Nasal fractures in children: influence on the development of the nose

Craniofacial Growth and Development: A Primer for the Facial Trauma Surgeon

Understanding craniofacial growth and development is important in the management of facial trauma in the growing pediatric patient. This manuscript is a review of craniofacial growth and development and clinical implications of pediatric facial fractures.

Pediatric Nasal and Septal Fractures

Pediatric nasal bone and septal fractures represent a large number of craniofacial injuries in children each year. Due to their differences in anatomy and potential for growth and development, the management of these injuries varies slightly from that of the adult population. As with most pediatric fractures, there is a bias toward less-invasive management to limit disruption to future growth. Often this includes closed reduction and splinting in the acute setting followed by open septorhinoplasty at skeletal maturity as needed. The overall goal of treatment is to restore the nose to its preinjury shape, structure, and function.

Does pediatric septoplasty compromise midfacial growth? A systematic review

OBJECTIVE

Septal deviation is an important cause of impaired nasal breathing among pediatric patients. A widespread solution to septal deviation is septoplasty. However, there are certain controversies surrounding the effect of this technique on pediatric patients and its influence on the growth centers of the nose. The objective of this review is to study if there is a strong and valid evidence in the literature that supports a detrimental effect of pediatric septo- and rhinoseptoplasty in facial growth DATA SOURCES: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database.

REVIEW METHODS

The outcome assessed was the midfacial growth after pediatric septoplasty.

RESULTS

Eight publications met the inclusion criteria. None found major disturbances in facial growth. Only minor nasal anomalies were reported by 4 authors.

CONCLUSION

Septoplasty in pediatric patients does not seem to affect midfacial growth according to available evidence. However, due to their design, the degree of recommendation of these studies was not superior to level C.

The impact of expanded endonasal skull base surgery on midfacial growth in pediatric patients

OBJECTIVE

Surgical resection of skull base tumors in children is increasingly accomplished through an expanded endonasal approach (EEA). We aim to evaluate the potential effect of the EEA on midfacial growth as a result of iatrogenic damage to nasal growth zones.

METHODS

We performed a retrospective review of children undergoing craniopharyngioma resection via an open transcranial or EEA. Pre- and postoperative magnetic resonance imaging was evaluated for growth in four midfacial measurements based on established cephalometric landmarks: anterior midface height, posterior midface height, palatal length, and sella-nasion distance. Statistical analysis was conducted using a mixed-effects linear regression model.

RESULTS

Twenty-two patients underwent an EEA (n = 12) or open transcranial approach (n = 10) for tumor resection with 3 years of imaging follow-up. There was no difference in midfacial growth between groups for each measurement. Compared to the open group, patients undergoing EEA demonstrated relative anterior midface height growth of -0.42 mm (P = 0.880), posterior midface height growth of -0.44 mm (P = 0.839), palatal length growth of 0.35 mm (P = 0.894), and sella-nasion distance growth of -2.16 (P = 0.365).

CONCLUSION

We found no difference in midfacial growth measurements between patients undergoing craniopharyngioma resection via an EEA and the open transcranial route after 3 years of imaging follow-up. Preliminary results on midfacial growth demonstrate that the EEA is a safe alternative to traditional transcranial approaches for the pediatric population. Further investigation with larger sample size and longer duration of follow-up is warranted to more thoroughly investigate the long-term implications of the EEA to the skull base.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:338-342, 2020.

The Effects of Sinus Surgery on Midfacial Growth in the Rabbit

The effects of pediatric sinus surgery on craniofacial growth have not been established. This study was designed to determine whether sinus surgery influences midfacial growth in New Zealand white rabbits. Surgery was performed on five groups of six rabbits each: Group 1—bilateral external dorsal approach to the maxillary sinus with enlargement of the sinus ostium and removal of the uncinate process; Group 2—bilateral external dorsal approach to the maxillary sinus; Group 3—unilateral external dorsal approach to the maxillary sinus with enlargement of the sinus ostium and removal of the uncinate process; Group 4—unilateral external dorsal approach to the maxillary sinus; Group 5—no operation. Rabbits were killed as adults, and dried skull measurements were performed using a Polhemus 3-space digitizer. Statistically significant regional restriction of midfacial growth was demonstrable when comparing Groups 1–4 with Group 5, and between sides in Groups 3–4. Enlargement of the sinus ostium and uncinectomy caused foreshortening of the snout on the operated side in Group 3. This effect was not observed following the approach alone in Group 4. These results suggest that midfacial growth is affected by sinus surgery in rabbits. Further animal studies should be done to test this hypothesis, and in the interim, a conservative approach to sinus surgery in children would be prudent.

Facial Growth after Middle Turbinate Resection: An Experimental Study in the Rabbit

Background

The aim of this study was to determine the effects of total middle turbinate resection on midfacial growth through a morphometric analysis on an animal model.

Methods

Twenty-eight male New Zealand white rabbits were used. The animals were divided into three groups: group 1, elevation and relocation of the nasal bone was performed; group 2, concha resection was performed; group 3, control group with no surgical procedure. The surgery was done at 8–10 weeks of age and the skull of each subject was sampled as they reached maturity. The determined distances then were measured by using landmarks identified on skull. The supplied data were evaluated by using the Mann-Whitney U test.

Results

Deviation of the nasal axis to the opposite side of the resected concha and an increase in the width of nasal bone were observed only in group 2. In group 1, an increase of nasal bone length and zygomaticonasal distances was determined in both the operated and the unoperated sides of nasal bones.

Conclusion

This animal experiment showed that operations on the nasal bone or concha resection affected the midfacial growth in rabbits. The effects of middle turbinate resection to midfacial development should be evaluated by additional studies. We recommend only limited, conservative surgical procedures on the middle turbinate, saving all the vital mucosa, periosteum, and bone.

Nasal Injuries in Sports

Nasal trauma is a common consequence of athletic competition. The nasal bones are the most commonly fractured facial bone and are particularly at risk during sports participation. Acute management of trauma to the nose includes thorough evaluation of all injuries and may require immediate management for repair of facial lacerations, epistaxis control, or septal hematoma drainage. Nasal fractures can often be addressed with closed reduction techniques; however, in the setting of complex nasal trauma, an open approach may be indicated. Using appropriate treatment techniques, posttraumatic nasal sequelae can be minimized; most patients report satisfactory long-term nasal form and function.

Nasalseptal hematoma/abscess: management and outcome in a tertiary hospital of a developing country

BACKGROUND

Nasal hematoma/abscess is an uncommon entity, but capable of leading to serious consequences if not handled meticulously, and with urgency.

OBJECTIVE

To present the management, and outcome of nasal septal hematoma/abscess in a Nigerian tertiary institution.

METHOD

Consecutive patients diagnosed with nasal septal hematoma/abscess over a 10-year period, treated at the University of Nigeria Teaching Hospital, Enugu, Nigeria, were prospectively studied. The processes leading to diagnosis, treatment, and outcome were sequentially evaluated.

RESULTS

Fifty-three patients (37 males and 16 females), age 5-65 years (with mean age of 23.10 years), were included. Surgical drainage of the hematoma/abscess, intranasal packing with insertion of drain was performed with total resolution of problem in all the cases.

CONCLUSION

Incision and drainage, and intranasal packing with insertion of drain was effective in treating nasal septal hematoma/abscess.

Complications in pediatric facial fractures

Despite recent advances in the diagnosis, treatment, and prevention of pediatric facial fractures, little has been published on the complications of these fractures. The existing literature is highly variable regarding both the definition and the reporting of adverse events. Although the incidence of pediatric facial fractures is relative low, they are strongly associated with other serious injuries. Both the fractures and their treatment may have long-term consequence on growth and development of the immature face. This article is a selective review of the literature on facial fracture complications with special emphasis on the complications unique to pediatric patients. We also present our classification system to evaluate adverse outcomes associated with pediatric facial fractures. Prospective, long-term studies are needed to fully understand and appreciate the complexity of treating children with facial fractures and determining the true incidence, subsequent growth, and nature of their complications.

Rhinosurgery in children: developmental and surgical aspects of the growing nose

The anatomy of the nasal skeleton in newborns and adults are not alike. The complete cartilaginous framework of the neonatal nose becomes partly and gradually ossified during the years of growth and is more vulnerable to trauma in that period. Injury in early youth may have large consequences for development and may result in a nasal deformity which will increase during growth and reach its peak during and after the adolescent growth spurt. To understand more of the underlying problems of nasal malformations and their surgical treatment (septorhinoplasty) these items became the focus of multiple animal studies in the last 40 years. The effects of surgery on the nasal septum varied considerably, seemingly depending on which experimental animal was used. In review, however, the very different techniques of the experimental surgery might be even more influential in this respect. Study of one of the larger series of experiments in young rabbits comprised skeletal measurements with statistical analysis, and microscopic observations of the tissues. The behaviour of hyaline cartilage of the human nose appeared to be comparable to that of other mammals. Cartilage, although resilient, can be easily fractured whereas its tendency to integrated healing is very low, even when the perichondrium has been saved. Also surgical procedures - like in septoplasty - may result in growth disturbances of the nasal skeleton like recurrent deviations or duplicature. Loss of cartilage, as might occur after a septum abscess, is never completely restored despite some cartilage regeneration. In this article experimental studies are reviewed and compared.Still there remains a lack of consensus in the literature concerning the developmental effects of rhinosurgry in children.Based on their observations in animals and a few clinical studies, mostly with small numbers of patients but with a long follow-up, the authors have compiled a list of guidelines to be considered before starting to perform surgery on the growing midface in children.

[Treatment of the nasal septal hematoma and abscess in children]

OBJECTIVES

Estimation of the treatment of the nasal septal hematoma and abscess after injury was performed.

MATERIAL AND METHODS

In 1998-2005 in Department of Otolaryngology Children's Hospital in Warsaw 2500 children after nasal injury were examined. Nasal septal hematoma and abscess were diagnosed in 22 (0,9%). They were reviewed retrospectively and some of them were examined 1-8 years after.

RESULTS

In 22 children with nasal septal hematoma and abscess no complication were observed during treatment. In 12 children examined 1-8 year after treatment 1 child developed saddle nose deformity (qualified to observation) and 1 child developed nasal septum deformities with nasal obstruction (qualified to septoplasty).

CONCLUSIONS

Complex treatment of nasal septal hematoma, drainage of the hematoma with septoplasty and reduction of fracture of the nose, makes good functional and cosmetic effect. Drainage of the nasal septal abscess with antibiotic prevent the early complications but it isn't enough functional and cosmetic effect in the future.

Immediate Lamina Papyracea Reconstruction during Endoscopic Sinus Surgery for Surgically Managed Subperiosteal Abscess in Children

The sinonasal area of a child's face is the keystone of facial architecture, and any trauma to this area may result in facial dysplasia. Animal studies have proven facial skeletal growth retardation following functional endoscopic sinus surgery. The effect of sinus surgery on facial skeletal growth in humans still needs to be established. Therefore, very conservative surgical resection during functional endoscopic sinus surgery in children is advocated. We present a surgical technique of immediate lamina papyracea reconstruction during endoscopic sinus surgery in children. We have used this technique in endoscopic surgical decompression of subperiosteal abscess secondary to sinusitis in children. We present two cases in which this technique was used in children aged 33 months and 8 years old. The postoperative computed tomography scans showed an intact lamina papyracea.

Pediatric craniofacial fractures: long-term consequences

Pediatric craniofacial fractures are distinct from adult fractures because of the anatomical differences that result in unique fracture patterns and challenges in management. The unanswered question remains the outcome with regards to subsequent growth and development. Upon review of all primary craniofacial fractures treated at the Children's Hospital of Philadelphia, the authors find that the majority are associated with favorable long-term outcome. Severe centrofacial bony and cartilaginous injury may result ingrowth and developmental anomalies in up to 40% of patients.

Nasal septum deformities in children and adolescents: a cross sectional study of children from Zagreb, Croatia

OBJECTIVE

Numerous epidemiologic studies on the prevalence of nasal septum deformities in children have been performed over the last three decades. As these studies were performed in children of various age groups and used different classifications of septal deformities (without detailed morphologic systematization), it is no surprise that the results differ greatly from study to study. The purpose of the study was to evaluate clinical data on the total prevalence of nasal septum deformities and particular types of deformity in children and adolescents.

METHODS

The study population consisted of 1797 randomly selected subjects divided into pre-school (aged 2-6), primary school (aged 7-14), secondary school (aged 15-18) and university (aged 19-22) groups. The native state was determined by means of anterior rhinoscopy without previous application of vasoconstrictive drugs. The observed pathologic septal deformities were classified into seven types according to Mladina's classification. A straight septum was designated as S. The prevalence of septum deformities in the population was calculated with 95% probability. Differences with respect to sex and types of deformity were tested by chi(2)-test.

RESULTS

The prevalence of nasal septum deformities according to age groups was 28.0% in the 2-6 group, 21.1% in the 7-14 group, 40.6% in the 15--18 group and 41.8% in the 19-22 group. The distribution of the seven types of septal deformity was 51.1, 23.5, 5, 0.8, 10.0, 9.0 and 0.6%, respectively. The mean values (%) and 95% confidence intervals for the seven types of septal deformity were 14.7 (13.1-16.4%), 6.8 (5.6-7.9%), 1.4 (0.9-1.9%), 0.2 (0.0-0.4%), 2.9 (2.1-3.7%), 2.6 (1.9-3.4%) and 0.2 (0.0-0.4%), respectively. Total distribution in gender showed no difference (P = 0.102).

CONCLUSIONS

In the youngest age group (2-6 years), types 1 and 2 (deformities of anterior septal segments) were exclusively found, whereas types 5 and 6 were found in older age groups (become visible during and after the puberty). Types 1 and 2 are characteristic septal deformities for small children. Since, septal deformities can affect the growth and development of the maxilla and vice versa, the authors recommend examination of the nasal septum by an rhinologist who will be a part of a team performing the regular systematic health examination of children.

Extradural frontal abscess complicating nasal septal abscess in a child

Nasal septal abscess (NSA) is an uncommon sequel to minor nasal trauma. Abscess extension beyond the nasal cavity is rarely documented. A case of a 10-year-old boy who presented with a NSA associated with a large extradural frontal abscess is presented and indications for CT scanning in the workup of pediatric patients with NSA is discussed.

Facial skeletal growth after endoscopic sinus surgery in the piglet model

This study examined the effects of varying degrees of endoscopic sinus surgery on the growing midface and snout in pigs. In this randomized, controlled experiment, thirty 40-60 pound pigs were placed in five experimental groups: (1) unilateral uncinectomy; (2) bilateral uncinectomy; (3) unilateral uncinectomy, anterior ethmoidectomy, maxillary antrostomy; (4) bilateral uncinectomy, anterior ethmoidectomy, maxillary antrostomy; (5) unoperated controls. Animals were killed after 3 months and growth was assessed, according to linear and spatial measurements of multiple craniofacial regions. Euclidean distance matrix analysis showed significant restrictive shape alterations in a linear fashion in groups 1-4 (p < .05). These alterations occurred in the surgical field of the snout, midsnout, and maxilla. Endoscopic sinus surgery causes significant restrictive effects in the growing porcine facial skeleton.

Nasal septal haematoma in Nigeria

A prospective study of 46 consecutive patients with nasal septal haematoma admitted at the General Hospital, Owerri, Nigeria over a five year period is presented. The disease was commoner in males than females. The majority of the cases (65.6 per cent) were of unknown cause and were therefore grouped as spontaneous haematoma while 30.4 per cent were due to trauma. Trauma was more common in patients below the age of 15 years while spontaneous haematoma was common in patients above that age. All the patients with septal haematoma represented 0.2 per cent of total attendances to the ENT clinic over the period. Most of the patients presented with severe and threatening symptoms necessitating intense aggressive management. All the patients were managed by surgical incision and drainage, four had marked nasal abnormalities. Three patients died from a brain abscess as a complication of infected haematoma.

Maxillofacial trauma

Although the general principles for evaluation and management of facial fractures in children are the same as for adults, some modification in assessment, timing, and technique must be considered. This article has a double purpose: to re-emphasize acute assessment and medical management so that the pediatrician can function as the coordinator of the maxillofacial trauma team, and to present both established and new techniques for the reduction of simple and complex fractures in children.

Experimental septoplasty in the growing cat. A histological study

Surgery on the nasal septum of a child is still a controversial issue, due to the fear of nasal growth inhibition. To elucidate the role that the Cottle premaxilla approach septoplasty play in the long term result, an operation using this technique was done in the growing cat, but no nasal packing nor stenting was applied. In several cases postoperative sequelae occurred, such as septal perforations, synnechia and thickening of the septum, due to dislodged cartilages. The complications were judged to be minor relative to the overall results. They have, however, to be carefully considered and weighed against the benefit of the operation.