.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries chapters on septal surgery in children and on rhinoplasty in children. They are written for surgeons and go further into technique than a patient page should.

• Pediatric Septoplasty
• Rhinoplasty in Children
• Surgical Treatment of Nasal Obstruction in Rhinoplasty

The reference summary

Septoplasty in StatPearls, Nasal Septal Fracture in StatPearls and Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, give the anatomy, the indications and the complication list in full text at no charge. Septal fracture is the common route into a childhood deviation.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

What is not settled

• The growth evidence does not rise above level C. Eight studies, none finding major disturbance, and none designed to detect a small one. [32200434]
• One review notes a study concluding that external septoplasty does not affect most aspects of nasal and facial growth but may negatively influence growth of the nasal dorsum. [22595463]
• The optimal age for each operation has not been determined. [40763773]
• Long-term data are thin. In the largest durability series only 24 patients had follow-up beyond a year, where the NOSE score was 32 at an average of 30 months against 23 at 12 months. [41085051]
• No pediatric-specific outcome measure has been agreed. [38035612]
• Pediatric rhinoplasty is a separate risk profile: 26.6% aesthetic dissatisfaction and 9.4% revision in one 64-patient series with 59 months of follow-up. [23958392]
• Most reviews advocate operating from age six and older, and whether earlier correction is safe has not been tested. [22595463]