Cleft-Related Nasal Airway Obstruction in Mixed Dentition: Prevalence and Improvement After Secondary Cleft Rhinoplasty
Anna R. Carlson, Mychajlo S. Kosyk, Zachary D. Zapatero, Christopher L. Kalmar, Jordan W. Swanson, Oksana A. Jackson, David W. Low, Scott P. Bartlett, Jesse A. Taylor
Division of Plastic and Reconstructive Surgery; The Children's Hospital of Philadelphia, Philadelphia, PA
Background: The cleft nasal deformity is well-known to represent one of the most significant aesthetic and functional challenges in cleft surgery. Nasal airway obstruction is an increasingly recognized phenomenon in patients with cleft lip and/or palate (CL/P), and has the potential to significantly affect quality of life in this patient population. To date, the effect of nasal surgery on airway obstruction in cleft patients in mixed dentition has not been studied. In this study, our objective was to compare nasal airway obstruction before and after secondary cleft rhinoplasty, and to identify factors associated with decreased nasal airway obstruction after secondary cleft tip rhinoplasty.
Methods: Patients undergoing secondary cleft rhinoplasty between 2015-2021 were identified via CPT codes. Medical records were reviewed for demographic information, cleft phenotype, operative details, and preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores. Statistical analysis was performed to compare NOSE scores before and after surgery, and to identify variation in NOSE scores dependent upon patient-related variables, operative maneuvers, and post-operative nasal stenting.
Results: 119 patients undergoing secondary cleft rhinoplasty between 2015-2021 were identified, and 80 patients had preoperative and postoperative NOSE scores recorded. The average age at secondary cleft rhinoplasty was 8.0 years, and 61 patients (76.3%) had unilateral CL/P, whereas 19 patients (23.7%) had bilateral CL/P. At the time of secondary cleft rhinoplasty, the majority of patients underwent a concomitant cleft-related procedure (alveolar bone grafting in 85%.) Nasal airway obstruction was present in mild-moderate severity in patients prior to secondary cleft rhinoplasty. Postoperatively, obstruction improved or resolved in the domains of nasal blockage/obstruction, trouble breathing through the nose, and ability to get enough air through the nose during exertion (p<0.05.) Overall composite NOSE scores significantly improved after secondary cleft rhinoplasty (Table 1.) Lateral crural strut grafting was associated with improvement in nasal blockage, whereas alar revision and tip sutures were associated with worsening in specific nasal obstruction symptoms (p<0.05.) Patients who underwent nasal stenting were found to report less trouble breathing than patients who did not (p<0.05.) Conclusions: Nasal airway obstruction is present in mild-moderate severity in patients with cleft lip and/or palate in mixed dentition and the severity of obstruction is decreased by secondary cleft rhinoplasty. Specific operative maneuvers are associated with an alteration in nasal airway obstructive symptoms, and nasal stenting is associated with an improvement in trouble breathing after secondary cleft rhinoplasty.
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