April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Zhang et al

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, author- ship, and/or publication of this article. References Abbott MM, Meara JG. Nasoalveolar molding in cleft care: is it effi- cacious? Plast Reconstr Surg . 2012;130(3):659-666. Barillas I, Dec W, Warren SM, Cutting CB, Grayson BH. Nasoalveo- lar molding improves long-term nasal symmetry in complete uni- lateral cleft lip–cleft palate patients. Plast Reconstr Surg . 2009; 123(3):1002-1006. Bromley GS, Rothaus KO, Goulian D. Cleft lip: morbidity and mor- tality in early repair. Ann Plas Surg . 1983;10(3):214-217. Byrne M, Chan J, Eoin O. Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: evaluation by patients versus health professionals. J Cranio Maxill Surg . 2014; 42(7):1062-1070. Chaithanyaa N, Rai KK, Shivakumar HR, Upasi A. Evaluation of the outcome of secondary rhinoplasty in cleft lip and palate patients. J Plast Reconstr Aesthetic Surg . 2011;64(1):27-33. Cheung T, Oberoi S. Three dimensional assessment of the pharyngeal airway in individuals with non-syndromic cleft lip and palate. PLoS One . 2012;7(8):e43405. Cutting CB. Secondary cleft lip nasal reconstruction: state of the art. Cleft Palate-craniofacial J . 2000;37(6):538-541. de Serres LM, Deleyiannis F, Eblen LE, Gruss JS, Richardson MA, Sie K. Results with sphincter pharyngoplasty and pharyngeal flap. Int J Pediatr Otorhi . 1999;48(1):17-25. Farmand M. Lip repair techniques and their influence on the nose. Facial Plast Surg . 2002;18(3):155-164. Fisher MD, Fisher DM, Marcus JR. Correction of the cleft nasal deformity from infancy to maturity. Clin in Plas Surg . 2014; 41(2):283-299. Friel MT, Starbuck JM, Ghoneima AM, Murage K, Kula KS, Thol- pady S, Havlik RJ, Flores RL. Airway obstruction and the unilat- eral cleft lip and palate deformity: contributions by the bony septum. Ann Plas Surg . 2015;75(1):37-43. Gandomi B, Bayat A, Kazemei T, Gandomi B, Bayat A, Kazemei T. Outcomes of septoplasty in young adults: the nasal obstruction septoplasty effectiveness study. Am J Otolaryngol . 2010;31(3): 189-192. Gosla-Reddy S, Nagy K, Mommaerts MY, Reddy RR, Bronkhorst EM, Prasad R, Kuijpers-Jagtman AM, Berg´e SJ. Primary septo- plasty in the repair of unilateral complete cleft lip and palate. Plast Reconstr Surg . 2011;127(2):761-767. Grayson BH, Maull D. Nasoalveolar molding for infants born with clefts of the lip, alveolus and palate. Clin in Plast Surg . 2004;31(2): 149-158. Grossmann N, Brin I, Aizenbud D, Sichel J-Y, Ruth G-I, Steiner J. Nasal airflow and olfactory function after the repair of cleft palate (with and without cleft lip). Oral Surg Oral Med Oral Pathol Oral Radiol Endodontology . 2005;100(5):539-544.

presenting to the multidisciplinary clinic as standard of care provided a larger sample size and avoid a low response rate and possible selection bias. Another limitation is that the results of the survey may reflect seasonal allergies and upper respiratory infections as opposed to chronic nasal obstruction. However, NOSE surveys were administered year-round for all patients presenting to clinic, and over multiple years, minimizing the influence of confounding temporal and environmental factors. Moreover, for each subject, both the survey with the highest NOSE composite score and the most recent NOSE survey were analyzed, allowing a more comprehensive assessment of chronic nasal obstruction. Although the large sample size was a strength, the study was still limited by the small sample size in certain phenotypic groups, particularly CL þ A. Moreover, the reduced sample sizes in subgroup analyses, including those within age groups, may have contributed to the lack of statis- tical significance findings. Additionally, the variability in recorded NOSE scores may have limited the ability to find more statistically significant findings despite the large sample size. Nevertheless, the results of this study point to important areas of continued study and opportunities to administer the NOSE to more critically assess nasal obstruction. Finally, the large sample size also included a wide range of ages. Therefore, the results include both surveys completed by (older) subjects themselves and surveys completed by parent proxies. It must be acknowledged that the significant differences in nasal obstruc- tive symptoms observed between different age groups may be in part due to parent observation bias. Parents may have the tendency to report more severe symptoms in children less than 5 years of age, who are not able to articulate their symptoms as clearly as older children. Nevertheless, the inclusion of all age groups provides valuable insight into the progression of nasal obstructive symptoms over the course of childhood. Nasal obstruction is a multifactorial issue, and the NOSE instrument offers a valuable tool for clinicians to assess the degree and the ways in which patients with cleft deformities experience symptoms. Aggregation of survey data can allow cleft programs to investigate potential patterns in symptoms in their patient population and to evaluate functional outcomes following different interventions. The findings of this study suggest that there is a high prevalence of nasal obstruction, with more severe symptoms among subjects older than 14 years of age, with CL þ A or unilateral CLP, and who have undergone PPF or SP. Adolescent subjects who underwent primary repair at later time, most of whom were adopted internationally, reported more severe symptoms than those who underwent primary repair earlier. Primary tip rhinoplasty, use of nasal stents, and NAM were not associated with lower NOSE scores. Future studies prospectively administering NOSE surveys before and after cleft rhinoplasty are needed to assess the func- tional benefit of this important intervention. Authors’ Note This study has been approved by the institutional review board for research involving human subjects at the Children’s Hospital of Philadelphia.

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