OBJECTIVECranial base development plays a large role in anterior and vertical maxillary growth through 7 years of age, and the effect of early endonasal cranial base surgery on midface growth is unknown. The authors present their experience with pediatric endoscopic endonasal surgery (EES) and long-term midface growth.METHODSThis is a retrospective review of cases where EES was performed from 2000 to 2016. Patients who underwent their first EES of the skull base before age 7 (prior to cranial suture fusion) and had a complete set of pre- and postoperative imaging studies (CT or MRI) with at least 1 year of follow-up were included. A radiologist performed measurements (sella-nasion [S-N] distance and angles between the sella, nasion, and the most concave points of the anterior maxilla [A point] or anterior mandibular synthesis [B point], the SNA, SNB, and ANB angles), which were compared to age- and sex-matched Bolton standards. A Z-score test was used; significance was set at p < 0.05.RESULTSThe early surgery group had 11 patients, with an average follow-up of 5 years; the late surgery group had 33 patients. Most tumors were benign; 1 patient with a panclival arteriovenous malformation was a significant outlier for all measurements. Comparing the measurements obtained in the early surgery group to Bolton standard norms, the authors found no significant difference in postoperative SNA (p = 0.10), SNB (p = 0.14), or ANB (0.67) angles. The S-N distance was reduced both pre- and postoperatively (SD 1.5, p = 0.01 and p = 0.009). Sex had no significant effect. Compared to patients who had surgery after the age of 7 years, the early surgery group demonstrated no significant difference in pre- to postoperative changes with regard to S-N distance (p = 0.87), SNA angle (p = 0.89), or ANB angle (p = 0.14). Lesion type (craniopharyngioma, angiofibroma, and other types) had no significant effect in either age group.CONCLUSIONSThough our cohort of patients with skull base lesions demonstrated some abnormal measurements in the maxillary-mandibular relationship before their operation, their postoperative cephalometrics fell within the normal range and showed no significant difference from those of patients who underwent operations at an older age. Therefore, there appears to be no evidence of impact of endoscopic endonasal skull base surgery on craniofacial development within the growth period studied.

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IMPORTANCE Pediatric chronic conditions have become a major public health challenge, and behavioral change plays an important role in overcoming this problem. Many health behavior interventions are described as theory-based, but evidence that such programs properly use theoretical constructs is scant.OBJECTIVE To identify effective theory-based behavioral interventions that motivate patients and families to adopt better self-management behaviors for chronic disease, to review theoretical constructs from each theory and identify the common elements for action, and to rate the level of evidence for each theory-based chronic disease intervention.EVIDENCE REVIEW Medline and PsycINFO electronic databases were searched for relevant randomized clinical trial articles published between January 1, 2000, and June 30, 2016, with English language and article type restrictions. These articles reported original data on children and young adults aged 21 years or younger, measured interventions for a pediatric chronic health problem, and assessed the association between interventions and health behavior, knowledge, and outcomes. The Jadad scale was used to evaluate the methods of each article. Articles that explicitly identified the theoretical basis for the intervention and scored 3 points or higher on the Jadad scale were included in the final analysis. FINDINGSThe database search yielded a total of 36 187 articles, from which duplicates and those that did not meet the inclusion criteria were eliminated, leaving 129 studies for the full review. Of the 129 studies, 29 (22.5%) had higher Jadad scale scores of 3 or 4 points and underwent the final detailed data abstraction and qualitative synthesis. Five chronic conditions were represented, including asthma (55% [16 of 29]), type 1 diabetes (21% [6 of 29]), obesity (14% [4 of 29]), attention-deficit/hyperactivity disorder (7% [2 of 29]), and autistic spectrum disorder (3% [1 of 29]). Most studies (55% [16 of 29]) used Social Cognitive Theory as the theoretical basis for intervention. The following intervention outcomes were reported: 23 (80%) saw a positive association with health-related behaviors (eg, adherence), 8 (28%) with knowledge, 7 (24%) with attitudes, and 26 (90%) with clinical outcomes. Ten studies (34%) showed results in both health behaviors and health outcomes. Twenty-two studies (76%) demonstrated short-term effects (within 6 months), whereas 12 (41%) reported longer-term changes. CONCLUSIONS AND RELEVANCE Identifying effective theory-based behavioral interventions can empower those who are involved in the care of children and young adults with chronic conditions.

INTRODUCTION Cranial base development plays a large role in anterior and vertical maxillary growth through age 7, and the effect of early endonasal cranial base surgery on midface growth is unknown. We present our experience with pediatric endoscopic endonasal surgery and long-term midface growth. METHODS This is a retrospective review (2000-2016). Pediatric patients were grouped by age at first endoscopic endonasal skull base surgery (<7 yo and >7 yo). Included patients had both pre- and post-operative (>1 yr) imaging. Radiologists performed measurements (Sella-Nasion distance and angles from S-N to maxilla and mandible (SNA, SNB, ANB)), which were compared to age- and sex-matched Bolton standards. Z score test was used; significance was set at P < 0.05. RESULTS >The <7 yo group had 11 patients, averaging follow-up of 5 yrs; the >7 yo group had 33 patients. Most tumors were benign; one patient with a panclival AVM was a significant outlier for all measurements. Comparing the <7 yo group to Bolton standard norms, there was no significant difference in post-operative SNA (P = 0.10), SNB (P = 0.14), or ANB (0.67). SN distance was reduced both pre- and post-operatively (SD = 1.5, P = 0.01 and P = 0.009). Sex had no significant effect. Compared to patients who had surgery in the >7 yo group, the <7 yo group demonstrated no significant difference in pre- to post-operative changes with regard to S-N (P = 0.87), SNA (P = 0.89), and ANB (P = 0.14). Tumor type (craniopharyngioma, angiofibroma, and other types) had no significant effect in either age group. CONCLUSION Though our cohort of patients with skull base tumors demonstrate some abnormal measurements before their operation, their post-operative cephalometrics fall within normal standard deviations and generally have no significant difference compared to patients who underwent operations at an older age. Therefore, there appears to be no evidence of impact of endoscopic endonasal skull base surgery on craniofacial development within the growth period studied.