April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Zhang et al

underwent cleft septorhinoplasty had both preintervention and postintervention NOSE surveys, precluding a meaningful assessment of change in nasal obstructive symptoms. A subgroup analysis of the oldest age brackets (n ¼ 104, mean age: 16.6 + 1.7 years) found a significant moderate correlation between older age of primary CL repair and more severe (1) composite NOSE score (0.331; P ¼ .023), (2) nasal congestion (0.323; P ¼ .027), (3) nasal blockage (0.288; P ¼ .050), and (4) trouble breathing through nose (0.389; P ¼ .007). No significant correlation was found in this subgroup analysis between age of palate repair and nasal obstructive symptoms. When all subjects were included, age of primary CL ( P ¼ .512) or CP repair ( P ¼ .426) was not significantly correlated with the severity of symptoms. Discussion Nasal obstruction is a common problem in the cleft population, with 67 % of the study cohort reporting symptoms at some point during the study period. Severity of symptoms reported varied according to age-group ( P ¼ .035), with respondents older than 14 years of age having the highest composite NOSE scores, followed by subjects younger than 5 years of age. The severity of symptoms also varied according to cleft phenotype. Subjects with unilateral CLP reported more severe nasal block age symptoms than bilateral CLP, although subjects with CL þ A reported the most severe symptoms in the cohort ( P ¼ .022). In a subgroup of skeletally mature subjects, older age of primary CL repair was associated with more severe nasal obstructive symptoms. Interestingly, severity of nasal obstructive symp- toms did not vary significantly with age of repair when con- sidering the entire cohort, nor with regard to NAM treatment, tip rhinoplasty at the time of primary repair, or use of nasal splints following primary repair ( P > .050). Older subjects with a history of speech surgery, either PPF or SP, reported signif- icantly more severe nasal obstructive symptoms than subjects with no history of speech surgery ( P ¼ .002). Previously, Sobol et al. (2016) found a high prevalence of nasal obstructive symptoms in children with CL/P, using NOSE surveys mailed to families of children with CL/P iden- tified through a state registry. Overall, the prevalence of nasal obstructive symptoms found in this study was similar to the prevalence reported by Sobol et al. For example, 16.1 % of children with CL/P reported “severe” or “fairly bad” nasal congestion/stuffiness, compared to 16.4 % of this cohort. This study’s sample size of subjects with CL/P (n ¼ 456) is notably larger than that of the prior study by Sobol et al. (n ¼ 176), increasing the power of analysis. The results of the Sobol et al and this study suggest the utility of NOSE tool in evaluating nasal obstruction, with its inclusion of multiple dimensions and symptoms presented in concrete language relating to daily activities. The instrument can allow patients/parents to more specifically report and quantify their experience, which in turn can enhance the clinician’s understanding of the issue. This study’s finding that subjects older than 14 years reported the highest NOSE scores in the cohort aligns with the

+ 4.19) than subjects who had incomplete unilateral CL + P deformities (3.00 + 3.77; P ¼ .071). Figure 2. Bar chart comparing mean composite NOSE scores by age- group, across the entire cohort and by Veau classification subgroups. NOSE indicates Nasal Obstruction Symptom Evaluation.

Nasal Obstruction According to Surgical Intervention History

Table 4 presents the results of NOSE surveys following spe- cific interventions. There was no significant difference in NOSE scores (either composite or individual symptom), when comparing subjects with regard to history of nasoalveolar molding (NAM) prior to primary CL repair, tip rhinoplasty at the time of primary CL repair, or use of nasal splints following primary CL repair ( P > .050). When comparing the most severe NOSE survey for each respondent, subjects with a history of speech surgery, either posterior pharyngeal flap (PPF) or sphincter pharyngoplasty (SP), had significantly higher composite scores than subjects who did not (5.42 + 4.38 vs 3.78 + 3.98; P ¼ .006). When comparing the most recent NOSE surveys, there was a trend of higher composite scores in the speech surgery cohort compared to the nonspeech surgery cohort (3.55 + 4.08 vs 2.52 + 3.21; P ¼ .098). Given that the 2 groups differed significantly in mean age, subanalyses were performed to assess the younger (9 years and younger) and older subjects (10 years and older) separately. In the older group, the difference in composite NOSE scores with regard to history of speech surgery remained statistically sig- nificant ( P ¼ .002). Among subjects 9 years and younger, however, there was no significant difference in composite NOSE scores ( P ¼ .482). Only 4 subjects had NOSE surveys administered both before and after speech surgery. All subjects had higher postinterven- tion composite NOSE scores, but the sample size precluded a meaningful statistical comparison of preintervention and post- intervention nasal obstruction. Similarly, only 1 subject who

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