Preoperative pharyngeal depth is associated with postoperative velopharyngeal function following primary cleft palate repair at the age of five and above

Validating the Modified Small Double Opposing Z-Plasty for Palatal Lengthening in Primary Palatoplasty

ObjectiveTo appraise the degree of intraoperative palatal lengthening with the modified Furlow small double-opposing Z-plasty (sDOZ).DesignRetrospective single-surgeon (R.D.) study.PatientsNonsyndromic children (n = 167) with Veau types I to IV cleft palates who underwent primary sDOZ palatoplasty.InterventionsIntraoperative measurements of palatal lengths and widths were collected using calipers, paper rulers, and metal rulers before the administration of local anesthetic solution and before the removal of the mouth gag (initial and final palatal dimensions, respectively).Main Outcome MeasuresAssessment of the intraoperative percentage change (difference between final and initial values) in surface palatal length, straight palatal length, and soft palatal length. Bivariate and multivariate analyses were performed to identify independent predictors (sex, age at surgery, Veau, Kernahan/ Stark, and Randall classifications, widest cleft width, presence of lateral relaxing incision, type of coverage with buccal fat flap, and postoperative complications) of soft palatal lengthening.ResultsSurface palatal, straight palatal, and soft palatal lengths had an intraoperative increase of 8%, 14.7%, and 27.7%, respectively. The degree of intraoperative soft palatal lengthening significantly varied among Veau cleft types (I = II < III = IV). Veau type III and cleft lip/palate were independent positive predictors (P < .001) of soft palatal lengthening, while other tested variables were not correlated (P > .05) with this outcome.ConclusionsOverall intraoperative palatal lengthening occurs with the modified sDOZ palatoplasty, with differences within the spectrum of cleft palate deformity.

Dutch Workflow for Diagnosis and Treatment of Velopharyngeal Insufficiency in Patients with Cleft Palate-A Survey Study

ObjectiveThe aim of this study was to investigate the workflow of cleft teams in the Netherlands with regard to the diagnosis and treatment of velopharyngeal insufficiency (VPI) in patients with cleft palate (CP).DesignThis is a cross-sectional survey study.SettingMulticenter study, tertiary hospital setting.ParticipantsEar-nose-throat surgeons, plastic surgeons and speech language pathologists of the eight cleft teams in the Netherlands.InterventionsA cross-sectional online survey was sent to the participants.Main Outcome Measure(s)The survey questions covered the following topics: diagnostic tests used to assess VPI, use of classification systems and cut-off values to determine the most optimal treatment, treatment of VPI, and postoperative follow-up.ResultsThe response rate was 88% (n = 7 cleft teams). Frequently described diagnostic tests to assess VPI include perceptual speech assessment, mirror test, nasendoscopy, oral inspection, patient-reported outcome measures, nasometry, and videofluoroscopy. Most centers reported that they did not use a classification system to determine the severity of VPI. None of the centers reported to use cut-off values based on the diagnostic tests to determine optimal treatment. The reported minimum duration of speech therapy prior to surgery varied. Many different surgical techniques were reported for the treatment of VPI. Regarding postoperative follow-up, survey responses indicate agreement on the multidisciplinary approach and diagnostic tests used. The timing of the visits varied.ConclusionFurther standardization of the diagnostic process and treatment workflow of VPI in patients with CP between Dutch cleft centers is needed in order to compare outcomes of different surgical techniques and to establish a national protocol for optimal treatment.

Indications for Furlow Double-Opposing Z-Plasty in Patients with Velopharyngeal Insufficiency following 2-Flap Palatoplasty

BACKGROUND

Various surgical methods have been developed for treating velopharyngeal insufficiency (VPI); however, the choice of surgical treatment is controversial. The pharyngeal flap, which is commonly used, has a high success rate but frequently leads to airway complications. Furlow double-opposing Z-plasty (DOZ) does not deform the velopharyngeal port; therefore, it is expected to show good speech outcomes while reducing airway complications if an appropriate indication is noted. This study aimed to identify indications for DOZ in cases of VPI after palatoplasty.

METHODS

Nonsyndromic patients who underwent palatoplasty were prospectively followed from 2008 to 2016, and those diagnosed with VPI were treated with DOZ. Preoperative facial computed tomography (CT) and postoperative nasometric assessment results were examined. Surgical indication was set based on a 30% threshold value for postoperative nasalance.

RESULTS

Comparing the preoperative CT measurements of both groups, high need ratio (NR), wide width of the nasopharynx (WNP), and long velopharyngeal depth (VPD) were contributing factors to VPI occurrence ( P < 0.05). Analyzing preoperative CT and postoperative speech evaluation results, a linear relationship was observed between preoperative NR, WNP, and VPD and postoperative nasalance. In cases where NR was less than 0.81, WNP was less than 27.64 mm, and VPD was less than 20.34 mm, DOZ showed favorable outcomes ( P < 0.05).

CONCLUSIONS

Preoperative CT evaluation should be performed in patients with VPI. When WNP, VPD, and NR values are small, DOZ can achieve sufficient correction of VPI and reduce the risk of airway complications. In cases where the indication range is exceeded, the pharyngeal flap is considered.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Repair of Cleft Palate in Adult Patients; Impact of Speech Therapy Following Surgical Intervention in Africa

Cleft lip and palate anomalies constitute both aesthetic and functional impairments for affected individuals. While an individual with an unrepaired cleft palate may adjust somewhat to the associated feeding challenges as he or she gets older, the consequent speech impairment is amenable primarily to surgery. It is pertinent to assess how well speech function is restored in individuals with cleft after surgical repairs. Findings of such assessments may inform on the factors affecting the impact of surgical intervention, and what additional interventions may be required and may form the baseline for further investigations into the speech characteristics of adults who have had delayed palatal repairs. No African report was found assessing speech outcomes in patients who had palatal repairs after the age of 18 years. This study is to assess the impact of speech therapy on adults who had their palates repaired at or after the age of 18 years. A retrospective review of "Smile Train" speech data was done. The speech data were videos of syllable and sentence screeners. The samples were individually assessed by 3 cleft speech therapy interventionists based on a predetermined set of parameters. These parameters were scored such that the higher the core, the poorer the outcome. The scores did not show statistically significant differences between the pre and post-speech therapy scores.

Update on using buccal myomucosal flaps for patients with cleft palate and velopharyngeal insufficiency: primary and secondary interventions

PURPOSE OF REVIEW

This review aims to examine the indications and anatomical circumstances for when to optimally incorporate buccal myomucosal flaps (BMFs) into palatal surgical reconstruction.

RECENT FINDINGS

Studies examining outcomes following primary cleft palate repair with incorporation of BMF have demonstrated excellent speech outcomes and low rates of fistula. Furthermore, some reports cite an association of buccal flap use with reduced midface hypoplasia and the need for later orthognathic surgery. When used for secondary speech surgery, BMFs have been shown to lead to speech improvements across multiple outcome measures. Advantages of BMF techniques over conventionally described pharyngeal flap and pharyngoplasty procedures include significant lengthening of the velum, favorable repositioning of the levator muscular sling, and lower rates of obstructive sleep apnea.

SUMMARY

Although the published data demonstrate excellent outcomes with use of BMFs for primary and secondary palatal surgery, there are limited data to conclude superiority over the traditional, more extensively investigated surgical techniques. The authors of this review agree with the evidence that BMF techniques can be useful in primary palatoplasty for congenitally wide clefts, secondary speech surgery for large velopharyngeal gaps, and/or in individuals with a predisposition for airway obstruction from traditional approaches.

Proposed clinical model for predicting speech outcomes in patients undergoing Furlow palatoplasty for velopharyngeal insufficiency after primary palatoplasty

This study aimed to validate the predictors of speech outcomes following Furlow palatoplasty in patients with velopharyngeal insufficiency (VPI) after primary palatoplasty and to propose and validate a model to predict the risk of persistent VPI. The study included patients with VPI after primary palatoplasty who underwent Furlow palatoplasty as a secondary surgery. Eleven variables were included: velar length, pharyngeal cavity depth, velopharyngeal gap, velopharyngeal closure pattern, sex, presence of cleft lip, existence of palatal fistula, surgeon, age at primary palatoplasty, age at secondary surgery, and time interval between primary palatoplasty and secondary surgery. Postoperative speech outcomes were assessed at least 1 year after the secondary surgery and classified as velopharyngeal competence (VPC) or VPI. Variables were analyzed using multivariate logistic regression analysis, and the area under the curve (AUC) was used to validate model accuracy. The study sample comprised 101 patients. Of the patients, 62 had VPC and 39 had VPI after secondary surgery. The results showed a younger age at secondary surgery, a smaller velopharyngeal gap, being female, having a coronal velopharyngeal closure pattern and a velopharyngeal closure ratio of 90% or greater produced a greater probability of VPC. Given the constraints of this study, it appears that the Furlow palatoplasty should be prioritized when the clinical model predicts a substantial likelihood of VPC post-surgery.

Dodonaea viscosa Jacq. induces cytotoxicity, antiproliferative activity, and cell death in colorectal cancer cells via regulation of caspase 3 and p53

Colorectal cancer (CRC) is the third most common cancer diagnosed worldwide and is the second leading cause of cancer-related death due to an insufficiency prognosis and is generally diagnosed in the last step of development. The Peruvian flora has a wide variety of medicinal plants with therapeutic potential in several diseases. Dodonaea viscosa Jacq. is a plant used to treat inflammatory process as well as gastrointestinal diseases. The aim of this study was to examine the cytotoxic, antiproliferative, and cell death-inducing effects of D. viscosa on colorectal cancer cells (SW480 and SW620). The hydroethanolic extract was obtained by maceration at 70% ethanol, the phytochemical constituents were identified by LC-ESI-MS. D. viscosa revealed 57 compounds some of them are: isorhamnetin, kaempferol, quercetin, methyl dodovisate B, hardwickiic acid, viscosol, and dodonic acid. Regarding the antitumoral activity, D. viscosa induced cytotoxic and antiproliferative activity in both SW480 and SW620 cancer cells, accompanied with, important changes in mitochondrial membrane potential, formation of the Sub G0/G1 population and increasing levels of apoptotic biomarkers (caspase 3 and the tumor suppressor protein p53) in the metastatic derivative cell line (SW620), suggesting an intrinsic apoptotic process after the treatment with the hydroethanolic extract of D. viscosa.

Speech assessment following microsurgical soft palate repair

The aim of this study was to analyze speech intelligibility of children, who had undergone microsurgical soft palate repair according to Sommerlad. Cleft palate patients were treated by closure of the soft palate according to Sommerlad at about 6 months of age. At the age of 11, their speech was evaluated through automatic speech recognition. Word recognition rate (WR) was used as the outcome parameter of automatic speech recognition. To validate automatic speech results, an institute for speech therapy evaluated the speech samples for perceptual intelligibility. The results of this study group were compared to an age-matched control group. A total of 61 children were evaluated in this study, 29 in the study group and 32 in the control group. Study group patients had a lower word recognition rate (mean 43.03, SD 12.31) compared to the control group (mean 49.98, SD 12.54, p = 0.033). The magnitude of the difference was considered small (95% CI of the difference 0.6-13.3). The study group patients received significantly lower scores in the perceptual evaluation (mean 1.82, SD 0.58) compared to the control group mean (mean 1.51, SD 0.48, p = 0.028). Again, the magnitude of the difference was small (95% CI of the difference 0.03-0.57). Within the limitations of the study it seems that microsurgical soft palate repair according to Sommerlad at the age of 6 months might be a relevant alternative to other well established surgical techniques.