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Received: 8 March 2024 Revised: 10 June 2024 Accepted: 13 June 2024 DOI: 10.1002/alr.23397 REVIEW ARTICLE American Rhinologic Society Expert Practice Statement: Indications and Recommendations for Septoplasty in Children Austin S. Rose MD, MBA1 Chadi A. Mak...

Received: 8 March 2024 Revised: 10 June 2024 Accepted: 13 June 2024 DOI: 10.1002/alr.23397 REVIEW ARTICLE American Rhinologic Society Expert Practice Statement: Indications and Recommendations for Septoplasty in Children Austin S. Rose MD, MBA1 Chadi A. Makary MD2 Zachary M. Soler MD3 Adam J. Kimple MD, PhD1 Aaron N. Pearlman MD4 Uma S. Ramaswamy MD5 Michael Setzen MD4 David A. Gudis MD6 1 Department of Otolaryngology—Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA 2 Department of Otolaryngology—Head & Neck Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA 3 Department of Otolaryngology—Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA 4 Department of Otolaryngology—Head & Neck Surgery, Weill Cornell Medical College, New York, New York, USA 5 Department of Otolaryngology—Head & Neck Surgery, Baylor College of Medicine, Houston, Texas, USA 6 Department of Otolaryngology—Head & Neck Surgery, Columbia University School of Medicine, New York, New York, USA Correspondence Chadi A. Makary, Department of Abstract Otolaryngology-Head & Neck Surgery, The goal of this American Rhinologic Society Expert Practice Statement (EPS) West Virginia University School of Medicine, Morgantown. is to provide recommendations and guidance through evidence-based consensus Email: [email protected] statements regarding pediatric septoplasty. This EPS was developed following the previously published methodology and approval process. The topics of interest included appropriate indications, safety and efficacy, timing, relevant quality of life instruments, and surgical techniques. Following a modified Delphi approach, six statements were developed, five of which reached consensus and one that did not. These statements and accompanying evidence are summarized along with an assessment of future needs. KEYWORDS children, nasal obstruction, nasal septal deviation, nasal septoplasty, pediatric 1 INTRODUCTION safely and effectively when necessary with minimal impact on craniofacial development if performed with meticu- Despite decades of concern regarding the impairment of lous surgical techniques.1,2–11 Pediatric septoplasty may nasal and midfacial growth, more recent literature sug- be indicated for congenital or traumatic deformity, nasal gests that nasal septoplasty appears safe in children when septal abscess, significant nasal obstruction due to septal indicated. A number of clinical studies from the late 1980s deviation, and exposure when necessary during functional through the present have demonstrated minimal long- endoscopic sinus surgery (FESS) and endoscopic skull base term effects on nasal or facial growth using anthropomet- surgery (ESBS) with evidence for improved quality of life ric measurements and cephalometric data. A growing body (QOL) based on validated instruments.12–17 Septoplasty in of evidence suggests that septoplasty may be performed children may be more surgically challenging than in adults Int Forum Allergy Rhinol. 2024;1–12. wileyonlinelibrary.com/journal/alr © 2024 ARS-AAOA, LLC. 1  20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23397 by Lib Herzen - HINARI - ARGENTINA , Wiley Online Library on [20/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 2 ARS PEDIATRIC RHINOLOGY COMMITTEE EPS patients and recommended techniques specific to children as any score ≥2.0 Likert points from the mean in either warrant review. direction).24 A statement was categorized as reaching near Pediatric nasal obstruction can significantly impact a consensus if a mean score of ≥6.50 was achieved with child’s QOL and contribute to other disease processes no more than two outliers.24 Those statements that did including obstructive sleep apnea. Historically, otolaryn- not meet the criteria of either category were classified as gologists were concerned that performing a septoplasty for not having reached consensus.24 After two iterations of deviated nasal septum (DNS) in the pediatric population this Delphi survey, five of the statements reached consen- could impact normal craniofacial skeletal development. sus and one did not (see Table 1). These statements and However, evidence that nasal obstruction from any cause accompanying evidence are summarized below. Aggregate may lead to obligate mouth breathing, which has itself grade of evidence is based on the Agency for Healthcare been associated with dental malocclusion and abnormal- Research and Quality scale of research grades and levels ities of craniofacial development, may have offset prior (see Addendum I). concerns.18–20 DNS specifically has also been shown to be associated with craniofacial and dental anomalies.21,22 Recent evidence suggests that septoplasty, often along with 3 EXPERT PRACTICE STATEMENTS an inferior turbinate reduction, is effective in treating WITH SUMMARY OF EXISTING pediatric nasal obstruction without resulting in significant EVIDENCE craniofacial growth abnormalities.1–11 3.1 Pediatric septoplasty: effect on facial growth 2 MATERIALS AND METHODS 3.1.1 Statement 1 (consensus = mean score This EPS was developed with methodology previously 8.50) described in a separate publication which involves the fol- lowing steps: (1) declaration of intent and idea proposal Septoplasty is both technically feasible and safe in chil- approval; (2) creation of a working group; (3) systematic dren, with available evidence suggesting minimal signifi- and transparent EPS production methodology to ensure cant impact on nasal and midfacial growth. consistency and high quality; (4) review and prelimi- nary approval of EPS; (5) legal review; (6) opportunity for comments from the American Rhinologic Society (ARS) 3.1.2 Aggregate grade of evidence: grade B membership at large; (7) integration of public comments and final revisions; (8) final approval by the ARS Board Benefit: Improved and more timely treatment of nasal of Directors; (9) submission for publication consideration obstruction due to septal deviation in children. Avoidance in the International Forum of Allergy and Rhinology; of malocclusion associated with septal deviation, chronic and (10) public posting on the ARS website.23 The work- sinusitis, obstructive sleep apnea, and facial asymmetry. group for this EPS statement was comprised of eight ARS Harm: Possible minor reductions in nasolabial angle, members, five of whom are members of the ARS Pedi- dorsal length, and nasal tip protrusion, which are primar- atric Rhinology Committee. Evidence was based in part ily associated with open surgical approaches. Possible need on a 2020 systematic review, supplemented by an updated for further surgery, including revision septoplasty. systematic literature search to capture recently published Cost: Surgical and anesthesia costs. studies.1 A series of six statements addressing septoplasty Benefit–harm assessment: Preponderance of benefit over in children was initially drafted by the EPS workgroup. harm. The choice of topics to address in the statements was Value judgment: Potential benefits of septoplasty in chil- decided based on the gaps and controversies in the litera- dren outweigh the risks of minor impacts on nasal growth ture and after discussion with the work group members. and associated costs and risks of surgery. Each member was then asked to score each statement Early animal studies appear to have had an outsized using a nine-point Likert scale: 1 = strongly disagree, influence on the otolaryngology community’s understand- 3 = disagree, 5 = neutral, 7 = agree, and 9 = strongly agree. ing of nasal septal development. In 1858 in Germany, The surveys were disseminated, responses were aggregated Fick demonstrated that nasal septal resection in growing and analyzed, and results were distributed to the pan- animals resulted in a shortened hard palate.25 In 1929, elists for discussion via teleconference. A statement was Landsberger found that nasal septal resection resulted in considered to have reached consensus if a mean score of hard palate elevation.26 In 1966, a study in growing rab- ≥7.00 was achieved with no more than one outlier (defined bits found that resection of both the cartilaginous septum  20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23397 by Lib Herzen - HINARI - ARGENTINA , Wiley Online Library on [20/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ROSE et al. 3 TA B L E 1 Expert Practice Statement (EPS) consensus statements. Final EPS statements Mean score outcome Impact on growth: Septoplasty is both technically feasible and safe in children, with 8.5 Consensus available evidence suggesting no significant impact on nasal and midfacial growth Indication: Septoplasty is indicated in children with nasal obstruction due to 8.5 Consensus significant septal deviation Surgical access: Septoplasty is indicated in pediatric endoscopic sinus and skull base 8.75 Consensus cases where there is a need for better instrument access and improved visualization Impact of delayed or non-treatment: The impact of nasal airway obstruction due to 8.25 Consensus septal deviation on midfacial growth, chronic mouth breathing, obstructive sleep apnea, malocclusion, and facial asymmetry should be considered when evaluating a pediatric patient for septoplasty Quality of life: There is strong evidence to support that septoplasty is effective in 8 Consensus children including significant improvements in quality of life Specialized instrumentation and care: Septoplasty in children requires specialized 5.5 No consensus instrumentation and perioperative care and mucoperichondrium resulted in underdevelopment more conservative procedure, with minimal and more tar- of the nasal and premaxillary bones, with the extent and get resection of deviated septal cartilage, demonstrated no severity of deformity proportional to the extent of the significant difference from controls (see Table 2). septal defect.27 However, more recent animal studies sub- In summary, although early animal studies showed sequently found that submucous cartilage resection did potential negative impacts of septoplasty on facial growth, not seem to impact craniofacial development.2,3 data from more recent studies in humans are more reassur- In the subsequent decades following these early animal ing with minimal negative impact mostly associated with studies, emerging evidence in the otolaryngology litera- external septoplasty approaches. ture began refuting the claim that pediatric septoplasty impairs craniofacial development. Several such studies were reported using an external open septoplasty tech- 3.2 Indications for pediatric nique. Jugo first reported that external septoplasty did septoplasty: Nasal obstruction not significantly alter craniofacial growth, although the analysis was limited to subjective visual assessment.4 3.2.1 Statement 2 (consensus = mean score More rigorous and objective anthropomorphic studies 8.50) of external septoplasty outcomes had similar findings. Béjar et al. performed an anthropomorphic analysis of 28 Septoplasty is indicated in children with nasal obstruction children following external septoplasty compared to nor- due to significant septal deviation. mative data, and reported minimal differences between the two groups.5 El-Hakim et al. then reported pre- and post- operative anthropomorphic measurements of 26 children 3.2.2 Aggregate grade of evidence: grade B following external septoplasty. Postoperatively, the nasal dorsum length and tip protrusion were decreased but not Benefit: Improved treatment of significant nasal obstruc- to a statistically significant degree.6 In a study of endonasal tion due to septal deviation in children. Recognition of pediatric septoplasty, Tasca and Compadretti reported nasal obstruction due to significant septal deviation as an long-term anthropometric measurements in 44 children important indication for septoplasty in children. compared to normative values with a mean follow-up of Harm: Possible minor reductions in nasolabial angle, 12.2 years (range: 6.5–14.4 years).7 While no significant dorsal length, and nasal tip protrusion, which are primar- differences were noted for 10 of 11 measured parameters, ily associated with open surgical approaches. Possible need there was a significant reduction in nasolabial angle for for further surgery, including revision septoplasty. both male and female subjects that underwent extracor- Cost: Surgical and anesthesia costs. poreal septoplasty in which the quadrangular cartilage Benefit–harm assessment: Preponderance of benefit over was removed and repositioned. Children that underwent a harm.  20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23397 by Lib Herzen - HINARI - ARGENTINA , Wiley Online Library on [20/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 4 ARS PEDIATRIC RHINOLOGY COMMITTEE EPS T A B L E 2 Evidence summary table—septoplasty in children (Oxford Centre for Evidence-Based Medicine Levels of Evidence, 2009—see Addendum II). Study Year LOE Study design Study group Clinical endpoint Conclusion Fick25 1858 4 Animal surgery to resect Dogs, cats, pigs, Palate Resection of septum results caudal septal cartilage; and goats measurements in shortened palate in autopsy animals Landsberger26 1929 4 Dog surgery to resect caudal Dogs Palate Resection of septum results septal cartilage; autopsy measurements in higher hard palate in dogs Sarnat and 1966 4 Rabbit septal resection and Rabbits Snout Extent of septal cartilage Wexler27 autopsy measurements measurements resection correlates to extent of facial deformity Bernstein2 1973 4 Dog septal resection and Dogs Snout and midface Septal resection does NOT autopsy measurements measurements impact snout/midface growth Cupero et al.3 2001 3B Ferret septal resection and Ferrets Cephalometry Septal resection does NOT cephalometry impact facial growth Jugo4 1987 4 Total septal reconstruction Children Descriptive Total septal reconstruction (extracorporeal septoplasty) in functional and in children yields good children cosmetic outcome functional/cosmetic without defined outcomes metrics Béjar et al.5 1996 3B Cephalometry in children who Children Cephalometry External septoplasty does had undergone external not affect most septoplasty measurements of nasal and facial growth, but may shorten nasal dorsum El-Hakim et al.6 2001 3B External septoplasty with pre- Children Cephalometry External septoplasty does and postoperative not affect development of cephalometry the nose and midface Tasca and 2011 3B Cephalometry in people who Mostly adults Cephalometry Endonasal septoplasty does Compadretti7 had undergone endonasal (mean f/u not affect development of septoplasty during childhood following surgery the nose and midface of 12.2 years) Calvo-Henríquez 2020 2A Systematic review assessing Children Anthroposcopy and None of the eight selected et al.1 outcomes (anthroposcopy and anthropometry papers found major anthropometry) of nasal and disturbances in facial midfacial growth in children growth after septoplasty or undergoing septoplasty or septorhinoplasty in septorhinoplasty pediatric patients Value judgment: Potential benefits of septoplasty in chil- in the pediatric population differ from adults and may dren outweigh the risks of minor impacts on nasal growth change during development. and associated costs and risks of surgery. Specifically in neonates and children less than 2 years Nasal obstruction is one of the most common indica- old, congenital causes of pediatric nasal obstruction tions for septoplasty in adults and children. A comprehen- should be ruled out including: choanal atresia (unilat- sive history and physical examination are the first steps eral or bilateral), pyriform aperture stenosis, midline in identifying patients who might benefit from surgery. In nasal masses, and nasolacrimal duct cysts.28 Septal devi- children, history should include laterality of symptoms, ation can be noted in neonates due to birth trauma and timing of symptoms, history, and laterality of epistaxis, studies have demonstrated a higher rate of septal devi- sleep function (snoring, frequent arousals, enuresis, etc.), ation in vaginal deliveries than in cesarean sections.29 cough, recurrent respiratory infections, and growth and Typically, neonatal septal deviation is managed with development. The work-up and indications for septoplasty observation but in more severe cases with respiratory  20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23397 by Lib Herzen - HINARI - ARGENTINA , Wiley Online Library on [20/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ROSE et al. 5 or feeding difficulties, early closed reduction may be 3.3.2 Aggregate grade of evidence: grade C beneficial.30 In children older than 2 years of age, congenital causes Benefit: Better visualization and access, with improved of nasal obstruction become less likely while inflammatory safety and effectiveness in pediatric endoscopic sinus and and infectious etiologies become more common. Despite skull base surgery. this shift in prevalence, it remains important to rule out Harm: Possible minor reductions in nasolabial angle, congenital causes. A complete head and neck examination dorsal length, and nasal tip protrusion, which are primar- should be performed specifically assessing for epiphora, ily associated with open surgical approaches. Possible need external asymmetry, adenoid facies, or lymphadenopathy. for further surgery, including revision septoplasty. Anterior rhinoscopy and nasal endoscopy should ideally Cost: Surgical and anesthesia costs. be performed to determine the cause of the nasal obstruc- Benefit–harm assessment: Preponderance of benefit over tion, assess adenoid hypertrophy, and evaluate for any harm. component of inferior turbinate hypertrophy as a con- Value judgment: Potential benefits of septoplasty in chil- tributing factor. A plain lateral radiograph of the neck may dren for improved safety and effectiveness in pediatric also be considered to, if necessary, to rule out significant endoscopic sinus and skull base cases outweigh the risks adenoid hypertrophy as a contributing factor. Optimizing of minor impacts on nasal growth and associated costs and management of allergic rhinitis when indicated prior to risks of surgery. considering surgical interventions is warranted. Recent literature largely supports the safety of FESS and When indicated, it is important to optimize man- ESBS in the pediatric population. Prior concerns of these agement of any component of allergic rhinitis prior to surgeries affecting midface growth and development in considering surgical interventions. A trial of nasal saline children have been allayed.8–11 spray/rinse, intranasal corticosteroids, and intranasal Clinical practice guidelines recommend FESS in pedi- and/or systemic antihistamines are generally recom- atric patients with chronic rhinosinusitis or recurrent mended. While this treatment is well tolerated in adults, acute sinusitis who have failed appropriate medical ther- compliance with topical regimens in pediatric populations apy with or without adenoidectomy.31 It is well accepted is generally lower. If there is no improvement after opti- that septoplasty in the setting of FESS helps improve visu- mal medical management and nasal endoscopy is unable alization and instrumentation, as well as postoperative to be performed in the clinic, it may be necessary to care.32 Although concurrent septoplasty and sinus surgery perform nasal endoscopy in the operating room poten- does not affect chronic sinusitis health-related QOL or tially in conjunction with an inferior turbinate reduction symptom outcomes in the adult population, septoplasty and/or adenoidectomy. In patients who are unable to is commonly performed when concurrent correction of tolerate nasal endoscopy in the clinic setting, especially DNS or resections of septal spurs help with instrumenta- young children, this allows one to assess for response tion, visualization, and postoperative nasal patency.33 High to other treatments prior to considering a septoplasty. In septal deviations can inhibit access to the frontal sinus older, cooperative children, clinic-based nasal endoscopy making instrumentation in an already complex procedure should be used to help guide a surgical plan. There are increasingly difficult. In cases of allergic fungal sinusitis, no universally agreed upon objective measures to use as septal spurs or deviations can make adequate evacuation an indication for septoplasty in either adults or children. of inspissated, eosinophilic mucin from the sinuses more However, a higher degree of septal deviation and associ- burdensome. Similarly, if left unaddressed, septal devia- ated reduction of nasal airway on examination is likely to tion can make postoperative debridement more difficult, correlate with more significant benefit postoperatively. especially in an office setting where pediatric patients are already apprehensive of nasal endoscopy. When the sep- tum is addressed for these purposes, it is usually performed 3.3 Indications for pediatric endoscopically, without an increase in complication rates septoplasty: surgical exposure in FESS and compared to a traditional open approach.34 ESBS For both benign and malignant pediatric skull base lesions, there has been an increasing shift in endoscopic 3.3.1 Statement 3 (consensus = mean score approaches, as these have been shown to be a safe and 8.75) minimally invasive alternative to open craniotomy. As in FESS, septoplasty during ESBS can help improve visualiza- Septoplasty is indicated in pediatric endoscopic sinus and tion and instrumentation. Highly complex cases requiring skull base cases where there is a need for better instrument a two-surgeon, four-handed technique can be challeng- access and improved visualization. ing when considering the already small pediatric nose, a  20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23397 by Lib Herzen - HINARI - ARGENTINA , Wiley Online Library on [20/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 6 ARS PEDIATRIC RHINOLOGY COMMITTEE EPS challenge that may be further compounded by septal devi- den et al. in 2008 in which growth velocity curves began ation. DNS may also be a contributing factor in limiting their steepest descending slope at 13.1 years for girls and access and achieving gross total resection for some skull 14.7 years for boys.36 Regarding the nasal septum more base tumors, which is essential for adequate treatment of specifically, van Loosen et al. reported in 1996 their find- many skull base pathologies. Therefore, septoplasty is an ings from the study of 30 postmortem specimens from birth important adjunct in cases where there is a need for bet- to 62 years. A rapid growth phase was described for the ter instrument access and improved visualization during total septum immediately after birth and lasting until age pediatric endoscopic sinus and skull base surgery. 2 years. There was then a gradual deceleration of growth plateauing at age 36 years. From their measurements, the authors further concluded that the cartilaginous septum 3.4 Recommendations regarding timing reaches adult dimensions at age 2 years while subsequent in pediatric septoplasty growth is due to the expansion of the bony perpendicu- lar plate.37 While these studies provide some initial basis 3.4.1 Statement 4 (consensus = mean score in determining the best timing for septoplasty in children 8.25) when possible, further work has explored the impact of the procedure on nasal and midfacial growth more directly. The impact of nasal airway obstruction due to septal A recent systematic review looking at the effects deviation on midfacial growth, chronic mouth breathing, of septoplasty on midfacial growth was performed.1 A obstructive sleep apnea, malocclusion, and facial asym- total of eight studies met inclusion criteria and were metry should be considered when evaluating a pediatric reviewed.5–7,38–42 The sample size of each study ranged patient for septoplasty. from 16 to 64 patients with an age range from 4 to 17 years. Mean follow-up was between 2 and 12.9 years. The proportion of patients lost to follow-up was reported as 3.4.2 Aggregate grade of evidence: grade B 6%–40%. Six out of the eight studies used anthropomet- ric methods to evaluate facial growth, while two solely Benefit: Potential avoidance of associated facial asymme- used anthroposcopy. The specific anthropometric mea- try, malocclusion associated with septal deviation, chronic surements (linear and angular measurements, indexes) mouth breathing, chronic sinusitis, and obstructive sleep were heterogeneous between studies. No study reported apnea in delayed or nontreatment of significant nasal delays in midface growth or major disturbances, defined airway obstruction due to septal deviation in children. as a disruption not easily corrected by surgery. When look- Harm: Possible minor reductions in nasolabial angle, ing at nasal growth specifically, no major disturbances dorsal length, and nasal tip protrusion, which are primar- were reported. However, minor disturbances, defined as ily associated with open surgical approaches. Possible need alterations easily correctable by surgery, were noted. Two for further surgery, including revision septoplasty. studies reported significant changes in the nasolabial Cost: Surgical and anesthesia costs. angle.7,39 However, when procedures were stratified into Benefit–harm assessment: Preponderance of benefit over open and endoscopic approaches, endoscopic septoplas- harm. ties did not appear to change the nasolabial angle.7 Two Value judgment: Potential benefits of septoplasty in chil- other studies described reduction in dorsum length.5,6 dren outweigh the risks of minor impacts on nasal growth Béjar et al. also reported reduction in dorsum indexes, and associated costs and risks of surgery. while El-Hakim et al. reported reduction in tip protru- Septal deviation is a common cause of nasal obstruction sion. Despite a lack of well-designed cohort or case–control in the pediatric population.35 Although septal deviation studies, the authors of the systematic review conclude that may be corrected surgically, concerns of disturbing growth there is currently enough evidence to challenge the idea centers of the nose must be weighed against the fact that that septoplasty leads to midface growth anomalies. septal deviation is also associated with chronic mouth A 2018 best practice paper in the Laryngoscope regarding breathing, obstructive sleep apnea, malocclusion, and timing of septoplasty in the pediatric population included facial growth asymmetry.18–20,22 Thus, there has been great an additional anthropometric study looking at the normal interest in the past few decades to determine the safest age development of the nose.43 This study of 140 male and 140 at which this procedure can be performed in the pediatric female patients suggests that the nose reaches maturity at population. the age of 15 years in males, and 13 years in females. In Insight can be gained through studies of the natural males, the nasal height, bridge length, and nasal tip pro- course of nasal growth in children. The common practice trusion were the last elements to reach maturity, while in of deferring elective septorhinoplasty until age 16 years has female patients, nasal tip protrusion was the last aspect of been supported by studies such as that by van der Heij- the nose to fully develop. Furthermore, the review article  20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23397 by Lib Herzen - HINARI - ARGENTINA , Wiley Online Library on [20/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ROSE et al. 7 highlights evidence that treating pediatric nasal obstruc- ies on the subject are level 3 or 4, further examination tion with a septoplasty is associated with increased QOL is required to determine the optimal age for septoplasty as measured by the visual analogue scale.12 Given that in the pediatric population. Currently, the literature does the youngest patient who underwent septoplasty in the not support consensus on a minimum age for septoplasty reviewed articles was 6 years old, the best practice rec- across all possible indications for the procedure. ommendation was that septoplasty could be a reasonable option in patients with congenital anomalies, trauma, and symptomatic nasal airway obstruction in patients as young 3.5 Quality of life after pediatric as 6 years of age. Thus, although the pediatric nose may not septoplasty reach maturity until adolescence, in some case it may not be appropriate to defer septoplasty until this age. Further 3.5.1 Statement 5 (consensus = mean score studies were encouraged. 8.00) In 2022, Raghavan and Carr published the largest cohort of pediatric patients undergoing septoplasty to date.44 There is strong evidence to support that septoplasty is This retrospective study, using the ACS NSQIP pediatric effective in children including significant improvements in database, examined a total of 2290 patients undergoing QOL. septoplasty between 2012 and 2019. Here, the average age of patients undergoing septoplasty was 14.2 years. When stratifying the age of patients according to the primary 3.5.2 Aggregate grade of evidence: grade B procedure being performed, patients undergoing cleft lip repair were found to be the youngest, followed by patients Benefit: Improved QOL resulting from treatment of nasal undergoing sinus surgery. The average ages were 9 and obstruction due to significant septal deviation in children. 14 years, respectively. Although this study does not give Harm: Possible minor reductions in nasolabial angle, any insight on the outcomes of the procedure on midfacial dorsal length, and nasal tip protrusion, which are primar- growth, the authors do paint a proper representation of the ily associated with open surgical approaches. Possible need patient characteristics. It should be noted, however, that for further surgery, including revision septoplasty. the specific procedures performed in different age groups Cost: Surgical and anesthesia costs. and for different indications likely differ. For example, sep- Benefit–harm assessment: Preponderance of benefit over toplasties performed in young children at the time of cleft harm. repair are more likely to involve repositioning of the sep- Value judgment: Potential benefits of septoplasty in chil- tum to the midline rather than the resection of significant dren, including QOL improvement, outweigh the risks of septal cartilage. This study also suggests that surgeons are minor impacts on nasal growth and associated costs and becoming more comfortable performing septoplasties in risks of surgery. younger patients, a change that may reflect progressive Multiple studies have evaluated QOL in children after acceptance of both the safety and efficacy of the procedure, septoplasty, including some which are based on validated as well as greater experience in technical capability. patient-reported outcome metrics (PROMs). In 2019, a In summary, the paradigm that septoplasty should review article was conducted to evaluate QOL after septo- always be deferred until the pediatric craniofacial skele- plasty or functional septorhinoplasty (FSR) in the pediatric ton has fully developed appears worthy of further review. population.45 While the methodology of this article did Evidence suggests that, in some cases, septal surgery not meet the criteria for a systematic review, the authors including septoplasty is being performed as early as the did include five studies published between 2014 and 2018, age of 1 year in the context of cleft lip repair and sinus including two prospective studies.12–16 Different subjective surgery. Studies examining the effects of septoplasty on assessment tools were used, including the Nasal Obstruc- nasal and midfacial growth suggest that few significant tion Symptom Evaluation (NOSE) scale in three of the disturbances of growth are associated with the procedure included studies.46 A total of 267 patients were included. when performed in patients as young as 4 years of age, While no pooled analysis was performed in this review, an although there may be possible minor nasal disturbances improved QOL was reported in all five studies. Complica- which require surgical correction at a later stage. More- tions included one patient who developed a nasal abscess over, endoscopic techniques may minimize the effects of and two patients requiring revision septoplasty. Other the procedure on nasolabial angle changes. Ultimately, the minor complications reported included minor synechiae negative effects of nasal airway obstruction on midfacial formation, residual septal deviation, pain, and hypersen- growth and QOL should be weighed carefully against any sitivity. potential risks for each individual patient depending on The NOSE scale is a PROM tool that has been extensively the severity of DNS regardless of age. Given that most stud- studied and utilized in the adult population, and recently  20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23397 by Lib Herzen - HINARI - ARGENTINA , Wiley Online Library on [20/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 8 ARS PEDIATRIC RHINOLOGY COMMITTEE EPS T A B L E 3 Evidence summary table—quality of life after pediatric septoplasty (Oxford Centre for Evidence-Based Medicine Levels of Evidence, 2009). Study Clinical Study Year LOE design Study group endpoint Conclusion Anderson et al.13 2016 4 Retro cohort 29 pediatric patients PedsQL, GCBI Positive postoperative GCBI (mean age 13 years) score of 35.1, and total mean of child PedsQL of 95.2 Lee et al.12 2017 4 Retro case 28 pediatric patients SN-5 and VAS Significant improvement in series (mean age not SN-5 from 3.5 to 2, reported) increased VAS from 5 to 8 Manteghi et al.16 2018 2B Prospective 136 pediatric patients NOSE score Significant improvement in cohort (mean age 15.7 years), NOSE from 75 to 20 mean follow up 3.6 (septoplasty group) and 15 months (septorhinoplasty group) Yilmaz et al.14 2014 4 Retro cohort 35 pediatric patients NOSE score and Significant improvement in (mean age 13.4 years), VAS NOSE from 71 to 22.6 at 3 follow-up at 3 and 12 months and 23.7 at 12 months months, VAS increased to 7.9 at 12 months Fuller et al.15 2018 4 Retro cohort 39 pediatric patients NOSE score, Significant improvement in (mean age 15.9 years), EuroQOL NOSE from 59 to 21.2, mean follow-up 8.5 five-dimension, increased PNIF from 66.2 to months PNIF 90.8 Kawai et al.17 2021 4 Retro cohort 38 pediatric patients NOSE score Significant improvement in (mean age 16.7 years) NOSE from 96.7 to 8.8 Abbreviations: GCBI, Glasgow Children’s Benefit Inventory; NOSE, Nasal Obstruction Symptom Evaluation; PedQL, pediatric Quality of Life Inventory; PNIF, peak nasal inspiratory flow; VAS, visual analog scale. validated in the pediatric population.46 In 2020, Din et al. Pediatric septoplasty can be a technically challenging showed that the NOSE scale is a robust tool that can evalu- procedure due to the constraints in the size of the nasal ate the severity of nasal obstruction in children undergoing vestibule, pyriform aperture, and space within the nasal septoplasty or FSR.47 The authors studied the psychome- cavity. While several of the surgical techniques developed tric properties of the NOSE scale and showed that it has for adult patients prove useful, there are a number of good reliability and validity in the pediatric population. recommended modifications, instruments, and steps in Another study in 2021 by Kawai et al. also confirmed perioperative care that are unique to safe and successful the validity of the NOSE scale in children, demonstrat- septoplasties in children.48 ing significant improvement in the NOSE score from 96.7 Septoplasty can be performed with open or endonasal preoperatively to 8.8 postoperatively.17 approaches. Open techniques generally involve a skin In conclusion, there is strong evidence to support that incision through the columella, allowing for improved septoplasty in the pediatric population is associated with visualization and access to the structures of the anterior significant improvements in QOL postoperatively (see nose including the caudal septum and medial crura of Table 3). Since its validation in the pediatric population, the lower lateral cartilages. For pathology located more more studies are expected to use the NOSE scale to report posteriorly (generally posterior to a line joining the ante- QOL outcomes. rior nasal spine and the anterior projection of the nasal bones), an endonasal approach may be preferred. As in adult patients, the endonasal approach may be carried 3.6 Recommendations regarding out through either a hemitransfixion incision if the cau- surgical techniques in pediatric septoplasty dal septum is significantly deviated or a Killian incision in cases of more posterior septal deviation. In either an 3.6.1 Statement 6 (no consensus = mean open or endonasal approach, a headlight, rigid fiberoptic score 5.50) endoscopes, or a combination of the two may be used. As in adult patients, septoplasty requires the elevation Septoplasty in children requires specialized instrumenta- of opposing mucoperichondrial flaps posterior to the ini- tion and perioperative care. tial incision. In the case of a hemitransfixion incision, care  20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23397 by Lib Herzen - HINARI - ARGENTINA , Wiley Online Library on [20/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License ROSE et al. 9 must be taken to preserve sufficient caudal and dorsal (Crescent Manufacturing Company), instead of the 15- cartilage (also known as the L-strut) to allow for ade- blade classically described. The tip of a microsurgical knife quate support of the nose postoperatively. Although the can also be bent with a hemostat at a 90◦ angle, 2 mm mucosal incision is made along the leading edge of the from the end, to reduce the risk of cartilage injury during nasal septum, the cartilaginous incision is carried out at incision, or cutting through the opposing mucoperichon- least 1 cm more posteriorly. The caudal deviation of septal drial flap during the septotomy following a Killian incision. cartilage in these cases is often corrected through eleva- In addition, a number of commonly used instruments, tion of mucoperichondrial flaps on either side, scoring, including regular and through-cut Blakesly forceps as well sutures anchoring the caudal septum to the anterior nasal as suction tips, can be obtained in smaller sizes for easier spine, and the careful removal of a small wedge of cartilage use in pediatric septoplasty. inferiorly to allow the anterior nasal septum to approxi- As in FESS, perioperative care in septoplasty can present mate in the midline over the nasal spine. Deformities of unique challenges in children. Adequate physical exami- the anterior nasal spine and septal spurs can also be safely nation, including sinonasal endoscopy, may not be possible corrected by removing deviated bone along the floor of the in all children. To this point, Crysdale recommends defer- nose with rongeurs or osteotomes. When using a Killian ring septoplasty until at least 6 years of age.50 Imaging incision, one of the mucoperichondrial flaps is raised first such as CT scan when needed and examination during (often with a suction Freer elevator), followed by the sep- endonasal surgery may allow for improved evaluation. totomy incision. This vertical incision through the septal While nasal splints, nasal packing, and/or sprays and irri- cartilage should be staggered by a few millimeters such gations have all been described in adult patients, each that it is not directly opposing the mucosal incision, thus poses certain challenges in children. Certainly, a whip- reducing the risk of septal perforation formation. Next, the stitch or through-and-through quilting of the opposing opposing-side flap is raised and deviated septal cartilage mucoperichondrial flaps with a 4-0 plain gut or chromic freed from the bony–cartilaginous junction with a Cottle suture may be better than placement of nasal packing that elevator and removed. Deviated bone of the vomer and per- will require removal later in an awake child in the clinic pendicular plate of the ethmoid can also be removed at this setting. Nasal saline sprays, rather than irrigations, may be time if necessary, though care should be taken as this junc- helpful in the prevention of crust formation and better tol- tion has been proposed as a possible center of nasal septal erated. Nasal splints, or thin (0.25 mm) silicone sheeting growth in children.49 cut to size, secured with an anterior septal suture may be While the basic techniques for septoplasty have been necessary if there is significant tearing of mucoperichon- well described in previous literature, there have also been drial flaps during the case or when submucosal resection a number of recommended modifications for use in chil- of turbinates is performed simultaneously (rare in young dren. Pediatric nasal specula, along with a headlight, children). While these can be removed without difficulty may be necessary for adequate visualization of the nasal in older children, perhaps 12 years and older, removal in vestibule and anterior nasal cavity in an open approach or younger children may require a second brief anesthesia at when creating a hemitransfixion incision along the cau- the appropriate time—commonly at 1 week. dal septum. As this location is so anterior and the incision Complications are similar in pediatric septoplasty when often requires two hands, it can be challenging to per- compared to adults. These include postoperative epistaxis, form endoscopically. Endoscopes may be introduced later, septal hematoma, septal perforation, and the need for revi- however, into the subperichondrial space for improved sion septoplasty. In a review of 194 patients, Bishop et al. visualization once the dissection has been carried more reported septal perforation in 0.52% of cases.51 While no posteriorly. While 4 mm 0◦ endoscopes are commonly septal hematomas were described, there were episodes of used for adult endoscopic septoplasty, 3 mm and smaller postoperative epistaxis in 12.4%. Interestingly, the need for endoscopes are available and often easier to introduce and revision septoplasty was found to be significantly higher in maneuver in smaller noses. In addition, endoscope irri- a younger cohort (0‒14 years), when compared with older gating sheaths often used during adult sinus surgery and children (14‒18 years). Perhaps, this might be explained septoplasty may prove cumbersome as they add an addi- by the need for more directed or limited septoplasty in tional 1–2 mm in diameter, and thus may be better if younger patients whose smaller nasal anatomy requires a avoided in pediatric patients; this difference is enough to focus on the deviated portions of septal cartilage that can significantly decrease maneuverability and visualization be adequately visualized, accessed, and safely removed. in pediatric endonasal surgery. Other, low-profile instru- This may also explain a more recent retrospective, obser- mentation may also prove useful in septoplasty performed vational cohort study of septoplasty by Shah et al. in 2022, in children. This may include the use of microsurgical that found pediatric patients were more likely to undergo knife, such as a Crescent Ophthalmic Micro Surgical Knife revision surgery than their adult counterparts.52  20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23397 by Lib Herzen - HINARI - ARGENTINA , Wiley Online Library on [20/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 10 ARS PEDIATRIC RHINOLOGY COMMITTEE EPS 4 NEEDS ASSESSMENT C O N F L I C T O F I N T E R E S T S TAT E M E N T The authors declare they have no conflicts of interest. The goal of this EPS is to provide recommendations and guidance through evidence-based consensus statements ORCID regarding the safety, efficacy, appropriate indications, Austin S. Rose MD, MBA https://orcid.org/0000-0003- timing, QOL impact, and surgical techniques for pedi- 3753-2329 atric septoplasty. Importantly, the most recent systematic Chadi A. Makary MD https://orcid.org/0000-0001-9967- review from 2020 suggests the procedure is both techni- 4045 cally feasible and safe, with little significant impact on David A. Gudis MD https://orcid.org/0000-0002-1938- nasal and midfacial growth and development.1 In addition, 9349 septoplasty may be indicated in children with significant nasal obstruction due to septal deviation and potentially REFERENCES for improved instrument access and visualization during 1. Calvo-Henríquez C, Neves JC, Arancibia-Tagle D, et al. Does FESS and ESBS. Furthermore, concerns regarding chronic pediatric septoplasty compromise midfacial growth? A system- mouth breathing, obstructive sleep apnea, dental mal- atic review. 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See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 12 ARS PEDIATRIC RHINOLOGY COMMITTEE EPS Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol gol Head Neck Surg. 2022;148(11):1044-1050. doi:10.1001/jamaoto. Head Neck Surg. 2004;130(2):157-163. doi:10.1016/j.otohns.2003. 2022.3041 09.016 47. Din H, Bundogji N, Leuin SC. Psychometric evaluation of the Nasal Obstruction Symptom Evaluation scale for pedi- atric patients. Otolaryngol Head Neck Surg. 2020;162(2):248-254. S U P P O RT I N G I N F O R M AT I O N doi:10.1177/0194599819890835 Additional supporting information can be found online 48. Martins MB, Lima RG, Lima FV, Barreto VM, Santos AC, Júnior in the Supporting Information section at the end of this RC. Demystifying septoplasty in children. Int Arch Otorhino- article. laryngol. 2014;18(1):54-56. doi:10.1055/s-0033-1358576 49. Cingi C, Muluk NB, Ulusoy S, et al. Septoplasty in children. Am J Rhinol Allergy. 2016;30(2):e42-e47. doi:10.2500/ajra.2016.30.4289 50. Crysdale WS. Septoplasty in children–yes, but do the right thing. How to cite this article: Rose AS, Makary CA, Arch Otolaryngol Head Neck Surg. 1999;125(6):701. doi:10.1001/ Soler ZM, et al. American Rhinologic Society archotol.125.6.701 Expert Practice Statement: Indications and 51. Bishop R, Sethia R, Allen D, Elmaraghy CA. Pediatric nasal sep- toplasty outcomes. Transl Pediatr. 2021;10(11):2883-2887. doi:10. Recommendations for Septoplasty in Children. Int 21037/tp-21-359 Forum Allergy Rhinol. 2024;1-12. 52. Shah JP, Youn GM, Wei EX, Kandathil C, Most SP. Septoplasty https://doi.org/10.1002/alr.23397 revision rates in pediatric vs adult populations. JAMA Otolaryn-