Tissue Augmenting Palatoplasty for the Treatment of Velopharyngeal Insufficiency

PURPOSE

Persistent velopharyngeal insufficiency (VPI) following primary palatoplasty remains a difficult problem to treat. This study evaluates speech outcomes following revision palatoplasty with tissue augmentation using buccal myomucosal flaps (BMF) as an alternative to pharyngoplasty for patients with VPI.

METHODS

A retrospective single-center review of revision palatoplasty with tissue augmentation at a tertiary pediatric hospital Cleft-Craniofacial Center between January 2017 and March 2021 was conducted. Patients with a history of previous palatoplasty, a diagnosis of persistent or recurrent VPI, and comprehensive pre- and postoperative speech evaluations who underwent revision palatoplasty with BMF were included.

RESULTS

Twenty patients met inclusion criteria (35% female, 20% syndromic). Mean age at the time of revision palatoplasty with BMF was 9.7 years. Preoperatively, all patients had stigmatizing speech and received the recommendation for speech surgery; the mean Pittsburgh Weighted Speech Score (PWSS) was 14.3 ± 4.9. The mean postoperative PWSS at the most recent assessment was 4.2 ± 2.3, representing a statistically significant improvement from preoperative scores (P < .001). Mean follow-up time was 8.9 months. Following revision palatoplasty with BMF, only one patient has received the recommendation for further speech surgery. No complications were noted.

CONCLUSION

In patients with VPI following primary palatoplasty, revision palatoplasty with tissue augmentation offers an alternative to pharyngoplasty. This approach preserves dynamic velopharyngeal function, improves speech outcomes, and should be considered an option when treating patients with post-primary palatoplasty VPI.

Fibrin with Laminin-Nidogen Reduces Fibrosis and Improves Soft Palate Regeneration Following Palatal Injury

This study aimed to analyze the effects of fibrin constructs enhanced with laminin-nidogen, implanted in the wounded rat soft palate. Fibrin constructs with and without laminin-nidogen were implanted in 1 mm excisional wounds in the soft palate of 9-week-old rats and compared with the wounded soft palate without implantation. Collagen deposition and myofiber formation were analyzed at days 3, 7, 28 and 56 after wounding by histochemistry. In addition, immune staining was performed for a-smooth muscle actin (a-SMA), myosin heavy chain (MyHC) and paired homeobox protein 7 (Pax7). At day 56, collagen areas were smaller in both implant groups (31.25 ± 7.73% fibrin only and 21.11 ± 6.06% fibrin with laminin-nidogen)) compared to the empty wounds (38.25 ± 8.89%, p < 0.05). Moreover, the collagen area in the fibrin with laminin-nidogen group was smaller than in the fibrin only group (p ˂ 0.05). The areas of myofiber formation in the fibrin only group (31.77 ± 10.81%) and fibrin with laminin-nidogen group (43.13 ± 10.39%) were larger than in the empty wounds (28.10 ± 11.68%, p ˂ 0.05). Fibrin-based constructs with laminin-nidogen reduce fibrosis and improve muscle regeneration in the wounded soft palate. This is a promising strategy to enhance cleft soft palate repair and other severe muscle injuries.

Ectomesenchymal Chondromyxoid Tumor: A Rare Association With an Asymmetrical Soft Palate Cleft

Ectomesenchymal chondromyxoid tumor (ECT) is a rare oral lesion first described by Smith et al. in 1995. These tumors are typically painless, slow growing and benign masses occurring predominantly on the anterior tongue dorsum. Prior to this seminal report, many ECTs may have been misdiagnosed due to the histological similarities with other lesions. Immunohistochemical stains aid in definitive diagnosis of an ECT. A total of 39 papers since published have reported 96 patients with ECT. Most lesions involve the anterior aspect of the tongue, with only 6 occurring in the posterior tongue and 2 involving the hard palate. ECTs are considered to develop from ectomesenchymal cells of neural crest cells that have migrated to the tongue during embryological development. This paper is of a rare case of ECT of the posterolateral tongue occurring in association with an unusual asymmetrical soft palate cleft. It is postulated that since the tongue develops before the formation of the soft palate, an ECT lesion occurring on the posterior aspect may have a causal contribution to the development of the soft palate cleft.

Scanning electron microscopy of the palatine mucosa with connective tissue papillae of the Egyptian red fox (Vulpes vulpes aegyptiaca, Linnaeus, 1758)

The present study investigated the morphological, as well as the histological features of the Egyptian red fox's palate, in addition to the three-dimensional characteristics of the connective tissue papillae (CTP) of the palate by scanning electron microscopy (SEM). The hard palate was narrow rostrally and its width increased caudally. The maximum width was located at the caudal border of the upper fourth premolar tooth. The incisive papilla was represented by a rounded median elevation surrounded on each side by a groove on which the oral openings of the incisive ducts opened. The rostral part of the hard palate had 9-10 caudally concave transverse palatine ridges while the caudal part appeared smooth without ridges. The palatine raphe was indistinct rostrally but formed a groove caudally. By SEM, the palatine ridges had low projections. Different microplicae systems were present on the epithelial surface of the incisive papilla, palatine rugae, interrugal areas, and the smooth part. The CTP of the incisive papilla, palatine ridges, and soft palate were conical-shaped, cylindrical-shaped, and parallel serrated ridges, respectively. Histologically, the hard palate was lined by a cornified stratified squamous epithelium resting on a dense connective layer of lamina propria while the soft palate was lined by a noncornified stratified squamous epithelium. The palatine salivary glands were present in the smooth part of the hard palate and the soft palate. The information presented in the current study might serve as a reference guide for the interpretation of pathological conditions of the palate of red fox.

The relationship between specific nasopharyngoscopic features and treatment deterioration with mandibular advancement devices: a prospective study

STUDY OBJECTIVES

The variable efficacy of mandibular advancement device (MAD) treatment necessitates both accessible and accurate methods for patient selection. However, the role of awake nasopharyngoscopy for this purpose remains dubious. We introduced an assessment method based on anatomical upper airway features during tidal breathing for nasopharyngoscopy. The current study aimed to relate these features to MAD treatment outcome.

METHODS

One hundred patients diagnosed with obstructive sleep apnea were prospectively recruited for MAD treatment in a fixed 75% degree of maximal protrusion. Nasopharyngoscopic observations during Müller's maneuver and tidal breathing were recorded both with and without MAD. Treatment outcome, confirmed by 3-month follow-up polysomnography with MAD, was classified as (1) apnea-hypopnea index reduction ≥ 50%, (2) treatment apnea-hypopnea index < 5 events/h, and (3) ≥ 10% increase in apnea-hypopnea index compared with baseline (treatment deterioration).

RESULTS

A complete dataset was obtained in 65 patients. After adjusting for baseline apnea-hypopnea index, body mass index, and supine dependency, the position of the soft palate (odds ratio, 4.0; 95% confidence interval, 1.3-11.8; P = .013) and crowding of the oropharynx (odds ratio, 7.7; 95% confidence interval, 1.4-41.4; P = .017) were related to treatment deterioration. Addition of both features significantly (P = .031) improved the accuracy of baseline models based on clinical measurements alone. Moreover, with the MAD in situ, a posteriorly located soft palate (odds ratio, 9.8; 95% confidence interval, 1.7-56.3; P = .010) and a posteriorly located tongue base (odds ratio, 7.4; 95% confidence interval, 1.5-35.9; P = .013) were associated with treatment deterioration.

CONCLUSIONS

Awake nasopharyngoscopy might be a valuable office-based examination to exclude the risk of treatment deterioration and improve patient selection for MAD treatment.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Predicting Therapeutic Outcome of Mandibular Advancement Device Treatment in Obstructive Sleep Apnea (PROMAD); URL: https://clinicaltrials.gov/ct2/show/NCT01532050; Identifier: NCT01532050.

Modified Z-Palatoplasty for Correction of Acquired Nasopharyngeal Stenosis Following Palatal Surgery: A Case Series

OBJECTIVES

To evaluate the efficacy of a novel surgical technique in management of nasopharyngeal stenosis (NPS), describing its steps and results. Study Design: Prospective clinical trial.

SETTING

This study was conducted at the Otolaryngology, Head and Neck Surgery Department, Zagazig University.

METHODS

This prospective study was conducted on patients with snoring ± obstructive sleep apnea due to acquired postsurgical NPS of grade Ι and ΙΙ. New surgical repair was employed on the patients and the pre and postoperative results were statistically compared.

RESULTS

The grade of NPS improved significantly postoperatively (P = .00136) throughout a follow-up of 1 year. Postoperatively, there was statistically significant improvement of apnea hypopnea index (P = .0005), Visual Analog Scale (VAS) of nasal obstruction (P < .0001) and VAS of snoring (P < .0001). Dysphagia showed early worsening, but it improved completely at 3 months postoperatively.

CONCLUSION

The utilized novel procedure appears effective, low cost, and easily applicable, and it does not require implants, special tools, or suture materials. Furthermore, it gives excellent results, with negligible pain, and rapid recovery without significant complications.

LEVEL OF EVIDENCE

4.

Cleft Lip and/or Palate in Infants Prenatally Exposed to Opioids

OBJECTIVE

To determine the prevalence and odds ratios for cleft lip and/or palate (CL/P) among infants prenatally exposed to opioids with or without neonatal opioid withdrawal syndrome (NOWS).

DESIGN

This study represents an exploratory, retrospective cohort study design of newborn medical health records from 2011 to 2016.

SETTING

Records were drawn from a regional health system located in South Central Appalachia.

POPULATION AND STUDY SAMPLE

The original population yielded 3 cohorts of infants: (1) infants with opioid exposure (OE) but not requiring pharmacological intervention (OE; N = 168); (2) infants with NOWS requiring pharmacological intervention (N = 294); and (3) infants with no opioid exposure (NOE; N = 16 090), the primary comparison group.

MAIN OUTCOME

Infants in the NOWS and OE groups showed significantly increased prevalence and odds ratios for CL/P when compared to those in the NOE group.

RESULTS

Prevalence rates per 1000 live births for infants with OE (35.71) and infants with NOWS (6.80) were significantly higher than those for infants with NOE (1.37). Comparison of infants with OE to the NOE group revealed significantly increased odds for CL/P, isolated cleft palate (CP), cleft lip (CL), and cleft lip and palate (CLP) (27.05, 41.81, 19.26, 19.37, respectively; all Ps < .008). The odds ratios for infants with NOWS compared to the NOE group were significantly higher for CL/P and CP (5.00 and 10.98, respectively; Ps < .03) but not for CL and CLP.

CONCLUSION

The results provide additional evidence that prenatal OE should be considered among the critical environmental risk factors that can contribute to CL/P.

Endoscopic findings in the soft palatal mucosa are associated with the risk of esophageal squamous cell carcinoma

BACKGROUND AND AIM

We investigated endoscopic findings of the soft palatal mucosa to identify factors associated with esophageal squamous cell carcinoma (ESCC).

METHODS

This study was conducted during endoscopic examinations of subjects at Osaka International Cancer Institute from January 2020 through May 2020. We took endoscopic images of the soft palate under non-magnifying and mild-magnifying observations. Subjects with ESCC or a history of ESCC were defined as the ESCC group. Two endoscopists who were blinded to subjects' clinical information interpreted 10 endoscopic findings: melanosis, brownish changes, whitish epithelium, vasodilation, circular alignment of dilated vessels, uneven surface, uneven epithelial color, uneven vessel visibility, palate ridge, and erosion. Subjects were interviewed about their alcohol use, smoking, and flushing reactions.

RESULTS

Two hundred eighty-two subjects, including 151 in the ESCC group and 131 in the non-ESCC group, were included in the analysis. Univariate analyses and multivariate logistic regression demonstrated that melanosis, whitish epithelium, and vasodilation were significantly associated with ESCC. The positive likelihood ratios (PLRs) of melanosis, whitish epithelium, and vasodilation were 3.3, 4.2, and 2.8, respectively. Additionally, the PLRs for three of the endoscopic findings in subjects with drinking and smoking habits were higher than in those without these habits-PLRs ranging from 7.23 to 19.1. High PLRs for three endoscopic findings suggested a high possibility of ESCC. Interobserver agreement was substantial for whitish epithelium, moderate for melanosis, and fair for vasodilation.

CONCLUSIONS

Three endoscopic findings in soft palate were considered to be useful as alarming signs that indicate ESCC risk.

Structural and Ultrastructural Characteristics of the Red-Rumped Agouti (Dasyprocta leporina-Linnaeus, 1758) Palatine Epithelium

The palate is a fundamental region in food swallowing and presents different adaptations in species. This research aimed to describe structural and ultrastructural characteristics of the palatine epithelium and the connective tissue cores (CTCs) of ten red-rumped agoutis (Dasyprocta leporina—Linnaeus, 1758) using macroscopic, light microscopy, scanning electron microscopy, and transmission electron microscopy. We found nine palatine ridges in the diastema and hard palate, and a smooth surface in the soft palate. Stratified squamous keratinized epithelium with projections of lamina propria and soft palate had gland clusters. Epithelial removal revealed CTCs with a conical shape with high density in the hard palate and the sides of the soft palate. Near the CTCs were nerve fibers in the hard palate, and the soft palate had muscular tissue below the gland clusters. The structural and ultrastructural characteristics enable stability of the hard palate and fixation to the soft palate sides, while the soft palate center has greater mobility thus assisting in food swallowing. We concluded that structural characteristics are similar to other mammals, although the morphology of agouti's palate differs in the amount and disposition of palatine ridges, and the conical CTC's morphology.

Registry-Based Study of Prevalence of Cleft Lip/Palate in Thailand from 2012 to 2015

OBJECTIVE

Two main objectives were established. First objective was to determine the prevalence of the cleft lip and/or cleft palate (CL/P) in Thailand from 2012 to 2015 using the orofacial clefts (OFCs) registry and civil registration. Second objective was to conduct a quality control of this OFC registry especially for the Birth Defects Registration (BDR).

DESIGN

Registry-based survey.

SETTING

Analyzing data from the Thailand National Health Security Office.

PARTICIPANTS

Registered patients with CL/P in Thailand from 2012 to 2015.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Duplicated records were verified using National Identity Number (Thai ID#) and date of birth. The prevalence of CL/P and specific phenotypes was then calculated. From this prevalence estimate method, quality assurance of the OFCs registry was possible.

RESULTS

For the main outcome, the population-weighted pool prevalence of CL/P was 2.14 per 1000 live births (95% confidence interval of 2.08-2.20). Thai ID# and expense reimbursement systems were the main factors driving this cases capturing. However, this OFCs registration still requires active case finding with clinical verification, improvement of staff training and databases networking.

CONCLUSIONS

This study reported a very high CL/P prevalence of Thailand. Strengths and limitations of these OFCs registry and BDR were described.

Transoral Robotic Surgery for Cancer of the Soft Palate Posterior Surface

The surgical treatment of oropharyngeal squamous cell carcinoma (OSCC) has undergone a considerable evolution, with, among others, transoral robotic surgery (TORS). However, TORS is rarely used for the surgery of soft palate. A 73-year-old man presented a human papilloma virus OSCC of the posterior soft palate. The tumor was resected using TORS. This report describes the surgical technique step by step of the tumor resection. The resection of early stage OSCC of the posterior surface of soft palate is possible through TORS. The procedure is noninvasive, rapid, and seems to be associated with excellent functional outcomes.

Innervation of human soft palate muscles

Our objective was to determine the branching and distribution of the motor nerves supplying the human soft palate muscles. Six adult specimens of the soft palate in continuity with the pharynx, larynx, and tongue were processed with Sihler's stain, a technique that can render large specimens transparent while counterstaining their nerves. The cranial nerves were identified and dissection followed their branches as they divided into smaller divisions toward their terminations in individual muscles. The results showed that both the glossopharyngeal (IX) and vagus (X) nerves have three distinct branches, superior, middle, and inferior. Only the middle branches of each nerve contributed to the pharyngeal plexus to which the facial nerve also contributed. The pharyngeal plexus was divided into two parts, a superior innervating the palatal and neighboring muscles and an inferior innervating pharyngeal constrictors. The superior branches of the IX and X nerves contributed innervation to the palatoglossus, whereas their middle branches innervated the palatopharyngeus. The palatoglossus and palatopharyngeus muscles appeared to be composed of at least two neuromuscular compartments. The lesser palatine nerve not only supplied the palatal mucosa and palatine glandular tissue but also innervated the musculus uvulae, palatopharyngeus, and levator veli palatine. The latter muscle also received its innervation from the superior branch of X nerve. The findings would be useful for better understanding the neural control of the soft palate and for developing novel neuromodulation therapies to treat certain upper airway disorders such as obstructive sleep apnea.

An unusual clinical vignette of oro-pharyngeal discomfort: Pterygoid Hamulus syndrome

Background

A straightforward clinical reasoning is always difficult in patients with persistent orofacial pain with vague symptoms. Craniofacial pain or Orofacial pain can have a mixture of causes ranging from neurogenic, myogenic, and psychogenic factors intertwined amidst the intricate anatomy with a high vascular network. This plethora of uncertainty blurs the judgment for such patients to whom we provide care. We hereby present a case of a 17 year old female with vague pain on talking, chewing and even swallowing when initially examined; this chronic orofacial pain often worsened her quality of life. The aim of this manuscript is to present a case of Pterygoid Hamulus syndrome that was misdiagnosed as glossopharyngeal and myofascial neuralgia.

Methods

The condition was managed by surgical excision of the elongated pterygoid hamulus, following a recurrence of her symptoms.

Results

The patient was relieved of pain only after the surgical excision of the elongated hamulus.

Conclusions

The surgery was decided upon only after conservative management had not provided much relief and the manuscript also discusses the ambiguous composite pain referral pattern in Pterygoid Hamulus syndrome.

Transforming Growth Factor-Beta and Sonic Hedgehog Signaling in Palatal Epithelium Regulate Tenascin-C Expression in Palatal Mesenchyme During Soft Palate Development

During palatogenesis, the palatal shelves first grow vertically on either side of the tongue before changing their direction of growth to horizontal. The extracellular matrix (ECM) plays an important role in these dynamic changes in palatal shelf morphology. Tenascin-C (TNC) is an ECM glycoprotein that shows unique expression in the posterior part of the palatal shelf, but little is known about the regulation of TNC expression. Since transforming growth factor-beta-3 (TGF-β3) and sonic hedgehog (SHH) signaling are known to play important roles in palatogenesis, we investigated whether TGF-β3 and SHH are involved in the regulation of TNC expression in the developing palate. TGF-β3 increased the expression of TNC mRNA and protein in primary mouse embryonic palatal mesenchymal cells (MEPM) obtained from palatal mesenchyme dissected at embryonic day 13.5-14.0. Interestingly, immunohistochemistry experiments revealed that TNC expression was diminished in K14-cre;Tgfbr2 ^fl/fl mice that lack the TGF-β type II receptor in palatal epithelial cells and exhibit cleft soft palate, whereas TNC expression was maintained in Wnt1-cre;Tgfbr2 ^fl/fl mice that lack the TGF-β type II receptor in palatal mesenchymal cells and exhibit a complete cleft palate. SHH also increased the expression of TNC mRNA and protein in MEPM cells. However, although TGF-β3 up-regulated TNC mRNA and protein expression in O9-1 cells (a cranial neural crest cell line), SHH did not. Furthermore, TGF-β inhibited the expression of osteoblastic differentiation markers (osterix and alkaline phosphatase) and induced the expression of fibroblastic markers (fibronectin and periostin) in O9-1 cells, whereas SHH did not affect the expression of osteoblastic and fibroblastic markers in O9-1 cells. However, immunohistochemistry experiments showed that TNC expression was diminished in the posterior palatal shelves of Shh^-/+ ;MFCS4 ^+/- mice, which have deficient SHH signaling in the posterior palatal epithelium. Taken together, our findings support the proposal that TGF-β and SHH signaling in palatal epithelium co-ordinate the expression of TNC in the posterior palatal mesenchyme through a paracrine mechanism. This signal cascade may work in the later stage of palatogenesis when cranial neural crest cells have differentiated into fibroblast-like cells. The spatiotemporal regulation of ECM-related proteins by TGF-β and SHH signaling may contribute not only to tissue construction but also to cell differentiation or determination along the anterior-posterior axis of the palatal shelves.

SOX10-Cre-Labeled Cells Under the Tongue Epithelium Serve as Progenitors for Taste Bud Cells That Are Mainly Type III and Keratin 8-Low

Taste bud cells are specialized epithelial cells that undergo continuous turnover, and thus require active progenitors for their renewal and an intact taste function. Our previous studies suggested that a population of taste bud cells originates from outside of the surrounding tongue epithelium-previously regarded sole source of taste bud progenitors. In this study, we demonstrated that SOX10 (SRY-related HMG-box gene 10)-expressing cells, known to be in the migrating neural crest, were also distributed in taste bud-surrounding tissue compartments under the tongue epithelium, that is, the connective tissue core of taste papillae and von Ebner's glands. By lineage tracing of SOX10-expressing cells using SOX10-Cre, a Cre model driven by the endogenous SOX10 promoter, crossing with a Cre reporter line R26-tdTomato (tdT), we found SOX10-Cre-labeled tdT+ cells within taste buds in all three types of taste papillae (fungiform, circumvallate, and foliate) as well as in the soft palate in postnatal mice. The tdT+ taste bud cells were progressively more abundant along the developmental stages, from virtually zero at birth to over 35% in adults. Most of tdT+ taste bud cells had a low intensity of immunosignals of Keratin 8 (a widely used taste bud cell marker). In circumvallate taste buds, tdT signals were co-localized principally with a type III taste bud cell marker, less so with type I and II cell makers. Together, our data demonstrate a novel progenitor source for taste buds of postnatal mice-SOX10-Cre-labeled cells in the connective tissue core and/or von Ebner's glands.

Ex-vivo Mechanical Testing of Novel Laryngeal Clamps Used for Laryngeal Advancement Constructs

Rostral laryngeal advancement, also known as laryngeal tie-forward, is used to treat horses for intermittent dorsal displacement of the soft palate and has a morbidity rate of about 6%. We hypothesized that a novel laryngeal clamp would prevent morbidity associated with the sutures tearing through the thyroid cartilage. Larynges (n = 35 horses) were used for ex vivo testing. For uniaxial testing, 15 equine larynges were tested in one of three laryngeal tie-forward constructs [standard laryngeal tie-forward; modified laryngeal tie-forward using a suture-button; and modified laryngeal tie-forward using a laryngeal clamp]. For biaxial testing, 20 larynges were tested in one of two treatment groups: laryngeal tie-forward and laryngeal tie-forward using a laryngeal clamp. Constructs were tested in single cycle-to-failure. Statistical analyses were performed using ANOVA for uniaxial testing and t-tests for biaxial testing. The laryngeal tie-forward using a laryngeal clamp construct was superior to laryngeal tie-forward and laryngeal tie-forward using a suture-button constructs in resistance to pullout in uniaxial testing. The laryngeal tie-forward using a laryngeal clamp presented a significantly different method of failure than the standard laryngeal tie-forward in the biaxial testing. Failure modes for each construct were primarily by suture failure at the clamp (laryngeal tie-forward using a laryngeal clamp), suture pullout through the thyroid cartilage, or, less commonly, tearing of the cricothyroid ligament (laryngeal tie-forward). In uniaxial testing, the laryngeal tie-forward using a laryngeal clamp failed most commonly due to tearing of the cricothyroid ligament, whereas the standard laryngeal tie-forward and the laryngeal tie-forward using a suture-button failed due to the tearing of the cartilage. The laryngeal clamps provided greater stiffness, load at yield, and tensile stress at yield than did the standard construct. Laryngeal clamps may offer an alternative to standard methods of anchoring the thyroid cartilage when performing the laryngeal tie-forward procedure. Further testing and clinical trials are needed to elucidate the utility of the laryngeal tie-forward using a laryngeal clamp.

Alexis Retractor: Institutional Experience of Its Applications in Head and Neck Surgery and Review of the Literature

BACKGROUND

The Alexis retractor is a device that provides simultaneous radial retraction and wound protection during surgical procedures. Although typically used in abdominal and pelvic surgeries, there has been increased development of novel operative techniques utilizing the Alexis retractors in head and neck surgeries.

METHODS

We describe 2 cases of utilizing the Alexis retractor to attain transoral exposure in the setting of free flap reconstruction of intraoral defects.

RESULTS

In both cases, the Alexis retractor provided improved retraction, decreasing the number of instruments required for adequate exposure. Additionally, the polyurethane sheath component acted as a protective membrane over the lips and mucosa.

CONCLUSIONS

The Alexis retractor can be a powerful retraction tool for certain surgical procedures involving the head and neck regions.

About a "New" Technique for Uvular Repair

This letter is about a recent publication in the Cleft Palate Craniofacial Journal titled: "The significance of uvula after palatoplasty: A new technique to improve the aesthetic outcome" published by Elsherbiny et al (Cleft Palate Craniofacial J 2018;55(3):451-455). The authors present the use of one hemi-uvula for uvular repair during primary palatoplasty as their "new technique." The method of primary uvuloplasty using one-hemiuvula was extensively used by different surgeons in south America and presented and published in different scientific meetings and indexed scientific journals since the 90s. The original concept was described by Carlos Navarro in Perú and published by me in different scientific indexed journals and a textbook.

Autogenous soft tissue grafting for periodontal and peri-implant plastic surgical reconstruction

This state-of-the-art review presents the latest evidence and the current status of autogenous soft tissue grafting for soft tissue augmentation and recession coverage at teeth and dental implant sites. The indications and predictability of the free gingival graft and connective tissue graft (CTG) techniques are highlighted, together with their expected clinical and esthetic outcomes. CTGs can be harvested from the maxillary tuberosity or from palate with different approaches that can have an impact on graft quality and patient morbidity. The influence of CTGs on soft tissue thickness and keratinized tissue width are also discussed.

Correlation of soft palate morphology to growth pattern: A retrospective cephalometric study

Aim

The aim of the present study was to evaluate the radiographic length of velum (LV), width of velum (WV), velum angle (AV), depth of pharynx (PD), Need's ratio (NR), inclination angle (AI) in different morphological types of soft palate according to growth patterns in skeletal class I individuals.

Methodology

80 pretreatment lateral cephalograms of patients with skeletal class I malocclusion (ANB 2--4°) were divided on basis of six types of soft palate and further into three subgroups according to growth pattern and evaluation of LV, WV, angle with the palatal plane, and NR was done. Kruskal--Wallis test was used for the comparison between the groups.

Results

Statistically significant difference was verified among all groups for measurement of NR. The highest NR was seen in Crook type of soft palate (mean 0.9). Similarly, the vertical growth pattern in all the six types of soft palate exhibited a higher NR than the average and horizontal growth pattern group; the highest being exhibited by vertical group in type VI (crook shaped). Velopharyngeal insufficiency is directly related to NR.

Conclusion

Vertical growth pattern has the highest susceptibility to velopharyngeal insuffiency and speech and sleep apnea disorders.

Airway Obstruction Risk in Unique Infant Cleft Phenotype: PSIO Protocol Modification Recommendations

Patients presenting with a unique unilateral cleft phenotype may be at risk of nasal airway obstruction which can be exacerbated by presurgical infant orthopedic (PSIO) appliance therapy and lip taping. Four patients presented to the UPMC Children's Hospital of Pittsburgh Cleft-Craniofacial Center with a cleft phenotype characterized by: An anteriorly projected greater alveolar segment and medial collapse of the lesser segment posteriorly, leading to cleft alar base displacement posteromedial to the anteriorly projected greater segment. Resultant bilateral nasal airway obstruction: cleft ala drape over the leading edge of the greater segment's alveolus (cleft side obstruction) and caudal septum displacement secondary to attachments to the orbicularis oris from the noncleft side (noncleft side obstruction). The patient described presented at 3 months old from an outside institution, where PSIO therapy was undertaken. A second opinion was sought due to concern of significant difficulty in breathing and feeding with the PSIO oral plate. Lip-nose adhesion (LNA) was elected and airway obstruction was immediately relieved after this intervention. Lip-nose adhesion releases the tethered cleft side alar base from the pyriform rim of the posteromedially collapsed lesser segment and unites the superior lip and nostril sill-relieving the cleft side nostril obstruction. During the LNA, the caudal septum is surgically released from the anterior nasal spine and is uprighted, relieving the obstructed noncleft nostril. In this cleft anatomy, the treatment alternatives of modification to the PSIO appliance or LNA should be carefully considered in consultation with the surgeon, PSIO provider, and the infant's caretakers.

Barbed palatoplasty vs. expansion sphincter pharyngoplasty with anterior palatoplasty

OBJECTIVE/HYPOTHESIS

To compare the functional outcomes and complication rates in patients who underwent expansion sphincter pharyngoplasty with anterior palatoplasty (ESPwAP) versus barbed pharyngoplasty (BP).

STUDY DESIGN

Retrospective cohort study.

METHODS

A medical database was used to retrieve the records of 129 patients who had an isolated palatoplasty surgery between January 2014 and July 2018. Patients who had mild or moderate obstructive sleep apnea without a history of revision surgery and underwent ESPwAP or BP in addition to traditional tonsillectomy were included in the study. Pre- and postoperative polysomnography and Epworth Sleepiness Scale (ESS) was evaluated in the patients who completed at least a 6-month follow-up period.

RESULTS

Forty-five and 53 patients met the inclusion, and were comprised of BP and ESPwAP groups, respectively. ESPwAP and BP significantly improved mean apnea hypopnea index (AHI) from 28.5 to 9.1 (P = .000) and 25.9 to 7.4 (P = .000), respectively. No significant statistical difference was found between the mean AHI scores of two groups. Selecting a threshold of a 50% reduction in AHI and AHI less than 20 events/h, success rates were 86.6% in BP group and 84.9% in ESPwAP group.

CONCLUSIONS

Our study showed that both types of surgeries are effective with comparable results. The BP technique may be preferred when possible to avoid soft tissue excision and seems to be a less invasive procedure with a similar success rate when compared to ESPwAP.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E275-E279, 2020.

The Use of Acellular Dermal Matrix in Combination With Pedicled Buccal Fat Pad in Wide Cleft Palate Repair: A Case Report and Literature Review

We describe a case of the combined use of acellular dermal matrix and pedicled buccal fat pad (BFP) in a wide U-shaped cleft palate repair. Acellular dermal matrix was used as a "patch" repair for the nasal mucosa defect as opposed to the conventional inlay graft. The advantages include reduced cost and a smaller avascular graft load. Lateral relaxing incisions were made to ensure tension-free closure of oromucosa at midline. Lateral oromucosa defect closure with well-vascularized pedicled BFP ensures enhanced healing, less palatal contracture and shortening, and reduced infection. The palate healed with mucosalization at 2 weeks, and no complications were noted at 6 months follow-up.

Comprehension of Online Educational Material Regarding Orofacial Clefts

BACKGROUND

Cleft lip and palate are among the common birth defects in the United States. Management is complex and may be difficult for parents and patients to understand. The goal of this study was to evaluate the readability of online educational material provided by the American Society of Plastic Surgeons (ASPS) and the American Cleft Palate-Craniofacial Association (ACPA) websites regarding cleft lip and palate and to assess parents' comprehension.

METHODS

Parents of children younger than 10 years of age presenting to the plastic and reconstructive surgery clinic at Johns Hopkins All Children's Hospital for conditions other than cleft lip and palate were recruited for participation. Parents were given the literature published on the ASPS and ACPA web sites to review and were asked to complete a 5-question test specifically targeted to the content of the passage they reviewed. We tested the readability of the 2 online passages using Readability Studio software (Oleander Software Solutions Ltd).

RESULTS

Sixty parents completed the study. Across all groups, the mean score was 4.35 of a possible 5. The mean score was 4.4 for the ASPS web site and 4.29 for the ACPA web site. Fifty-three percent of participants answered all questions correctly. No significant difference in scores was noted between web sites (P = .48).

CONCLUSIONS

Despite containing content of varying reading-level difficulty, the literature posted on the ACPA and ASPS web sites concerning cleft lip and palate conveyed information equally well to the target parent demographic with high levels of comprehension.