Quality of life after otoplasty for prominent ears in children

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Marinho, Joana Barbosa-Sequeira, Mário R. Correia, José Banquart-Leitão, Fátima Carvalho" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Catarina" "apellidos" => "Carvalho" "email" => array:1 [ 0 => "catarinabarbosadecarvalho@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Ana S." "apellidos" => "Marinho" ] 2 => array:2 [ "nombre" => "Joana" "apellidos" => "Barbosa-Sequeira" ] 3 => array:2 [ "nombre" => "Mário R." "apellidos" => "Correia" ] 4 => array:2 [ "nombre" => "José" "apellidos" => "Banquart-Leitão" ] 5 => array:2 [ "nombre" => "Fátima" "apellidos" => "Carvalho" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Pediatric Surgery, Centro Hospitalar Universitário do Porto, Porto, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1362 "Ancho" => 2175 "Tamanyo" => 73180 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Pediatric Quality of Life Inventory (PedsQL) results: patient’s self-report current quality of life. Age in years." ] ] ] "textoCompleto" => "IntroductionProminent ears are a common congenital malformation of the ear with a prevalence of 5%.<a class="elsevierStyleCrossRefs" href="#bib0005">1–8</a>This deformity is inherited as an autosomal dominant trait<a class="elsevierStyleCrossRefs" href="#bib0010">2,7</a> and may result from multiple ear defects, such as underdevelopment of the antihelix, conchal hypertrophy and increased conchoscaphal angle.<a class="elsevierStyleCrossRefs" href="#bib0005">1,3–8</a>Prominent ears are now perceived as more than an aesthetic defect. As many studies have shown, these patients frequently suffer from low self-esteem, social isolation, anxiety, teasing and bullying from peers,<a class="elsevierStyleCrossRefs" href="#bib0005">1,3,6–10</a> often leading to diminished health-related quality of life and a decline in school performance.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Health-related quality of life (HRQoL) is defined as wellbeing in the physical, psychological and social domains of health<a class="elsevierStyleCrossRefs" href="#bib0035">7,11</a> and nowadays is considered to be an important parameter of aesthetic surgery’s outcomes.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>In order to minimize deleterious social, surgery is often recommended before entering school<a class="elsevierStyleCrossRef" href="#bib0010">2</a>; at this age, ear cartilage is almost completely developed and surgical manipulation will not affect its growth.<a class="elsevierStyleCrossRefs" href="#bib0005">1,12</a>Cartilage suture techniques are commonly used and include Mustarde’s conchoscaphal mattress suture and Furna’s conchal fixation to the mastoid periosteum,<a class="elsevierStyleCrossRef" href="#bib0025">5</a> both invariably used in our patients. Today, this procedure permits the correction of prominent ears with little pain and minimal absenteeism from school.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>To the authors’ knowledge, there are 8 studies in the literature evaluating the effect of bilateral otoplasty in children’s health-related quality of life,<a class="elsevierStyleCrossRefs" href="#bib0035">7,8,13–18</a> only 2 of which included self-reported quality of life. We conducted the present study to evaluate clinical outcomes and to assess the influence of surgery on health-related quality of children submitted to otoplasty, as reported by patients and their caregivers.Material and methodsStudy designAll patients submitted to otoplasty between January 2016 and December 2018 in a tertiary pediatric surgery center and were identified through digital medical records. A total of 173 procedures were performed. Each patient was summoned for a re-evaluation consult in our center. The first appointment was within the first week post-operative and reevaluations were conducted on the first and sixth month after the procedure; additional consults were made if any complications were identified (maximum follow-up in our series was 21 months). Seventy patients and respective caregivers attended. At this appointment, clinical outcomes were reassessed, and patients and their parents were asked to complete the inquiries.All procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.SurgeryAll procedures were performed under general anesthesia with orotracheal intubation. Eighty percent were outpatient surgeries. Surgery was performed by either pediatric surgery residents or specialists. Mustarde and Furnas cartilage suture techniques with non-absorbable monofilament were used in all patients. A closed dressing was placed after surgery and removed after one week. A headband was used for playground and sleep for an additional month.SurveyTwo sets of inquiries were conducted: Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL; Portuguese version) both for parent proxy-report and child’s self-report, and an adaptation of the Glasgow Children Benefit Inventory (GCBI), for parent-reported post-intervention health-related benefit measurement.GCBI is a validated retrospective questionnaire designed to evaluated changes in children’s health-related quality of life after a pediatric surgery procedure, such as otoplasty.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> GCBI contains 24 questions, divided into four subgroups: emotion, physical health, learning and vitality; each question is measured in a five-point Linkert scale (−2: much worse; −1: worse; 0: neutral; +1: better; +2: much better). A total score is obtained on a scale of −100 (maximal negative effect) and +100 (maximal positive effect). However, there is no validated Portuguese version of this questionnaire. For this reason, we performed a translation based on the original survey. Three questions were removed from our questionnaire (GCBI-based survey; GCBI-b) for not being considered significant for the outcomes pursued: “Has your child's operation affected how prone he/she is to catch colds or infections?”, “Has your child's operation affected how often he/she needs to visit a doctor?” and “Has your child's operation affected how much medication he/she has needed to take?”. Parents’ expectations regarding quality of life change were added to this survey, so a total of 22 questions were included.PedsQL is a standardized questionary of pediatric current quality of life applicable for healthy children and to pediatric patients with acute and chronic conditions. It consists of 23 questions regarding physical, emotional, social and school health, parallel to children’s self-report and parent proxy-report.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Three sets of inquiries were used, divided by age groups: 5–7, 8–12, and 13–18 years, both for children self-report as for parent proxy-report. This inquiry was used for positive current quality of life assessment and GCBI-b result validation.Motivation for surgery, pre-operative negative experiences (parent concern, aesthetic dissatisfaction, self-esteem, teasing, bullying and anxiety) and satisfaction with aesthetic result were also assessed in the survey (parent-reported).Statistical analysisStatistical analysis was performed with IBM SPSS Statistics, Version 27. PedsQL and GBCI-b scales were evaluated against age, gender, expectations and negative experiences profiles. Descriptive statistics summarize PedsQL and GBCI-b scales performance for each analysis factors. Box plots were generated to visualize the influence of such analysis factors on quality-of-life scales. Secondly, Kruskal-Wallis non-parametric tests were applied in view of comparing the distribution of PedsQL and GBCI-b scales by age, gender, expectations and negative experiences profiles analysis factors. Finally, it was applied a least squares regression analysis to determine the signal and significance of negative experiences profiles for stated PedsQL and GBCI-b performance indicators.ResultsFifty-five patients and respective caregivers completed the questionnaires (78.6%). Patient’s median age at time of questionnaire response was 9 years and at time of surgery was 7 years; 70.9% were male (N = 39). Seven patients had significant comorbidities (namely asthma, epilepsy and hypospadias). There were no surgical or anesthesia-related complications. Median post-operative follow-up was 6 months. Five patients developed hypertrophic scars, four resolved after local triamcinolone injection and one denied treatment. Four patients had residual ear asymmetry, none aesthetically significant, and one suffered from partial dehiscence. No suture extrusion was identified during follow-up.Parents were asked to identify negative experiences before prominent ear correction and motivations to seek surgery. Aesthetic dissatisfaction was the main negative experience reported(see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Seventeen parents denied any traumatic previous experience related to their children’s prominent ears (30.9%). Regarding motivations for surgery, parent concern (67.3%; N = 37) and aesthetic dissatisfaction (63.6%; N = 35) were the most frequently reported, followed by low self-esteem (32.7%; N = 18), teasing (29%; N = 16), bullying (18.2%; N = 10) and anxiety (14.5%; N = 8). Fifty-three parents (96.4%) would recommend surgery to other children and 51 claimed to be satisfied with the aesthetic result. The remaining caregivers had no opinion on either topic.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>PedsQL 4.0 Generic Core ScalesAll patients completed the PedsQL 4.0 Generic Core Scales. Median total score of self-reported HRQoL was 85.6 ± 12 [50–100]. Patients were divided in three groups, according to their age: 5–7 (group 1), 8–12 (group 2), and 13–18 years (group 3), as depicted in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. No statistical difference was identified between groups (p = 0.092).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Median total score for parent-proxy HRQoL was 86.9 ± 13.5 [46.7–100] (see <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). No statistical difference was identified between groups (p = 0.187). Patient’s gender and parent’s expectations did not influence either self-reported or parent-proxy HRQoL (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). History of teasing was associated with higher self-reported HRQoL (p = 0.021; effect 2,389); low self-esteem, on the other hand, is associated with diminished patient’s self-reported HRQoL (p = 0.028; effect −0,344).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>GCBI-based surveyAll parents complete the GCBIb. Median score was 20.5 ± 19.8, with 98.2% positive scores found, representing a positive effect of surgery in children’s HRQoL. In only one case, a score of zero was reported and no negative values were found. The majority of caregivers expected an improvement in their children’s quality of life (better or much better; 49.1%, N = 27). The expectation of a much better quality of life post-surgery was predictive of higher GCBIb values (p = 0.025; effect 2,310). When analyzing the effects of previous pejorative experiences, bullying was the only with significant effect on quality of life change and children who suffered from it had higher scores of GCBIb (p = 0.011; effect 2,630). Gender and age did not influence GCBIb (p > 0.05; see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).DiscussionChildren with visible differences, such as prominent ears, commonly face challenging and painful social interactions.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> These early life events can exert a powerful influence on a person’s development.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Children may become overly preoccupated with their appearance and may develop distressful behaviors, such as social withdrawal, anxiety and diminished self-esteem.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> In the particular case of prominent ears, surgery has the potential to alleviate their psychosocial problems<a class="elsevierStyleCrossRef" href="#bib0010">2</a>: it has even been described as effective in reducing and eliminating bullying.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Having this in consideration, we designed the present study to evaluate and assess clinical outcomes, parental satisfaction and quality of life after otoplasty, both self- and parent-reported. As surgeons, we are only capable of conducting an analysis of the technical and esthetic results; however, as the main goal of surgery is QoL change, patient and parental opinion evaluating is fundamental for surgical success validation.Our significant results confirm the positive effect of bilateral otoplasty in children in quality of life, paralleling the existing literature. Hao et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> conducted a study in 2013 to assess HRQoL after otoplasty in 50 pediatric patients: a mean GCBI score of 24.4 and a mean Pediatric Quality of Life Inventory of 94.3 (self-reported) and 93.3 (parent proxy) translated their positive outcome. Toplu et al.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> compared clinical and HRQoL outcomes in 132 adults and children submitted to otoplasty; both groups reported a significant increase in GBI and GCBI post-surgery. Songu et al.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> evaluated 67 children and measured post-interventional GCBI; their results were compatible with a raised HRQoL. Similarly, Braun et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> shared similar results in their pediatric patients, reporting a mean GCBI of 24.1.Although we could not use Glasgow Children’s Benefit Inventory validated questionnaire to measure HRQoL after otoplasty, we overcame this issue by translating and adapting the original inquiry (GCBI-based survey; GCBIb). As in GCBI, the score of our GCBIb may vary between −100 and +100; negative values represent a negative effect of the procedure on HRQoL, zero: no effect and positive values translate into an increase in HRQoL after surgery. The analysis of our data demonstrated a positive effect of otoplasty in children with prominent ears, as measured by our GCBIb median score of 20.5. GCBIb mean score (12.3) and standard deviation (1.1) were submitted to a t-statistic (10.7) corresponding, reaching a p-value near zero (p < 0.001), confirming the significance of GCBIb and of such surgery’ positive effects in patient’s quality of life. Despite our questionnaire’s obvious limitations, we still believe these results represent an improved HRQoL, keeping up with current literature.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Parents were asked to identify past negative experiences. Not surprisingly, most pointed out at least one and the most common were aesthetic dissatisfaction and teasing by peers. We tested the effect of these experiences on GCBIb score and bullying was the only with significant result. Victims of bullying scored significantly higher, probably because surgery addressed the focus of aggression. As we can conclude, aesthetic surgery improves not only the anatomical defect, but also psychological and social suffering. Hao et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> reported a similar effect on patients with a history of being teased.Parental expectations also influenced GCBIb scores: parents who expected a much better quality of life of their offspring after surgery scored significantly higher. Parents’ hope for a life-changing event probably influences their own perception of the surgical outcomes, namely in HRQoL.Teasing was also influential in self-reported quality of life. Children who had been teased by peers had a higher score in the PedsQL self-report, probably due to a similar phenomenon as in bullying.Although the positive global impact we found in HRQoL after surgery in ear deformities patients, the ones with low self-esteem scored significantly lower in self-report quality of life. An explanation for this result is that these patient’s psychological fragilities are probably multifactorial, and surgery obviously does not address all of them.As in any other procedure, otoplasty may have complications and they should be addressed before surgery. In our patients, we had a small number of patients suffering from hypertrophic scarring, most resolved after topic triamcinolone injection. Another non-negligible complication was partial relapse, found in four patients, none of which required reintervention. Despite these hurdles, all reported both high levels of self- and parent-reported quality of life and high levels of satisfaction and recommendation. Despite suture extrusion is one of the most common complications described in the literature, no case was present in our cohort; however, this was probably due to the median follow-up of six months; a longer follow-up is required to evaluate such complication.Regarding limitations, the most striking one is the use of a non-validated tool to evaluate HRQoL. As we previously stated, there isn’t an official Portuguese version to apply to our families and for that reason a translation was conducted by us, as well as a minor alteration of the original inquiry. Despite not being able to be directly compared with previous studies, our study obtained 98.2% positive results in the GCBIb, indicating an incremental effect of surgery in HRQoL; this is supported by the high scores of self-report and parent proxy quality of life, measured by PedsQL 4.0. Secondly, no control group was used. Third, the use of questionnaires is fallible, particularly when taken several months after the procedure. Fourth, this is a retrospective analysis; a study comparing pre- and post-intervention quality of life would allow us to better understand the effect of surgery on HRQoL of these patients. Finally, there is a possible child bias, as previously identified by Hao et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>: as parents help their children to fill the questionnaire, they may lead their children to select certain options they see more fit.In conclusion, otoplasty is a safe procedure in children and positively addresses not only the aesthetic dimension but also health-related quality of life, as reported both by parents and patients in our retrospective survey. A prospective study should be conducted to better define the precise effect of surgery on these patients.Financial disclosure statementThe authors have no conflicts of interest to declare. No funding was received for this article.Ethical approvalAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Institutional ethics approval was obtained.Informed consentInformed consent was obtained from the guardians of the patients included in this study.Authors’ role in the manuscriptStudy conception and design: Catarina Carvalho, Fátima Carvalho.Data acquisition: Catarina Carvalho, Ana Sofia Marinho, Joana Barbosa-Sequeira, Mário Rui Correia.Analysis and data interpretation: Catarina Carvalho, Ana Sofia Marinho, Joana Barbosa-Sequeira, Mário Rui Correia.Drafting of the manuscript: Catarina Carvalho, José Banquart-Leitão, Fátima Carvalho.Critical revision: José Banquart-Leitão, Fátima Carvalho." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1930064" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Two sets of inquiries were performed" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1663776" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Surgery" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Survey" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 4 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0040" "titulo" => "PedsQL 4.0 Generic Core Scales" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "GCBI-based survey" ] ] ] ] ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Financial disclosure statement" ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Ethical approval" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Informed consent" ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Authors’ role in the manuscript" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-05-13" "fechaAceptado" => "2022-07-28" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1663776" "palabras" => array:5 [ 0 => "Prominent ears" 1 => "Otoplasty" 2 => "Quality of life" 3 => "Children" 4 => "Pediatric surgery" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "AimProminent ears are a common congenital malformation and are associated with low self-esteem, social isolation and diminished school performance. Our goal was to evaluate the influence of otoplasty on children’s quality of life (QoL). Material and methodsPatients submitted to otoplasty from 2016 to 2018 were summoned for a reevaluation. Seventy patients and respective caregivers agreed to participate. Surgical, demographic and clinical data were reviewed from electronic registries. Two sets of inquiries were performedPediatric Quality of Life Inventory 4.0 (for parent and child) and an adaptation of the Glasgow Children Benefit Inventory (GCBI-b). Fifteen patients were excluded for incomplete inquiries. ResultsFifty-five patients were included, 70.9% were males. Median age at surgery was 7.7 ± 3.3 years. Aesthetic dissatisfaction was the main previous negative experience. Median self-report quality of life was 85.6% and parent-report was 86.9%. Median GCBI-b was +20.5, indicating an improvement in patients’ QoL. Bullying and high parental expectations for life change post-surgery were predictive of higher GCBI-b scores (p < 0.05). Ninety-six percent of parents would recommend surgery to other children. ConclusionsOtoplasty is a valid treatment option for prominent ears in children,improving not only aesthetics but also health-related QoL." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Two sets of inquiries were performed" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1362 "Ancho" => 2175 "Tamanyo" => 73180 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Pediatric Quality of Life Inventory (PedsQL) results: patient’s self-report current quality of life. Age in years." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1211 "Ancho" => 2176 "Tamanyo" => 85262 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Pediatric Quality of Life Inventory (PedsQL) results: parent proxy-report current quality of life. Age in years." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">PedsQL patient \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">PedsQL parent \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">GCBIb \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">z = −1.911 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">z = −1.568 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">z = −0.483 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.056 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.117 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.629 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age groups</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5−7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H = 4.778 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H = 3.348 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H = 1.216 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8−12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.092 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.187 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.544 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13−18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expectations Difference to neutral experience (0)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Much worse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H = 3.133 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H = 2.957 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H = 9.613 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Worse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.536 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.565 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.047 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Better \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Much better \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous negative life experiences</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aesthetic dissatisfaction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = 0.799 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = 0.696 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = -0.071 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.428 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.490 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.944 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Teasing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = 2.389 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = 1.337 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = 0.547 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.021 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.187 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.587 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low self-esteem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = -2.259 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = -1.646 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = 0.752 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.028 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.456 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bullying \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = -1.615 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = -1.067 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = 2.630 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.113 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.291 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.011 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anxiety \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t=-1.983 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t=-0.743 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t = 0.506 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.053 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.461 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p = 0.615 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3213577.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Variable effects on PedsQL and GCBI-b results. Summary statistics for each category refer to gender: z score in Mann–Whitney U test and corresponding critical p-values; age groups and expectations: H statistic of Kruskal–Wallis and corresponding critical p-values; previous negative life experiences: Least squares t-statistics and corresponding critical p-values." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Otoplasty for prominent ears deformity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P. Fioramonti" 1 => "F. Serratore" 2 => "M. Tarallo" 3 => "M. Ruggieri" 4 => "D. Ribuffo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Eur Rev Med Pharmacol Sci" "fecha" => "2014" "volumen" => "18" "numero" => "21" "paginaInicial" => "3156" "paginaFinal" => "3165" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25487923" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Otoplasty in children younger than 5 years of age" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Songu" 1 => "H. Adibelli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijporl.2009.12.010" "Revista" => array:7 [ "tituloSerie" => "Int J Pediatr Otorhinolaryngol" "fecha" => "2010" "volumen" => "74" "numero" => "3" "paginaInicial" => "292" "paginaFinal" => "296" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20089317" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications of otoplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E.B. Handler" 1 => "T. Song" 2 => "C. 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Quality of life after otoplasty for prominent ears in children

Catarina Carvalho

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catarinabarbosadecarvalho@gmail.com

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, Ana S. Marinho, Joana Barbosa-Sequeira, Mário R. Correia, José Banquart-Leitão, Fátima Carvalho

Department of Pediatric Surgery, Centro Hospitalar Universitário do Porto, Porto, Portugal

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    "titulo" => "Quality of life after otoplasty for prominent ears in children"
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        "autoresLista" => "Catarina Carvalho, Ana S&#46; Marinho, Joana Barbosa-Sequeira, M&#225;rio R&#46; Correia, Jos&#233; Banquart-Leit&#227;o, F&#225;tima Carvalho"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pediatric Quality of Life Inventory &#40;PedsQL&#41; results&#58; patient&#8217;s self-report current quality of life&#46; <span class="elsevierStyleItalic">Age in years</span>&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Prominent ears are a common congenital malformation of the ear with a prevalence of 5&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This deformity is inherited as an autosomal dominant trait<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7</span></a> and may result from multiple ear defects&#44; such as underdevelopment of the antihelix&#44; conchal hypertrophy and increased conchoscaphal angle&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Prominent ears are now perceived as more than an aesthetic defect&#46; As many studies have shown&#44; these patients frequently suffer from low self-esteem&#44; social isolation&#44; anxiety&#44; teasing and bullying from peers&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;6&#8211;10</span></a> often leading to diminished health-related quality of life and a decline in school performance&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Health-related quality of life &#40;HRQoL&#41; is defined as wellbeing in the physical&#44; psychological and social domains of health<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;11</span></a> and nowadays is considered to be an important parameter of aesthetic surgery&#8217;s outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In order to minimize deleterious social&#44; surgery is often recommended before entering school<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#59; at this age&#44; ear cartilage is almost completely developed and surgical manipulation will not affect its growth&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Cartilage suture techniques are commonly used and include Mustarde&#8217;s conchoscaphal mattress suture and Furna&#8217;s conchal fixation to the mastoid periosteum&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> both invariably used in our patients&#46; Today&#44; this procedure permits the correction of prominent ears with little pain and minimal absenteeism from school&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">To the authors&#8217; knowledge&#44; there are 8 studies in the literature evaluating the effect of bilateral otoplasty in children&#8217;s health-related quality of life&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8&#44;13&#8211;18</span></a> only 2 of which included self-reported quality of life&#46; We conducted the present study to evaluate clinical outcomes and to assess the influence of surgery on health-related quality of children submitted to otoplasty&#44; as reported by patients and their caregivers&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">All patients submitted to otoplasty between January 2016 and December 2018 in a tertiary pediatric surgery center and were identified through digital medical records&#46; A total of 173 procedures were performed&#46; Each patient was summoned for a re-evaluation consult in our center&#46; The first appointment was within the first week post-operative and reevaluations were conducted on the first and sixth month after the procedure&#59; additional consults were made if any complications were identified &#40;maximum follow-up in our series was 21 months&#41;&#46; Seventy patients and respective caregivers attended&#46; At this appointment&#44; clinical outcomes were reassessed&#44; and patients and their parents were asked to complete the inquiries&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Surgery</span><p id="par0045" class="elsevierStylePara elsevierViewall">All procedures were performed under general anesthesia with orotracheal intubation&#46; Eighty percent were outpatient surgeries&#46; Surgery was performed by either pediatric surgery residents or specialists&#46; Mustarde and Furnas cartilage suture techniques with non-absorbable monofilament were used in all patients&#46; A closed dressing was placed after surgery and removed after one week&#46; A headband was used for playground and sleep for an additional month&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Survey</span><p id="par0050" class="elsevierStylePara elsevierViewall">Two sets of inquiries were conducted&#58; Pediatric Quality of Life Inventory 4&#46;0 Generic Core Scales &#40;PedsQL&#59; Portuguese version&#41; both for parent proxy-report and child&#8217;s self-report&#44; and an adaptation of the Glasgow Children Benefit Inventory &#40;GCBI&#41;&#44; for parent-reported post-intervention health-related benefit measurement&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">GCBI is a validated retrospective questionnaire designed to evaluated changes in children&#8217;s health-related quality of life after a pediatric surgery procedure&#44; such as otoplasty&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> GCBI contains 24 questions&#44; divided into four subgroups&#58; emotion&#44; physical health&#44; learning and vitality&#59; each question is measured in a five-point Linkert scale &#40;&#8722;2&#58; much worse&#59; &#8722;1&#58; worse&#59; 0&#58; neutral&#59; &#43;1&#58; better&#59; &#43;2&#58; much better&#41;&#46; A total score is obtained on a scale of &#8722;100 &#40;maximal negative effect&#41; and &#43;100 &#40;maximal positive effect&#41;&#46; However&#44; there is no validated Portuguese version of this questionnaire&#46; For this reason&#44; we performed a translation based on the original survey&#46; Three questions were removed from our questionnaire &#40;GCBI-based survey&#59; GCBI-b&#41; for not being considered significant for the outcomes pursued&#58; &#8220;Has your child&#39;s operation affected how prone he&#47;she is to catch colds or infections&#63;&#8221;&#44; &#8220;Has your child&#39;s operation affected how often he&#47;she needs to visit a doctor&#63;&#8221; and &#8220;Has your child&#39;s operation affected how much medication he&#47;she has needed to take&#63;&#8221;&#46; Parents&#8217; expectations regarding quality of life change were added to this survey&#44; so a total of 22 questions were included&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">PedsQL is a standardized questionary of pediatric current quality of life applicable for healthy children and to pediatric patients with acute and chronic conditions&#46; It consists of 23 questions regarding physical&#44; emotional&#44; social and school health&#44; parallel to children&#8217;s self-report and parent proxy-report&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Three sets of inquiries were used&#44; divided by age groups&#58; 5&#8211;7&#44; 8&#8211;12&#44; and 13&#8211;18 years&#44; both for children self-report as for parent proxy-report&#46; This inquiry was used for positive current quality of life assessment and GCBI-b result validation&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Motivation for surgery&#44; pre-operative negative experiences &#40;parent concern&#44; aesthetic dissatisfaction&#44; self-esteem&#44; teasing&#44; bullying and anxiety&#41; and satisfaction with aesthetic result were also assessed in the survey &#40;parent-reported&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">Statistical analysis was performed with IBM SPSS Statistics&#44; Version 27&#46; PedsQL and GBCI-b scales were evaluated against age&#44; gender&#44; expectations and negative experiences profiles&#46; Descriptive statistics summarize PedsQL and GBCI-b scales performance for each analysis factors&#46; Box plots were generated to visualize the influence of such analysis factors on quality-of-life scales&#46; Secondly&#44; Kruskal-Wallis non-parametric tests were applied in view of comparing the distribution of PedsQL and GBCI-b scales by age&#44; gender&#44; expectations and negative experiences profiles analysis factors&#46; Finally&#44; it was applied a least squares regression analysis to determine the signal and significance of negative experiences profiles for stated PedsQL and GBCI-b performance indicators&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">Fifty-five patients and respective caregivers completed the questionnaires &#40;78&#46;6&#37;&#41;&#46; Patient&#8217;s median age at time of questionnaire response was 9 years and at time of surgery was 7 years&#59; 70&#46;9&#37; were male &#40;N&#8239;&#61;&#8239;39&#41;&#46; Seven patients had significant comorbidities &#40;namely asthma&#44; epilepsy and hypospadias&#41;&#46; There were no surgical or anesthesia-related complications&#46; Median post-operative follow-up was 6 months&#46; Five patients developed hypertrophic scars&#44; four resolved after local triamcinolone injection and one denied treatment&#46; Four patients had residual ear asymmetry&#44; none aesthetically significant&#44; and one suffered from partial dehiscence&#46; No suture extrusion was identified during follow-up&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Parents were asked to identify negative experiences before prominent ear correction and motivations to seek surgery&#46; Aesthetic dissatisfaction was the main negative experience reported</p><p id="par0085" class="elsevierStylePara elsevierViewall">&#40;see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Seventeen parents denied any traumatic previous experience related to their children&#8217;s prominent ears &#40;30&#46;9&#37;&#41;&#46; Regarding motivations for surgery&#44; parent concern &#40;67&#46;3&#37;&#59; N&#8239;&#61;&#8239;37&#41; and aesthetic dissatisfaction &#40;63&#46;6&#37;&#59; N&#8239;&#61;&#8239;35&#41; were the most frequently reported&#44; followed by low self-esteem &#40;32&#46;7&#37;&#59; N&#8239;&#61;&#8239;18&#41;&#44; teasing &#40;29&#37;&#59; N&#8239;&#61;&#8239;16&#41;&#44; bullying &#40;18&#46;2&#37;&#59; N&#8239;&#61;&#8239;10&#41; and anxiety &#40;14&#46;5&#37;&#59; N&#8239;&#61;&#8239;8&#41;&#46; Fifty-three parents &#40;96&#46;4&#37;&#41; would recommend surgery to other children and 51 claimed to be satisfied with the aesthetic result&#46; The remaining caregivers had no opinion on either topic&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">PedsQL 4&#46;0 Generic Core Scales</span><p id="par0090" class="elsevierStylePara elsevierViewall">All patients completed the PedsQL 4&#46;0 Generic Core Scales&#46; Median total score of self-reported HRQoL was 85&#46;6&#8239;&#177;&#8239;12 &#91;50&#8211;100&#93;&#46; Patients were divided in three groups&#44; according to their age&#58; 5&#8211;7 &#40;group 1&#41;&#44; 8&#8211;12 &#40;group 2&#41;&#44; and 13&#8211;18 years &#40;group 3&#41;&#44; as depicted in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; No statistical difference was identified between groups &#40;p&#8239;&#61;&#8239;0&#46;092&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Median total score for parent-proxy HRQoL was 86&#46;9&#8239;&#177;&#8239;13&#46;5 &#91;46&#46;7&#8211;100&#93; &#40;see <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; No statistical difference was identified between groups &#40;p&#8239;&#61;&#8239;0&#46;187&#41;&#46; Patient&#8217;s gender and parent&#8217;s expectations did not influence either self-reported or parent-proxy HRQoL &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; History of teasing was associated with higher self-reported HRQoL &#40;p&#8239;&#61;&#8239;0&#46;021&#59; effect 2&#44;389&#41;&#59; low self-esteem&#44; on the other hand&#44; is associated with diminished patient&#8217;s self-reported HRQoL &#40;p&#8239;&#61;&#8239;0&#46;028&#59; effect &#8722;0&#44;344&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">GCBI-based survey</span><p id="par0100" class="elsevierStylePara elsevierViewall">All parents complete the GCBIb&#46; Median score was 20&#46;5&#8239;&#177;&#8239;19&#46;8&#44; with 98&#46;2&#37; positive scores found&#44; representing a positive effect of surgery in children&#8217;s HRQoL&#46; In only one case&#44; a score of zero was reported and no negative values were found&#46; The majority of caregivers expected an improvement in their children&#8217;s quality of life &#40;better or much better&#59; 49&#46;1&#37;&#44; N&#8239;&#61;&#8239;27&#41;&#46; The expectation of a much better quality of life post-surgery was predictive of higher GCBIb values &#40;p&#8239;&#61;&#8239;0&#46;025&#59; effect 2&#44;310&#41;&#46; When analyzing the effects of previous pejorative experiences&#44; bullying was the only with significant effect on quality of life change and children who suffered from it had higher scores of GCBIb &#40;p&#8239;&#61;&#8239;0&#46;011&#59; effect 2&#44;630&#41;&#46; Gender and age did not influence GCBIb &#40;p&#8239;&#62;&#8239;0&#46;05&#59; see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p></span></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Children with visible differences&#44; such as prominent ears&#44; commonly face challenging and painful social interactions&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> These early life events can exert a powerful influence on a person&#8217;s development&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Children may become overly preoccupated with their appearance and may develop distressful behaviors&#44; such as social withdrawal&#44; anxiety and diminished self-esteem&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In the particular case of prominent ears&#44; surgery has the potential to alleviate their psychosocial problems<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58; it has even been described as effective in reducing and eliminating bullying&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Having this in consideration&#44; we designed the present study to evaluate and assess clinical outcomes&#44; parental satisfaction and quality of life after otoplasty&#44; both self- and parent-reported&#46; As surgeons&#44; we are only capable of conducting an analysis of the technical and esthetic results&#59; however&#44; as the main goal of surgery is QoL change&#44; patient and parental opinion evaluating is fundamental for surgical success validation&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Our significant results confirm the positive effect of bilateral otoplasty in children in quality of life&#44; paralleling the existing literature&#46; Hao et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> conducted a study in 2013 to assess HRQoL after otoplasty in 50 pediatric patients&#58; a mean GCBI score of 24&#46;4 and a mean Pediatric Quality of Life Inventory of 94&#46;3 &#40;self-reported&#41; and 93&#46;3 &#40;parent proxy&#41; translated their positive outcome&#46; Toplu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> compared clinical and HRQoL outcomes in 132 adults and children submitted to otoplasty&#59; both groups reported a significant increase in GBI and GCBI post-surgery&#46; Songu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> evaluated 67 children and measured post-interventional GCBI&#59; their results were compatible with a raised HRQoL&#46; Similarly&#44; Braun et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> shared similar results in their pediatric patients&#44; reporting a mean GCBI of 24&#46;1&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Although we could not use Glasgow Children&#8217;s Benefit Inventory validated questionnaire to measure HRQoL after otoplasty&#44; we overcame this issue by translating and adapting the original inquiry &#40;GCBI-based survey&#59; GCBIb&#41;&#46; As in GCBI&#44; the score of our GCBIb may vary between &#8722;100 and &#43;100&#59; negative values represent a negative effect of the procedure on HRQoL&#44; zero&#58; no effect and positive values translate into an increase in HRQoL after surgery&#46; The analysis of our data demonstrated a positive effect of otoplasty in children with prominent ears&#44; as measured by our GCBIb median score of 20&#46;5&#46; GCBIb mean score &#40;12&#46;3&#41; and standard deviation &#40;1&#46;1&#41; were submitted to a t-statistic &#40;10&#46;7&#41; corresponding&#44; reaching a p-value near zero &#40;p&#8239;&#60;&#8239;0&#46;001&#41;&#44; confirming the significance of GCBIb and of such surgery&#8217; positive effects in patient&#8217;s quality of life&#46; Despite our questionnaire&#8217;s obvious limitations&#44; we still believe these results represent an improved HRQoL&#44; keeping up with current literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Parents were asked to identify past negative experiences&#46; Not surprisingly&#44; most pointed out at least one and the most common were aesthetic dissatisfaction and teasing by peers&#46; We tested the effect of these experiences on GCBIb score and bullying was the only with significant result&#46; Victims of bullying scored significantly higher&#44; probably because surgery addressed the focus of aggression&#46; As we can conclude&#44; aesthetic surgery improves not only the anatomical defect&#44; but also psychological and social suffering&#46; Hao et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> reported a similar effect on patients with a history of being teased&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Parental expectations also influenced GCBIb scores&#58; parents who expected a much better quality of life of their offspring after surgery scored significantly higher&#46; Parents&#8217; hope for a life-changing event probably influences their own perception of the surgical outcomes&#44; namely in HRQoL&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Teasing was also influential in self-reported quality of life&#46; Children who had been teased by peers had a higher score in the PedsQL self-report&#44; probably due to a similar phenomenon as in bullying&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Although the positive global impact we found in HRQoL after surgery in ear deformities patients&#44; the ones with low self-esteem scored significantly lower in self-report quality of life&#46; An explanation for this result is that these patient&#8217;s psychological fragilities are probably multifactorial&#44; and surgery obviously does not address all of them&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">As in any other procedure&#44; otoplasty may have complications and they should be addressed before surgery&#46; In our patients&#44; we had a small number of patients suffering from hypertrophic scarring&#44; most resolved after topic triamcinolone injection&#46; Another non-negligible complication was partial relapse&#44; found in four patients&#44; none of which required reintervention&#46; Despite these hurdles&#44; all reported both high levels of self- and parent-reported quality of life and high levels of satisfaction and recommendation&#46; Despite suture extrusion is one of the most common complications described in the literature&#44; no case was present in our cohort&#59; however&#44; this was probably due to the median follow-up of six months&#59; a longer follow-up is required to evaluate such complication&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Regarding limitations&#44; the most striking one is the use of a non-validated tool to evaluate HRQoL&#46; As we previously stated&#44; there isn&#8217;t an official Portuguese version to apply to our families and for that reason a translation was conducted by us&#44; as well as a minor alteration of the original inquiry&#46; Despite not being able to be directly compared with previous studies&#44; our study obtained 98&#46;2&#37; positive results in the GCBIb&#44; indicating an incremental effect of surgery in HRQoL&#59; this is supported by the high scores of self-report and parent proxy quality of life&#44; measured by PedsQL 4&#46;0&#46; Secondly&#44; no control group was used&#46; Third&#44; the use of questionnaires is fallible&#44; particularly when taken several months after the procedure&#46; Fourth&#44; this is a retrospective analysis&#59; a study comparing pre- and post-intervention quality of life would allow us to better understand the effect of surgery on HRQoL of these patients&#46; Finally&#44; there is a possible child bias&#44; as previously identified by Hao et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#58; as parents help their children to fill the questionnaire&#44; they may lead their children to select certain options they see more fit&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In conclusion&#44; otoplasty is a safe procedure in children and positively addresses not only the aesthetic dimension but also health-related quality of life&#44; as reported both by parents and patients in our retrospective survey&#46; A prospective study should be conducted to better define the precise effect of surgery on these patients&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Financial disclosure statement</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46; No funding was received for this article&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical approval</span><p id="par0155" class="elsevierStylePara elsevierViewall">All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and&#47;or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards&#46; Institutional ethics approval was obtained&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Informed consent</span><p id="par0160" class="elsevierStylePara elsevierViewall">Informed consent was obtained from the guardians of the patients included in this study&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Authors&#8217; role in the manuscript</span><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Study conception and design&#58;</span> Catarina Carvalho&#44; F&#225;tima Carvalho&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Data acquisition&#58;</span> Catarina Carvalho&#44; Ana Sofia Marinho&#44; Joana Barbosa-Sequeira&#44; M&#225;rio Rui Correia&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Analysis and data interpretation&#58;</span> Catarina Carvalho&#44; Ana Sofia Marinho&#44; Joana Barbosa-Sequeira&#44; M&#225;rio Rui Correia&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Drafting of the manuscript&#58;</span> Catarina Carvalho&#44; Jos&#233; Banquart-Leit&#227;o&#44; F&#225;tima Carvalho&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Critical revision</span>&#58; Jos&#233; Banquart-Leit&#227;o&#44; F&#225;tima Carvalho&#46;</p></span></span>"
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    "fechaAceptado" => "2022-07-28"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Prominent ears are a common congenital malformation and are associated with low self-esteem&#44; social isolation and diminished school performance&#46; Our goal was to evaluate the influence of otoplasty on children&#8217;s quality of life &#40;QoL&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Patients submitted to otoplasty from 2016 to 2018 were summoned for a reevaluation&#46; Seventy patients and respective caregivers agreed to participate&#46; Surgical&#44; demographic and clinical data were reviewed from electronic registries&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Two sets of inquiries were performed</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Pediatric Quality of Life Inventory 4&#46;0 &#40;for parent and child&#41; and an adaptation of the Glasgow Children Benefit Inventory &#40;GCBI-b&#41;&#46; Fifteen patients were excluded for incomplete inquiries&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Fifty-five patients were included&#44; 70&#46;9&#37; were males&#46; Median age at surgery was 7&#46;7&#8239;&#177;&#8239;3&#46;3 years&#46; Aesthetic dissatisfaction was the main previous negative experience&#46; Median self-report quality of life was 85&#46;6&#37; and parent-report was 86&#46;9&#37;&#46; Median GCBI-b was &#43;20&#46;5&#44; indicating an improvement in patients&#8217; QoL&#46; Bullying and high parental expectations for life change post-surgery were predictive of higher GCBI-b scores &#40;p&#8239;&#60;&#8239;0&#46;05&#41;&#46; Ninety-six percent of parents would recommend surgery to other children&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Otoplasty is a valid treatment option for prominent ears in children&#44;improving not only aesthetics but also health-related QoL&#46;</p></span>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Expectations</span> Difference to neutral experience &#40;0&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Much worse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">H&#8239;&#61;&#8239;3&#46;133&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">H&#8239;&#61;&#8239;2&#46;957&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">H&#8239;&#61;&#8239;9&#46;613&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Worse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;536&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;565&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;047&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Better&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Much better&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Previous negative life experiences</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aesthetic dissatisfaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;0&#46;799&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;0&#46;696&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;-0&#46;071&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;428&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;490&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;944&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Teasing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;2&#46;389&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;1&#46;337&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;0&#46;547&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;187&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;587&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low self-esteem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;-2&#46;259&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;-1&#46;646&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;0&#46;752&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;028&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;106&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bullying&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;-1&#46;615&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;-1&#46;067&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">t&#8239;&#61;&#8239;2&#46;630&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;113&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;291&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#8239;&#61;&#8239;0&#46;011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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Article information

ISSN: 00016519
Original language: English

DOI:10.1016/j.otorri.2022.07.004

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2023 December	5	0	5
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