April 2020 HSC Section 4 - Plastic and Reconstructive Problems

The Cleft Palate-Craniofacial Journal 56(2)

Table 4. Results According to Intervention.

Most Severe NOSE Score, mean (SD)

Most Recent NOSE Score, mean (SD)

Age Surveyed

Composite

Age Surveyed

Composite

NAM (n)

No (39) Yes (38)

5.39 (1.99) 5.09 (1.55)

4.61 (4.55) 5.11 (4.33)

6.23 (1.72) 6.16 (1.96)

2.74 (3.33) 3.84 (4.07)

P value

.528

.555

.427

.161

Primary tip rhinoplasty (n) No (54)

8.76 (3.70) 8.75 (3.98)

3.83 (3.60) 4.43 (4.65)

9.28 (3.50) 9.43 (3.83)

2.780 (3.28) 3.00 (3.71)

Yes (115)

P value

.907

.904

.94

.986

Nasal splint (n) No (92)

9.06 (3.74) 8.38 (4.07)

3.99 (4.30) 4.58 (4.40)

9.66 (3.70) 9.03 (3.76)

2.59 (3.44) 3.39 (3.70)

Yes (76)

P value

.321

.237

.354

.061

Speech surgery No (404)

9.02 (4.40) 13.88 (3.97)

3.78 (3.98) 5.42 (4.38)

9.63 (4.25) 14.43 (4.05)

2.52 (3.21) 3.55 (4.08)

Yes (38)

.006 a

<.001

.098

P value

<.001

Abbreviations: NOSE, Nasal Obstruction Symptom Evaluation; SD, standard deviation. a Indicating statistical significance ( p value <0.05)

3 deformity will have more severe nasal obstruction by the time of skeletal maturity and stand to gain the greatest functional benefit from cleft rhinoplasty. The presence and severity of nasal obstruction measured by the NOSE scale can prompt the surgeon to evaluate for potential anatomical causes of nasal obstruction during the cleft rhinoplasty procedure. Further- more, prospective studies administering the NOSE survey before and after surgery would contribute significantly to assess the functional outcomes of these interventions. Finally, the higher composite NOSE scores seen in subjects who had undergone speech surgery are expected, considering previous findings of obstructive sleep apnea following PPF (Orr et al., 1987), postoperative hyponasality, and obstructive sleep symptoms following SP or PPF (de Serres et al., 1999). This study suggests the potential clinical utility of using the NOSE scale as a consistent method for monitoring the degree of nasal obstruction, a potentially bothersome symptom for patients. Furthermore, the relatively high severity of nasal obstructive symptoms indicates a potential important role of preoperative articulation therapy. Therapy prior to surgery can help increase movements of the velopharyngeal sphincter and minimize the nasal obstruction necessary to eliminate velo- pharyngeal insufficiency surgically (Ysunza et al., 1992; Pamplona et al., 1996; Ysunza et al., 2002). This study has a number of limitations. First, the surveys were not administered to a control cohort, and thus, the study is not able to definitively assess whether the prevalence of nasal obstruction in the CLP cohort differs significantly from unaf- fected children living in the region. Although based in a dif- ferent geographic region, Sobol et al. (2016) convincingly showed that patients with cleft deformities have significantly more nasal obstructive symptoms than unaffected children. Furthermore, administering the NOSE survey to all patients

progressive deformity as the nose develops (Sykes and Jang, 2009). In this study, the degree of nasal obstruction between those treated with and without primary nasal repair was similar. This suggests that the procedure may not confer a long-term functional benefit, despite the benefit of early improved nasal appearance and potential to reduce psychosocial distress (Lo, 2006; Mcheik et al., 2006; Guyuron, 2008). Another debated procedure performed at the time of initial CL repair is primary septoplasty. Studies have shown that primary septoplasty achieves greater nasal symmetry in regard to colu- mella-to-Cupid’s bowdistance, nostril gap area, and nostril height (Gosla-Reddy et al., 2011) and does not negatively impact max- illary growth (Joanna et al., 2013). The authors’ institution is in the early phase of incorporating septoplasty at the time of primary repair. The authors intend to follow this cohort of patients long term, using the NOSE to evaluate the potential to reduce the incidence of nasal obstruction with this procedure. Definitive cleft rhinoplasty correction is performed after skeletal maturity and after the completion of necessary alveolar bone grafting and orthognathic procedures (Cutting, 2000). The functional and aesthetic outcomes of definitive secondary cleft rhinoplasty have been evaluated using subjective clinical assessments, patient-reported satisfaction, and generic quality of life instruments (Chaithanyaa et al., 2011; Byrne et al., 2014; Roosenboom et al., 2014). Although the NOSE survey has been used to evaluate functional outcomes of septoplasty in young noncleft adults (Stewart et al., 2004; Gandomi et al., 2010), no prior study has utilized the NOSE survey to evaluate functional outcomes of nasal surgical interventions in cleft patients. Because the subjects who underwent cleft rhinoplasty subse- quently graduated from the study institution’s cleft clinic, post- intervention surveys were not available to be analyzed. The results of this study suggest that subjects with CL þ A or Veau

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