RESUMO
OBJECTIVE: To assess the impact of age at referral on treatment options in craniosynostosis and to identify risk factors for referral delays in this population. STUDY DESIGN: A retrospective cohort study was performed on patients with an abnormal head shape diagnosis treated at a single academic medical center between January 1, 2004 and January 1, 2014. Newly diagnosed patients with craniosynostosis were identified and referral patterns were examined. A multivariate logistic regression model was used to identify risk factors associated with the range of ages at initial referral. RESULTS: A total of 477 patients were evaluated at our institution, 197 of whom were subsequently diagnosed with craniosynostosis. The median age at initial appointment was 5.6 months (mean 8.2 months). Only 28% of children were referred within 3 months of birth. Patients referred within 3 months of birth were less likely to have had preappointment imaging than those patients referred slightly later (OR 2.53, CI 1.07-5.98, P = .035). Several variables were associated with referral after 12 months of age including multiple suture involvement (OR 4.21, CI 1.06-16.68, P = .041), minority race (OR 4.96, CI 1.91-12.9, P ≤ .0001), and referral by a nonpediatrician (OR 6.9, CI 1.73-27.49, P = .006). CONCLUSIONS: Obtaining imaging before referral to a specialist for abnormal head shape was associated with a delay in evaluation and potentially increases radiation exposure and limits treatment options in patients with craniosynostosis. In addition, children from minority groups, children referred from someone other than a pediatrician's office, and those with multiple suture craniosynostosis are at increased risk of delayed referral. Further studies into the cause of these delays are warranted.
Assuntos
Craniossinostoses/diagnóstico , Craniossinostoses/terapia , Encaminhamento e Consulta , Especialidades Cirúrgicas , Fatores Etários , Diagnóstico Tardio , Feminino , Humanos , Lactente , Modelos Logísticos , Masculino , Estudos Retrospectivos , Fatores de Risco , Tempo para o TratamentoRESUMO
BACKGROUND: The physiologic effects of specific rhinoplasty maneuvers are incompletely understood, largely because of a limited ability to objectively examine such interventions. The purpose of this study was to develop and validate a cadaveric model for rhinoplasty testing. METHODS: Ten cadaver heads were methodically prepared to simulate ventilatory conditions. Airway dimensions were measured with three-dimensional computed tomography and acoustic rhinometry. Airflow, pressure, and resistance were measured under conditions of both inhalation and exhalation. Resistance was determined using active anterior rhinomanometry and a continuously variable pressure gradient. Anatomic and physiologic properties were first compared against normative data. Measurements were then taken after application of an adhesive external midvault dilator (BreatheRight; GlaxoSmithKline). RESULTS: The average minimal cross-sectional areas by acoustic rhinometry and by computed tomography were 0.87 cm2 and 0.84 cm2 per nostril, respectively (n = 20). The average distance from the nostril to the internal nasal valve was 1.7 cm by acoustic rhinometry and 1.5 cm by computed tomography, consistent with published in vivo normative data at the internal nasal valve. The average resistance with simulated exhalation closely approximated known normative values. With the application of the adhesive nasal dilator, the average area (acoustic rhinometry) increased by 50 percent at the internal nasal valve. During inhalation, the resistance decreased by 21 percent following application of the adhesive dilator. CONCLUSIONS: The model provides an accurate representation of nasal anatomy and physiology suitable for objective analysis of rhinoplasty maneuvers. The objective modalities used herein may be applied to rhinoplasty study using this model with accuracy and reproducibility. The external dilator increased area at the internal valve (minimal cross-sectional area) and decreased resistance.