Nasal surgery in children, most often performed after trauma, can be performed safely in selected patients with articulate, deliberate, and conscientious operative plan. All nasal surgery in children seeks to avoid disruption of the growth centers, preserving and optimizing nasal growth while improving the form and function of the nose. A solid appreciation of long-term outcomes and effects on growth remain elusive.
Key points
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Nasal surgery in children, most often performed after trauma, can be performed safely in selected patients with articulate, deliberate, and conscientious operative plan.
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In addition to form and function, nasal growth is also a consideration.
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Nasal septal abscess and hematoma can lead to long-term changes that benefit from early reconstruction.
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Primary cleft rhinoplasty can improve nasal appearance and reduce severity of cleft-related nasal deformity.
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Neonatal septal deviation may correct itself when minor; severe obstruction can benefit from intervention.
Introduction
Nasal surgery in the pediatric patient continues to be controversial. Contention persists on what impact there is to the growing nose. Currently, most surgeons wait until after puberty for elective nasal surgery. Surgery of the nose in children intends to improve function and appearance while preserving conditions for future development and growth. There are potential effects of misdirected growth after trauma in which significant deviation is exacerbated during nasal growth. Likewise, it remains unclear what the effect of surgical intervention is on growth. The current state of thought holds that surgery of the nose and septum should be avoided in prepubescent children, unless severe derangement, trauma, mass, or congenital defect exist to avoid risk of growth center disruption.
Rhinoplasty in children has been met with mixed opinions. Initially, it was thought that surgery should be avoided at all costs when it pertained to a child’s nose. Over time, after investigation, this thinking changed. It is now believed that well-thought-out and deliberate surgery of the child’s nose can improve the nasal airway and the nasal aesthetics and even optimize growth.
Introduction
Nasal surgery in the pediatric patient continues to be controversial. Contention persists on what impact there is to the growing nose. Currently, most surgeons wait until after puberty for elective nasal surgery. Surgery of the nose in children intends to improve function and appearance while preserving conditions for future development and growth. There are potential effects of misdirected growth after trauma in which significant deviation is exacerbated during nasal growth. Likewise, it remains unclear what the effect of surgical intervention is on growth. The current state of thought holds that surgery of the nose and septum should be avoided in prepubescent children, unless severe derangement, trauma, mass, or congenital defect exist to avoid risk of growth center disruption.
Rhinoplasty in children has been met with mixed opinions. Initially, it was thought that surgery should be avoided at all costs when it pertained to a child’s nose. Over time, after investigation, this thinking changed. It is now believed that well-thought-out and deliberate surgery of the child’s nose can improve the nasal airway and the nasal aesthetics and even optimize growth.
Historical perspective
First descriptions of pediatric rhinoplasty date back to 1902. The next decade followed with reports of adverse effects: saddle nose, growth inhibition, and maxillary retrusion. After early sequelae of nasal surgery were identified, there was a movement for avoidance of all surgery on the child’s nose. Between the 1950s and the 1970s literature warned about disrupting the septal cartilage owing to its role in ventral and caudal projection or resecting the keystone area before completion of growth. The sentiment was to delay surgery until growth was complete believing severe disturbance would interfere with further development.
Animal studies
Animal studies were performed in the 1950s and 1960s on various models. The most prominent were completed by Sarnat and Wexler using a rabbit model resecting septal cartilage with perichondrium, which resulted in dramatic impairment of nasal and midface growth. Hartshorn showed altered growth in canines repeating the study. Squier and colleagues examined histology showing that fibrosis after resection may contribute to a pattern of restricted growth. However, study in Guinea pigs with varied amount of resected cartilage only showed variable growth when extensive cartilage was resected. Fuchs showed impacted growth with only resecting perichondrium. Bernstein, in a canine model, preserved the mucoperichondrium, elevating flaps and removing septal cartilage or autotransplanting cartilage. Autografted septum remained viable and removed areas had regeneration of cartilage at 10 months. Additional study of maneuvers consistent with septorhinoplasty and perichondrial preservation in ferrets showed no change to facial growth on cephalogram
Nasal anatomy and growth
Embryology
The region within the frontonasal process differentiates into nasal placodes, which invaginate to a pit, eventually becoming the nasal passages and choana. Each nasal pit is flanked by part of the lateral and medial nasal prominence. In the midline, the medial nasal prominences fuse, ultimately becoming central nasal structures and the philtrum. The maxilla, arising from the first arch, the maxillary prominence, moves medially with the lateral nasal process to fuse with the combined medial nasal prominence. These processes are complete at around 10 weeks. During fifth to seventh week of gestation, ossification centers arise for maxilla and nasal bones. By the eighth week, vomer ossifies. Chondrification of lateral nasal walls happens during the third month. At the sixth month, cartilages differentiate from a single unit into upper lateral cartilage (ULC), lower lateral cartilage (LLC), and septal cartilage.
Anatomy
There are distinct differences in the child’s nose compared with the adult nose, beginning with smaller dimensions. Even during childhood, the amount of cartilage and the profile of the nose changes. The overlying skin and soft tissue contains more fat and is generally thicker than that in the adult nose. The T-bar complex forms much of the nasal support. The pediatric nose has typical differences from that of the adult. The septum has variable thickness. The tip is slightly elevated and less projected with an increased nasolabial angle. The tip is flat and the columella is short. The dorsal length is reduced. The nares are small and rounded. The nasal vestibule is smaller in children comparatively, which can limit exposure in endonasal surgery.
Septum
The septum in an infant’s nose has significantly more cartilage than bone compared with that of an adult. In the infant, septal cartilage spans from the nasal spine to the sphenoid rostrum. There are thicker areas corresponding to growth centers and thinner areas that are at risk for fracture during injury.
Perpendicular plate and vomer
Vomer arises from progressive ossifying fragments flanking a basal of cartilage along the palatal bone. Endochondral ossification adjacent to the skull base in ventrocaudal direction results in the perpendicular plate. Nasal growth proceeds with both continued ossification and cartilage growth. By age 6 to 8 years, the perpendicular plate and vomer reach contact with each other.
Lateral cartilages
The ULC extends superiority under the nasal bones. The dorsoseptal T bar, composed of septum and upper lateral cartilages, fused initially, is the main support in neonates and children.
Nasal bones
Nasal bones are shorter. The suture lines remain open. As in adults, they include the nasal process of frontal bones and ascending process of the maxilla completing the bony nasal vault.
Growth
There are 2 periods of nasal growth: the first occurs during the initial 2 to 5 years of life, the second is during puberty. The septal cartilage in children is similar in size to adult cartilaginous septum by 2 years of age. There is continued enlargement in the dorsocaudal direction and enlargement of the bony proportion of septum. The pubertal nasal growth occurs between ages 12 and 16 years for girls and 15 and 18 years for boys. Additional studies found continued increases in nasal growth to age 20 in women and 25 in men. The nasal septum has been shown to grow until age 36 years.
Nasal septal cartilage is thought to be a driving factor in nasal growth ( Fig. 1 ). During fetal development, as the cartilaginous structures are fusing, the sphenoid rostrum grows anteriorly meeting the posterior septum. The vomer develops bilaterally, posteriorly, and inferiorly to the cartilage septum. It fuses and ossifies as it grows forward. The suture line between the vomer and premaxilla is an important growth center. This suture line is abnormal in orofacial clefts and may contribute to the observed asymmetric growth disturbances. Septal cartilage growth centers include the sphenospinal and sphenodorsal regions. Nasal bones develop over the triangular cartilage capsule, absorbing this precursor of the bony pyramid. As the LLC extends downward, the tip becomes more bulbous and drops, and the nares are no longer visible. The LLC becomes more resilient and firms in adolescence. Nasal dorsal height and anterior-posterior projection increase.
Abnormal Growth
Septal deviation present during the rapid phase of development can cause irregular growth and amplify the deviation. Compelled oral breathing, such as in severe obstruction, disrupts normal craniofacial and maxillofacial growth. Altered craniofacial development, similar that of adenoid facies, from open mouth, anterior tongue placement, and decreased maxilla facial tone, changes the developmental forces. Septal deviation produces a pattern of narrow maxilla, maxillary protrusion, arched palate, malocclusion, micrognathia, retrognathia, and an increased anterior lower vertical facial height.
Cartilage Regeneration
In children, after cartilage injury, the response may be loss, incomplete regeneration, or complete regeneration. In adults, regeneration is not observed; rather, fibrosis in child and adult cartilaginous fractures never heal, they fibrose between segments. Histologically, regenerated cartilage seems to have random arrangement of chondrocytes. Intact perichondrium is necessary to facilitate regeneration. Excessive regeneration can be detrimental causing undirected growth, even to the point of new obstruction.
Nasal deformities
Nasal deformity in children primarily arises from trauma or inheritance. Both of these contribute to early and late deformities. Nasal masses and congenital malformations are additional causes. Intrauterine growth restriction, birth injury, and familial characteristics can all lead to preadolescent deformity.
Nasal abnormality can be classified by the timing of when it was thought to have occurred (ie, prenatal, neonatal, infant). Perhaps more useful is classifying by contributing forces: trauma, trauma with growth, growth alone, or developmental. The last category includes congenital anomalies.
Patient evaluation
Nasal airway obstruction (NAO) is a common finding in the pediatric population; the variety of etiologies includes adenoid hypertrophy, septal deviation, turbinate hypertrophy, nasal polyposis, and nasal tumors. NAO in children often has multiple causes, rarely owing solely to septal deviation. Symptoms include: diminished quality of life, chronic rhinitis, mouth breathing, sleep-disordered breathing (SDB), and obstructive sleep apnea (OSA). Associated symptoms include recurrent sinusitis, malocclusion, and recurrent otitis media. Uncorrected septal deformities worsen over time and can impact frequency of these symptoms.
An appropriate and thorough evaluation identifying the contributing factors may find ways to avoid need for surgery. The examination should include anterior rhinoscopy to assess degree of septal deflection/deformity and flexible fiberoptic examination to aid in finding the pathology of NAO and eliminating others. It is prudent to perform endoscopy in pediatric patients before surgery. Computed tomography is rarely needed unless there is concern for a mass or posterior anomaly.
Nasal surgery
All pediatric nasal surgery has the goals of improving the nasal airway, restoring normal anatomy and appearance, and preservation of growth potential. These goals are accomplished by conservative surgery with restoration of the nasal framework, projection, dorsum, tip, and tip position. There remains no consensus to absolute or relative indications for surgery. Generally accepted indications for surgery include septal hematoma or abscess, severe deformity from acute trauma, reconstruction after removal of nasal mass, and cleft lip nasal deformity. Severely deviated septum causing significant NAO or anticipated progressive distortion of the nose with growth is considered by many a reasonable indication for intervention. Procedure selection should consider the patient’s anatomy and goals of surgery. An external approach would be best in cases of free graft technique or septal explant with autologous grafting.
Turbinates
Turbinate hypertrophy is a common cause of pediatric NAO. In the past, turbinate surgery was performed via multiple methods. Resection of partial or complete turbinate was favored in the early 1990s, followed in late 1990s with transition to the use of lasers. Currently, submucosal microdebridement and radiofrequency thermal ablation are favored.
Typically, children are treated medically for 3 months before considering surgery for turbinates. Hypertrophy can be bony or mucosal. Examination of the turbinates should include response to topical decongestants. Surgery is offered empirically, depending on reported symptoms and clinical assessment. A recent survey study of practice patterns in pediatric turbinate surgery reported indications for surgery of 82% for nasal obstruction and 16% for SDB. It was the only procedure 20% of the time and concomitant with others in 80%, typically with adenotonsillectomy, septoplasty, or sinus surgery. The overall complication rate is around 4%, with the most common complication being intranasal synechiae. Others include epistaxis, pain, or nasal crusting. There are no reports of atrophic rhinitis.
Sullivan and colleagues found improved respiratory parameters in pediatric patients who underwent adenotonsillectomy with inferior turbinate reduction versus those who underwent adenotonsillectomy alone. Improvement in sleep parameters was documented on polysomnography. A review by Leong and colleagues reported Oxford Centre for Evidence-Based Medicine grade C recommendation to support inferior turbinate reduction in children. No studies have long-term follow-up results, as such long-term efficacy and impact on facial growth, if any, is unclear. The natural history of turbinate hypertrophy in children also lacks data. Severe turbinate hypertrophy contacting the septum is hypothesized to cause septal deviation. Despite poor evidence and lack of long-term outcomes, it is still a reasonable treatment in children with medically nonresponsive chronic rhinitis, OSA/SDB, NAO, and mild-to-moderate septal deviation to avoid nasal surgery.
Septoplasty
Septal surgery is reasonable after age 5 to 6 years when performed appropriately. Avoiding surgery in children with severely deviated nasal septum (DNS) can lead to facial abnormalities, malocclusion, and respiratory symptoms. Endonasal approaches are typically used, such as Killian or hemitransfixion incisions. Visualization can be difficult, especially in very young patients. A sublabial approach can improve access. Endoscopic assistance can aid in seeing and targeting areas. Often spurs can be removed by elevation of an ipsilateral submucoperichondrial flap. A microdebrider can be used to precisely remove a spur or specific area of deviation. With broad deviations, the convex surface of the cartilage can be scored to relax the deviation. Deviated cartilage can be resected and reimplanted. Excess cartilage can be judiciously excised. With any repair, superimposing segments of cartilage or bone should be avoided. Christophel and Gross highlight pitfalls and techniques to optimize operations on the nasal septum. They emphasize the fragile nature of mucoperichondrium, clearly important to preserve for cartilage survival and thus growth. An endoscope can be instrumental in visualization. And whenever possible, bone and cartilage should be restored to its position after straightening.
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Preserve perichondrium
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Preserve cartilage, avoid large resections, no submucosal resection
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Maintain the bony-cartilaginous junction whenever possible
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Remodel and reposition cartilage
Rhinoplasty
Pediatric rhinoplasty generally is defined as rhinoplasty in girls less than 14 and boy less than 16 years of age. Selecting appropriate patients (trauma, tumor, congenital anomaly) with preservation of key structures and sparing use of grafts will provide benefit. Rhinoplasy is most commonly used in cases of deformity and dysfunction after nasal trauma and severe crooked nose accompanied by functional impairment. It may also be considered in severe deformity, after tumor resection, and for cleft nasal deformity or other congenital reasons. The argument for surgical intervention includes redirection of what would have been abnormal and deviated growth as well as the benefits of improved nasal airway function, aesthetics, and positive psychosocial impacts.
To a degree, the goals of surgery will vary according to the etiology: after trauma, return to preinjury state; after tumor or mass removal, restoring premorbid nasal function; in congenital malformations, creating a more normal anatomic configuration. As above, conservation of septal structures is key. As in adults, ensuring adequate septum for tip support is important. Cautious grafting is paramount, since even though the proportion of cartilaginous septum is higher, less cartilage is available for graft creation. Grafting is used when required to ensure tip projection, position, and support. Auricular cartilage and small amounts of septum are available. Maintaining the T-bar of ULC and septum keeps the dorsum stable. In removal of dorsal structures or with total septal reconstruction, spreaders are necessary to stabilize and sustain midline dorsal support. Spreader grafts can also stabilize a severe dorsal deviation toward the midline. Native structures are preserved when possible, resection is conservative, and improvements are achieved through sculpting, augmentation, and other changes. The objective is not to create the sculpted adult nose but restore function with age-appropriate appearance. Medial and lateral osteotomies can be performed to center the nasal pyramid, especially after trauma. Osteotomies can be performed through previous fracture lines. Dorsal hump reduction is best postponed until after puberty. Consideration should be taken of age, severity of associated septal deviation, and further growth potential. When performing the procedure, native length and projection of the nose should be kept. Saddle defects of the dorsum may require grafting to recreate normal nasal dimensions.
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Keep maximal structure allowable while achieving goals
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Minimize grafting
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Maintain caudal tip support
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Consider spreaders for dorsal strength where appropriate
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Consider auricular cartilage for grafting
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Reduce dorsal hump only when accompanied by severe deviation
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Medial and Lateral osteotomies may be used in redirecting upper nose
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