From Birth to Maturity: A Group of Patients Who Have Completed Their Protocol Management. Part II. Isolated Cleft Palate

Investigating the Impact of Patient-Related Factors on Speech Outcomes at 5 Years of Age in Children With a Cleft Palate

To investigate the relationship between patient-related factors (sex, cleft type, cleft extent, and Robin Sequence [RS]) and speech outcome at 5 years of age for children born with a cleft palate ±  lip (CP ± L).

3157 Children (1426 female:1731 male) with a nonsyndromic CP ± L, born between 2006 and 2014 in England, Wales, and Northern Ireland.

Perceptual speech analysis utilized the Cleft Audit Protocol for Speech-Augmented (CAPS-A) rating and UK National Speech Outcome Standards: Speech Standard 1 (SS1)-speech within the normal range, SS2a-no structurally related speech difficulties or history of speech surgery, and SS3-speech without significant cleft-related articulation difficulties.

Odds of achieving SS1 were lower among boys (aOR 0.771 [CI 0.660-0.901]), those with clefts involving the lip and palate (vs palate only) (UCLP-aOR 0.719 [CI 0.591-0.875]; BCLP-aOR 0.360 [CI 0.279-0.463]), and clefts involving the hard palate (incomplete-aOR 0.701 [CI 0.540-0.909]; complete-aOR 0.393 [CI 0.308-0.501]). Similar relationships with these patient factors were observed for SS3. SS2 was affected by the extent of hard palate involvement (complete; aOR 0.449 [CI 0.348-0.580]). Although those with CP and RS were less likely to meet all 3 standards than those without RS, odds ratios were not significant when adjusting for sex and cleft extent.

Sex, cleft type, and extent of hard palate involvement have a significant impact on speech outcome at 5 years of age. Incorporating these factors into risk-adjustment models for service-level outcome reporting is recommended.

Clinical Outcomes of Bilateral Cleft Lip and Palate Repair with Nasoalveolar Molding and Gingivoperiosteoplasty to Facial Maturity

BACKGROUND

The long-term effects of nasoalveolar molding (NAM) on patients with bilateral cleft lip and palate (BCLP) are unknown. The authors report clinical outcomes of facially mature patients with complete BCLP who underwent NAM and gingivoperiosteoplasty (GPP).

METHODS

A single-institution retrospective study of nonsyndromic patients with complete BCLP who underwent NAM between 1991 and 2000 was performed. All study patients were followed to skeletal maturity, at which time a lateral cephalogram was obtained. The total number of cleft operations and cephalometric measures was compared with a previously published external cohort of patients with complete and incomplete BCLP in which a minority (16.7%) underwent presurgical orthopedics before cleft lip repair without GPP.

RESULTS

Twenty-four patients with BCLP comprised the study cohort. All patients underwent GPP, 13 (54.2%) underwent alveolar bone graft, and nine (37.5%) required speech surgery. The median number of operations per patient was five (interquartile range, two), compared with eight (interquartile range, three) in the external cohort ( P < 0.001). Average age at the time of lateral cephalogram was 18.64 years (1.92). There was no significant difference between our cohort and the external cohort with respect to sella-nasion-point A angle (SNA) [73 degrees (6 degrees) versus 75 degrees (11 degrees); P = 0.186] or sella-nasion-point B angle (SNA) [78 degrees (6 degrees) versus 74 degrees (9 degrees); P = 0.574]. Median ANB (SNA - SNB) was -3 degrees (5 degrees) compared with -1 degree (7 degrees; P = 0.024). Twenty patients (83.3%) underwent orthognathic surgery.

CONCLUSION

Patients with BCLP who underwent NAM and GPP had significantly fewer total cleft operations and mixed midface growth outcomes at facial maturity compared with patients who did not undergo this treatment protocol.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Multidisciplinary Optimal Outcomes Reporting and Team Clinic Retention in Isolated Nonsyndromic Cleft Palate

OBJECTIVE

Optimal Outcomes Reporting was recently introduced to categorize outcomes after cleft palate repair. We seek to propose an expanded version of Optimal Outcomes Reporting and to determine if correlation exists between the expanded outcomes and persistence with team care follow-up through age 9.

DESIGN

Retrospective cohort study.

SETTING

Cleft team at large pediatric hospital.

PATIENTS

Patients with isolated nonsyndromic cleft palate (n = 83) born from 2001-2012.

MAIN OUTCOME MEASURES

Patients who continued to present at age 5 or greater were assessed for optimal outcomes. Optimal outcomes were: surgery - no fistula or velopharyngeal insufficiency; otolaryngology - no obstructive sleep apnea or signs of chronic middle ear disease; audiology - no hearing loss; speech-language pathology - no assessed need for speech therapy.

RESULTS

Of the 83 patients identified, 41 were assessed for optimal outcomes. Optimal outcome in any discipline was not associated with follow-up through age 9 (0.112 ≤ p ≤ 0.999). For all disciplines, the group with suboptimal outcomes had a higher proportion of patients from geographic areas in the most disadvantaged quartile of social vulnerability index, with the strongest association in the group with suboptimal speech outcome (OR 6.75, 95% CI 0.841-81.1).

CONCLUSIONS

Optimal outcomes and retention in team clinic were not statistically significantly associated, but clinically relevant associations were found between patients in the most disadvantaged quartile of social vulnerability and their outcomes. A patient-centered approach, including caregiver education about long-term care for patients with cleft palate, would allow for enhanced resource utilization to improve retention for patients of concern.

Influence of Primary Palatal Surgery on Craniofacial Morphology in Patients with Cleft Palate Only (CPO)-Systematic Review with Meta-Analysis

BACKGROUND

Cleft palate only (CPO) is the second most prevalent cleft type. Both the cleft and palatal scarring may affect craniofacial growth. The aim of this systematic review was to summarize scientific evidence on effect of palatal surgery on craniofacial morphology in CPO.

METHODS

A search was conducted in PubMed, PMC, WoS, Scopus, Embase, using the keywords: "cleft palate" AND ("craniofacial morphology" OR "cephalometric analysis") NOT "lip" with inclusion and exclusion criteria ensuring confident, direct comparison between study groups. The quality assessment was performed with Arrive's scale for radiologic examinations.

RESULTS

Of 713 potential articles, 19 were subjected to qualitative analysis and 17 to meta-analysis, which confirmed reduced SNA in unoperated CPO versus non-cleft individuals. No scientific evidence was found directly assessing the effect of surgery on craniofacial morphology. The negative effect of palatal surgery was seen indirectly: in treated CPO versus non-cleft, the size effect of SNA is bigger than in untreated CPO versus non-cleft. A high heterogeneity came from a few non-European publications.

CONCLUSIONS

CPO is associated with sagittal maxillary deficiency resulting both from the cleft and from primary surgery, disregarding cleft severity in operated CPO patients. Ethnic differences influence craniofacial morphology in CPO. This research received no external funding. Study protocol number in PROSPERO database: CRD42021268957.

Primary palatoplasty: A comparison of results by various techniques - A retrospective study

Introduction:

To identify a better method for primary cleft palate (CP) repairs with respect to velopharyngeal function.

Materials and Methods:

A retrospective, longitudinal review of medical charts of patients with congenital CP who underwent four different techniques of palatoplasty, performed by three different surgeons in the Department of Maxillofacial Surgery of the National Center for Maternal and Child Health. Nasopharyngoscopy (NPS) was used for velopharyngeal function evaluation. CP was classified according to the Veau system and the “Golding-Kushner” scale for NPS results was used for assessing the patient’s velopharyngeal function and its association with cleft types and the primary palatoplasty techniques. Pearson’s Chi-square analysis and binary logistic regression were used for statistical analysis.

Results:

A total of 335 patients were included in the study. The mean age at primary palate repair was 22.9 ± 13.6 months. There were 56, 42, 177, and 60 patients with Veau-I, Veau-II, Veau-III, and Veau-IV types, respectively, whereas for primary palatoplasty 65 patients underwent Furlow, 148 patients – Mongolian, 108 patients – two flap, 34 patients – von Langenbeck technique. NPS assessment of adequate velopharyngeal function was followed by Furlow’s technique in 89.4% of cases, Mongolian technique in 62.2% of cases but by “two flap” only in 48.1% and von Langenbeck in 47.1% of cases.

Discussion:

The Furlow and Mongolian techniques were superior for maintaining velopharyngeal function after primary palatoplasty.

Analysis of the Intrinsic Predictors of Oronasal Fistula in Primary Cleft Palate Repair Using Intravelar Veloplasty

Introduction:

The purpose of the present study was to investigate various factors of cleft palate and to analyze their effect on fistula occurrence following palatal muscle repair using intravelar veloplasty.

Methods:

A retrospective review of patients who underwent palatoplasty was performed. Primary palatoplasty was performed by a single surgeon in a single center. A total of 165 patients who underwent palatoplasty were enrolled. Primary palatoplasty with levator veli palatini muscle repair using intravelar veloplasty was performed. Three extrinsic factors (age, gender, and body weight) and 6 intrinsic factors (cleft width, ratio of cleft width to intermaxillary tuberosity distance, cleft anterior margin shape, uvula position, cleft lip, and radical intravelar veloplasty) were analyzed.

Results:

Palatal fistula occurred in 11 (6.67%) patients. The occurrence of fistula was significantly correlated with a specific Veau classification, that is, type II ( P = .041). Fistula tended to occur more frequently with a wide cleft palate ( P = .063), and the high-risk cutoff value of the width was 7.75 mm.

Conclusions:

A larger cleft width tended to increase the occurrence of fistula. Close observation and information about the higher risk of fistula formation should be given to patients with a large cleft width who underwent intravelar veloplasty.

Evaluation of Multidisciplinary Team Clinic for Patients With Isolated Cleft Lip

OBJECTIVE

To report the incidences of secondary lip and nose operations, otolaryngology procedures, speech-language therapy, neurodevelopmental concerns, and dental and orthodontic issues in children with isolated cleft lip to inform multidisciplinary cleft team protocols.

SETTING

An American Cleft Palate-Craniofacial Association-approved team at a tertiary academic children's hospital.

DESIGN

Retrospective cohort study of patients evaluated through longitudinal clinic visits by a multidisciplinary cleft palate and craniofacial team between January 2000 and June 2018.

PATIENTS, PARTICIPANTS

Children with nonsyndromic cleft lip with or without cleft alveolus (n = 92).

RESULTS

Median age at final team visit was 4.9 years (interquartile range: 2.4-8.2 years). Secondary plastic surgery procedures were most common between ages 3 and 5 (135 per 1000 person-years), and the majority of these procedures were minor lip revisions. The rate of tympanostomy tube insertion was highest before age 3 (122 per 1000 person-years). By their final team visit, 88% of patients had normal hearing and 11% had only slight to mild conductive hearing loss. No patients had speech errors attributable to lip abnormalities. Psychological interventions, learning disabilities, and dental or orthodontic concerns were uncommon.

CONCLUSIONS

Most patients with isolated cleft lip may not require long-term, longitudinal evaluation by cleft team specialists. Cleft teams should develop limited follow-up protocols for these children to improve resource allocation and promote value-based care in this patient population.

Incidence of Speech-Correcting Surgery in Children With Isolated Cleft Palate

Objective:

Speech-correcting surgeries (pharyngoplasty) are performed to correct velopharyngeal insufficiency (VPI). This study aimed to analyze the need for speech-correcting surgery in children with isolated cleft palate (ICP) and to determine differences among cleft extent, gender, and primary technique used. In addition, we assessed the timing and number of secondary procedures performed and the incidence of operated fistulas.

Design:

Retrospective medical chart review study from hospital archives and electronic records.

Participants:

These comprised the 423 consecutive nonsyndromic children (157 males and 266 females) with ICP treated at the Cleft Palate and Craniofacial Center of Helsinki University Hospital during 1990 to 2016.

Results:

The total incidence of VPI surgery was 33.3% and the fistula repair rate, 7.8%. Children with cleft of both the hard and soft palate (n = 300) had a VPI secondary surgery rate of 37.3% (fistula repair rate 10.7%), whereas children with only cleft of the soft palate (n = 123) had a corresponding rate of 23.6% (fistula repair rate 0.8%). Gender and primary palatoplasty technique were not considered significant factors in need for VPI surgery. The majority of VPI surgeries were performed before school age. One fifth of patients receiving speech-correcting surgery had more than one subsequent procedure.

Conclusion:

The need for speech-correcting surgery and fistula repair was related to the severity of the cleft. Although the majority of the corrective surgeries were done before the age of 7 years, a considerable number were performed at a later stage, necessitating long-term observation.

Incidence of velopharyngeal insufficiency and oronasal fistulae after cleft palate repair: A retrospective study of children referred to Isfahan Cleft Care Team between 2005 and 2009

OBJECTIVE

The purpose of this study is to determine the incidence of velopharyngeal insufficiency (VPI) and fistulae development in patients seen by the Isfahan Cleft Care Team and also determine the association of gender, age at repair, and cleft type with the incidence of each.

METHODS

This retrospective study was completed using records of patients referred to Isfahan Cleft Care Team between 2005 and 2009. One hundred thirty-one patients with a history of cleft palate (with or without cleft lip) who had undergone primary palate repair and were at least 4 years of age at the time of the speech evaluation were included in this review. The main outcome of this study was the incidence of fistulae and hypernasality following palatoplasty. A secondary outcome was the association of gender, age at the time of repair, and cleft type on the incidence of fistulae and hypernasality.

RESULTS

A post-surgical fistula was present in 23.7% of the patients studied. Fistula rates were significantly higher in patients who had undergone repair of bilateral clefts of the lip and palate (40.9%) than for those patients who had undergone repair of a unilateral cleft lip and palate (16.9%) (p=0.02). Presence of a fistula was not associated with gender (p=0.99) or age at time of primary surgical repair (p=0.71). Mild hypernasality was noted in 15.3% of patients. Moderate or severe hypernasality was present in 66.5% of the patients and the remaining cases presented with normal resonance. Severe hypernasality was significantly higher in patients with a Veau IV type cleft as compared to patients with Veau III cleft types (p=0.04). There was a significantly higher incidence of hypernasality in boys than in girls (p<0.001). The association of age at the time of palatal repair and incidence of hypernasality was not significant (r=0.13, p=0.07).

CONCLUSIONS

Overall, post-surgical complications were high in this cohort of patients who had undergone cleft palate repair by Isfahan Cleft Care Team during the study time frame. Therefore, there is a high priority need for increased training of best practices for the surgeons.

Perioperative Complications in Posterior Pharyngeal Flap Surgery: Review of the National Surgical Quality Improvement Program Pediatric (NSQIP-PEDS) Database

BACKGROUND

Posterior pharyngeal flap (PPF) surgery is effective for treating velopharyngeal insufficiency but has historically been associated with risk of airway compromise. This study aims to identify risk factors for complications from and readmission after PPF using a national database.

METHODS

Patients who underwent PPF surgery were selected from the 2012 American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-PEDS) database. Patient characteristics, comorbidities, and complication/readmission data were analyzed.

RESULTS

Among 225 study patients, 12 (5.3%) suffered perioperative complications. The most common complications were pulmonary in nature (5 patients, 2.2%), including prolonged postoperative mechanical ventilation (3 patients, 1.3%). Underlying asthma (P = .024) or any cardiac risk factor (P = .047) conveyed significant complication risk. Further, severe cardiac risk factors were associated with postoperative bleeding (P = .024). Readmission (4 patients, 1.7%) and reoperation (3 patients, 1.3%) occurred at mean intervals of 9 and 10 days after the original procedure. Seventy-nine patients (35%) were discharged postoperatively on an outpatient basis, and this subgroup included only one patient (1.2%) with a complication (P = .038).

CONCLUSIONS

The overall perioperative complication rate for PPF surgery is low at 5.3%. Patients with underlying cardiac risk factors, severe American Society of Anesthesiologists Physical Status class, and asthma should prompt greater attention given their heightened risk profiles.

The Need for Orthognathic Surgery in Nonsyndromic Patients with Repaired Isolated Cleft Palate

Objective

To determine the frequency of need for orthognathic surgery among nonsyndromic patients with isolated cleft palate repaired during infancy at The Hospital for Sick Children in Toronto, Canada.

Design

Retrospective cohort study.

Patients

Patients with nonsyndromic isolated cleft palate born between 1970 and 1997 with available records including a lateral cephalometric radiograph taken at 15 years of age.

Methods

Patients who had undergone or were being prepared for orthognathic surgery were automatically counted as requiring surgery. For the remaining patients, lateral cephalometric radiographs were traced and analyzed. Arbitrarily set cephalometric criteria were used to identify the “objective” need for orthognathic surgery.

Results

Of the 189 patients identified with nonsyndromic isolated cleft palate and for whom records were available, 25 (13.2%) were deemed to require orthognathic surgery. Of the surgical cohort, 92% required surgical correction for a Class III malocclusion. Similar percentages of males and females required orthognathic surgery. An apparently greater proportion of patients of Asian background (18.5%) than of white background (10.6%) required surgery, but this difference was not significant ( P = .205).

Conclusions

The current results suggest that approximately one in eight patients at our institution with nonsyndromic isolated cleft palate requires orthognathic surgery. There is a tendency for this to be higher in patients of Asian descent and lower in patients of white descent. Variability in extent, severity, and phenotype of the cleft, which may be attributed largely to genetics, may play an important role in dictating the need for orthognathic surgery.

Extent of maxillary deficiency in patients with complete UCLP and BCLP

Objectives

Primary surgery in patients with complete unilateral and bilateral cleft lip and palate restricts transverse and sagittal maxillary growth. Additional surgical maxillary advancement might become necessary after completion of growth. The aim of this study was to determine the extent of maxillary deficiency at an early stage during the transitory dentition, and to identify factors that might indicate the need for a later maxillary advancement.

Materials and methods

Lateral head films and casts of 40 non-syndromatic patients with complete UCLP (n = 29) and BCLP (n = 11) were evaluated. This retrospective evaluation included measurements of casts and lateral head films from all patients at the beginning of orthodontic treatment during the transitory dentition (T1), after completion of orthodontic treatment (T2) and after completion of growth (T3). The statistic analysis comprised t-tests (Anova) and correlation analyses (Pearson).

Results

SNA decreased significantly between T1 and T2. At T3, 27.5% of the patients showed a sagittal maxillary deficiency with need for osteotomy. There were no statistical differences between patients with UCLP and BCLP. Significant positive correlations occurred between SNA and WITS-appraisal (+0.62), and significant negative correlations between SNA and NL/NS (−0.66).

Conclusions

During craniofacial growth patients with complete UCLP and BCLP experience sagittal growth inhibition of the maxilla after primary surgery. A later need for maxillary advancement after completion of growth occurs equally in both cleft types. There are no correlations regarding the need for osteotomy with gender or number of primary surgical measures. It is impossible to predict a need for later maxillary osteotomy during the transitory dentition.

Clinical relevance

Patients with clefts typically receive long-term treatment. The present results provide useful information for treatment planning and implementation.

From birth to maturity: midline tessier 0-14 craniofacial cleft patients who have completed protocol management at a single craniofacial unit

INTRODUCTION

The rare craniofacial clefts form an important component of craniofacial pathology, but little has been written regarding the definitive management of affected patients. This report describes the presentation, management, and outcomes in a group of patients who have completed their protocol management for treatment of midline Tessier 0-14 clefts.

METHODS

A retrospective review of the clinical, photographic, and radiographic records of all midline cleft patients treated at a single center was performed. Data describing each patient's presenting features, surgical management, and final outcomes are presented.

RESULTS

Four patients were identified as having completed protocol management for Tessier 0-14 midline clefting at the unit. The age range at the most recent follow-up was 19.3 to 36.3 years. Three patients had entered protocol management during infancy, and the remaining patient presented to the unit at 13.8 years of age. The surgical management regimen is described in detail. Outcomes for development, hearing, speech, and vision at maturity were all acceptable. Three patients attained a respectable educational and social status. With respect to facial aesthetics scores, the only significant difference after management was a significant worsening of deformity in the region of the orbits. The Whitaker grade for repeat surgery improved after management (3.25 before to 2.63 postmanagement), but this improvement was not statistically significant.

CONCLUSION

Presented are the results of the first cohort of midline Tessier 0-14 cleft patients to have completed protocol management at a single craniofacial unit. As more patients complete their management in the future, further refinements to the protocol could be made.

Prospective analysis of presurgical risk factors for outcomes in primary palatoplasty

BACKGROUND

The authors present a single surgeon's series of primary palatoplasty over a 10-year period in order to determine which presurgical factors might influence postoperative fistula rate and speech outcome.

METHODS

Data were prospectively acquired for all patients undergoing primary palatoplasty between January of 2000 and January of 2010. Standard demographic data were captured together with classification of cleft type and severity (as defined by palate length and cleft width). Outcome data were assessed in terms of fistula rate and the requirement for secondary speech surgery for velopharyngeal insufficiency.

RESULTS

There were 485 primary procedures; 276 patients were male. Mean age at primary surgery was 20.4 months. Clefts were classified according to Kernahan and Stark (cleft palate, n = 260; cleft lip/palate, n = 225) and Veau class (I, n = 85; II, n = 175; III, n = 165; and IV, n = 60). Palate length was assessed according to Randall's classification (I, n = 81; II, n = 319; III, n = 58; IV, n = 2). Mean palate width was 7.7 mm (range, 0 to 19 mm). Cleft lip/palate was associated with wider mean cleft width and a higher incidence of shorter palates than cleft palate. Velopharyngeal insufficiency was more frequent in cleft lip/palate than in cleft palate. Male sex, greater cleft width, and shorter palate length were independent predictors of velopharyngeal insufficiency.

CONCLUSIONS

Distributions of sex, cleft width, and palate length vary among the differing cleft types and may explain some of the variation in outcomes among centers and protocols. These data should be recorded to facilitate valid comparisons among future studies.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Influence of pharyngeal flap surgery on maxillary outgrowth in cleft patients

The aim of this study was to investigate the influence of the pharyngeal flap procedure on the frequency of Le Fort I osteotomies in full-grown nonsyndromic cleft patients. A retrospective review of 508 full-grown cleft patients born between 1 January 1983 and 31 December 1992 was performed. Following data analysis, 140 males older than 18 years and 111 females over the age of 16 years were included. 69 of the 251 included cleft patients required pharyngeal flap surgery (27.5%). Revision flap surgery was performed in 17.4% of the cases. A significantly lower age at time of the initial pharyngeal flap procedure was found in patients requiring revision surgery (5.6 years versus 6.8 years). The frequency of Le Fort I osteotomies was significantly higher in the patients with a pharyngeal flap (19%) compared to those without (8%) (p<0.05). The results of this study point towards the pharyngeal flap procedure being one of the possible limiting factors for maxillary antero-posterior growth in cleft patients.

General Health-Related Quality of Life and Oral Health Impact among Australians with Cleft Compared with Population Norms; Age and Gender Differences

Objective

To evaluate general health-related quality of life (HRQoL) and oral health impact among adults treated for cleft to determine age and gender differences, and to compare against population norms.

Design

Cross-sectional prospective study.

Participants/Setting

Nonsyndromic cleft patients treated by the Australian Craniofacial Unit from 1975 to 2009 were recruited (n = 112). Response rate was 79% (n = 88).

Main outcome measures

HRQoL was measured by the Short Form (SF)-36 questionnaire. Oral health impact was measured by the Oral Health Impact Profile (OHIP)-14 questionnaire. State-based and national norms were used for comparative purposes.

Results

There were no significant age or sex differences in the cleft sample's SF-36 and OHIP-14 scores. When compared against South Australian 2002 state-level norms, cleft participants scored higher on physical function and physical role function but lower on vitality and mental health. The prevalence of having experienced one or more of OHIP–14 items “fairly often” or “very often” was 2.7 times higher than national-level estimates, while extent was 2.8 times and severity 1.7 times higher.

Conclusions

The oral health impact among cleft patients included in our study was poor compared with population-level estimates. The HRQoL showed mixed results, with the vitality and mental health components being poorer in the cleft group compared with population-level estimates. These results indicate that treatment for orofacial clefting does not entirely remove the factors contributing to poor HRQoL and oral health.

The Frequency of Le Fort I Osteotomy in Cleft Patients

Objective

The aim of this research was to study the frequency of Le Fort I osteotomy (LFI) in cleft patients treated according to the protocol of the Erasmus University Medical Center, Rotterdam.

Design

Retrospective cohort study.

Patients

508 cleft patients born between January 1, 1983, and December 31, 1992, were evaluated.

Main Outcome Measures

Frequency of LFI and correlations with type and extent of cleft, gender, number of previous surgical procedures, age during alveolar augmentation, and missing teeth, respectively.

Results

251 patients met the inclusion criteria. Overall, 28 of the 251 patients (11.2%) required LFI: none for cleft lip (0.0%); 2 of 43 (4.7%) for cleft lip and alveolus; 24 of 100 (24.0%) for cleft lip, alveolus, and palate; 2 of 50 (4.0%) for cleft palate; and none for submucous clefts or the miscellaneous group (0.0%). The frequency of LFI increased with the severity of the cleft type. The number of previous surgical interventions is significantly higher in cases with an indication for LFI (p < .001). The frequency of LFI is significantly higher in male cleft patients (p < .05).

Conclusions

The overall frequency of LFI in the study group was 11.2%; this increased with the severity of the cleft type. A significant difference was noted in the number of previous surgical interventions between patients with and without an indication for an LFI. Delayed closure of the hard palate in the protocol might have influenced the low frequency of LFI.

Submucous Cleft Palate and Velopharyngeal Insufficiency: Comparison of Speech Outcomes Using Three Operative Techniques by One Surgeon

Objective

Our purpose was to compare speech outcomes among three primary procedures for symptomatic submucous cleft palate (SMCP): two-flap palatoplasty with muscular retropositioning, double-opposing Z-palatoplasty, or pharyngeal flap.

Design

Retrospective review.

Setting

Tertiary hospital.

Patients, Participants

All children with SMCP treated by the senior author between 1984 and 2008.

Interventions

One of three primary procedures: two-flap palatoplasty with muscular retropositioning, double-opposing Z-palatoplasty, or pharyngeal flap.

Main outcome Measures

Speech outcome and need for a secondary operation were analyzed among procedures. Success was defined as normal or borderline competent velopharyngeal function. Failure was defined as persistent borderline insufficiency or velopharyngeal insufficiency with recommendation for a secondary operation.

Results

We identified 58 patients with SMCP who were treated for velopharyngeal insufficiency. We found significant differences in median age at operation among the procedures ( p < .001). Two-flap palatoplasty with muscular retropositioning (n = 24), double-opposing Z-palatoplasty (n = 19), and pharyngeal flap (n = 15) were performed at a median of 2.5, 3.6, and 9.5 years, respectively. There were significant differences in success among procedures (p = .018). Normal or borderline competent function was achieved in 6/20 (30%) patients who underwent two-flap palatoplasty, 10/15 (67%) following double-opposing Z-palatoplasty, and 11/12 (92%) following pharyngeal flap. Among patients treated with palatoplasty, success was independent of age at operation (p = .16).

Conclusions

Double-opposing Z-palatoplasty is more effective than two-flap palatoplasty with muscular retropositioning. For children older than 4 years, primary pharyngeal flap is also highly successful but equally so as a secondary operation and can be reserved, if necessary, following double-opposing Z-palatoplasty.

Modified transoral approach for resection of skull base chordomas in children

PURPOSE

Chordomas are rare slow growing, locally destructive tumours originating from remnants of the primitive notocord and are found most commonly in the clivus and saccrococcygeal region. These tumours usually present in early adult life but on occasion can present in childhood. The combination of the skull base location and paediatric patient size makes access to these tumours particularly challenging.

METHODS AND RESULTS

We report a multidisciplinary technique used in two cases in children where a modified extended palatal split was undertaken to allow greater access for tumour excision.

CONCLUSION

This approach allows for good access to the skull base region to allow for maximal tumour resection. This technique also appears to have minimal impact on palatal function and no adverse effects on the upper airway management.