Nasal region dimensions in children: a CT study and clinical implications

Rapid initiation of nasal saline irrigation to reduce severity in high-risk COVID+ outpatients

OBJECTIVE

To determine whether initiating saline nasal irrigation after COVID-19 diagnosis reduces hospitalization and death in high-risk outpatients compared with observational controls, and if irrigant composition impacts severity.

METHODS

Participants 55 and older were enrolled within 24 hours of a + PCR COVID-19 test between September 24 and December 21, 2020. Among 826 screened, 79 participants were enrolled and randomly assigned to add 2.5 mL povidone-iodine 10% or 2.5 mL sodium bicarbonate to 240 mL of isotonic nasal irrigation twice daily for 14 days. The primary outcome was hospitalization or death from COVID-19 within 28 days of enrollment by daily self-report confirmed with phone calls and hospital records, compared to the CDC Surveillance Dataset covering the same time. Secondary outcomes compared symptom resolution by irrigant additive.

RESULTS

Seventy-nine high-risk participants were enrolled (mean [SD] age, 64 [8] years; 36 [46%] women; 71% Non-Hispanic White), with mean BMI 30.3. Analyzed by intention-to-treat, by day 28, COVID-19 symptoms resulted in one ED visit and no hospitalizations in 42 irrigating with alkalinization, one hospitalization of 37 in the povidone-iodine group, (1.27%) and no deaths. Of nearly three million CDC cases, 9.47% were known to be hospitalized, with an additional 1.5% mortality in those without hospitalization data. Age, sex, and percentage with pre-existing conditions did not significantly differ by exact binomial test from the CDC dataset, while reported race and hospitalization rate did. The total risk of hospitalization or death (11%) was 8.57 times that of enrolled nasal irrigation participants (SE = 2.74; P = .006). Sixty-two participants completed daily surveys (78%), averaging 1.8 irrigations/day. Eleven reported irrigation-related complaints and four discontinued use. Symptom resolution was more likely for those reporting twice daily irrigation (X2 = 8.728, P = .0031) regardless of additive.

CONCLUSION

SARS-CoV-2+ participants initiating nasal irrigation were over 8 times less likely to be hospitalized than the national rate.

Special Considerations in Pediatric Endoscopic Skull Base Surgery

Originally pioneered in adults, endoscopic endonasal approaches for skull base pathology are being increasingly applied as a minimally invasive alternative for young children. Intrinsic anatomic differences between these patient populations have sparked discussions on the feasibility, safety, and efficacy of these techniques in pediatric patients. This work aims to serve as a primer for clinicians engaged in the rapidly evolving field of pediatric endoscopic skull base surgery. A succinct overview of relevant embryology, sinonasal anatomy, and diagnostic workup is presented to emphasize key differences and unique technical considerations. Additional discussions regarding select skull base lesions, reconstructive paradigms, potential surgical complications, and postoperative care are also highlighted in the setting of multidisciplinary teams.

Sexual dimorphism in human midfacial growth patterns from newborn to 5 years old based on computed tomography

Recent studies have supported the presence and varying nature of craniofacial sexual dimorphism (SD) from the very first stages of ontogeny. But the exact patterns of between-sex differences during the first years of life remain obscure despite the importance of these data for craniofacial surgery treatment and forensic studies. Our study employs a large dataset of clinical computed tomography scans of individuals of East Slavonic descent from birth to 5 years of age (247 males and 184 females) to address the pattern of age-related between-sex differences in 22 linear measurements of the mid-face. At birth, SD of most dimensions is low, but it increases significantly during the first year of life. The level of SD of most variables fluctuates in both directions during the second year and peaks during the third and fourth years of life. During the sixth year, SD of about half of the variables markedly decreases. In adults, SD of all variables increases, but to a very different extent: from 2% to 13%. Most sexually dimorphic features of the facial skeleton begin to develop early in postnatal ontogeny and then may or may not become accentuated during puberty. Importantly, the patterns of age changes in the level of SD differ strongly between various dimensions, and so cannot be expressed by a single value for the whole face. Additionally, the level of SD for a particular variable is not ontogenetically stable during the first years of life.

Radiological Parameters Review for Choanal Atresia

(1) Background: The study aims to identify which imaging parameters are necessary for a new correct surgical approach in the study of choanal atresia, and which anatomical findings are essential for correct planning of endoscopic treatment in choanal atresia. (2) Methods: In this retrospective study, 19 patients with choanal atresia had high-resolution multiplanar imaging (14 cases aged ≤1 year and 5 cases aged 1 to 3 years) and 35 patients in the control group similarly distributed by age. Fourteen variables, the most relevant from a surgical point of view, were selected and measured. A comparison was made between the averages of the study group and the different control groups, either directly observed or selected from the literature, using Pearson's correlation. (3) Results: In 14 out of 26 cases, the differences were statistically significant. There was a correlation between the structures assessed, such as choanal height, rostrum height, and age. (4) Conclusions: Thanks to volumetric reformatting, this work identified and provided the clinician with useful information that helped choose the correct surgical approach. Furthermore, it focused on which imaging parameters are necessary to improve the planning of the surgical correction of choanal atresia.

Nasomaxillary effects of miniscrew-assisted rapid palatal expansion and two surgically assisted rapid palatal expansion approaches

This retrospective study was performed to evaluate nasomaxillary changes in 36 patients at an advanced stage of skeletal maturity who underwent miniscrew-assisted rapid palatal expansion (MARPE) or surgically assisted rapid palatal expansion (SARPE) with/without an alar base cinch. Cone beam computed tomography images taken before and after expansion were analysed. Changes in the width of the dental arch (D66S, D66I), maxillary base (MxMol), and nasal floor and nasal cavity in the molar and canine regions (NaFMol, NaFCan, NaCMol, NaCCan) were compared, as well as changes in the choanal aperture (CA) and nasal soft tissue (NW). The MARPE technique produced smaller dental changes (D66S; P=0.025) and greater nasomaxillary expansion (MxMol, P=0.010; NaCMol, P=0.016; NaCCan, P=0.017; NaFMol, P=0.001; CA, P=0.002) than both SARPE techniques. Changes in NW did not differ significantly between the groups (P=0.200). MARPE uniformly increased the anterior and posterior widths of the nasal cavity. SARPE expanded the nasal cavity in a 'V-shape' pattern. Changes in the nasal cavity and choanal aperture related to the amount of dental arch expansion were greater for MARPE than for SARPE. All three approaches increased the width of the nasal soft tissue, although the cinch in SARPE limited this increase.

Measured CPAP in a Noninvasive Pediatric Airway and Lung Model

BACKGROUND

Bronchiolitis is the most common cause of admission in children < 2 y of age in the United States. The standard of care involves supportive measures, including noninvasive interventions such as CPAP. CPAP is traditionally delivered through a full face mask; however, pediatric ICUs have been exploring the use of the RAM cannula by Neotech as a mode of CPAP delivery. The level of CPAP delivered via the RAM cannula is uncertain. We performed an in vitro study to determine the level of CPAP delivered via the RAM cannula utilizing a pediatric lung model.

METHODS

Models of 7 sizes of pediatric upper airways, produced with a 3-dimensional printer, were connected to a breathing simulator. We applied each size of RAM cannula to weight-appropriate airway and lung compliance parameters, delivering pressures of 5, 7, and 10 cm H₂O using a ventilator in the CPAP mode. Leaks of 0%, 20%, 40%, and 60% were generated to emulate a complete seal, a poor fit, and open-mouth breathing. The outcome measure was the difference in CPAP, referred to as "%leak effect," measured by the lung simulator relative to the CPAP set on the ventilator.

RESULTS

We found that set CPAP of 5-10 cm H₂O generated measured CPAP ranging from 2.6 to 9.7 cm H₂O. For the set CPAP levels of 5, 7, and 10 cm H₂O, the mean %leak effect values of measured CPAP from the set CPAP were -25%, -26%, and -25.7%, respectively. For each specific cannula-airway combination, increasing the set pressure and decreasing the air leak resulted in higher levels of CPAP delivered.

CONCLUSIONS

The RAM cannula delivered varying amounts of CPAP, with a percent loss of approximately -25% depending on the level of leak in the system. With minimal leak, it is conceivable that the RAM cannula can be used to deliver clinically meaningful CPAP.

Airway Development Relevant to Cranial Vault Suture Synostosis Subtype in Apert Syndrome

Introduction: Based on an established classification system of Apert syndrome subtypes, we aim to directly analyze the correlation between segmented airway volume changes and different skull suture synostosis, so as to provide individualized surgical planning for each subgroup of Apert patients. Methods: CT scans of 44 unoperated Apert syndrome and 53 controls were included and subgrouped as: type I. Bilateral coronal synostosis; type II. Pansynostosis; type III. Perpendicular combinations of cranial vault synostosis. CT scans were measured using Mimics and 3-matics software. Results: Type I developed a 41% ( P = .116) reduction in the nasal cavity, yet a normal sized pharyngeal airway. The reduced nasal airway was linked to the decreased cross sectional area ( r = 0.598, P = .001), vertical dimension ( r = 0.719, P < .001), and narrower width ( r = 0.727, P < .001). Type II developed proportionally reduced nasal airway and pharyngeal airway volumes (both 47%, P = .113 and P = .041), along with the proportionally restricted cross sectional areas at choana and condylion levels by 62 to 65%. This reduction is related to the cranial base length ( r = 0.712, P = .048), and also cranial base angulation ( r = 0.780, P = .023). Nasal and pharyngeal airway developed normal volume in type III. However, the cross sectional areas at the gonion level diminished by 74% ( P < .001). Conclusion: Airway development is influenced by subtype of Apert suture synostosis. Type II pansynostosis Apert patients developed synchronous reduced nasal and pharyngeal airways, which is correlated with the slightly flattened cranial base. Type I bicoronal patients have a smaller nasal cavity, but normally sized hypopharynx. Yet, type III patients developed normal nasopharyngeal airway volume overall.

The expanded endonasal approach in pediatric skull base surgery: A review

OBJECTIVE

Surgery of the pediatric skull base has multiple unique challenges and has seen recent rapid advances. The objective of this review is to assess key issues in pediatric skull base surgery (SBS), including anatomic limitations, surgical approaches, reconstruction techniques, postoperative care, complications, and outcomes.

DATA SOURCES

PubMed literature review.

REVIEW METHODS

A review of the literature was conducted to assess the challenges, recent advances, and reported outcomes in pediatric SBS.

RESULTS

The pediatric skull base presents multiple anatomic challenges, including variable patterns of pneumatization, narrow piriform aperture width, and narrow intercarotid distance at the level of the cavernous sinus but not the superior clivus. These issues may be particularly challenging in patients less than 2 years of age. Endoscopic endonasal approaches in the sagittal and coronal plane have been applied to the pediatric skull base while open approaches may still be necessary in the setting of extensive intracranial or orbital disease, as well as disease lateral to critical neurovascular structures. While the nasoseptal flap was initially called into question for pediatric cases, it has been shown through multiple reports to be a feasible and robust reconstructive option. Complications and outcomes often depend upon the pathology. In children, response to noxious stimuli, ability to avoid Valsalva, and adherence to nasal precautions is variable. The use of lumbar drains is more common in pediatric than adult patients.

CONCLUSION

While the pediatric skull base presents unique challenges, outcomes data support that endoscopic endonasal approaches are a pertinent surgical technique in appropriately selected patients.

LEVEL OF EVIDENCE

3a.

Skull base anatomy and surgical safety in isolated and CHARGE-associated bilateral choanal atresia

INTRODUCTION

Bilateral choanal atresia (BCA) is associated with a high incidence of congenital abnormalities that include skull base anomalies and defects. Surgical repair of BCA is necessary in the early neonatal period and any altered anatomy of the adjacent skull base will heighten the risk of intracranial injury. This risk may be further increased in patients with CHARGE syndrome.

OBJECTIVES

To measure surgically relevant nasal and skull base dimensions in neonates with BCA in order to determine whether any difference exists between isolated and CHARGE syndrome associated subgroups, thereby optimizing the safety of surgical repair.

METHODS

A retrospective review of medical charts and computed tomography was undertaken at a tertiary pediatric hospital of all neonates diagnosed with BCA between 2004 and 2016. Isolated and CHARGE syndrome subgroups of BCA were identified from clinical records and CT data was analyzed and compared between the two. The skull base parameters measured were choanal width, choanal height, mid-nasal skull base height and skull base slope.

RESULTS

Of the 13 patients included, 3 had CHARGE syndrome and 10 had isolated BCA. Whilst the difference in mid-nasal height approached significance for the two groups, numbers were too small for a statistical difference to be identified. The mean value for choanal width in the isolated BCA group was significantly less the largest series of normative data available in the literature for comparison (p < 0.001). No skull base anomalies were noted in either group.

CONCLUSION

While this is a small study with limited numbers, it is the first that has attempted to identify and measure the posterior nasal and skull base anatomy most pertinent to avoiding skull base injury in the surgical management of BCA.

How does nonsyndromic craniosynostosis affect on bone width of nasal cavity in children? - Computed tomography study

Craniosynostosis is caused by premature fusion of one or more cranial sutures, restricting skull, brain and face growth. Nonsyndromic craniosynostosis could disturb the proportions of face. Although morphometric diameters of nasal cavity in healthy children are already known, they have not been established yet in children with nonsyndromic craniosynostosis. The aim our study was to check whether diameters of bone structures of nasal cavity in children with nonsyndromic craniosynostosis measured in CT are within normal range. 249 children aged 0–36 months (96 with clinical diagnosis of nonsyndromic craniosynostosis and 153 in control group) were included into the study. The following diameters were measured on head CT scans: anterior bony width (ABW), bony choanal aperture width (BCAW), right and left posterior bony width (between bone sidewall and nasal cavity septum—RPBW and LPBW). The study group has been divided into 4 categories, depending on child’s age. The dimensions measured between bone structures of nasal cavity were statistically significantly lower in comparison to the control group. They did not depend on the sex for ABW, nor on age in groups 7–12 months and < 2 years for BCAW, RPBW and LPBW. The measured dimensions increased with age. In children with nonsyndromic craniosynostosis the diameter of pyriform aperture and bony choanal aperture were lower than in controls, what may be described as fronto-orbital anomalies. Morphometric measurements of anthropometric indicators on CT scans could be used as standards in the clinical identification of craniosynostosis type and may help in planning surgical procedures, particularly in the facial skeleton in children.

Midfacial growth patterns in males from newborn to 5 years old based on computed tomography

OBJECTIVES

Growth patterns of the human facial skeleton have been of great interest and importance for biological anthropologists, forensic scientists, craniofacial surgeons, and orthopedists. Nevertheless, growth trends of the facial skeleton in infancy and early childhood are still poorly known and clinical CT data have been insufficiently used for studying craniofacial ontogeny. The purpose of this study was to provide a comprehensive quantitative description of human midfacial ontogeny in infancy and early childhood, and to contribute to debates regarding the role of modularity vs. integration in shaping the human face.

METHODS

Our dataset includes 146 high resolution clinical CT datasets of males from the 2nd to 6th years of life and 101 dataset of infants (males) in the 1st year of life. Forty landmarks were collected from each 3D reconstructed skull, then 25 linear measurements describing the morphological features of the facial skeleton were calculated. The integration/modularity issue was addressed via comparison of intragroup correlation matrices at different ages.

RESULTS

Growth trends for all the measurements are presented in charts and tables of statistical parameters that can be used as normative data. The midfacial variables display a great diversity of growth patterns. The correlation structure of the measurements is different at different ages.

CONCLUSIONS

Variables commonly assigned to the same unit of the facial skeleton can exhibit rather different growth trends, but some measurements display seemingly coordinated patterns of growth change. The level of interindividual variation of most measurements is stable after the second half of the first year of life.

The Relationship Between Hard Tissue and Soft Tissue Dimensions of the Nose in Children: A 3D Cone Beam Computed Tomography Study

This study using three-dimensional cone beam computed tomography (CBCT) images of children determined relationships between nasal skeletal and soft tissue measurements and assessed the association with sex, age, and skeletal maturation stage. Following reliability studies, skeletal and soft tissue parameters were measured on coded CBCTs of 73 children (28M:45F;6-13 yoa). Pearson and Mantel correlations were used to analyze associations between skeletal and soft tissues. Partial Mantel correlations were used to study the associations between skeletal and soft tissue, adjusting for sex, age, and skeletal maturation. Linear regression analyses were used to predict soft tissues sizes. Logistic regression was used to study the relationships between soft and skeletal tissue symmetry. Except for nasal aperture width and interalar width, skeletal landmarks best predicted corresponding soft tissue landmarks. Significant positive associations existed between skeletal and soft tissues after adjusting for sex, skeletal maturation, and age. Children's nasal skeletal tissues predicted nasal soft tissue reasonably well.

Maxillary Hypoplasia: Differential Diagnosis of Nasal Obstruction in Infants

Maxillary hypoplasia (MH) is a rare cause of respiratory dysfunction in infants and may occur in association with genetic abnormalities or as an isolated condition. It is included in the differential diagnosis of congenital nasal obstruction. This paper seeks to report a case series of infants with MH, discuss methods for its diagnosis, and compare computed tomography (CT) measurements of nasal cavities of infants with MH and without craniomaxillofacial abnormalities. The therapeutic approach in each patient is also described. All infants with MH admitted to a tertiary hospital between 2012 and 2015 were included. Baseline nasal endoscopy was performed at bedside. The width of the infants' nasal cavities was measured by a radiologist with experience in CT scanning of facial bones. Control patients were infants of matched sex and similar age who underwent head CT scanning for various reasons. Overall, 8 infants with MH and 8 controls were assessed. All nasal cavity dimensions of infants with MH were significantly smaller than those of control subjects. The authors conclude that the diagnosis of MH should be considered in infants with nasal obstruction and nasal cavity narrowing at nasal endoscopy.