Astrid G. W. Korsten-Meijer

Nasal Growth and Maturation Age in Adolescents: A Systematic Review

OBJECTIVE To define the end of the nasofacial growth spurt in order to schedule rhinoseptoplasty in patients with cleft without disturbing nasofacial growth. DATA SOURCES We searched the PubMed and Cochrane bibliographic databases from inception through December 31, 2007, using the primary indexing term facial growth with the confining search terms growth AND (face OR nose) AND (cephalometry OR anthropometry). The reference lists of the retrieved articles were searched for missed relevant studies. Articles written in English, German, or Dutch were included in the review. STUDY SELECTION Studies of white adolescents without genetic disorders or malformations whose growth patterns had been followed up from at least 12 years of age until 18 years of age, with intervals between relevant measurements not longer than 2 years, were selected for this review. DATA EXTRACTION A reviewer performed data extraction by obtaining raw study data from the selected studies or by requesting them from the authors. DATA SYNTHESIS Growth velocity curves were fit to different relevant measures for nasofacial growth. The end of the nasofacial growth spurt was defined as the age at which these growth velocity curves have their steepest descending slope. This definition yielded an average age of 13.1 years for adolescent girls and 14.7 years for adolescent boys. Because no information could be found for the spread in age of nasal growth spurt of individuals, 2 SDs of the age distribution for body height growth velocity were added. This resulted in 98% of white adolescent girls being nasally mature at the age of 15.8 years and 98% of white adolescent boys being nasally mature at the age of 16.9 years. CONCLUSION Rhinoseptoplasty can safely be performed after the age of 16 years in girls and 17 years in boys.

Limited Evidence for the Effect of Presurgical Nasoalveolar Molding in Unilateral Cleft on Nasal Symmetry : A Call for Unified Research

Background: In the past two decades, presurgical nasoalveolar molding has been applied increasingly in the care of patients with a cleft to improve nasal symmetry and facilitate closure of the lip and secondary rhinoplasty. Many cleft centers do not apply presurgical molding, because its effect is disputed. This review aims to quantify the effect of nasal symmetry in the long term. Methods: A systematic review of the literature with the intention of performing a meta-analysis was performed. The search terms “cleft” AND (“molding” OR “moulding”) were used in three databases. Twelve studies met the following inclusion criteria: (1) participants were humans with nonsyndromic unilateral cleft; (2) data concerning the effect of nasoalveolar molding on symmetry of the nose are reported or can be deduced; (3) article was written in English, German, or Dutch. Results: The heterogeneity of the study designs, outcome variables, outcome variable expressions, follow-up periods, and inadequate data reporting made it impossible to calculate effect sizes and to perform a meta-analysis. All studies had a low Grading of Recommendations Assessment, Development and Evaluation level. Five studies reported exclusively positive effects on nasal symmetry, six studies reported mixed effects, and one study reported exclusively no effects. Conclusions: Results of studies of nasoalveolar molding are inconsistent regarding changes in nasal symmetry; however, there is a trend toward a positive effect. Studies concerning nasoalveolar molding in unilateral cleft lip, jaw, and palate are heterogeneous and lack adequate reporting. Recommendations for future research were provided to construct a consensus about the effect of nasoalveolar molding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Communicative abilities in toddlers and in early school age children with cleft palate.

OBJECTIVES Evaluation of improvement in communicative abilities in children with nonsyndromic cleft palate. METHODS Longitudinal retrospective case history study. Out of 117 children with cleft lip and/or cleft palate born in 1998, 1999 and 2000 and enrolled in the cleft palate team of the University Medical Centre Groningen (UMCG), 63 children were included in the study; 29 (46%) boys and 34 (54%) girls. From these 63 Dutch speaking children communicative abilities were measured when toddlers and at early school age. Cleft types were cleft lip with or without cleft alveolus (CL+/-A; n=10, 5%), unilateral cleft lip and palate (UCLP; n=23, 37%), bilateral cleft lip and palate (BCLP; n=9, 14%) and isolated cleft palate (CP; n=21, 33%). The percentage of problems in language comprehension, language production, articulation, hearing and hypernasality, present when toddlers, were compared with the percentage of problems found at early school age. The treatments executed were also analysed. RESULTS Except for hearing problems, problems in all other communicative fields improved significantly. In the total group language comprehension problems decreased from 23% to 2% (p=0.00), language production problems from 21% to 6% (p=0.01), articulation problems from 57% to 25% (p=0.00) and hypernasality from 38% to 10% (p=0.04). Hearing problems appeared more difficult to treat effectively, they decreased from 42% to 31% (p=0.29). Children with BCLP appeared to have the most problems, followed by children with UCLP and then children with CP. Children with CL+/-A show the least problems. In the intervening period, often a combination of treatments was performed. Pharyngoplasty appeared to be very successful in treating hypernasality, with a success rate of 86%. CONCLUSIONS At early school age, in children with clefts, speech and language problems were significantly improved following a multidisciplinary approach to treatment and resemble their peers without clefts. Hearing problems were more difficult to treat.

Nasometry normative data for young Dutch children

OBJECTIVE Hypernasality is a common problem in cleft care. It should be treated before the age of six, because of the impact it can have on speech sound development in young children. An objective method of nasalance evaluation is nasometry. To decide whether a nasometer test result is normal or abnormal, normative data and cut off points are needed. Normative data for children are not available for every language and age. For Dutch children two sets of Dutch speech stimuli, the Van Zundert sentences or the Moolenaar-Bijl, sentences, are often used in the diagnostic process for hypernasality. Primary goal of this study is to determine normative data and cut off points for two sets of Dutch speech stimuli for Dutch children from four to six years of age. Secondary is to compare those two sets of oral sentences. METHOD Children without clefts were recruited from schools. According to their teachers their speech was normal. They were tested with the nasometer with the two sets of speech stimuli. The set from Van Zundert has oral and oronasal sentences, the Moolenaar-Bijl set only has oral sentences. RESULTS 118 children were recruited. Out of these children, 55 produced recording samples which were suitable for analysis. There were no significant differences between age groups or gender. The two different sets of speech stimuli used were significantly different, but the confidence intervals overlapped. CONCLUSIONS Normal nasalance scores of the tested sentences are between 3 and 19% for oral sentences and between 17 and 37% for oronasal sentences. The Moolenaar-Bijl speech sentences are preferred to evaluate hypernasality in young Dutch children, because of the shortness and intelligibility. Normative nasalance scores are applicable to the whole group of children from four to six years of age.

Age of diagnosis and evaluation of consequences of submucous cleft palate

OBJECTIVES To evaluate the frequency of submucous cleft palate (SMCP) in a group of children with clefts. The reason for suspecting submucous cleft, age of diagnosis, effect of age on speech development, problems in speech, hearing and swallowing were compared with previous literature. METHODS Retrospective chart review: Out of 33 patients with SMCP, registered by the Groninger cleft team over approximately 20 years (1990 until July 2012), 28 non-syndromic patients with a proven diagnosis of SMCP were included: 17 males and 11 females. Speech and hearing were examined and the number of patients with SMCP and age at time of diagnosis were evaluated. The percentages of problems in resonance, articulation and hearing, present at time of diagnosis, were compared with the percentages of problems found after surgery. RESULTS Out of 800 patients with clefts, 28 patients (3,5%) were diagnosed with SMCP at a mean age of 3;9 years. All patients presented one or more symptomatic complaints at time of diagnosis: hypernasality (65%), problems in articulation (46%), conductive hearing loss (39%) and/or swallowing problems (32%). A bifid uvula was found in 92%. Following surgery, hypernasal speech and swallowing problems were no longer observed. The articulation problems remained after surgery. Age of diagnosis seems no predictor of articulation problems. An improvement in hearing was observed but normal hearing was not achieved. Pharyngoplasty appeared to be a successful and save treatment of hypernasality. CONCLUSIONS SMCP is a rare cleft palate which is, despite the presence of a bifid uvula and symptoms of velopharyngeal insufficiency, often diagnosed late. In children with a bifid uvula and mild problems in speech, hearing and swallowing, it is important to be alert to SMCP because SMCP may account for these persistent mild complaints. Therefore, early detecting of SMCP can yield profits.

Cranialization of the frontal sinus—the final remedy for refractory chronic frontal sinusitis

OBJECT Chronic sinusitis can be a debilitating disease with significant impact on quality of life. Frontal sinusitis has a relatively low prevalence, but complications can be severe due to its anatomical location. After failure of conservative measures, typically endoscopic procedures are performed to improve the drainage of the frontal sinus. The cranialization of the frontal sinus is the final surgical measure, in which the affected frontal sinus is truly removed. In this study the authors describe the surgical technique of cranialization of the frontal sinus for refractory chronic frontal sinusitis, systematically search the literature for its application, and assess patient satisfaction in a cohort of consecutively treated patients after long-term follow-up. METHODS A consecutive cohort of 15 patients with refractory chronic frontal sinusitis was treated by cranialization of the frontal sinus and followed over a 20-year period (1989-2008) for the direct results and complications of the surgery. Long-term follow-up (mean 6.5 years) was obtained to assess the long-term effects of the cranialization. RESULTS In all patients the signs and symptoms of chronic frontal sinusitis responded very well to the cranialization. Five patients had surgical complications, of which 2 were serious. One patient died of an unrelated cause and 1 patient was lost to follow-up. The remaining 13 patients had a long-term follow-up, which revealed that 12 of them thought that their life was better after the surgical procedure. CONCLUSIONS Cranialization of the frontal sinus deserves consideration as the final remedy for refractory chronic frontal sinusitis after definite failure of other options.

Nasometry cooperation in children 4–6 years of age

OBJECTIVE Hypernasality is a common problem in cleft care. It should be treated before the age of six, because of the impact it can have on speech sound development in young children. An objective method of nasalance evaluation is nasometry. Cooperation of young children, by nature, differs over time and situations. First aim of this study is to indicate a minimum age for cooperation with the nasometer. Second aim is to compare the cooperation of children in the most used research setting (school) with the cooperation of children in the most used setting in daily practice (ENT outpatient clinic). METHOD Children from four to six years of age were recruited from schools. Outpatient clinic children were recruited from the Groningen ENT clinic. Both groups were tested with the nasometer. The cooperation with installation and repetition of speech stimuli were noted. RESULTS 118 school children and 41 outpatient clinic children were recruited. Six years old children cooperated significantly better than the five years old. The five years old cooperated better than the four years old. Moreover, school children cooperated significantly better than the outpatient children. CONCLUSION Most children of 6 years of age and older, will show good cooperation with nasometry. In children aged 5, cooperation depends on the situation in which the nasometer is used. In a school setting the cooperation is better than in an outpatient clinic setting. In the 4 years old children the cooperation with the nasometer often is insufficient, probably due to normal, unpredictable cooperative behavior belonging to this age.

Calculating nasoseptal flap dimensions: a cadaveric study using cone beam computed tomography

We hypothesize that three-dimensional imaging using cone beam computed tomography (CBCT) is suitable for calculating nasoseptal flap (NSF) dimensions. To evaluate our hypothesis, we compared CBCT NSF dimensions with anatomical dissections. The NSF reach and vascularity were studied. In an anatomical study (n = 10), CBCT NSF length and surface were calculated and compared with anatomical dissections. The NSF position was evaluated by placing the NSF from the anterior sphenoid sinus wall and from the sella along the skull base towards the frontal sinus. To visualize the NSF vascularity in CBCT, the external carotic arteries were perfused with colored Iomeron. Correlations between CBCT NSFs and anatomical dissections were strongly positive (r > 0.70). The CBCT NSF surface was 19.8 cm2 [16.6–22.3] and the left and right CBCT NSF lengths were 78.3 mm [73.2–89.5] and 77.7 mm [72.2–88.4] respectively. Covering of the anterior skull base was possible by positioning the NSF anterior to the sphenoid sinus. If the NSF was positioned from the sella along the skull base towards the frontal sinus, the NSF reached partially into the anterior ethmoidal sinuses. CBCT is a valuable technique for calculating NSF dimensions. CBCT to demonstrate septum vascularity in cadavers proved to be less suitable. The NSF reach for covering the anterior skull base depends on positioning. This study encourages preoperative planning of a customized NSF, in an attempt to spare septal mucosa. In the concept of minimal invasive surgery, accompanied by providing customized care, this can benefit the patients’ postoperative complaints.

Epistaxis caused by a dural AV-fistula at the cribriform plate.

A dural arteriovenous fistula (DAVF) with cortical venous reflux (CVR) is a dangerous neurovascular entity. A DAVF at the cribriform plate is typically silent until its inevitable presentation with intracranial hemorrhage.

Development of the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire

The patients’ perspective of health outcomes has become important input for assessing treatment effects. However, existing endoscopic endonasal surgery (EES) instruments are not fully aligned with the concept of health‐related quality of life (HRQoL). A prospective cohort study was therefore conducted to develop a suitable quality‐of‐life tool to assess nasal morbidity after EES: the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES‐Q).