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A Study of Anthropometric Measures Before and After External Septoplasty in Children
A Preliminary Study
Hamdy El-Hakim, FRCSEd(Orl);
William S. Crysdale, MD, FRCSC;
Mohammed Abdollel, MSc;
Leslie G. Farkas, MD, PhD, DSc, FRCSC
Arch Otolaryngol Head Neck Surg. 2001;127:1362-1366.
ABSTRACT
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Objective To test the hypothesis that surgery on the growing nasal septum does
not adversely affect nasal and midfacial dimensions.
Design Paired study.
Setting Tertiary care center.
Participants Children treated consecutively during a 4-year period; all had significant
nasal obstruction and cosmetic disfigurement secondary to skeletal septal
deformities.
Intervention Nasal septal surgery (using an external approach), in which the quadrilateral
cartilage was removed, remodeled, and reinserted as a free graft.
Outcome Measures Anthropometric linear measurements and indexes of the face and nose
preoperatively and postoperatively; nasal dorsum length, nasal height, nasal
dorsum index, nasal tip protrusion, columellar length, facial height, face
width, upper face height, facial index, nose–upper face height index,
and columellar length–nasal tip protrusion index. Continuous measurements
were transformed into ordered categories with reference to normative data.
Data were analyzed using Wilcoxon signed rank sum test ( level of .05)
and by applying the Bonferroni adjustment for multiple testing.
Results Twenty-six children were studied (12 females and 14 males); age at surgery
ranged from 4.5 to 15.5 years (mean age, 9.5 years); average age at postoperative
measurement, 12.5 years; mean follow-up, 3.1 years. Only nasal dorsum length
(P = .007) and nasal tip protrusion (P = .04) were decreased by a statistically significant level before
the Bonferroni adjustment. The change was not considered clinically significant.
Thus, relative to age-appropriate norms, the dimensions of the nose and midface
and their proportionality did not change after surgery.
Conclusions Appropriate nasal septal surgery involving excision and subsequent reinsertion
of a remodeled segment of the quadrilateral cartilage has no deleterious effects
on development of the nose and midface. We question the absolute dogma that
nasal surgery in children must always be avoided.
INTRODUCTION
SURGERY ON the growing nasal septum has always been the epicenter of
debates. The sources of such debates are the controversial findings and views
found in human and animal studies. As observed by Freng and Haye,1 views based on animal studies vary according to the
model implemented (species, surgical procedure, and age of animals). At the
same time, interventional clinical studies in humans have failed to provide
good evidence for accepted practice. Consequently, blanket statements urging
caution are common in the literature, as Gilbert et al2
write:
Because the quadrilateral septal cartilage is the keystone in
development of the profile projection of the cartilaginous vault, dare we
either chip away at it or even undermine it without fear of subsequent interference
with the continuous profile growth of the cartilaginous vault in children?2(p677)
The conclusion of Farrior and Connolly3
after their review of the literature appears fairly balanced, despite the
lack of supporting evidence. They recommended that surgery (as conservative
as possible) be delayed until nearly full development has taken place, unless
marked disturbance in function or distortion exists that also interferes with
growth and facial development.
All human studies of pediatric septoplasty will, unavoidably, be confounded
by the previous trauma and its effects, making it difficult to attribute to
either the surgery or the trauma any retardation of growth detected. However,
critical reading of the main published clinical series in the English literature
(Table 1) disclosed some avoidable
faults in execution and design.4-11
The investigators used either subjective outcome measures or objective measures,
with no control subjects or longitudinal follow-up. The processes of analysis
and extrapolation were further confounded by the inclusion of patients who
had undergone septal surgery that used various techniques, osteotomies, and
other rhinoplasty maneuvers. This diversity adds to the difficulty in drawing
conclusions that are based on the type of surgery performed.
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Table 1. Major Clinical Studies in Pediatric Septoplasty*
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The present work was undertaken to reconcile some of these problems
through a paired design study that compared preoperative with postoperative
anthropometric measurements. We tested the hypothesis that septal surgery
in children using the quadrilateral cartilage as a free graft after reshaping
it does not cause significant growth retardation postoperatively.
MATERIALS AND METHODS
The database kept by one of us (W.S.C.) holds the medical records of
patients who have undergone septoplasty and/or rhinoplasty and were treated
during a 13-year period (1986-1999). All patients whose anthropometric measurements
were recorded preoperatively were identified. Preoperative anthropometric
measurements have been recorded routinely by one of us (W.S.C.) since early
1995. For the purpose of this investigation, we included only those patients
whose septoplasty had been performed via the external approach and in whom
the free graft technique (previously described6, 12-13)
had been used. We considered only those who had undergone the procedure before
16 years of age, as different nasal measurements reach maturation at variable
ages (between 14 and 16 years), and these vary further between sexes.14
Subsequent to approval by the relevant ethics committee, the patients'
addresses and telephone numbers were retrieved from the Health Records department
of The Hospital for Sick Children, Toronto, Ontario. The patients were then
contacted by mail and telephone and solicited to attend a specific appointment
at the Craniofacial Measurements Laboratory at The Hospital for Sick Children.
The consent of parents and children were obtained as appropriate, after explanation
of the purpose of the examination.
The measurements were performed by one of us (L.G.F.) according to a
standard technique with the use of sliding and spreading calipers,15 and proportions were calculated using standard formulae.16
The anthropometric linear measurements used are illustrated in Figure 1, and the indexes were calculated
from their values. Although the linear measurements are individual dimensions
in their own right, the indexes or proportions demonstrate the harmony between
these dimensions. Together, they indicate some aspects of nasal and facial
growth.
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Figure 1. Anatomical landmarks for linear
anthropometric measurements. n Indicates nasion; prn, pronasale; sn, subnasale;
sto, stomion; zy, zygion; gn, gnathion; and c', apex of columella.
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The variables used as outcome measures (many of which are illustrated
in Figure 1) were as follows:
- Nasal dorsum length
- Nasal height
- Nasal index or (n to prn)/(n to sn), ie, the nasal dorsum length
(nasion [n] to pronasale [prn]) divided by the nasal dorsum height (n to subnasale
[sn])
- Collumellar length
- Nasal tip protrusion
- Columellar length–nasal tip protrusion index or (sn to c')/(sn
to prn), ie, the relationship between the columellar length (sn to apex of
columella [c']) and the nasal tip protrusion (sn to prn)
- Facial height
- Face width
- Facial index or (n to gn)/(zy to zy), ie, the relationship between
the facial height (n to gnation [gn]) and the face width (distance from one
zygion [zy] to the other)
- Upper face height
- Nose–upper face height index or (n to sn)/(n to sto), ie,
the relationship between the nasal height (n to sn) and the upper face height
(n to sto).
All measurements were in millimeters.
The linear measurements and indexes before and after surgery were transformed
into 1 of 5 possible ordered categories (-2, -1, 0, 1, and 2).
These indicate whether the measured variable is subnormal, borderline small,
optimal, borderline large, or supernormal, respectively, as compared with
documented norms of North American whites.15
An optimal measurement or proportion is within 1 SD from the mean, whereas
borderline (small or large) values lie within 2 SDs. Abnormally large or small
measurements are those values beyond 2 SDs from the mean.
The Wilcoxon signed rank test was applied to the paired differences
between each of the ordered measurements to determine whether they changed
after surgery. A Bonferroni adjustment for multiple testing was performed
( x P), and the interpretation of our
results was based on the adjusted P values. Ninety-five
percent confidence intervals were computed for the medians of the paired differences.17
RESULTS
The spreadsheet from the computerized database (created using Microsoft
Excel software [Microsoft Corporation, Redmond, Wash]) contains records of
295 patients who were operated on between January 1, 1986, and December 31,
1999, in The Hospital for Sick Children. We identified 40 patients who qualified
for the entry criteria. Eight patients could not be contacted with the available
addresses or telephone numbers, and we had no access to their new locations.
The remaining 32 were contacted by mail and telephone and were invited for
follow-up. Only 1 parent declined initially, and another 5 patients failed
to attend.
The study patients were treated between March 1, 1995, and December
31, 1999. Their follow-up ranged from 10 months to 5.4 years (mean, 3.1 years).
Twelve were females and 14 were males, with an age range (at operation) from
4.5 to 15.5 years (mean age, 9.5 years). (Average age at postoperative measurement,
12.5 years.) Seven patients had isolated cleft lip and/or palate and 1 had
Crouzon syndrome; 16 had previously undergone septoplasty. The patients fell
into 4 different ethnic groups: most (n = 14) were whites of European descent,
7 were East Indians, 4 were whites of Middle Eastern descent, and 1 was West
Indian.
Altogether, 26 rhinoplasty maneuvers were performed in addition to the
free-graft septoplasty in all the patients: 14 dorsal grafts, 4 columellar
struts, 4 dome sutures, 2 lower lateral cartilage trimmings, and 2 tip grafts.
None of the patients underwent an osteotomy. Only 2 postoperative complications
had been recorded: 1 vestibular granuloma that required resection and 1 postoperative
epistaxis that required packing for control.
The variables for all patients were available for analysis, with 3 exceptions.
One measurement for the columellar length was not documented. Also, in both
the columellar length–nasal tip protrusion index and nose–upper
face height index, there were no available norms for children younger than
5 years,which led to the omission of 1 patient who was aged 4 years
at the time of surgery.
The details of the paired analysis are presented in Table 2 and Table 3.
They demonstrate that only 2 of the differences between the medians were statistically
significant before the Bonferroni adjustment (the nasal dorsum length [P = .007] and nasal tip protrusion [P = .04]). After adjustment (multiplication by the number of variables,
ie, 11), this significance was lost. Two more important observations support
this notion. First, if the confidence intervals are examined, it will be observed
that they all encompass the 0, ie, no difference between medians, indicating
that the significance of the P values is not supported.
Second, the median differences are either 0 or 0.5; in other words, the change
is less than 1 ordered category, which cannot be clinically significant. Also,
none of the indexes changed significantly, since they represent proportionality
measures between individual linear dimensions.
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Table 2. Results of Paired Analysis for Linear Anthropometric Measurements,
Comparing Preoperative and Postoperative Status*
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Table 3. Results of Paired Analysis for Indexes, Comparing Preoperative
and Postoperative Status*
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However, since the 2 variables under scrutiny are a reflection of the
length of the nose, there may be a trend toward some shortening of the noses
that were operated on. The data pertaining to the nasal dorsum length in particular
is described in Figure 2. The numbers
of the patients in each ordered category are plotted for preoperative and
postoperative status. Note that the numbers of patients are increasing in
the categories indicating smaller lengths. This strengthens the impression
of the trend already mentioned.
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Figure 2. Number of patients in each ordered
category for nasal dorsum length (nasion to pronasale) before and after surgery.
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COMMENT
Our study documents that these children did not exhibit clinically significant
retardation of growth after external approach septoplasty using quadrilateral
cartilage as a free graft. This extrapolation derives from the categorization
of the postoperative anthropometric measurements in relation to documented
norms for North American whites, which was not significantly different from
the preoperative status. However, there is an observed trend for the noses
operated on to shorten, as noted in the results of 2 variables.
This is the first longitudinal clinical study on pediatric septoplasty,
to our knowledge, to use objective measures in a paired design. With individual
patients acting as their own controls, the confounding effect of the heterogeneity
of the sample (ie, inclusion of patients with craniofacial abnormalities and
various ethnic origins) is overcome. Objections may be raised that the norms
used are those based on North American whites. However, since we used the
order of the categorization to facilitate analysis rather than its implications
with regard to normality (as Bejar et al11
did), the issue has less bearing on the final conclusions. The current study
has its shortcomings. We are aware that the sample size is a limiting factor.
Also, the measurements had been taken at different points in time after surgery
for individual subjects.
At this stage, and since the study contributes significantly to the
debate on pediatric septoplasty, it is appropriate to review the results of
work performed in animals. Experimental reports are divided to some extent.
Destructive procedures on the nasal septum, including resection of the mucoperichondrium
in addition to the cartilage, were found to result in significant deformity
and growth retardation in rodents.18-19
Others have reproduced the same results in the same species, even though they
preserved the mucoperichondrium.20 On the other
hand, procedures preserving the mucoperichondrium, especially those with reimplantation
of resected cartilage, produced fewer21 or
no1, 22-23 adverse
results.
In most of the studies cited, and where histological examination had
been performed, evidence of cartilage regeneration and survival after autotransplantation
had been documented. After noting these facts and the occurrence of duplications
and deviations after the use of autografts, Nolst Trenite and colleagues21 stated that possible adjustments in operative techniques
to achieve a better connection between parts of septal cartilage with a prolonged
fixation of the septum in the midline might be required for successful pediatric
septoplasty.
Finally, it is pertinent to examine some of the literature that deals
with patterns of growth of the nasal septal cartilage. In this context, Van
Loosen and coworkers had shown in 199624 and
199725 that the growth of the nasal septum
decelerates remarkably after age 2 years and that it reaches a plateau by
age 36 years. They also postulated that the septal cartilage reaches adult
size by age 2 years and that further growth occurs courtesy of the bony perpendicular
plate. They did not document any particular spurts of growth at any ages.
Recent work from Brazil26 adds that there is
histological evidence of a reduction in the rate of growth of the quadrilateral
cartilage by age 5 years and that deceleration starts by age 8 years.
The philosophy of the intervention used in this group of patients respects
these issues. This intervention is based on a conservative technique that
emphasizes precision in the preparation of a carefully sized and shaped graft
and in its method of fixation.6, 12-13
Equally important are the patient choice and the indication for surgery. The
age limit has never fallen below 6 years, except for one of the patients in
this series who had documented sleep apnea due to nasal airway obstruction
that was subsequently relieved by surgery. The indication for this type of
surgery is severe nasal obstruction associated with external deformity. In
particular, septal deformities anterior to the anterior nasal spine are the
specific abnormality addressed by this technique. These patients are always
scrutinized for causes of obstruction other than the septum.
In conclusion, we believe that, where indicated, reconstructive septal
surgery does not cause significant growth retardation in children. Achievement
of these results will only be possible by using a technique that preserves
the integrity of the mucoperichondrium and restores skeletal continuity (by
using refashioned quadrilateral cartilage as free graft) as much as possible,
along with meticulous fixation of the reconstructed septum. This is not an
open invitation for septal surgery in any deviated pediatric nasal septum
or by an inexperienced surgeon.
AUTHOR INFORMATION
Accepted for publication June 20, 2001.
Corresponding author and reprints: Hamdy El-Hakim, FRCSEd(Orl), Otolaryngology
Department, Ward 45, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB9
2ZB, Scotland (e-mail: helhakim{at}aol.com).
From the Departments of Otolaryngology (Drs El-Hakim and Crysdale)
and Epidemiology (Mr Abdollel) and the Craniofacial Measurement Laboratory,
Department of Plastic and Reconstructive Surgery (Dr Farkas), The Hospital
for Sick Children, Toronto, Ontario. Dr El-Hakim is now with the Otolaryngology
Department, Aberdeen Royal Infirmary, Foresterhill, Scotland.
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