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Long BD, Petersson RS. Primary Cleft Palate Repair. Facial Plast Surg Clin North Am 2024; 32:55-62. [PMID: 37981416 DOI: 10.1016/j.fsc.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
There are several factors to consider when planning cleft palate repair. It is important to review the patient's associated comorbidities, as they impact decisions on perioperative management and family counseling. Many comorbidities change the risk of postoperative airway obstruction, velopharyngeal insufficiency, or fistula formation. It is also critical to determine the type of cleft palate to be addressed, as this influences the decision on which technique is most appropriate for optimal patient outcome. Common surgical techniques for palatoplasty are reviewed in detail and outcomes are discussed as it relates to various techniques. Intraoperative photographs are included to detail the procedures.
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Affiliation(s)
- Barry Daniel Long
- Department of Otolaryngology/Head and Neck Surgery, Virginia Commonwealth University SOM, Richmond, VA, USA
| | - Rajanya Shah Petersson
- Department of Otolaryngology/Head and Neck Surgery, Virginia Commonwealth University SOM, Richmond, VA, USA; Department of Otolaryngology/Head and Neck Surgery, Children's Hospital of Richmond at VCU, Richmond, VA, USA.
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Huang Z, Bo Z, Li J, Zheng Q, Shi B, Zeng N. Proposed clinical model for predicting speech outcomes in patients undergoing Furlow palatoplasty for velopharyngeal insufficiency after primary palatoplasty. J Craniomaxillofac Surg 2024; 52:234-239. [PMID: 38161074 DOI: 10.1016/j.jcms.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/23/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024] Open
Abstract
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.
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Affiliation(s)
- Zhongping Huang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Zhenyan Bo
- West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jingtao Li
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Qian Zheng
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Ni Zeng
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
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Hofman L, van Dongen JA, van Rees RCM, Jenniskens K, Haverkamp SJ, Beentjes YS, van der Molen ABM, Paes EC. Speech correcting surgery after primary palatoplasty: a systematic literature review and meta-analysis. Clin Oral Investig 2023; 28:58. [PMID: 38157017 DOI: 10.1007/s00784-023-05391-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES In cleft palate patients, the soft palate is commonly closed using straight-line palatoplasty, Z-palatoplasty, or palatoplasty with buccal flaps. Currently, it is unknown which surgical technique is superior regarding speech outcomes. The aim of this review is to study the incidence of speech correcting surgery (SCS) per soft palatoplasty technique and to identify variables which are associated with this outcome. MATERIALS AND METHODS A systematic literature search was carried out according to the PRISMA guidelines. Inclusion and exclusion criteria were applied to focus on the incidence of SCS after soft palatoplasty. Additional variables like surgical modification, cleft morphology, syndrome, age at palatoplasty, fistula and assessment of velopharyngeal function were reported. A modified New-Ottawa Scale (NOS) was used for quality appraisal. Pooled estimates from the meta-analysis were calculated using a random-effects model. RESULTS One thousand twenty-nine studies were found of which 54 were included in the analysis. The pooled estimate proportion of SCS after straight-line palatoplasty was 19% (95% CI 15-24), after Z-palatoplasty 6% (95% CI 4-9), and after palatoplasty with buccal flaps 7% (95% CI 4-11). CONCLUSIONS A lower SCS rate was found in patients receiving Z-palatoplasty when compared to straight-line palatoplasty. We propose a minimum set of outcome parameters which ideally should be included in future studies regarding speech outcomes after cleft palate repair. CLINICAL RELEVANCE Current literature reports highly heterogenous data regarding cleft palate repair. Our recommended set of parameters may address this inconsistency and could make intercenter comparison possible and of better quality.
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Affiliation(s)
- Lieke Hofman
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands.
| | - Joris A van Dongen
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | | | - Kevin Jenniskens
- Department of Epidemiology & Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sarah J Haverkamp
- Speech and Language Therapy, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Yente S Beentjes
- Utrecht University, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Aebele B Mink van der Molen
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Emma C Paes
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
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Ha J, Gu GY, Yeou SH, Kim H, Choo OS, Jang JH, Park HY, Choung YH. Determination of Tympanostomy Tube Types for Otitis Media with Effusion in Patients with Cleft Palate: Comparison between Paparella Type 1 and Type 2 Tubes. J Clin Med 2023; 12:6651. [PMID: 37892790 PMCID: PMC10607012 DOI: 10.3390/jcm12206651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 09/30/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023] Open
Abstract
This study examined the effects of different types of tympanostomy tubes in pediatric patients undergoing cleft palate (CP) surgery in order to provide guidance for the proper insertion of tympanostomy tubes in the management of otitis media with effusion (OME). A total of 101 ears with middle ear effusion in 51 patients with CP were included in this study. Patients underwent palatoplasty and tympanostomy tube surgery at the same time. The type of tube inserted (Paparella type 1 or 2), the severity of CP, and types of palatoplasty surgeries were investigated. All patients were followed up for at least 6 months, and recurrence rates, complications, and reinsertion surgery were evaluated. The rate of OME recurrence after spontaneous tube extrusion was significantly higher in the type 1 group than in the type 2 group (44.3% vs. 19.4%, respectively, p = 0.016). Persistent eardrum perforation was more common in the type 2 group than in the type 1 group (41.9% vs. 12.9%, respectively, p = 0.001). The tube reinsertion rate was higher in the type 1 group than in the type 2 group (22.9% vs. 3.2%, respectively, p = 0.015). The tube reinsertion rate decreased to 8.6% in cases of palatoplasty with Sommerlad's technique, even with type 1 tube insertion, which was not significantly different from the reinsertion rate in the type 2 group (3.7%, p = 0.439). The Paparella type 1 tube would be a better choice in cases of palatoplasty performed using Sommerlad's technique, particularly considering the higher rate of persistent eardrum perforation after extrusion associated with the Paparella type 2 tube. Alternatively, a larger size type 2 tube may be considered in other surgeries to decrease the frequency of recurrence and tube reinsertion.
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Affiliation(s)
- Jungho Ha
- Department of Otolaryngology, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.H.); (G.Y.G.); (S.H.Y.); (J.H.J.); (H.Y.P.)
- Department of Medical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea; (H.K.); (O.-S.C.)
| | - Ga Young Gu
- Department of Otolaryngology, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.H.); (G.Y.G.); (S.H.Y.); (J.H.J.); (H.Y.P.)
- Department of Medical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea; (H.K.); (O.-S.C.)
| | - Se Hyun Yeou
- Department of Otolaryngology, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.H.); (G.Y.G.); (S.H.Y.); (J.H.J.); (H.Y.P.)
- Department of Medical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea; (H.K.); (O.-S.C.)
| | - Hantai Kim
- Department of Medical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea; (H.K.); (O.-S.C.)
- Department of Otorhinolaryngology, Konyang University College of Medicine, Daejeon 35365, Republic of Korea
| | - Oak-Sung Choo
- Department of Medical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea; (H.K.); (O.-S.C.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea
| | - Jeong Hun Jang
- Department of Otolaryngology, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.H.); (G.Y.G.); (S.H.Y.); (J.H.J.); (H.Y.P.)
| | - Hun Yi Park
- Department of Otolaryngology, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.H.); (G.Y.G.); (S.H.Y.); (J.H.J.); (H.Y.P.)
| | - Yun-Hoon Choung
- Department of Otolaryngology, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.H.); (G.Y.G.); (S.H.Y.); (J.H.J.); (H.Y.P.)
- Department of Medical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea; (H.K.); (O.-S.C.)
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Impact of a Modified Restoration of Tensor Veli Palatini on Hearing and Middle Ear Function in Cleft Palate Children-a Retrospective Study. J Craniofac Surg 2022; 34:e259-e263. [PMID: 36728970 PMCID: PMC10128907 DOI: 10.1097/scs.0000000000009148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/26/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Many children with cleft palate also exhibit hearing loss and middle ear dysfunction, which could last for years. There are still arguments on how to treat this problem. This study aimed to evaluate the impact of a modified restoration of tensor veli palatine (TVP) on hearing and middle ear function in the cleft palate children. METHODS This retrospective study was completed using records of the cleft palate children who received surgery in Peking Union Medical College Hospital from May 2013 to December 2020. They were divided into 2 groups: Group 1: children who received cleft palate surgery without specific restoration of TVP; Group 2: children who received palate surgery with a specific TVP restoration technique. Perioperative information was collected. The conductive auditory brainstem response and the 226-Hz tympanometry before and after the cleft surgery were compared intragroup and intergroup. RESULTS Totally 42 children were included in this study, 21 children in each group. There were no significant differences considering clinical characteristics between the 2 groups. The modified TVP restoration didn't increase operation time or complication compared with no TVP restoration. Statistically, neither the auditory brainstem response air conduction hearing thresholds nor the 226-Hz tympanometry results had significant differences between the 2 groups after the surgery. CONCLUSIONS This modified restoration of TVP was not time-consuming and did not increase complications. The beneficial effect of the modified TVP restoration on the hearing or the middle ear function of cleft palate children was uncertain around 6 months after surgery compared with no restoration.
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Huang H, Zeng N, Yang C, Wang Y, Zheng Q, Shi B, Cheng X. The pilot study of a blended learning module using porcine tongue for surgical simulation of double‐opposing Z‐plasty. J Dent Educ 2022; 87:462-470. [PMID: 36507707 DOI: 10.1002/jdd.13155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/08/2022] [Accepted: 11/19/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Simulation course serves as an efficient supplement to the experiential learning inside the operation room in surgical residency programs. Furlow double-opposing Z-plasty (DOZ) remains an important and challenging surgical technique in cleft palate repair, but the simulation is currently limited. This study aims to develop a blended learning module with low-cost and easy-to-promote DOZ simulation. METHODS Comparison among the common rodent experimental animals and the readily available porcine tongue was made to select the ideal animal for surgical simulation, with which a DOZ learning module was developed. Oral surgery residents were enrolled to attend the blended learning module. An after-session questionnaire and a quiz were distributed to the participants to collect their feedback of the course perceptions and to assess their learning outcomes. RESULTS The porcine tongue had more advantages in simulating the human soft palate over the common experimental animals. The surgical procedure of DOZ could be well designed and simulated on the porcine tongue. The vast majority of the participant liked the learning module regarded it as beneficial for the comprehension if DOZ principles and procedures. With the help of the porcine tongue simulator, the blended learning module helped the participants grasp the designing principles of DOZ procedure and promote their associative learning. CONCLUSIONS The blended learning module incorporating the porcine tongue simulator can help oral surgery residents master the principles and procedures of DOZ palatoplasty.
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Affiliation(s)
- Hanyao Huang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology Sichuan University Chengdu China
| | - Ni Zeng
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology Sichuan University Chengdu China
| | - Chao Yang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology Sichuan University Chengdu China
| | - Yan Wang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology Sichuan University Chengdu China
| | - Qian Zheng
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology Sichuan University Chengdu China
| | - Bing Shi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology Sichuan University Chengdu China
| | - Xu Cheng
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology Sichuan University Chengdu China
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Pollet N, Mennes T, Denys S, Loos E, Verhaert N, Vander Poorten V, Hens G. Otomicroscopic and functional outcomes after cleft palate repair via Sommerlad intravelar veloplasty vs. modified Veau-Wardill-Kilner push-back. Int J Pediatr Otorhinolaryngol 2022; 162:111283. [PMID: 35998528 DOI: 10.1016/j.ijporl.2022.111283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/18/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We aim to compare the modified Veau-Wardill-Kilner push-back technique (VWK) and the Sommerlad intravelar veloplasty (Sommerlad IVVP) in terms of middle ear outcomes and oronasal fistulae frequency in three years old children. METHODS For this retrospective cohort study, data were collected and anonymized from consecutive patients with cleft palate (with or without cleft lip) who underwent surgery in our hospital between January 2008 and December 2018. Patients with syndromic diagnoses and patients who underwent surgical treatment elsewhere were excluded. We collected data from 101 children (202 ears) regarding middle ear complications at the age of three, including acute otitis media, middle ear effusion, tympanic membrane retraction, tympanic membrane perforation, tympanic membrane atelectasis and chronic otitis media with cholesteatoma. In addition, the presence of oronasal fistulae and the number of ventilation tubes received by the age of three were recorded. RESULTS The odds of children having a normal middle ear evaluation were 3.07 (95% Confidence interval (95%CI): [1.52, 6.12]; p < 0.05) times higher when children received Sommerlad IVVP compared to modified VWK. With 40.7% compared to 26.7%, a significantly higher incidence of middle ear effusion was present in the modified VWK group compared to Sommerlad IVVP (X2(1) = 4.38, p < 0.05). Furthermore, this group needed significantly more ventilation tube reinsertions (X2(2) = 12.22, p < 0.05) and was found to have a significantly higher incidence of oronasal fistula (53.5% vs. 17.2%, X2(1) = 14.75, p < 0.05). The latter was significantly associated with a higher need for ventilation tube reinsertion (X2(1) = 7.34, p < 0.05). CONCLUSION This study shows superior middle ear outcomes and fewer oronasal fistulae after Sommerlad IVVP compared to modified Veau-Wardill-Kilner push-back at the age of three.
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Affiliation(s)
- Naomi Pollet
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Tillo Mennes
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Sam Denys
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium; Department of Neurosciences, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Elke Loos
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium; Department of Neurosciences, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Nicolas Verhaert
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium; Department of Neurosciences, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Vincent Vander Poorten
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium; Department of Oncology, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Greet Hens
- Otorhinolaryngology, Head & Neck Surgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium; Department of Neurosciences, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium.
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Weiss NM, Bennöhr F, Lenz JH, Mlynski R, Rettschlag S. [Eustachian tube dysfunction after cleft palate surgery : Use of the latest diagnostics]. HNO 2022; 70:557-563. [PMID: 35318498 PMCID: PMC9242949 DOI: 10.1007/s00106-022-01147-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In patients with cleft palate, a high incidence of chronic obstructive Eustachian tube dysfunction (ETD) is assumed after surgery. Consequently, an increased rate of retracted eardrum or cholesteatoma is expected. Even though no common standard for investigating ETD is available, the development of objective tests has increased during the past 10 years. This study aimed to investigate the incidence of persisting chronic obstructive ETD in adult patients with cleft palate surgically treated in early childhood by using a combination of diagnostic tools. METHODS Adult participants with cleft palate repair in early childhood were invited for a follow-up examination and compared to a control group. Examination included tympanometry, tubomanometry, the Eustachian Tube Dysfunction Questionnaire (ETDQ-7), and the Eustachian Tube Score 7 (ETS-7). RESULTS A total of 16 adult patients were re-examined after cleft palate surgery and compared to a control group of 40 healthy individuals. Significant differences were found in the median ETS‑7 (p < 0.0001) score but not in the median ETDQ‑7 (p = 0.09) score. Only 2 of the 32 investigated ears (6%) had pathologic scores in ETS‑7 and ETDQ‑7 (p = 0.09), whereas 5 (31%) cleft palate patients showed symptoms of chronic obstructive ETD according to ETS‑7. No patient had examination findings indicating a requirement for further treatment. CONCLUSION By combining diagnostic tools for ETD, a lower rate of persisting obstructive ETD in adults after cleft palate surgery was found than previously reported. Successful surgical treatment of cleft palate seems to lead to physiological Eustachian tube function in long-term follow up.
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Affiliation(s)
- Nora M Weiss
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie "Otto Körner", Universitätsmedizin Rostock, Doberaner Str. 137-139, 18057, Rostock, Deutschland.
| | - Franziska Bennöhr
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie "Otto Körner", Universitätsmedizin Rostock, Doberaner Str. 137-139, 18057, Rostock, Deutschland
| | - Jan-Hendrik Lenz
- Klinik und Poliklinik für Mund‑, Kiefer- und Plastische Gesichtschirurgie, Klinik und Polikliniken für Zahn‑, Mund- und Kieferheilkunde, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Robert Mlynski
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie "Otto Körner", Universitätsmedizin Rostock, Doberaner Str. 137-139, 18057, Rostock, Deutschland
| | - Stefanie Rettschlag
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie "Otto Körner", Universitätsmedizin Rostock, Doberaner Str. 137-139, 18057, Rostock, Deutschland
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Mink van der Molen AB, van Breugel JMM, Janssen NG, Admiraal RJC, van Adrichem LNA, Bierenbroodspot F, Bittermann D, van den Boogaard MJH, Broos PH, Dijkstra-Putkamer JJM, van Gemert-Schriks MCM, Kortlever ALJ, Mouës-Vink CM, Swanenburg de Veye HFN, van Tol-Verbeek N, Vermeij-Keers C, de Wilde H, Kuijpers-Jagtman AM. Clinical Practice Guidelines on the Treatment of Patients with Cleft Lip, Alveolus, and Palate: An Executive Summary. J Clin Med 2021; 10:jcm10214813. [PMID: 34768332 PMCID: PMC8584510 DOI: 10.3390/jcm10214813] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/06/2021] [Accepted: 10/10/2021] [Indexed: 11/16/2022] Open
Abstract
Significant treatment variation exists in the Netherlands between teams treating patients with cleft lip, alveolus, and/or palate, resulting in a confusing and undesirable situation for patients, parents, and practitioners. Therefore, to optimize cleft care, clinical practice guidelines (CPGs) were developed. The aim of this report is to describe CPG development, share the main recommendations, and indicate knowledge gaps regarding cleft care. Together with patients and parents, a multidisciplinary working group of representatives from all relevant disciplines assisted by two experienced epidemiologists identified the topics to be addressed in the CPGs. Searching the Medline, Embase, and Cochrane Library databases identified 5157 articles, 60 of which remained after applying inclusion and exclusion criteria. We rated the quality of the evidence from moderate to very low. The working group formulated 71 recommendations regarding genetic testing, feeding, lip and palate closure, hearing, hypernasality, bone grafting, orthodontics, psychosocial guidance, dentistry, osteotomy versus distraction, and rhinoplasty. The final CPGs were obtained after review by all stakeholders and allow cleft teams to base their treatment on current knowledge. With high-quality evidence lacking, the need for additional high-quality studies has become apparent.
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Affiliation(s)
- Aebele B. Mink van der Molen
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.M.v.B.); (L.N.A.v.A.)
- Correspondence: ; Tel.: +31-88-7554-004
| | - Johanna M. M. van Breugel
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.M.v.B.); (L.N.A.v.A.)
| | - Nard G. Janssen
- Department Maxillo Facial Surgery and Dentistry, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (N.G.J.); (D.B.)
| | - Ronald J. C. Admiraal
- Department of Oto-Rhino-Laryngology, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands;
| | - Leon N. A. van Adrichem
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.M.v.B.); (L.N.A.v.A.)
| | | | - Dirk Bittermann
- Department Maxillo Facial Surgery and Dentistry, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (N.G.J.); (D.B.)
| | | | - Pieter H. Broos
- Knowledge Institute of the Federation of Medical Specialists, 3528 BL Utrecht, The Netherlands; (P.H.B.); (A.L.J.K.)
| | | | | | - Andrea L. J. Kortlever
- Knowledge Institute of the Federation of Medical Specialists, 3528 BL Utrecht, The Netherlands; (P.H.B.); (A.L.J.K.)
| | - Chantal M. Mouës-Vink
- Department of Plastic and Reconstructive Surgery, Medical Center Leeuwarden, 8934 AD Leeuwarden, The Netherlands;
| | | | | | - Christl Vermeij-Keers
- Dutch Association for Cleft Palate and Craniofacial Anomalies, 3643 AE Mijdrecht, The Netherlands;
| | - Hester de Wilde
- Department of Speech Therapy, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Anne Marie Kuijpers-Jagtman
- Department of Orthodontics, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
- Department of Orthodontics and Dentofacial Orthopedics, School of Dental Medicine, Medical Faculty, University of Bern, CH-3010 Bern, Switzerland
- Faculty of Dentistry, Universitas Indonesia, Jakarta 10430, Indonesia
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Harada T, Yamanishi T, Kurimoto T, Uematsu S, Yamamoto Y, Inoue N, Nishio J. Long-term Morphological Changes of the Velum and the Nasopharynx in Patients With Cleft Palate. Cleft Palate Craniofac J 2021; 59:1264-1270. [PMID: 34662220 DOI: 10.1177/10556656211045287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate long-term morphological changes in the soft palate length and nasopharynx in patients with cleft palate. We hypothesized that there would be differences in the morphological development of the soft palate and nasopharynx between patients with and without cleft palate and that these developmental changes would negatively affect the soft palate length to pharyngeal depth ratio involved in velopharyngeal closure for patients with cleft palate. DESIGN Retrospective, case-control study. SETTING Institutional practice. PATIENTS Ninety-two patients (Group F) with unilateral cleft lip, alveolus, and palate and 67 patients (Group CLA) with unilateral cleft lip and alveolus not requiring palatoplasty were included. MAIN OUTCOME MEASURES The soft palate length, nasopharyngeal size, and soft palate length to pharyngeal depth ratio were measured via lateral cephalograms obtained at three different periods. RESULTS Group F showed a shorter soft palate length and smaller nasopharyngeal size than Group CLA at all periods. Both these parameters increased with age, but the increase in amount was significantly less in Group F compared with that in Group CLA. The soft palate length to pharyngeal depth ratio in Group F decreased with age. CONCLUSIONS In patients with cleft palate, the soft palate length to pharyngeal depth ratio, which is involved in velopharyngeal closure, can change with age. Less soft palate length growth and unfavorable relationship between the soft palate and nasopharynx may be masked in early childhood but can manifest later on with age.
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Affiliation(s)
- Takeshi Harada
- 13608Osaka Women's and Children's Hospital, Izumi, Osaka, Japan.,38654Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | | | | | - Setsuko Uematsu
- 13608Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Yuri Yamamoto
- 13608Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Naoko Inoue
- 13608Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Juntaro Nishio
- 13608Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
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11
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Hoghoughi MA, Kazemi T, Khojasteh A, Habibagahi R, Kalkate Z, Zarei Z, Hosseinpour H, Salimi M. The effect of intervelar veloplasty under magnification (Sommerlad's Technique) without tympanostomy on middle ear effusion in cleft palate patients. BMC Pediatr 2021; 21:377. [PMID: 34470606 PMCID: PMC8408983 DOI: 10.1186/s12887-021-02856-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/25/2021] [Indexed: 12/30/2022] Open
Abstract
Objective Different surgical techniques and management approaches have been introduced to manage the cleft palate (CP) and its complications, such as otitis media with effusion (OME) and auditory problems. The optimal method, as well as the ideal time for palatoplasty and ventilation tube insertion, are the subject of controversy in the literature. We aimed to evaluate The Effect of Intervelar Veloplasty under Magnification (Sommerlad’s Technique) without Tympanostomy on Middle Ear Effusion in Cleft Palate Patients. Methods non-syndromic cleft palate patients from birth to 24 months who needed primary palatoplasty from April 2017 to 2019 were enrolled in this study. intravelar veloplasty (IVVP) surgery under magnification has been done by the same surgeon. Likewise, Otoscopy, Auditory Brainstem Response (ABR), and tympanometry were performed for all the patients before and six months after palatoplasty. Results Tympanograms were classified into two categories according to shape and middle ear pressure, and it was done in 42 children (84 ears). Type B curve was seen in 40 cases (80 ears) before surgery which reduced significantly (P < 0.005) to 12 cases in the left ear and 14 cases in the right ear after surgery. So, after surgery, 70 % of the tympanogram of left ears and 66.6 % of the tympanogram of Rt ears were in normal condition (type A tympanometry). ABR was done for 43 patients (86 ears) before surgery and six months after palatoplasty. Data were shown that 40 of the patients had mild to moderate hearing loss before surgery, which reduced significantly (P < 0.005) to 9 in the left ear and 11 in the right ear after palatoplasty. So, after surgery, 79 % of ABR of left ears and 73.8 % of ABR of right ears were in normal status (normal hearing threshold). Conclusions Intervelar veloplasty under magnification (Sommerlad’s technique) significantly improved the middle ear effusion without the need for tympanostomy tube insertion.
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Affiliation(s)
- Mohammad Ali Hoghoughi
- Plastic & Reconstructive Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Tayebeh Kazemi
- Otolaryngology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Khojasteh
- Burn and Wound Healing Research Center, Shiraz University of Medical Science, Shiraz, Iran
| | - Raha Habibagahi
- Orthodontic Research Center, Shiraz University of Medical Science, Shiraz, Iran
| | - Zahra Kalkate
- Orthodontic Research Center, Shiraz University of Medical Science, Shiraz, Iran
| | - Zeynab Zarei
- Orthodontic Research Center, Shiraz University of Medical Science, Shiraz, Iran
| | - Hamidreza Hosseinpour
- Student Research Committee, Shiraz University of Medical Sciences, 71936 - 13311, Shiraz, Iran
| | - Maryam Salimi
- Student Research Committee, Shiraz University of Medical Sciences, 71936 - 13311, Shiraz, Iran.
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12
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Seswandhana R, Makrufardi F, Sudjatmiko G. Fistula incidence after primary repair and correlation with cleft width-to-palatum width ratio: A prospective cohort study. Ann Med Surg (Lond) 2021; 63:102183. [PMID: 33717475 PMCID: PMC7921748 DOI: 10.1016/j.amsu.2021.102183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/13/2021] [Accepted: 02/14/2021] [Indexed: 11/22/2022] Open
Abstract
Background Cleft lip with or without cleft palate is one of the most common birth defects and is certainly the most visible. Fistula rate after primary palatoplasty was ranging between 10 and 23% and could be detected in the first three weeks after surgery. The cleft width is the frequent factor which was assumed to correspond to fistula occurrence. This study aimed to find correlation between fistula occurrence with cleft width and palatum width ratio after primary palate repair. Methods A prospective cohort study was conducted on 16 subjects, which consisted of 10 males and 6 females. We measured width of cleft palate, width of rest palate and width of palate arch on three level measurements (posterior, junction and anterior). The surgery was performed using the two-flap and three layers suturing technique. Results Sixteen patients were enrolled in this study during January and February 2008 . Ten patients were diagnosed with unilateral cleft palate while six patients had bilateral cleft palate. Mean of age was 22.31 ± 5.86 month. Correlation analysis between fistula occurrence and cleft width, cleft width-remnant palate width ratio and cleft width-palate arch width ratio using logistic regression did not show statistical correlation, and the same result was found between fistula occurrence and hemoglobin level, white blood count, nutritional status, cleft type and caries dentis factors (p > 0.05). Conclusion Width of the cleft is not a factor associated with fistula occurrence. Two-flap three layers technique could be considered as a simple technique and gives a low rate of fistula occurrence. Cleft lip is one of the most common birth defects and is certainly the most visible. Two-flap three layers technique gives a low rate of fistula occurrence. Two-flap three layers technique could be considered as a simple technique.
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Affiliation(s)
- Rosadi Seswandhana
- Plastic, Reconstructive, and Aesthetic Surgery Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Firdian Makrufardi
- Plastic, Reconstructive, and Aesthetic Surgery Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Gentur Sudjatmiko
- Department of Plastic Reconstructive, and Aesthetic Surgery, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Baillie L, Sell D. Benchmarking Speech, Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique. Cleft Palate Craniofac J 2020; 57:1197-1215. [DOI: 10.1177/1055665620923925] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Objective: To report speech and velopharyngeal function (VPF) outcomes, and surgical characteristics, at age 5 following early complete palate closure using the Sommerlad protocol. Design: A retrospective, descriptive, cross-sectional consecutive series. Setting: A regional twin site center; a district general hospital and tertiary children’s hospital. Participants: Between 1993 and 2006, 877 participants underwent surgery; 712 (81%) were eligible for inclusion; 391 (55%) were included, 321 (45%) excluded. Thirteen percent had bilateral cleft lip and palate (CLP), 40% unilateral CLP, and 47% isolated cleft palate. Intervention: Lip and vomerine flap repair at 3 months of age (BCLP, UCLP) with soft palate closure using radical muscle dissection and retropositioning at a mean age of 6.6 months, range 4 to 23 months, as described and undertaken by Sommerlad. Outcome Measures: Velopharyngeal Composite (VPC) CAPS-A and articulation summary scores derived from analysis using the Cleft Audit Protocol for Speech-Augmented. Results: A VPC-SUM CAPS-A score of “0” was found in 97% reflecting adequate VPF; 73% had no cleft articulation difficulties. The BCLP group had the poorest articulation. Secondary speech surgery rate was 2.6% and 10.7% had fistula repair. Levator muscle quality and degree of retropositioning was associated with speech outcomes related to VPF. 2.6% had current features of VPI. Conclusions: Complete palate closure by around 6 months of age by the surgeon who described the technique led to excellent perceived VPF and very good speech outcomes at age 5, with less speech therapy and secondary speech surgery than commonly reported. These findings serve as a benchmark for the Sommerlad protocol and technique.
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Affiliation(s)
- Lauren Baillie
- Speech and Language Therapy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Debbie Sell
- Centre for Outcomes and Experience Research in Children’s Health, Illness and Disability (ORCHID), Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
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14
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Mapar D, Khanlar F, Sadeghi S, Abdali H, Memarzadeh M, Davari HA, Derakhshandeh F. The incidence of velopharyngeal insufficiency and oronasal fistula after primary palatal surgery with Sommerlad intravelar veloplasty: A retrospective study in Isfahan Cleft Care Team. Int J Pediatr Otorhinolaryngol 2019; 120:6-10. [PMID: 30739010 DOI: 10.1016/j.ijporl.2018.12.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/27/2018] [Accepted: 12/27/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study was designed to determine the incidence of velopharyngeal insufficiency (VPI), oronasal fistula development and facial grimace in patients seen by Isfahan Cleft Care Team (ICCT) after primary Sommerlad intravelar veloplasty (SIVV). Furthermore the association of gender, cleft type and age at primary surgery with the incidence of hypernasality and fistula is determined. METHODS A group of 40 patients with history of cleft palate with or without cleft lip were identified from the records of ICCT between 2011 and 2014. The main outcome measures were the incidence of hypernasality and fistula after primary palate repair with SIVV. Speech recordings were analyzed by consensus by two speech therapists according to the Cleft Audit Protocol for Speech- Augmented (CAPS-A), (Kappa = 82.4). Deciding whether or not to have a fistula was based on the oral examination videos. RESULTS Severe and moderate hypernasality was observed in 42.5% of patients. Normal resonance and mild/borderline hypernasality was observed in 37.5% and 20% of patients, respectively. The frequency of fistulas was 7.5%. There was a significant association between hypernasality with cleft type and the age at primary surgery (p < 0.05). CONCLUSION Significant progress has been made in the outcomes of the primary palate surgeries with the SIVV technique compared to the previous study in the ICCT.
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Affiliation(s)
- Dorsa Mapar
- Craniofacial & Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Khanlar
- Craniofacial & Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saba Sadeghi
- Craniofacial & Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Abdali
- Craniofacial & Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrdad Memarzadeh
- Craniofacial & Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Heydar Ali Davari
- Craniofacial & Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Derakhshandeh
- Craniofacial & Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
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15
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Téblick S, Ruymaekers M, Van de Casteele E, Nadjmi N. Effect of Cleft Palate Closure Technique on Speech and Middle Ear Outcome: A Systematic Review. J Oral Maxillofac Surg 2019; 77:405.e1-405.e15. [DOI: 10.1016/j.joms.2018.09.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/21/2018] [Accepted: 09/21/2018] [Indexed: 12/01/2022]
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16
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Karanth TK, Whittemore KR. Middle-ear disease in children with cleft palate. Auris Nasus Larynx 2018; 45:1143-1151. [DOI: 10.1016/j.anl.2018.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/21/2018] [Accepted: 04/25/2018] [Indexed: 10/28/2022]
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Jodeh DS, Buller M, Rottgers SA. The Impact of Presurgical Infant Orthopedics on Oronasal Fistula Rates Following Cleft Repair: A Meta-Analysis. Cleft Palate Craniofac J 2018; 56:576-585. [DOI: 10.1177/1055665618806104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Presurgical infant orthopedics (PSIO) techniques were introduced to improve the outcomes achieved when treating children with complete cleft lip and palate. The effect of PSIO on the incidence of postoperative fistulae has never been reliably demonstrated. We conducted a meta-analysis to assess the effectiveness of PSIO in reducing postoperative fistulas in patients with complete cleft lip and palate. Methods: A search of the PubMed and Embase databases was performed to identify relevant articles that included primary palate repairs of patients with unilateral or bilateral complete clefts, reported the incidence of postoperative fistulae, and explicitly stated if PSIO was used. Details including author, number of subjects, use of PSIO, and fistula rate were cataloged. Results: A review of the PubMed database yielded 1135 unique citations, and Embase yielded 507 articles. Review of these yielded 15 studies, comprising 1241 children, which met inclusion criteria. The overall rate of oronasal fistula development was 7.09%. The average fistula rate for studies using PSIO was 5.93% versus 9.71% in the non-PSIO group. This difference was not statistically significant ( P = .34). Conclusions: The use of PSIO prior to cleft lip and palate repair provides multiple benefits related to facial and nasal form and is supported by a body of literature. The effect of PSIO on the incidence of postoperative fistulae has received less attention in the literature. Our meta-analysis of the available literature does not provide evidence to support the premise that the use of PSIO affects the incidence of fistulae after cleft palate repair.
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Affiliation(s)
- Diana S. Jodeh
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
| | - Mitchell Buller
- Department of Plastic Surgery, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - S. Alex Rottgers
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
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Abstract
This study presents a systematic review of randomized controlled trials (RCTs) in cleft and craniofacial surgery. All studies reporting on RCTs in cleft and craniofacial surgery were identified on PubMed using the search terms "cleft," "velopharyngeal insufficiency," "velopharyngeal dysfunction," "nasoalveolar molding," "gingivoperiosteoplasty," "Pierre Robin sequence," "craniofacial," "craniosynostosis," "craniofacial microsomia," "hemifacial microsomia," "hypertelorism," "Le Fort," "monobloc," "distraction osteogenesis," "Treacher Collins," and "Goldenhar." Studies were excluded if they were not randomized, did not focus primarily on topics related to cleft or craniofacial surgery, included repeat publications of data, or were unavailable in English. Studies were evaluated on demographic and bibliometric data, study size, specific area of focus, and findings reported. Four hundred forty-seven unique studies were identified. One hundred eighty-three papers met inclusion criteria (115 cleft lip and palate, 65 craniofacial, and 3 spanning both disciplines). Sixty-six (36%) were dedicated to topics related to surgical techniques. There were no studies comparing current cleft lip or soft palate repair techniques and no studies on cleft rhinoplasty. The most frequently reported surgical topic was cleft palate. There were several studies on orthognathic techniques which compared distraction osteogenesis to traditional advancement. Most craniofacial operations, such as cranial vault remodeling and frontofacial advancement/distraction, were not represented. Several standard operations in cleft and craniofacial surgery are not supported by Level I evidence from randomized controlled trials. Our community should consider methods by which more RCTs can be performed, or redefine the acceptable standards of evidence to guide our clinical decisions.
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D'Andréa G, Maschi C, Savoldelli C, Caci H, Bailleux S. Otologic Outcomes With Two Different Surgical Protocols in Patients With a Cleft Palate: A Retrospective Study. Cleft Palate Craniofac J 2018; 55:1289-1295. [PMID: 29489418 DOI: 10.1177/1055665618758686] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To compare otologic outcomes in patients with cleft palate who underwent 2 different surgical protocols. DESIGN Monocentric retrospective analysis of medical reports. PATIENTS, PARTICIPANTS All consecutively treated patients affected by a cleft palate, born between January 1998 and December 2002 (group 1) and between January 2007 and December 2010 (group 2). INTERVENTIONS Patients in group 1 underwent Veau-Wardill-Kilner palatoplasty at 10 months and had ventilation tubes inserted in case of otitis media with effusion (OME) during surgery. Patients in group 2 underwent Sommerlad intravelar veloplasty at 5 months. Ventilation tubes were inserted only in case of persistent OME. MAIN OUTCOME MEASURE(S) The need for a second set of ventilation tubes to be inserted in case of persistent OME, the presence of OME at the age of 2 years, and tympanic abnormalities at the age of 5 years were analyzed. RESULTS There was no statistically significant difference either for the presence of OME at the age of 2 years (27 [45%] vs 32 [57.14%], respectively, in groups 1 and 2; P = .191) or for tympanic abnormalities at the age of 5 years (20 [33.33%] vs 15 [26.79%]; P = .433). Statistically significant difference was found for the need to insert a second set of ventilation tubes in case of persistent OME (29 [48.33%] vs 12 [21.42%], respectively; P = .02). CONCLUSION Early Sommerlad intravelar veloplasty may reduce persistent OME and consequently the need for ventilation tubes insertion, compared to later Veau-Wardill-Kilner palatoplasty.
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Affiliation(s)
- Grégoire D'Andréa
- 1 Hôpitaux Pédiatriques de Nice CHU Lenval, Nice, France.,2 Institut Universitaire de la Face et du Cou, CHU Nice, Nice, France
| | - Claude Maschi
- 1 Hôpitaux Pédiatriques de Nice CHU Lenval, Nice, France
| | - Charles Savoldelli
- 1 Hôpitaux Pédiatriques de Nice CHU Lenval, Nice, France.,2 Institut Universitaire de la Face et du Cou, CHU Nice, Nice, France
| | - Hervé Caci
- 1 Hôpitaux Pédiatriques de Nice CHU Lenval, Nice, France
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21
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Abstract
Repair of the cleft palate intends to establish the division between the oral and nasal cavity, thereby improving feeding, speech, and eustachian tube dysfunction all while minimizing the negative impact on maxillary growth. Before palate repair candidacy, timing and surgical method of repair is dependent on comorbid conditions, particularly cardiac disease, mandibular length, and palate width. Additionally, management of the alveolar cleft and the indications for gingivoperiosteoplasty versus secondary alveolar bone grafting is a controversial topic that weighs the risks and benefits of potentially sparing the patient an additional surgery against iatrogenic restriction of facial growth and malocclusion.
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Cleft Palate Repair without Lateral Relaxing Incision. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1256. [PMID: 28458970 PMCID: PMC5404441 DOI: 10.1097/gox.0000000000001256] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/11/2017] [Indexed: 11/27/2022]
Abstract
Background: The goals of successful palate repair include optimization of speech and feeding, avoidance of fistula formation, and mitigation of adverse maxillary growth. However, the effects of scar formation on maxillary growth have not been discussed in detail. Methods: Between November 2010 and December 2011, the palateplasty was performed for 24 patients with cleft palate (median age, 12 months; range, 11–18 months). In the velum, a symmetrical intravelar veloplasty with mucosal Z-plasty was performed on both the nasal and oral sides. In the hard palate, instead of lateral relaxing incisions, a 1-line mucoperiosteal incision along the cleft margins was designed with subperiosteal undermining in the entire palatine bone. The palatal mucoperiosteum was sutured together in the middle of the cleft, and the cleft was directly closed without lateral relaxing incisions. The patients were monitored for 6 months to 1.6 years. Results: None of the cases had issues concerning flap viability, and all palate repairs healed well. Postoperative results were satisfactory, without any complications such as dehiscence, perforation, or palatal fistula. Conclusions: The method presented in this article was effective, with successful palatal closure and without scar formation or mucosal defects along the alveolus. We conclude that minimum contracture of the hard palate was useful for not only mitigating adverse maxillary growth but also for orthodontics.
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Hardwicke J, Nassimizadeh M, Richard B. Reporting of Randomized Controlled Trials in Cleft Lip and Palate: A 10-Year Review. Cleft Palate Craniofac J 2017; 54:142-152. [PMID: 26101810 DOI: 10.1597/14-267] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objectives Reviews of the quality of reporting of randomized controlled trials (RCTs) have recently been conducted in different surgical specialties. In this review of RCTs relating to cleft lip, cleft palate, and cleft lip and palate (CL/P), we investigate the quality of reporting against the Consolidated Standards of Reporting Trials (CONSORT) checklist. Design A systematic review of CL/P RCTs published from 2004 to 2013, with the included articles scored against the CONSORT checklist. Patients, Participants The literature search identified 174 articles. Studies were selected for participants with CL/P who were involved in an RCT with prospective data collection and reported in a full journal article. A total of 6352 participants were included from 65 CUP RCTs during the study period. Main Outcome Measures The methodological quality of RCTs was assessed using the CONSORT checklist and Jadad scale. Results The mean CONSORT score was 15.8, and the mean Jadad score was 3.3. There was a significant positive correlation between the CONSORT and Jadad score ( P < .0001, ρ = .47). The only significant correlation showed that with an increasing number of authors, both the CONSORT and the Jadad score increased. Conclusion This analysis has shown that that there are deficiencies in the transparent reporting of factors such as randomization implementation, blinding, and participant flow. Interventions, outcomes, and the interpretation of results are well presented. We would recommend that RCTs are conceived and undertaken using the CONSORT checklist and reported in a clear and reproducible manner.
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Affiliation(s)
- Joseph Hardwicke
- West Midlands Cleft Lip and Palate Service, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom, and School of Dentistry, University of Birmingham, Birmingham, United Kingdom
| | - Mohammad Nassimizadeh
- West Midlands Cleft Lip and Palate Service, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Bruce Richard
- West Midlands Cleft Lip and Palate Service, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
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Alper CM, Losee JE, Seroky JT, Mandel EM, Richert BC, Doyle WJ. Resolution of Otitis Media With Effusion in Children With Cleft Palate Followed Through Five Years of Age. Cleft Palate Craniofac J 2016; 53:607-13. [PMID: 27533493 PMCID: PMC5074527 DOI: 10.1597/15-130] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To describe the temporal pattern of otitis media with effusion (OME) resolution for a cohort of nonsyndromic cleft palate children enrolled before palatoplasty and followed through 5 years of age. DESIGN This is a prospective, longitudinal study of the time course for OME resolution in infants and children with palatal clefts. SETTING Cleft Palate Craniofacial Center of a tertiary care pediatric hospital. PARTICIPANTS This study included 52 children with cleft palate (29 boys, 45 white, Veau 1 through 4) who had a Furlow-type palatoplasty between 10 and 24 months of age performed by one of six surgeons. INTERVENTIONS Standard cleft palate management was supplemented with study visits to the research clinic pre- and postpalatoplasty and then yearly to 6 years of age for assessments of middle ear status by interval history, otoscopy, and tympanometry. MAIN OUTCOME MEASURE The main outcome measure was age at otitis media resolution defined as the age in years at the first in a sequence of "disease-free" diagnoses not interrupted or followed by any other diagnosis. RESULTS The cumulative percent OME resolution for ears/children at ages <1, 1, 2, 3, 4, 5 years was 4.1/4.4, 14.3/10.9, 31.6/21.7, 45.9/37.0, 56.1/50.0, and 70.4/60.9%. OME resolution followed a simple linear time curve with slopes of 13.5% (confidence interval [CI] = 12.2% to 14.8%, r(2) = .99) and 11.9% (CI = 10.1% to 13.6%, r(2) = .99) resolutions per year for ears and children, respectively. CONCLUSIONS There is a natural, age-related pattern of resolution for persistent OME that affects most infants and young children with cleft palate that is not affected by palatoplasty.
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Affiliation(s)
- Cuneyt M. Alper
- Division of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh of UPMC
- Department of Otolaryngology, University of Pittsburgh School of Medicine
| | - Joseph E. Losee
- Department of Plastic Surgery, Children’s Hospital of Pittsburgh of the UPMC and the University of Pittsburgh School of Medicine
| | - James T. Seroky
- Department of Otolaryngology, University of Pittsburgh School of Medicine
| | - Ellen M. Mandel
- Department of Otolaryngology, University of Pittsburgh School of Medicine
| | - Beverly C. Richert
- Division of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh of UPMC
- Department of Otolaryngology, University of Pittsburgh School of Medicine
| | - William J. Doyle
- Department of Otolaryngology, University of Pittsburgh School of Medicine
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Progressive Tightening of the Levator Veli Palatini Muscle Improves Velopharyngeal Dysfunction in Early Outcomes of Primary Palatoplasty. Plast Reconstr Surg 2015; 136:131-141. [PMID: 26111318 DOI: 10.1097/prs.0000000000001323] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Management of the levator veli palatini with intravelar veloplasty has been shown to improve speech resonance. The senior author has introduced a more aggressive procedure where the levator is separately dissected, overlapped, and tightened. This study compares resonance results from four levator management protocols: non-intravelar veloplasty, Kriens intravelar veloplasty, radical intravelar veloplasty, and overlapping intravelar veloplasty. METHODS Retrospective chart review was conducted on 252 patients who underwent primary palatoplasty with speech follow-up at 3 years of age. Velopharyngeal function was evaluated with perceptual speech examinations, and subjects were scored on a four-point scale (0 = normal resonance; 1 = occasional hypernasality/nasal emission/turbulence/grimacing, no further assessment warranted; 2 = mild hypernasality/intermittent nasal turbulence/grimacing, velopharyngeal imaging suggested; and 3 = severe hypernasality, surgical intervention recommended). Fisher's exact test was used to compare outcomes. RESULTS A single surgeon performed all the non-intravelar veloplasty (n = 92), Kriens intravelar veloplasty (n = 103), and radical intravelar veloplasty (n = 31), whereas the senior author performed the overlapping intravelar veloplasty (n = 26). Cleft severity proportions were equivalent across the four methods (p = 0.28). Patients who underwent overlapping intravelar veloplasty demonstrated significantly better velopharyngeal function, and none required further imaging or secondary surgery compared with the other three procedures (p < 0.001). CONCLUSIONS Speech resonance outcomes at 3 years of age are improved and need for secondary velopharyngeal dysfunction management is reduced with more aggressive levator dissection and reconstruction during primary one-stage palatoplasty. Results were best when the muscle was overlapped. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Smarius B, Breugem C. Surgical learning curve in performing palatoplasty: A retrospective study in 200 patients. J Craniomaxillofac Surg 2015; 43:1868-74. [PMID: 26421467 DOI: 10.1016/j.jcms.2015.08.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 08/15/2015] [Accepted: 08/26/2015] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The aim of the study was to assess the influence of the experience of the surgeon on the occurrence of fistulas following palatoplasty. MATERIALS AND METHODS A retrospective review was performed of consecutive children treated between 2006 and 2013 for cleft palate by a single surgeon. Cleft palate repair was performed using the von Langenbeck technique, Furlow palatoplasty, buccal flap or Vomer flap. Data was collected for age, sex, date of birth, syndrome, adoption, cleft palate type, type of repair, cleft width, fistula occurrence and location of fistula. RESULTS A total of 276 operations were performed in 200 children (Veau I, II, III, IV). Mean age at surgery was 21.9 months (range: 6.2 months to 26 years 8.3 months). Postoperatively, palatal fistulas occurred in eight patients (4.0%), however, the incidence was 3.0% in the non-adoption group and 9.7% in the adoption population. In this study there was no statistically significant evidence of a surgical learning curve, and no significant associations between fistula rate and sex, adoption, syndrome, cleft type, cleft width, or type of repair. CONCLUSION AND CLINICAL RELEVANCE This study demonstrates a fistula formation rate of 3.0% for the non-adoption population and 9.7% for the adoption population. There was no statistically significant evidence of a learning curve during the first few years of performing cleft palate repair. No other independent risk factors for postoperative fistula formation were identified; however, the benefit of a vomer flap and subsequent reduction in fistula incidence was demonstrated.
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Affiliation(s)
- Bram Smarius
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
| | - Corstiaan Breugem
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, P.O. Box 85090, 3508 AB Utrecht, The Netherlands; Department of Plastic Surgery Meander Medical Center, 3813 TZ Amersfoort, The Netherlands
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Oral Mucosal Z-Plasty in Combination with Intravelar Veloplasty. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e456. [PMID: 26301145 PMCID: PMC4527630 DOI: 10.1097/gox.0000000000000424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 05/28/2015] [Indexed: 11/27/2022]
Abstract
Our aim was to establish a reliable, functional surgical technique for soft palate closure. A step-by-step description of the operative procedure is presented. A cross-over procedure has been developed by combining the principles of a mucosal Z-plasty only on the oral side of the cleft palate, the intravelar veloplasty following Sommerlad’s principles and a straight line closure on the nasal side. In the last 2 years, 25 patients have undergone the operation at the Cleft Centre of the 1st Paediatric Department of the Semmelweis University Budapest, Hungary. In all cases the operative technique could be adapted, operations were uneventful and straightforward. This technique was appropriate to close all the soft palate clefts, even the wide ones. This procedure combines the advantages of both procedures and has shown very good early postoperative results.
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30
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Pet MA, Marty-Grames L, Blount-Stahl M, Saltzman BS, Molter DW, Woo AS. The Furlow Palatoplasty for Velopharyngeal Dysfunction: Velopharyngeal Changes, Speech Improvements, and Where They Intersect. Cleft Palate Craniofac J 2015; 52:12-22. [DOI: 10.1597/13-033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective We investigated how Furlow palatoplasty changes velopharyngeal morphology and speech characteristics, as well as how the anatomical and clinical results might be related. We hypothesized that Furlow palatoplasty would result in measurable velar elongation, tightening of the genu angle, and retropositioning of the levator sling and that the achievement of these modifications might be associated with clinical speech improvement. Design Retrospective analysis of preoperative and postoperative videofluoroscopic and speech data. Setting Tertiary care center. Patients/Participants A total of 29 patients with velopharyngeal insufficiency in the setting of previous cleft palate repair or submucous cleft palate. Interventions Furlow palatoplasty for treatment of velopharyngeal insufficiency. Outcome Measures Lateral videofluoroscopy and perceptual speech examination were conducted preoperatively and postoperatively in order to measure velopharyngeal dimensions and speech quality. We describe anatomical and speech changes associated with the Furlow palatoplasty and undertake an exploratory analysis of the relationship between surgical changes to the velopharynx and clinical outcomes. Results Furlow palatoplasty results in significant velar elongation, increased acuity of the genu angle, and retropositioning of the levator sling. Postoperative speech improvement was identified on the three subscales of resonance, nasal emission, and stops/plosives. Speech improvement and the absence of need for reoperation were most consistently associated with tightening of the genu angle. Conclusions Furlow palatoplasty lengthens the palate, while both tightening and retropositioning the levator sling. These changes reflect transverse recruitment of lateral velar tissues, along with transverse tightening and anterior release of the muscle fibers, respectively. Levator tightening is most consistently associated with improved speech outcomes.
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Affiliation(s)
- Mitchell A. Pet
- Division of Plastic and Reconstructive Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Lynn Marty-Grames
- Cleft Palate and Craniofacial Institute, St. Louis Children's Hospital, St. Louis, Missouri
| | - Mary Blount-Stahl
- Cleft Palate and Craniofacial Institute, St. Louis Children's Hospital, St. Louis, Missouri
| | - Babette S. Saltzman
- Craniofacial Outcomes Research and Epidemiology Group, Seattle Children's Hospital, Seattle, Washington
| | | | - Albert S. Woo
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
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31
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McIlvaine E, Borzabadi-Farahani A, Lane CJ, Azen SP, Yen SLK. Apriori feasibility testing of randomized clinical trial design in patients with cleft deformities and Class III malocclusion. Int J Pediatr Otorhinolaryngol 2014; 78:725-30. [PMID: 24630053 PMCID: PMC4336545 DOI: 10.1016/j.ijporl.2014.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 01/06/2014] [Accepted: 01/08/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess the feasibility of randomizing treatment (surgical vs. non-surgical) for correction of a Class III malocclusion (underbite) resulting from an earlier repair of cleft lip and palate. MATERIALS AND METHODS Surveys about willingness to accept randomized treatment during adolescence were mailed to the parents of cleft lip and palate patients under the care of Children's Hospital Los Angeles between 2005 and 2010. The inclusion criteria were patients with cleft lip and palate, Class III malocclusion due to maxillary deficiency, and absence of medical and cognitive contraindications to treatment. RESULTS Out of 287 surveys, 82 (28%) were completed and returned; 47% of the subjects held a strong treatment preference (95% CI, 35-58%), while 30% were willing to accept randomization (95% CI, 20-41%). Seventy-eight percent would drop out of a randomized trial if dissatisfied with the assigned treatment (95% CI, 67-86%). The three most commonly cited reasons for being unwilling to accept random treatment assignment were 1) the desire for doctors to choose the best treatment, 2) the desire for parents to have input on treatment, and 3) the desire to correct the underbite as early as possible. CONCLUSION Based on this study, parents and patients would be unwilling to accept a randomly assigned treatment and would not remain in an assigned group if treatment did not meet expectations. This highlight the limitations associated with randomization trials involving surgical modalities and provide justification for other research models (e.g., cohort studies) to compare two treatment options when randomization is not feasible.
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Affiliation(s)
- Elizabeth McIlvaine
- Statistical Consultation and Research Center, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ali Borzabadi-Farahani
- Orthodontics, Warwick Dentistry, Warwick Medical School, University of Warwick, Coventry, UK,Formerly, Craniofacial Orthodontics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Christianne J. Lane
- Statistical Consultation and Research Center, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Stanley P. Azen
- Statistical Consultation and Research Center, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Stephen L.-K. Yen
- Craniofacial Orthodontics, Children's Hospital Los Angeles, Los Angeles, CA, USA,Center for Craniofacial Molecular Biology, Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA,Corresponding author at: CCMB, CSA103, 2250 Alcazar St., Los Angeles, CA 90027, USA., Tel.: +1 323 442 1747; fax: +1 323 442 2981
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32
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Chan EKW, Lee KH, Tsui BSY, Wong SYS, Pang KKY, Mou JWC, Tam PYH. From von Langenbeck to Furlow palatoplasty: A 16-year review of cleft palate repair. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Edwin Kin-Wai Chan
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Kim-Hung Lee
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Bess Siu-Yan Tsui
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Sammi Yuen-Shan Wong
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Kristine Kit-Yi Pang
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Jennifer Wai-Cheung Mou
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
| | - Peter Yuk-Him Tam
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
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Abstract
Velopharyngeal dysfunction (VPD) is a generic term which describes a set of disorders resulting in the leakage of air into the nasal passages during speech production. As a result, speech samples can demonstrate hypernasality, nasal emissions, and poor intelligibility. The finding of VPD can be secondary to several causes: anatomic, musculoneuronal, or behavioral/mislearning. To identify the etiology of VPD, patients must undergo a thorough velopharyngeal assessment comprised of perceptual speech evaluation and functional imaging, including video nasendoscopy and speech videofluoroscopy. These studies are then evaluated by a multidisciplinary team of specialists, who can decide on an optimal course for patient management. A treatment plan is developed and may include speech therapy, use of a prosthetic device, and/or surgical intervention. Different surgical options are discussed, including posterior pharyngeal flap, sphincter pharyngoplasty, Furlow palatoplasty, palatal re-repair, and posterior pharyngeal wall augmentation.
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Affiliation(s)
- Albert S Woo
- Cleft Palate-Craniofacial Institute and Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
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34
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Speech outcomes of early palatal repair with or without intravelar veloplasty in children with complete unilateral cleft lip and palate. Br J Oral Maxillofac Surg 2013; 51:845-50. [PMID: 23742818 DOI: 10.1016/j.bjoms.2013.04.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 04/22/2013] [Indexed: 11/22/2022]
Abstract
We compared the early speech outcomes of 40 consecutive children with complete unilateral cleft lip and palate (UCLP) who had been treated according to different 2-stage protocols: the Malek protocol (soft palate closure without intravelar veloplasty at 3 months; lip and hard palate repair at 6 months) (n=20), and the Talmant protocol (cheilorhinoplasty and soft palate repair with intravelar veloplasty at 6 months; hard palate closure at 18 months) (n=20). We compared the speech assessments obtained at a mean (SD) age of 3.3 (0.35) years after treatment by the same surgeon. The main outcome measures evaluated were acquisition and intelligibility of speech, velopharyngeal insufficiency, and incidence of complications. A delay in speech articulation of one year or more was seen more often in patients treated by the Malek protocol (11/20) than in those treated according to the Talmant protocol (3/20, p=0.019). Good intelligibility was noted in 15/20 in the Talmant group compared with 6/20 in the Malek group (p=0.010). Assessment with an aerophonoscope showed that nasal air emission was most pronounced in patients in the Malek group (p=0.007). Velopharyngeal insufficiency was present in 11/20 in the Malek group, and in 3/20 in the Talmant group (p=0.019). No patients in the Talmant group had an oronasal fistula (p<0.001). All other outcomes were similar. Despite later closure of the soft and hard palate, early speech outcomes were better in the Talmant group because intravelar veloplasty was successful and there were no fistulas after closure of the hard palate in 2 layers.
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35
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Becker M, Hansson E. Low rate of fistula formation after Sommerlad palatoplasty with or without lateral incisions: an analysis of risk factors for formation of fistulas after palatoplasty. J Plast Reconstr Aesthet Surg 2013; 66:697-703. [PMID: 23462210 DOI: 10.1016/j.bjps.2013.01.031] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 09/28/2012] [Accepted: 01/29/2013] [Indexed: 10/27/2022]
Abstract
The aim of palate repair is to restore normal eating and drinking function and normal speech development and still maintain undisturbed facial growth. The repair should be performed with a low frequency of complications. A number of factors are thought to contribute to the formation of fistulas after palatoplasty; they include patient factors and treatment issues. The aim of this study was to review all patients operated on with palatoplasties according to Sommerlad in our clinic, examine the fistula frequency and analyse risk factors for the development of fistulas after palate repair. During the study period, 175 patients were operated on with palatoplasties according to Sommerlad by the senior cleft surgeon. The group included 150 native patients and 25 adopted children. In the native population, seven patients developed fistulas and the fistula frequency was thus 5%. In the non-native group four patients developed fistulas, which gave a fistula frequency of 16%. In conclusion, the fistula frequency after Sommerlad repair of cleft palate is low in our material and few patients need fistula repair. The liberal usage of Langenbeck flaps might give a lower fistula rate. The most common place for fistulas is the junction of the soft and hard palate. No clear difference could be seen between different types of clefts. Syndromes and associated malformation seem to play a small role in the formation of fistulas. The fistula frequency in the non-native population is higher. A number of factors are different in the non-native population.
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Affiliation(s)
- Magnus Becker
- Department of Clinical Sciences, Malmö, Lund University, Sweden
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36
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Kobayashi H, Sakuma T, Terao H, Sanbe T, Suzaki H, Ohkubo F. Palatoplasty and Growth of the Temporal Bone Mastoid Air Cells. Cleft Palate Craniofac J 2012; 49:541-5. [DOI: 10.1597/10-108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objectives The present study was undertaken to analyze the relationship between the method used for manipulation of the levator veli palatini muscle and the area of the mastoid air cells in patients with cleft palate. Design Retrospective study. Patients The subjects were 50 patients seen for surgical treatment of cleft palate. Interventions Palatoplasty was carried out using the mucosal flap method in 25 patients and the mucoperiosteal flap method in 25 patients. In the mucosal flap method, the levator veli palatini muscle was overlapped and sutured, followed by posterior movement of the muscle bundle (the posterior relocation group). In the mucoperiosteal flap method (the control group), the mucoperiosteal flap was pushed back, followed by end-to-end suturing of the muscle. The area of the mastoid air cells was measured on X-rays when patients were 5 years old. Results The mastoid air cell area did not differ significantly between the posterior relocation group (mean, 5.00 cm2; range, 1.66 to 19.7 cm2) and the control group (mean, 5.3 cm2; range, 2.29 to 15.9 cm2). Conclusion No significant growth of mastoid air cells was noted following posterior relocation of the levator veli palatini muscle. Thus, in cases of cleft palate in which significant growth of mastoid air cells is not expected following reconstruction of the levator veli palatini muscle, the results confirm the view that tympanic ventilation tube insertion is the most suitable method for the treatment of otitis media.
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Affiliation(s)
- Hitome Kobayashi
- Department of Otorhinolaryngology, Showa University School of Medicine, Tokyo, Japan
| | - Takaaki Sakuma
- Department of Otorhinolaryngology, Showa University School of Medicine, Tokyo, Japan
| | - Hajime Terao
- Department of Otorhinolaryngology, Showa University School of Medicine, Tokyo, Japan
| | - Takeyuki Sanbe
- Department of Otorhinolaryngology, Showa University School of Medicine, Tokyo, Japan
| | - Harumi Suzaki
- Department of Otorhinolaryngology, Showa University School of Medicine, Tokyo, Japan
| | - Fumio Ohkubo
- Department of Plastic and Reconstructive Surgery, Showa University School of Medicine, Tokyo, Japan
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37
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Al-Nawas B, Wriedt S, Reinhard J, Keilmann A, Wehrbein H, Wagner W. Influence of patient age and experience of the surgeon on early complications after surgical closure of the cleft palate--a retrospective cohort study. J Craniomaxillofac Surg 2012; 41:135-9. [PMID: 22841383 DOI: 10.1016/j.jcms.2012.06.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 06/04/2012] [Accepted: 06/04/2012] [Indexed: 11/26/2022] Open
Abstract
Comparative studies on timing of palatoplasty are rare. The aim of this retrospective cohort study was to compare the influence of early (<14 months) and later (>14 months) one-step closure of the soft and hard palate on early complications. All non-syndromic patients from 1999 to 2009 were included; 6-14 months n = 41 and 15-24 months n = 53. Each palatoplasty was performed as a single-step procedure using bipedicled flaps by a team of two Maxillofacial Surgeons either supervising or operating. The surgeon was rated as "non-experienced" when having performed less than 10 palatoplasties under supervision. Main outcome variable is the occurrence of residual fistula. Fistula occurred in four (4.5%) of the patients. In the multivariate model with respect to the occurrence of fistula neither age, leucocyte count, duration of surgery, nor experience of the surgeon showed a significant influence on the occurrence of a fistula. Only reduced weight contributed to a significantly higher risk of post-operative fistula. In conclusion patient age, experience of surgeon, and duration of surgery had no influence on the early outcome. High leucocyte count had a tendency for and reduced weight had a significant influence on fistula occurrence. Long-term outcome on speech development and maxillary growth have to be collected.
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Affiliation(s)
- Bilal Al-Nawas
- Oral-, Maxillofacial- and Plastic Surgery, University Medical Hospital of the J. Gutenberg UniversityMainz, Germany.
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Ahn JH, Kang WS, Kim JH, Koh KS, Yoon TH. Clinical manifestation and risk factors of children with cleft palate receiving repeated ventilating tube insertions for treatment of recurrent otitis media with effusion. Acta Otolaryngol 2012; 132:702-7. [PMID: 22668076 DOI: 10.3109/00016489.2011.652309] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION From this study, we suggest that male gender and complete type of cleft palate contribute to the recurrence of otitis media with effusion (OME) in the patients with cleft palate. OBJECTIVES It is well known that children with cleft palate have a high prevalence of OME due to anatomic dysfunction of the eustachian tube. Our goal was to determine clinical manifestations and risk factors for children with cleft palate who received additional ventilating tube insertions after initial tube insertion during palatoplasty. METHODS We retrospectively reviewed the medical and operation records of 213 patients who received ventilating tube insertion during palatoplasty from January 1993 to June 2006. The single-VT group (n = 140) included patients who had one ventilating tube insertion only, and the repeated-VT group (n = 73) included patients who received ventilating tube insertion repeatedly because of recurring chronic OME. We analyzed age, sex, types of cleft palate, preoperative tympanogram, characteristics of discharge during myringotomy, and duration of first ventilating tube in situ. RESULTS There were significant differences between the single- and repeated-VT groups in the rate of male patients (43.6 vs 72.6%), the rate of complete cleft palate (30.0 vs 61.6%) and incomplete cleft palate (61.4 vs 26.0%), the rate of preoperative type A tympanogram (30.0 vs 13.7%) and type B tympanogram (57.1 vs 75.3%), the proportion of discharge during myringotomy (72.1 vs 86.3%), and the mean indwelling period of the first ventilating tube (12.7 ± 9.6 vs 10.5 ± 6.5 months). In addition, sex and type of cleft palate were proved to affect the repetition of VT independently. However, when we performed multivariate analysis, only complete type of cleft palate and male gender showed significant differences between single- and repeated-VT groups.
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Affiliation(s)
- Joong Ho Ahn
- Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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39
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Alper CM, Losee JE, Mandel EM, Seroky JT, Swarts JD, Doyle WJ. Pre- and post-palatoplasty Eustachian tube function in infants with cleft palate. Int J Pediatr Otorhinolaryngol 2012; 76:388-91. [PMID: 22230559 PMCID: PMC3615537 DOI: 10.1016/j.ijporl.2011.12.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/16/2011] [Accepted: 12/17/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE One past study conducted in 1986 reported Eustachian tube dilation with swallowing during the forced response test (FRT) in a very high percentage (>80%) of cleft palate patients both before and after palatoplasty. The present study was designed to determine the reproducibility of those results. METHODS The FRT was used to evaluate Eustachian tube function in a cohort of cleft palate children before and after palatoplasty. Pre-palatoplasty FRT data were available for 25 ears and post-palatoplasty data were available for 31 ears; 14 ears had paired pre-post palatoplasty test data. The results for the FRT tests were compared between the pre- and post-palatoplasty groups for the cross-sectional data and for the paired subset of ears. RESULTS The 3 passive function measures of the FRT, the opening pressure, closing pressure and passive resistance were not different before and after palatoplasty for either data set. Similarly, 2 of the 3 active function measures, active resistance and dilatory efficiency, were not different pre- and post-palatoplasty, but the percent of ears evidencing tubal dilation for the cross-sectional data was 39% and 62% (p=NS) and for the paired subset was 33% and 83% (p=0.04) at the pre- and post-palatoplasty tests. CONCLUSION Palatoplasty had no effect on most measures of the FRT, but may have had a positive effect on the ability to dilate the Eustachian tube during swallowing. The high frequency of ears with tubal dilation before palatoplasty reported in the 1986 study was not reproduced but that frequency after palatoplasty was similar.
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Affiliation(s)
- Cuneyt M Alper
- Department of Otolaryngology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States.
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40
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Yamashita RP, Carvalho ELL, Fukushiro AP, Zorzetto NL, Trindade IEK. Efeito da veloplastia intravelar sobre a nasalidade em indivíduos com insuficiência velofaríngea. REVISTA CEFAC 2011. [DOI: 10.1590/s1516-18462011005000040] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: verificar o efeito da palatoplastia secundária realizada com veloplastia intravelar sobre a nasalidade e nasalância dos pacientes com fissura de palato reparada e insuficiência velofaríngea (IVF) e comparar os resultados entre estes pacientes, de acordo com o grau de fechamento velofaríngeo aferido na nasofaringoscopia. MÉTODO: estudo prospectivo com 40 pacientes de ambos os sexos, com idades entre 4 e 48 anos, com fissura de palato reparada e IVF residual, avaliado 3 dias antes e 8 meses após a palatoplastia, em média, divididos em dois grupos: um com 25 pacientes com falhas pequenas (grupo I) e outro com 15 pacientes com falhas médias a grandes (grupo II) no fechamento velofaríngeo. A hipernasalidade foi avaliada perceptivamente e nasalância foi avaliada por meio da nasometria. Diferenças entre grupos e etapas foram consideradas significativas ao nível de 5%. O estudo foi aprovado pelo Comitê de Ética para Pesquisa com Seres Humanos da Instituição. RESULTADOS: após a cirurgia, verificou-se redução da hipernasalidade em 84% dos pacientes do grupo I e em 73% dos pacientes do grupo II. Redução da nasalância foi observada em 52% dos casos do grupo I e em 43% dos pacientes do grupo II. CONCLUSÃO: a palatoplastia secundária com veloplastia intravelar levou à melhora da nasalidade na maioria dos pacientes analisados. Os resultados também demonstraram que a cirurgia foi mais efetiva nos pacientes que apresentavam falhas pequenas no fechamento velofaríngeo.
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Affiliation(s)
| | | | | | - Neivo Luiz Zorzetto
- Universidade de São Paulo; Universidade Estadual Paulista Julio de Mesquita Filho
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41
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Campbell A, Costello BJ, Ruiz RL. Cleft lip and palate surgery: an update of clinical outcomes for primary repair. Oral Maxillofac Surg Clin North Am 2010; 22:43-58. [PMID: 20159477 DOI: 10.1016/j.coms.2009.11.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The comprehensive management of cleft lip and palate has received significant attention in the surgical literature over the last half century. It is the most common congenital facial malformation and has a significant developmental, physical, and psychological impact on those with the deformity and their families. In the United States, current estimates place the prevalence of cleft lip and palate or isolated cleft lip at approximately 1 in 600. There is significant phenotypic variation in the specific presentation of facial clefts. Understanding outcome data is important when making clinical decisions for patients with clefts. This article provides an update on current primary cleft lip and palate outcome data.
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Affiliation(s)
- Andrew Campbell
- Division of Craniofacial and Cleft Surgery, Department of Oral and Maxillofacial Surgery, University of Pittsburgh School of Dental Medicine, 3471 Fifth Avenue, Suite 1112, Pittsburgh, PA 15213, USA
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42
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Katzel EB, Basile P, Koltz PF, Marcus JR, Girotto JA. Current surgical practices in cleft care: cleft palate repair techniques and postoperative care. Plast Reconstr Surg 2009; 124:899-906. [PMID: 19730310 DOI: 10.1097/prs.0b013e3181b03824] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to objectively report practices commonly used in cleft palate repair in the United States. This study investigates current surgical techniques, postoperative care, and complication rates for cleft palate repair surgery. METHODS All 803 surgeon members of the American Cleft Palate-Craniofacial Association were sent online and/or paper surveys inquiring about their management of cleft palate patients. RESULTS Three-hundred six surveys were received, a 38 percent response rate. This represented responses of surgeons from 100 percent of American Cleft Palate-Craniofacial Association registered cleft teams. Ninety-six percent of respondents perform a one-stage repair. Eighty-five percent of surgeons perform palate surgery when the patient is between 6 and 12 months of age. The most common one-stage repair techniques are the Bardach style (two flaps) with intravelar veloplasty and the Furlow palatoplasty. After surgery, 39 percent of surgeons discharge patients within 24 hours. Another 43 percent discharge patients within 48 hours. During postoperative management, 92 percent of respondents implement feeding restrictions. Eighty-five percent of physicians use arm restraints. Surgeons' self-reported complications rates are minimal: 54 percent report a fistula in less than 5 percent of cases. The reported need for secondary speech surgery varies widely. CONCLUSIONS The majority of respondents repair clefts in one stage. The most frequently used repair techniques are the Furlow palatoplasty and the Bardach style with intravelar veloplasty. After surgery, the majority of surgeons discharge patients in 1 or 2 days, and nearly all surgeons implement feeding restrictions and the use of arm restraints. The varying feeding protocols are reviewed in this article.
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Affiliation(s)
- Evan B Katzel
- Rochester, N.Y.; and Durham, N.C. From the University of Rochester School of Medicine and Duke University
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The Importance of Radical Intravelar Veloplasty during Two-Flap Palatoplasty. Plast Reconstr Surg 2008; 122:1121-1130. [DOI: 10.1097/prs.0b013e3181845a21] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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