SAN DIEGO—A review of the literature tells a story about septoplasty for nasal obstruction that differs from what many otolaryngologists might think: Very young patients can be considered for the procedure, well before facial growth is complete, an expert said here in January at the Triological Society Combined Sections Meeting.
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April 2020The distillation of the data was one of several points experts made in a series of talks, which also covered topical agents for scarring, asymmetric sensorineural hearing loss and imaging, topical epinephrine and endoscopic sinus surgery, and peri-operative steroids in parotid surgery. The presentations often changed viewpoints among audience members, who participated in informal polling.
Pediatric Septoplasty
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Sukgi Choi, MD, from the Department of Otolaryngology and Communication Enhancement at Boston Children’s Hospital, said the evidence shows that pediatric septoplasty for nasal obstruction can be done safely, without a significant effect on nasal and facial growth, in very young children.
“In patients with functional problems due to nasal obstruction, early septoplasty represents a reasonable and supported treatment option for children as young as age six,” she said.
In a study of 25 boys and 19 girls, researchers assessed patients 12 years after septoplasty and compared them to normal controls on 11 measures of facial growth. The ages of the children who underwent septoplasty ranged from 5.6 to 12.5. Researchers found no significant differences on any measurements except reduced nasolabial angle in girls—and even then, only in extracorporeal procedures (Am J Rhinol Allergy. 2011;25:e7-12).
No investigation has demonstrated a positive correlation of corticosteroids on improved facial nerve function. —Maie St. John, MD, PhD
Other studies have found that adolescent growth can cause more alteration of nasal structures that are already deviated, and that septoplasty might even be acceptable in patients younger than six (Am J Rhinol Allergy. 2016;30:e42-47).
Post-Incision Scarring
In another talk, David Hom, MD, co-director of facial plastic and reconstructive surgery at the University of California, San Diego, said that research shows topical silicone gel, cyanoacrylates, and paper taping reduce post-incision scarring, while vitamin E and onion extract are not helpful.
A randomized controlled study (Clin Exp Dermatol. 2009;34:688-693) found that silicone gel applied twice a day for 60 days significantly reduced scarring and keloids—a more than 50% reduction—as compared with zinc oxide. The study included 65 people in the treatment group and 45 people in the control group, with wounds in different areas of the body. The findings are Evidence Level 1, considered the most rigorous, as are findings from studies that produced similar results for cyanoacrylates and paper taping (Aesthetic Plast Surg. 2011;35:373-381). Randomized studies found onion gel and vitamin E are ineffective as compared with controls, when applied for six or eight weeks (J Plast Reconstr Aesthet Surg. 2011;64:e137-145).
Vestibular Schwannoma Screening
David Kaylie, MD, MS, associate professor of head and neck surgery at Duke University in Durham, N.C., said there is not enough evidence to make a firm recommendation on which patients with asymmetric sensorineural hearing loss should be screened for vestibular schwannoma (VS), typically found in about 5% of this patient group. But there are some data suggesting that a threshold of 3 kHz could be considered. He presented the findings from a review by Amar Gupta, MD, and Edwin Monsell, MD, PhD, of Wayne State University in Detroit (Laryngoscope. 2018;128(9):1990-1991).
One study of 74 patients with VS (Otol Neurotol. 2009;30:515-521) found that the greatest asymmetry was seen at 3 kHz, and the researchers suggested that an asymmetry of at least 15 dB at 3 kHz should be considered for screening. This recommendation—known by physicians in the field as the “rule of 3,000”—was also a suggestion that stemmed from another study. But, as Dr. Kaylie noted, the variation in asymmetry from the first test to a re-test was about 5 dB, which could affect the screening results. Another consideration is that 3 kHz can be an awkward standard because it is an inter-octave frequency that is not always tested, he said.
All things considered, Dr. Kaylie said, 3 kHz should not be used as a sole measure.
“Many other factors may also influence the decision to get an MRI,” he said, including tinnitus and asymmetric discrimination.
Epinephrine for Endoscopic Endonasal Surgery
Edward Kuan, MD, assistant professor of otolaryngology-head and neck surgery at the University of California, Irvine, said that topical epinephrine is a safe option for maintaining hemostasis during endoscopic endonasal surgery. The literature shows just two adverse events with the agent across 4,398 cases—a 0.05% rate (Am J Rhinol Allergy. 2010;24(2):140-142; Int Forum Allergy Rhinol. 2016;6:135-139; Int Forum Allergy Rhinol. 2015;5:1118-1123).
But physicians and surgeons should use caution with epinephrine in patients with a cardiovascular history and in young children, he said. Dr. Kuan added that the pledgets that are used should be wrung out so that too much of it isn’t applied. It’s critical, he said, to properly label solutions of different concentrations to prevent accidental administration.
Steroids for Facial Nerve Function
Maie St. John, MD, PhD, professor and chair in the department of head and neck surgery at the University of California, Los Angeles, said that the existing evidence doesn’t support using steroids peri-operatively to help with facial nerve function.
“No investigation has demonstrated a positive correlation of corticosteroids on improved facial nerve function,” she said. That is the case for both immediate post-operative outcomes and recovery rates in long-term follow-up.
A systematic Cochrane Review, which included two placebo-controlled randomized trials, for instance, found no advantage for corticosteroid use in immediate facial nerve function recovery, nor in how fast patients respond, Dr. St. John said. But she did point out that no adverse events stemmed from their use (World J Clin Cases. 2015;3(2):180-185). The analysis was limited, however, because it was challenging to make comparisons between the studies. “Future research should focus on well-designed randomized prospective trials,” she said.
Thomas Collins is a freelance medical writer based in Florida.