When Should Pediatric Septoplasty Be Performed for Nasal Airway Obstruction?
First published: 04 December 2018
The authors have no funding, financial relationships, or conflicts of interest to disclose.
BACKGROUND
Historically, otolaryngologists have been concerned about the potential detrimental effects of pediatric nasal surgery on the nasoseptal growth process. Septal cartilage is important for the development of the midface, and pediatric septoplasty was reserved for patients with functional problems secondary to congenital anomaly, tumor, or septal hematoma/abscess. More recently, there has been mounting evidence that the septum can be repaired without compromising facial development. In fact, a deviated septum causing nasal airway obstruction (NAO) represents an increasingly compelling indication to perform septoplasty. Otolaryngologists report functional improvement and patients report quality‐of‐life (QOL) improvement following septoplasty.1 However, high‐quality guidelines for when to perform pediatric septoplasty are lacking. This review seeks to evaluate the current evidence for pediatric septoplasty, focusing on the indications to perform septoplasty and the most appropriate timeline for surgical intervention.
LITERATURE REVIEW
Early treatment of septal deformity is a matter of ongoing deliberation. There is concern that surgical intervention on a developing structure can adversely affect the normal growth of the nose and face. Conversely, failure to correct a septal deformity might allow the condition to worsen and increase the risk of sinusitis or facial asymmetry. Indications for septoplasty have traditionally been divided into absolute and relative indications (Table 1). Although NAO has been regarded as a relative indication, NAO is uncomfortable, can exacerbate oral breathing, and can worsen over time. The shortage of excellent clinical studies worsens the surgeon's concern regarding the long‐term ramifications of pediatric septoplasty. We review two anthropometric studies focused on anatomical considerations, as well as two retrospective studies and one review that examine the effects of septoplasty on NAO, nasal growth and development, and QOL.
| Absolute Indications | Relative Indications |
|---|---|
| Septal hematoma/septal abscess | Nasal airway obstruction |
| Severe nasoseptal deformity following trauma | Progressive growth deformity |
| Congenital anomalies such as cleft lip/palate | |
| Nasal tumor |
Anthropometric studies have illustrated typical development of the pediatric nose. Akgüner et al.2 examined age‐related changes in nasal architecture in 140 female and 140 male subjects. The authors found that nasal height and bridge length reached maturity at 15 years of age in males and 12 years in females. Upper and lower dorsum and anterior and posterior nasal depth became fully mature in males at 14 years of age compared to 12 years in females; nasal tip protrusion became fully mature in males at 15 years of age and in females at 13 years.
Tasca and Compadretti3 examined anthropometric variables in Italian patients who had undergone septoplasty during childhood. Twenty‐five male patients and 19 female patients were reassessed after a mean follow‐up of 12.2 years and were compared to normative controls via five linear parameters, three angular parameters, and three proportional indexes. There were no differences between the sample and control data with regard to sex, with the exception that the nasolabial angle of female patients was significantly reduced when compared with controls (P = .04), whereas that of male patients was reduced but not significantly (P = .08). However, when operations were stratified into endoscopic and open approaches, no nasolabial angle change was noted with endoscopic septoplasty. The authors concluded that septoplasty via endoscopic approach does not interfere with the normal nasal growth process.
To further clarify the role and effect of intervention, Dispenza et al.4 performed a retrospective review of 46 patients ages 4 to 12 years with post‐traumatic nasoseptal deviation, with a follow‐up time of 10 years. Sixteen patients had septal deviation without nasal pyramid alterations and underwent septoplasty alone. The remaining 30 suffered from both septal deviation and nasal pyramid deformity. Sixteen underwent septoplasty alone, whereas the remaining 14 were managed by both septoplasty and rhinoplasty (including osteotomies). The patients with isolated septal deviation had no growth deficit at follow‐up. However, when only septoplasty was performed and a nasal pyramid deformity was present but not corrected, deformity was accentuated in all patients at follow‐up. The best results were obtained when septoplasty and rhinoplasty were both performed together, irrespective of age, leading the authors to conclude that adolescent growth can cause further alteration of deviated structures.
In a review article by Cingi et al.5 which included the studies by Akguner et al.,2 Tasca and Compadretti,3 Dispenza et al.,4 and four other studies, the authors advocate for correction of septal deviation if the deformity causes nasal stenosis, oral breathing, or other breathing problems in children as young as 6 years of age. They hypothesize that septal cartilage should not be separated from the perpendicular plate because this area is important for the growth of the nasal septum and dorsum. Highlighting the change from prior ideology, Cingi et al.5 emphasize that early pediatric septoplasty may prevent worsening of derangements to facial growth.
Against the backdrop of anthropometric data and the potential to augment midface development, otolaryngologists have begun to explore the QOL impact associated with pediatric septoplasty. Subjective QOL outcome measures focus on patient‐reported symptoms and may not directly correlate with objective outcome measures. Lee et al.1studied 28 patients who underwent septoplasty for nasal trauma or NAO and found a significant improvement in visual analog scale (VAS) (range, 0–10) following pediatric septoplasty. Female patients reported a more significant improvement in VAS when compared with male patients (5.0 compared to 3.0, P = .007). Eight of the patients were under 13 years of age, though comparisons of change by age and surgical approach did not differ. This significant improvement in QOL regardless of age, in the context of minimal impact on facial growth, suggests that earlier pediatric septoplasty might provide additional years of QOL benefit.
BEST PRACTICE
Pediatric septoplasty may be safely performed without significantly affecting future nasal and facial growth. Septoplasty should be performed in patients with functional problems related to congenital anomalies or trauma, whereas a deviated septum causing NAO symptomatology also represents a reasonable and supported cause for early septoplasty in children as young as six years of age. Endoscopic septoplasty has not been shown to cause a change in postoperative nasolabial angle. Anthropometric studies suggest nasal growth is completed around 14 years of age in females and 15 years of age in males. However, in appropriate situations, pediatric septoplasty should not be deferred until adolescence. Some believe that conservative management of septal deviations may lead to increased facial asymmetry. More clinical studies are required to determine evidence for best timeline for correction in younger children. Septoplasty has been shown to improve QOL measures on VAS. Further research will likely focus on characterizing patient‐reported outcome measures of septoplasty.
LEVEL OF EVIDENCE
BIBLIOGRAPHY
- 1 , , . Short‐term quality of life outcomes following pediatric septoplasty. Acta Otolaryngol 2017; 137: 293– 296.
- 2 , , . Adolescent growth patterns of the bony and cartilaginous framework of the nose: a cephalometric study. Ann Plast Surg 1998; 41: 66– 69.
- 3 , . Nasal growth after pediatric septoplasty at long‐term follow‐up. Am J Rhinol Allergy 2011; 25: e7– e12.
- 4 , , , , . Management of naso‐septal deformity in childhood: long‐term results. Auris Nasus Larynx 2009; 36: 665– 670.
- 5 , , , et al. Septoplasty in children. Am J Rhinol Allergy 2016; 30: e42– e47.
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