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Sullivan NAT, Sijtsema V, Lachkar N, Paes EC, Breugem CC, Logjes RJH. Velopharyngeal insufficiency after cleft palate repair in patients with isolated Robin sequence versus isolated cleft palate: A systematic review. JPRAS Open 2024; 42:58-80. [PMID: 39290399 PMCID: PMC11405636 DOI: 10.1016/j.jpra.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 07/26/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND Robin sequence (RS) is characterized by micrognathia, glossoptosis, and upper airway obstruction, and is often combined with a cleft palate. It is unclear whether RS negatively impacts the development of velopharyngeal incompetence (VPI) and attainable speech outcomes. This study systematically reviewed speech outcomes in patients with cleft and isolated RS (IRS) compared with only isolated cleft palate (ICP). METHODS A literature search following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines was performed using the PubMed and EMBASE databases. Articles reporting speech outcomes following primary palatoplasty in patients with IRS only or IRS versus ICP were identified. Study characteristics and methods, primary- and VPI palatoplasty, speech measurements, and post-operative complications were collected. Primary outcomes included VPI and need for speech correcting surgery (SCS). Methodological quality was appraised using the methodological index for non-randomized studies (MINORS) criteria (range: 0-16 and 0-24). RESULTS Nineteen studies reported VPI event rates that varied between 14% and 88% for IRS and 0% and 62% for ICP. Five out of 8 studies (67%) comparing VPI event rates between IRS and ICP found no significant difference. SCS rates varied between 0% and 48% for IRS and 0% and 24% for ICP. Six out of 9 studies (67%) comparing SCS rates between IRS and ICP, found no significant difference. Combined VPI event rates were 36.1% for the IRS group and 26% for the ICP group, for SCS rates this was 20% for IRS and 13% for ICP. CONCLUSION Most articles found no significant difference between the VPI and SCS rates indicating that speech outcomes might be similar in patients with IRS and ICP. To better compare these groups a standardized international protocol is needed.
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Affiliation(s)
- N A T Sullivan
- Amsterdam University Medical Centers, location University of Amsterdam, department of Plastic Surgery
- Amsterdam Reproduction & Development Research Institute
| | - V Sijtsema
- Amsterdam University Medical Centers, location University of Amsterdam, department of Plastic Surgery
| | - N Lachkar
- Amsterdam University Medical Centers, location University of Amsterdam, department of Plastic Surgery
| | - E C Paes
- University Medical Center Utrecht, department of Plastic Surgery
| | - C C Breugem
- Amsterdam University Medical Centers, location University of Amsterdam, department of Plastic Surgery
- Amsterdam Reproduction & Development Research Institute
| | - R J H Logjes
- Amsterdam University Medical Centers, location University of Amsterdam, department of Plastic Surgery
- University Medical Center Utrecht, department of Plastic Surgery
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van de Velde S, Smit MM, Logjes RJH, Martin E, Haasnoot M, Mink van der Molen AB, Paes EC. Postoperative respiratory difficulties following primary cleft palate repair in infants with Robin sequence versus isolated cleft palate: A retrospective study. J Craniomaxillofac Surg 2024:S1010-5182(24)00250-6. [PMID: 39256140 DOI: 10.1016/j.jcms.2024.08.021] [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: 12/19/2023] [Revised: 05/24/2024] [Accepted: 08/21/2024] [Indexed: 09/12/2024] Open
Abstract
The study aimed to: (1) compare the occurrence of postoperative respiratory difficulties (PRD) following primary cleft palate repair (CPR) in infants with an isolated cleft palate (iCP) and infants with Robin sequence (RS), and (2) describe the possible benefit of preoperative analysis with palatal plate in infants with RS. All consecutive infants with an iCP and infants with RS who underwent CPR between January 2009 and June 2022 in the Wilhelmina Children's Hospital were retrospectively reviewed. A total of 127 infants were included of which 74 infants with an iCP and 53 infants with RS. The group of infants with RS consisted of 35 infants with non-isolated RS (niRS) and 18 infants with isolated RS (iRS). Significant more PRD were seen in infants with RS compared to infants with an iCP (14/53 versus 9/74; p = 0.04). Especially infants with niRS have a significant higher risk of developing PRD in comparison with infants with an iCP (OR = 4.16, 95% CI [1.17-15.99], p = 0.031). The preoperative palatal plate screening in infants with RS (n = 25) did not show abnormalities and had no effect on the perioperative policy. Within the limitations of this study it seems that infants with niRS are more prone to develop PRD following primary CPR when compared to infants with iRS or an iCP. No clear benefit was found in postponing surgery until 12 months or later in infants with RS to avoid PRD. The preoperative palatal plate screening did not demonstrate signs of UAO in infants with RS that developed PRD. These findings suggest that preoperative analysis with palatal plate has a low predictive value.
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Affiliation(s)
- Shirley van de Velde
- Department of Pediatric Plastic and Reconstructive Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA, Utrecht, the Netherlands.
| | - Merel M Smit
- Department of Pediatric Plastic and Reconstructive Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
| | - Robrecht J H Logjes
- Department of Pediatric Plastic and Reconstructive Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
| | - Enrico Martin
- Department of Pediatric Plastic and Reconstructive Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
| | - Maartje Haasnoot
- Department of Pediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
| | - Aebele B Mink van der Molen
- Department of Pediatric Plastic and Reconstructive Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
| | - Emma C Paes
- Department of Pediatric Plastic and Reconstructive Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
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Sullivan NAT, Lachkar N, Don Griot JPW, Kruisinga FH, Leeuwenburgh-Pronk WG, Broers CJM, Breugem CC. Respiratory outcomes after cleft palate closure in Robin sequence: a retrospective study. Clin Oral Investig 2024; 28:247. [PMID: 38602599 PMCID: PMC11008067 DOI: 10.1007/s00784-024-05647-w] [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: 06/12/2023] [Accepted: 04/01/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVES There is a paucity of information about the possible risk factors that could identify patients with Robin sequence (RS) who are more prone to developing obstructive airway complications after palate closure. This study aimed to compare the respiratory complication rates in patients with RS and isolated cleft palate (ICP). MATERIALS AND METHODS In this retrospective study, we reviewed the medical records of 243 consecutive patients with RS and ICP who were treated at Amsterdam University Medical Centers over the past 25 years. We collected preoperative data on previous treatment, diagnostic findings, surgical technique, weight, and presence of congenital anomalies. RESULTS During cleft palate closure, patients with RS were older (11.9 versus 10.1 months; p = 0.001) and had a lower gestational age than those with ICP (37.7 versus 38.5 weeks; p = 0.002). Patients with RS had more respiratory complications (17 versus 5%; p = 0.005), were more often non-electively admitted to the pediatric intensive care unit (PICU) (13 versus 4.1%; p = 0.022), and had a longer hospital stay duration (3.7 versus 2.7 days; p = 0.011) than those with ICP. The identified risk factors for respiratory problems were a history of tongue-lip-adhesion (TLA) (p = 0.007) and a preoperative weight of < 8 kg (p = 0.015). Similar risk factors were identified for PICU admission (p = 0.015 and 0.004, respectively). CONCLUSIONS The possible risk factors for these outcomes were a low preoperative weight and history of TLA. Closer postoperative surveillance should be considered for patients with these risk factors. CLINICAL RELEVANCE Identifying risk factors for respiratory complications could provide clinicians better insight into their patients and allows them to provide optimal care for their patients.
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Affiliation(s)
- Nathaniel A T Sullivan
- Amsterdam UMC, Department of Plastic Surgery, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands.
| | - Nadia Lachkar
- Amsterdam UMC, Department of Plastic Surgery, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - J Peter W Don Griot
- Amsterdam UMC, Department of Plastic Surgery, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Frea H Kruisinga
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
| | - Wendela G Leeuwenburgh-Pronk
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
| | - Chantal J M Broers
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
| | - Corstiaan C Breugem
- Amsterdam UMC, Department of Plastic Surgery, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
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Williams JL, Lien KM, Kirschner R, Allen G, Chapman K. Feeding Management and Palate Repair Timing in Infants with Cleft Palate with and without Pierre Robin Sequence: A Multisite Study. Cleft Palate Craniofac J 2024:10556656241239766. [PMID: 38490219 PMCID: PMC11401965 DOI: 10.1177/10556656241239766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVES Compare the feeding management practices in infants with cleft palate with and without Pierre Robin sequence (PRS) and determine if specific feeding difficulties or interventions predict delayed palate repair. DESIGN Retrospective cross-sectional study. SETTING Seventeen cleft palate teams contributed data. PATIENTS 414 infants were included in this study: 268 infants with cleft palate only and 146 infants with cleft palate and PRS. PROCEDURES Data were collected via parent interview and electronic health records. MAIN OUTCOME MEASURES Outcomes for the primary objective included categorical data for: history of poor growth, feeding therapy, milk fortification, use of enteral feeding, and feeding difficulties. The outcome for the secondary objective was age in months at primary palate repair. RESULTS Infants with PRS had a significantly higher prevalence of feeding difficulties (81% versus 61%) and poor growth (29% versus 15%) compared to infants with cleft palate only. Infants with PRS received all feeding interventions-including feeding therapy, milk fortification, and enteral feeding-at a significantly higher frequency. Infants with PRS underwent primary palate repair at a mean age of 13.55 months (SD = 3.29) which was significantly (P < .00001) later than infants with cleft palate only who underwent palate repair at a mean age of 12.05 months (SD = 2.36). Predictors of delayed palate repair included diagnosis of PRS as well as Hispanic ethnicity and a history of poor growth. CONCLUSIONS These findings can be used to establish clinical directives focused on providing early, multimodal feeding interventions to promote optimal growth and timely palate repair for infants with PRS.
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Affiliation(s)
- Jessica L Williams
- Phoenix Children's Center for Cleft and Craniofacial Care a Division of Plastic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
- Program of Speech and Hearing Science, College of Health Solutions, Arizona State University, Tempe, AZ, USA
| | - Kari M Lien
- Department of Communication Sciences and Disorders, College of Health, University of Utah, Salt Lake City, UT, USA
| | - Richard Kirschner
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Plastic Surgery, The Ohio State University Medical College, Columbus, OH, USA
| | - Gregory Allen
- Department of Otolaryngology, Children's Hospital Colorado, Aurora, CO, USA
| | - Kathy Chapman
- Department of Communication Sciences and Disorders, College of Health, University of Utah, Salt Lake City, UT, USA
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Wang C, Shi B, Li J. Management of cleft palate among patients with Pierre Robin sequence. Br J Oral Maxillofac Surg 2023; 61:475-481. [PMID: 37453893 DOI: 10.1016/j.bjoms.2023.06.003] [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: 12/04/2022] [Revised: 05/29/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
Pierre Robin Sequence (PRS) is a congenital craniofacial anomaly distinguished by the presence of micrognathia, glossoptosis, and upper airway obstruction. Cleft palate occurs in over 3/4 of patients with PRS. The wide U-shape cleft and airway dysfunction create challenges in clinical management. Currently, disputes exist on the treatment protocol and prognosis of cleft palate management among patients with PRS. This review is focused on the deformity features, intervention timing, technique selection, airway support, and outcome evaluation of cleft palate among patients with PRS, aiming to provide reference to further evolution in the management of PRS-related cleft palate.
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Affiliation(s)
- Chunyi Wang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, PR China
| | - Bing Shi
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, PR China
| | - Jingtao Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, PR China.
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Scott AR, Shumrick CM, Hussein M, Ebert BE, Schnell A, Roby BB. Unplanned Intensive Care Unit Admission Following Cleft Palate Repair by Head and Neck Surgeons. Otolaryngol Head Neck Surg 2023; 168:688-695. [PMID: 35998034 DOI: 10.1177/01945998221119730] [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: 02/16/2022] [Accepted: 07/24/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine the incidence of pediatric intensive care unit (PICU) admission following primary repair of cleft palate by otolaryngologist-head and neck surgeons at 2 tertiary centers. To identify potential diagnoses associated with admission or unanticipated PICU transfer. STUDY DESIGN Multi-institutional case series with chart review. SETTING Two tertiary pediatric medical centers. METHODS Children who underwent primary repair of cleft palate at 2 cleft centers over a 10-year period were identified. Charts were reviewed for demographics, comorbidities, and whether PICU admission was required. RESULTS From 2009 to 2019, 464 patients underwent primary repair of a cleft palate by 1 of 6 otolaryngologist-head and neck surgeons with subspecialty training in cleft surgery; 459 patients had sufficient postoperative documentation and 443 children met inclusion criteria. The incidence of PICU admission was 9.3% (41/443), with 33 (7.4%) planned admissions and 8 (1.8%) unexpected PICU transfers. Syndromic conditions were associated with both planned and unanticipated PICU admissions. CONCLUSION The incidence of unanticipated postoperative PICU admission following cleft palate repair by otolaryngologist-head and neck surgeons was low. Risk stratification by surgeons with expertise in airway management may inform decisions regarding postoperative disposition of patients with medical or airway complexity who are undergoing cleft palate repair. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Andrew R Scott
- Department of Otolaryngology-Head & Neck Surgery, Tufts Medical Center and Tufts Children's Hospital, Boston, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Christopher M Shumrick
- Department of Otolaryngology-Head & Neck Surgery, Tufts Medical Center and Tufts Children's Hospital, Boston, Massachusetts, USA
| | - Musse Hussein
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Bridget E Ebert
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Avery Schnell
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Brianne B Roby
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Children's Minnesota ENT and Facial Plastic Surgery, Minneapolis, Minnesota, USA
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Kosyk MS, Carlson AR, Zapatero ZD, Kalmar CL, Swanson JW, Bartlett SP, Taylor JA. Cleft Palate Repair in Robin Sequence following Mandibular Distraction Osteogenesis Compared to Tongue-Lip Adhesion. Cleft Palate Craniofac J 2023; 60:151-158. [PMID: 34730034 DOI: 10.1177/10556656211055019] [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: 01/18/2023] Open
Abstract
OBJECTIVE To evaluate the timing and safety of cleft palate (CP) repair in patients with Robin sequence (RS) treated with mandibular distraction osteogenesis (MDO) or tongue-lip adhesion (TLA) for airway obstruction. DESIGN Retrospective cohort study. SETTING Tertiary Pediatric Hospital during 2004-2020. PATIENTS 148 patients with RS underwent MDO, 66 met inclusion by having MDO and followed by palatoplasty. 26 patients with RS underwent TLA, 14 met inclusion by having TLA and followed by palatoplasty. MAIN OUTCOME MEASURES Patient characteristics, hospital/operative details, postoperative complications, and polysomnographic (PSG) data were compared. RESULTS Groups were well-matched except more patients with syndromes underwent MDO (N = 27, 41%, P ≤ .002). In the MDO and TLA cohorts, mean CP repair age was 12.8 ± 1.9 months and 14.6 ± 1.6 months, respectively (P ≤ .002). Despite the earlier CP repair in the MDO group, there were no differences in peri-operative complication rates after palatoplasty in either group. All sleep respiratory parameters improved after MDO/TLA prior to palatoplasty P ≤ .050. All PSG parameters remained significantly improved after palatoplasty compared to preoperative values, P ≤ .043. Obstructive apnea hypopnea index and Oxygen saturation nadir further improved after palatoplasty within the MDO group, P ≤ .050, while no changes in the TLA group, P ≥ .500. CONCLUSIONS MDO was associated with earlier age at palatoplasty than TLA with a similar perioperative risk profile. In those patients with pre- and post-palatoplasty PSG data, palatoplasty was not associated with a deterioration in PSG parameters, and in fact in the MDO group, PSG data improved.
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Affiliation(s)
- Mychajlo S Kosyk
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anna R Carlson
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary D Zapatero
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher L Kalmar
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan W Swanson
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott P Bartlett
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Speech Outcomes following Mandibular Distraction Osteogenesis for Robin Sequence: Midchildhood Results. Plast Reconstr Surg 2023; 151:149-157. [PMID: 36576825 DOI: 10.1097/prs.0000000000009784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this study was to compare midchildhood speech outcomes in patients with nonsyndromic Robin sequence with cleft palate (RSCP) treated with mandibular distraction osteogenesis (MDO) to patients with nonsyndromic Veau class I and Veau class II cleft palate (CP). METHODS The authors performed a retrospective review of patients with nonsyndromic Robin sequence from 2000 to 2017, comparing those who underwent MDO to patients with nonsyndromic CP. Demographics, operative details, length of hospital stay, complications, and Pittsburgh Weighted Speech Scale scores were collected. RESULTS Thirty-three patients met inclusion criteria in the MDO group with 127 patients as controls. Despite similar median age (RSCP, 4.5 years; CP only, 4.6 years) and Veau cleft type at early evaluation, there was a significant increase in composite Pittsburgh Weighted Speech Scale score within the MDO cohort ( P ≤ 0.002); specifically, with worse visible nasal emission ( P ≤ 0.007), hypernasality ( P ≤ 0.001), and compensatory articulation ( P ≤ 0.015). However, these differences were not present at age-matched midchildhood evaluation (median, RSCP, 6.5; CP only, 7.1; P ≥ 0.092). Median age-matched follow-up was 6.4 years in the MDO group and 7.1 years in the control group ( P ≥ 0.136). There was also no difference in the rate of secondary speech surgery at midchildhood evaluation ( P ≥ 0.688). CONCLUSIONS The authors' retrospective comparison of speech outcomes in RSCP versus CP only demonstrates no difference in midchildhood speech, conflicting with recent reports. Although patients with Robin sequence treated with MDO had worse visible nasal emission, hypernasality, and compensatory articulation in early childhood, this appears to have resolved in the interim without additional intervention. Longitudinal follow-up is needed to fully understand the speech ramifications of RSCP. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Impact of Cleft Palate on Tongue-Based Upper Airway Obstruction in Pierre Robin Sequence: Implications for Mandibular Distraction Osteogenesis and Timing of Cleft Palate Repair. J Craniofac Surg 2021; 33:459-462. [PMID: 34538802 DOI: 10.1097/scs.0000000000008178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The objectives of this study are to analyze the impact of cleft palate (CP) on upper airway obstruction using polysomnography in patients with Pierre Robin Sequence (PRS) undergoing mandibular distraction osteogenesis (MDO) and subsequent CP repair. METHODS A single-surgeon, retrospective chart review was performed of all patients with nonsyndromic PRS treated with MDO. Severity of upper airway obstruction was evaluated pre- and post-distraction via polysomnography. Details of MDO and CP repair were collected and any complications recorded. RESULTS Twenty-one nonsyndromic PRS patients with CP and 6 patients without CP met inclusion criteria. There was no significant difference in predistraction apnea-hypopnea index between the 2 groups (53.4 ± 42.1 versus 34.4 ± 18.9; P = 0.3). Patients with CP had significantly higher predistraction SpO2 saturation (94.5 ± 1.6% versus 91.0% ± 4.8%; P = 0.01), SpO2 nadir (74.5% ± 9.1% versus 63.6% ± 11.6%; P = 0.03) and lower percentage time spent below 90% SpO2 (6.0% ± 7.2% versus 23.6% ± 29.9%; P = 0.04). The rate of oronasal fistulas formation was 38%. The time between MDO and CP repair was shorter for patients with complications (250.8 ± 3.3 versus 370.8 ± 191.9 days; P = 0.08). Five patients experienced relapse of respiratory difficulties after CP repair. CONCLUSIONS The presence of CP in nonsyndromic PRS patients decreases the severity of obstructive sleep apnea by oxygen parameters on PSG. Palatal fistulas and relapse of respiratory distress are common complications of CP repair following MDO. Delaying CP repair may help to decrease complication rates.
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Abstract
BACKGROUND Pierre Robin sequence (Robin sequence) is defined as the triad of micrognathia, glossoptosis, and airway obstruction. It is frequently associated with palatal clefting. In recent years, increased interest in speech outcomes of cleft patients diagnosed with Robin sequence has been shown. METHODS Speech outcomes of cleft patients with Robin sequence were assessed at age 5 in comparison with a cleft palate-only cohort. Speech parameters were evaluated according to the Cleft Audit Protocol for Speech-Augmented and analyzed using the National Audit Standards for Speech (United Kingdom). All patients were treated in the same institution during the same period (2005 to 2012). Subjects who needed nasopharyngeal airway support and those whose airway was managed by positioning only were eligible. RESULTS Fifty-one cleft patients diagnosed with Robin sequence were included in this study. Outcomes were compared to those of 128 nonsyndromic cleft palate-only patients.Patients with Robin sequence were shown to present with a significantly higher rate of cleft speech characteristics in comparison to the reference cohort (p = 0.001). Furthermore, it was shown that Robin sequence is associated with a significantly higher rate of secondary speech surgery for velopharyngeal dysfunction before the age of 5 (p = 0.016). Robin sequence patients with a nasopharyngeal airway presented with a higher rate of cleft speech characteristics compared to Robin sequence patients managed with positioning only. CONCLUSION Cleft patients with Robin sequence are more likely to need further surgery to correct velopharyngeal dysfunction before the age of 5 and are more prone to present with cleft speech characteristics at the age of 5. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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van Eeden S, Wren Y, McKean C, Stringer H. Early Communication Behaviors in Infants With Cleft Palate With and Without Robin Sequence: A Preliminary Study. Cleft Palate Craniofac J 2021; 59:984-994. [PMID: 34259062 PMCID: PMC9272514 DOI: 10.1177/10556656211031877] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To investigate the early communication behaviors in infants with nonsyndromic isolated cleft palate (iCP) and Robin sequence (RS). DESIGN Group comparison using parent report. PARTICIPANTS There were 106 participants included in this study. Two groups were selected from the UK Cleft Collective resource. Parents had completed the Language ENvironment Analysis Developmental Snapshot questionnaire when their child turned 13 months. There were 78 participants in the iCP group and 28 in the RS group. MAIN OUTCOME MEASURE(S) Total number of communication behaviors reported on the questionnaire. Subdomains for expressive and receptive language and social communication behaviors were also analyzed. RESULTS There were no statistically significant group differences. Parents of infants with RS reported fewer later communication behaviors compared to the iCP group. Infants in both groups had fewer communication behaviors compared to the normative sample. Across the whole sample, post hoc analysis revealed a significant correlation between severity of the cleft and social communication behaviors and expressive but not receptive language. Infants with a cleft of the hard and soft palate were more likely to be in the RS group (odds ratio: 7.04 [95% CI: 1.55-32.04]; P = .01). CONCLUSIONS Both groups reported similar levels of early communication. Some divergence of more complex language skills was seen, although there were no significant group differences. A relationship with the diagnosis of a cleft of the hard or soft palate with expressive language behaviors was found. Further study into the impact of cleft severity on early speech development and the relationship with later language skills is needed along with longitudinal follow-up of this population.
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Affiliation(s)
- Stephanie van Eeden
- School of Education, Communication and Language Sciences, 5994Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Yvonne Wren
- Bristol Speech and Language Therapy Research Unit, North Bristol NHS Trust, Bristol, United Kingdom.,1980University of Bristol, Bristol, United Kingdom
| | - Cristina McKean
- School of Education, Communication and Language Sciences, 5994Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helen Stringer
- School of Education, Communication and Language Sciences, 5994Newcastle University, Newcastle upon Tyne, United Kingdom
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Tsuji K, Haruyama N, Nomura S, Murata N, Yoshizaki K, Mitsuyasu T, Nakano H, Nakamura S, Mori Y, Takahashi I. Characteristics of craniofacial morphology and factors affecting them in patients with isolated cleft palate. PeerJ 2021; 9:e11297. [PMID: 33976983 PMCID: PMC8063870 DOI: 10.7717/peerj.11297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/28/2021] [Indexed: 11/20/2022] Open
Abstract
Background Myriad maxillo-mandibular occlusal relationships are observed in patients with isolated cleft palate (ICP), unlike in patients with other cleft types, such as cleft lip and palate. Objectives This study aimed to categorise the characteristics of craniofacial morphology in patients with ICP, and investigate the clinical factors affecting these categorised morphological characteristics. Methods Thirty-six girls with ICP (age (mean ± SD): 5.36 ± 0.36 years) underwent cephalometric measurement. Their craniofacial morphology was categorised using cluster analysis. Profilograms were created and superimposed onto the standard Japanese profilograms to visualise the morphological characteristics of each group (cluster). The mean values and variations in the linear and angular measurements of each group were compared with the Japanese standards and statistically analysed using Dunnett’s test after the analysis of variance. Fisher’s exact test was used to analyse the differences between the cleft types (cleft in the hard and/or soft palate) and skills of the operating surgeons in the groups. Results Cluster analysis of craniofacial morphologies in patients with ICP resulted in the formation of three categories: the first cluster exhibited a relatively harmonious anteroposterior relationship between the maxilla and the mandible (22.2%); the second cluster exhibited crossbite owing to a significantly smaller maxilla (33.3%); and the third cluster exhibited a smaller mandible with posterior rotation showing skeletal class II malocclusion (44.4%). Differences in cleft types and surgeons were not associated with the distribution of patients in each cluster. Conclusions Patients with ICP exhibited characteristic morphological patterns, such as bimaxillary retrusion or severe mandibular retrusion, besides the anterior crossbite frequently found in patients with cleft lip and palate . Understanding the typical morphological characteristics could enable better diagnostic categorisation of patients with ICP, which may eventually improve orthodontic treatment planning.
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Affiliation(s)
- Kyoko Tsuji
- Section of Orthodontics and Dentofacial Orthopedics, Faculty of Dental Science, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Naoto Haruyama
- Section of Orthodontics and Dentofacial Orthopedics, Faculty of Dental Science, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Shunsuke Nomura
- Section of Orthodontics and Dentofacial Orthopedics, Faculty of Dental Science, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Naohisa Murata
- Section of Orthodontics and Dentofacial Orthopedics, Faculty of Dental Science, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Keigo Yoshizaki
- Section of Orthodontics and Dentofacial Orthopedics, Faculty of Dental Science, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Takeshi Mitsuyasu
- Section of Oral and Maxillofacial Oncology, Faculty of Dental Science, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Hiroyuki Nakano
- Department of Dentistry and Oral Surgery, Division of Medicine for Function and Morphology of Sensory Organs, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Seiji Nakamura
- Section of Oral and Maxillofacial Oncology, Faculty of Dental Science, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Yoshihide Mori
- Section of Oral and Maxillofacial Surgery, Faculty of Dental Science, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Ichiro Takahashi
- Section of Orthodontics and Dentofacial Orthopedics, Faculty of Dental Science, Kyushu University, Fukuoka, Fukuoka, Japan
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Discussion: The Effect of Surgical Timing on 30-Day Outcomes in Cleft Palate Repair. Plast Reconstr Surg 2021; 147:138-140. [PMID: 33370057 DOI: 10.1097/prs.0000000000007459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Naros A, Krimmel M, Zengerle F, Bacher M, Koos B, Mack U, Wiechers C, Poets CF, Reinert S. Perioperative complications in cleft palate repair with Robin sequence following Tuebingen palatal plate treatment. J Craniomaxillofac Surg 2021; 49:298-303. [PMID: 33612407 DOI: 10.1016/j.jcms.2021.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/03/2020] [Accepted: 02/07/2021] [Indexed: 11/21/2022] Open
Abstract
Our study aimed to evaluate perioperative complications following our institutional pre- and intraoperative management in cleft palate repair with Robin sequence (RS). RS patients who underwent cleft palate repair between 2000 and 2020 were retrospectively analysed. RS children with complete documentation and whose initial treatment involved the Tuebingen palatal plate (TPP) were included. Clinical records and operative charts were reviewed with regard to clinical characteristics as well as the neonatal and perioperative course. Results before and after adjustment of the anesthesiology protocol in 2014 were compared. 143 RS patients (41% male, 59% female) were included. Median pretherapeutic mixed-obstructive apnea index (MOAI) after birth was 9.4/hour (IQR 20.0). TPP treatment was associated with normalisation of the MOAI and adequate weight gain until surgery. At surgery, median age was 10 months (IQR 3), MOAI 0.1/h (IQR 0.5), and weight 8.7 kg (IQR 1.7). In 93% of cases (n = 133), the postoperative course was uneventful. Refinement of the anesthesiology protocol showed positive effects on the perioperative course and led to a reduction in perioperative events (10.7% vs. 2.9%). No severe perioperative complications occurred. We recommend the adoption of TPP treatment in the therapy of RS children. Our favourable results show that early TPP treatment minimizes perioperative complications in cleft palate repair by effectively and sustainably correcting upper airway obstruction.
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Affiliation(s)
- Andreas Naros
- Department of Oral and Maxillofacial Surgery, Tuebingen University Hospital, Germany; Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, Tuebingen University Hospital, Germany.
| | - Michael Krimmel
- Department of Oral and Maxillofacial Surgery, Tuebingen University Hospital, Germany; Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, Tuebingen University Hospital, Germany
| | - Franziska Zengerle
- Department of Oral and Maxillofacial Surgery, Tuebingen University Hospital, Germany
| | - Margit Bacher
- Department of Orthodontics, Tuebingen University Hospital, Germany; BIP-Orthodontic Practice, Tuebingen, Germany
| | - Bernd Koos
- Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, Tuebingen University Hospital, Germany; Department of Orthodontics, Tuebingen University Hospital, Germany
| | - Ulrich Mack
- Department of Anaesthesiology and Intensive Care Medicine, BG Unfallklinik Tuebingen, Germany
| | - Cornelia Wiechers
- Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, Tuebingen University Hospital, Germany; Department of Neonatology, Tuebingen University Hospital, Germany
| | - Christian F Poets
- Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, Tuebingen University Hospital, Germany; Department of Neonatology, Tuebingen University Hospital, Germany
| | - Siegmar Reinert
- Department of Oral and Maxillofacial Surgery, Tuebingen University Hospital, Germany; Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, Tuebingen University Hospital, Germany
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Long-term Speech Outcomes of Cleft Palate Repair in Robin Sequence versus Isolated Cleft Palate. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3351. [PMID: 33564582 PMCID: PMC7859383 DOI: 10.1097/gox.0000000000003351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/16/2020] [Indexed: 12/28/2022]
Abstract
Supplemental Digital Content is available in the text. Whether treatment of cleft palate (CP) associated with Robin sequence (RS) should attain outcomes similar to those of isolated cleft palate (ICP) remains unknown. This study compares treatment and outcomes in both conditions and delineates predictors of long-term outcome.
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Abstract
BACKGROUND This cohort study aimed to assess how age at repair affects outcomes in nonsyndromic patients with and without Robin Sequence using a national database of commercial healthcare claims. METHODS Children under 4 years of age undergoing palatoplasty were identified in the IBM MarketScan Commercial Database based on ICD-9-CM and CPT procedure codes. They were divided into Robin and non-Robin cleft palate groups, and further divided by time of initial cleft palate repair: Robin Sequence into 2 groups: age ≤10 months or >10 months; non-Robin cleft palate into 3 groups: age ≤10 months, >10-14 months, or >14 months age. Time to cleft palate revision within each group was assessed using Cox proportional-hazard models. RESULTS A total of 261 patients with Robin Sequence and 3046 with non-Robin cleft palate were identified. In patients with Robin, later repair was associated with decreased risk of secondary procedures compared with early repair (Hazard Ratio (HR) 0.19, 95%CI 0.09-0.39, P < 0.001). In patients with non-Robin cleft palate, decreased risk of revision compared to early repair was associated both with repair at >10-14 months (adjusted HR 0.40, 95%CI 0.31-0.52, P < 0.001) and > 14 months (adjusted HR 0.71, 95%CI 0.57-0.88, P = 0.002). Adjusting for timing of repair, patients with non-Robin cleft palate were at significantly increased risk of secondary procedure if diagnosed with failure to thrive or anemia in the 30 days prior to palatoplasty. CONCLUSIONS In patients with and without Robin sequence, cleft palate repair at or before 10 months of age was associated with higher risk for secondary procedures.
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Neonatal Mandibular Distraction Osteogenesis in Infants With Pierre Robin Sequence. J Craniofac Surg 2020; 31:1137-1141. [DOI: 10.1097/scs.0000000000006343] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kishimoto T, Kanazawa T, Kawasaki T, Ueta I, Park S, Horimoto Y. Postoperative complications associated with extubation strategies following palatoplasty: a single-center retrospective analysis. J Anesth 2015; 30:20-5. [PMID: 26545801 DOI: 10.1007/s00540-015-2093-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 10/21/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE Palatoplasty carries a high risk of airway obstruction as a postoperative complication. Since 2007, the protocol in our hospital has been to leave an endotracheal tube in place after surgery while the patient is moved to the pediatric intensive care unit. Extubation is then performed after achievement of hemostasis and recovery of consciousness. We compared the cases over the 5-year periods before and after the introduction of this revised postsurgical management plan to investigate its effect on postoperative complications. METHODS This was a retrospective cohort study involving a single pediatric hospital. The subjects were 199 children aged 1-3 years, who underwent palatoplasty between January 2002 and July 2012. Changes in the incidence rates of postoperative complications were statistically examined. RESULTS There were significantly more postoperative complications among the patients who were extubated in the operating room than among those extubated in the intensive care unit (operating room group, 22/94 cases; intensive care unit group, 10/105 cases; P < 0.01). Serious complications, such as hypoxemia and airway obstruction, also occurred more frequently in the operating room group. CONCLUSION Extubation in an intensive care unit was possibly associated with a reduction in postoperative complications.
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Affiliation(s)
- Takuma Kishimoto
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan. .,Department of Critical and Intensive Care Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Takamori Kanazawa
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Ikuya Ueta
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Susam Park
- Department of Plastic Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Yoh Horimoto
- Department of Anesthesiology, Shizuoka Children's Hospital, Shizuoka, Japan
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Transverse mucoperiosteal flap inset by rotation for cleft palate repair: technique and outcomes. Ann Plast Surg 2015; 72:S90-3. [PMID: 24691322 DOI: 10.1097/sap.0000000000000153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Cleft palate is a relatively common deformity with various techniques described for its repair. Most techniques address the hard palate portion of the cleft with bilateral mucoperiosteal flaps transposed to the midline. This results in superimposed, linear closure layers directly over the cleft and may predispose the repair to oronasal fistula formation. This report details an alternative technique of flap rotation with an outcome analysis. METHODS A retrospective chart analysis was performed of all patients having undergone primary palatoplasty for cleft palate. Demographics and cleft Veau type were recorded. Postoperative speech outcomes were assessed by standardized speech evaluation performed by 2 speech language pathologists. The presence and location of oronasal fistulae was assessed and recorded by the surgeon and speech language pathologists in follow-up evaluations. RESULTS The study revealed an overall incidence of velopharyngeal insufficiency of 5.7% using this surgical technique. It also revealed a fistula rate of 8.6%. Secondary surgery has been successful in those patients in which it was indicated. Eleven (31%) patients were diagnosed with Robin sequence. CONCLUSIONS This technique demonstrates excellent early outcomes in a difficult subset of cleft patients including a high proportion of those with Pierre Robin sequence. The technique addresses the inherent disadvantages to a linear closure over the bony cleft. The variability in its design provides the surgeon another option for correction of this deformity.
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Abstract
Mandibular distraction has revolutionized the treatment of Robin sequence associated with severe airway obstruction. The distraction technique remains the only intervention that directly corrects mandibular hypoplasia and the retropositioned tongue, providing efficient relief of airway stenosis. Multiple studies have demonstrated the efficacy of distraction in avoiding tracheostomy and decreasing the severity airway obstruction in this patient population. The benefit to avoiding tracheostomy and relieving airway obstruction is superior to that of tongue-lip adhesion. It is, therefore, not surprising that mandibular distraction has become the first-line intervention at many centers for the surgical treatment of Robin sequence. The complication profile associated with mandibular distraction appears low; the most common complication is infection, which can be treated by antibiotics alone. The severity of airway obstruction can be quantified by polysomnogram: This tool has become one of the most widely used objective metrics in the Robin sequence population. Therefore indications for surgery, timing of palatoplasty and long-term assessment of airway function should be performed in conjunction with sleep study analysis. The effects of mandibular lengthening on feeding difficulty in Robin sequence patient remains a topic of controversy. Studies have demonstrated conflicting results: This can be an area of future study. Agreed-upon indications for surgery and definitive protocols of care have yet to be formulized; future research should focus on achieving these goals. Such studies would require agreed-upon terminology for Robin sequence, an increase in comparative and prospective analysis, and the use of quantifiable metrics of clinical results.
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Affiliation(s)
- Roberto L Flores
- Department of Plastic Surgery, NYU Langone Medical Center, New York, New York
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Abstract
BACKGROUND Pierre Robin sequence (PRS) is a congenital condition characterized by micrognathia, glossoptosis, airway obstruction, and often clefting of the soft and hard palate. The purpose of this study was to compare oronasal fistula rates, long-term speech outcomes, and rates of secondary surgery for velopharyngeal insufficiency (VPI) after primary cleft palate repair using the modified Furlow technique between nonsyndromic patients with and without PRS. This study also sought to determine if type of airway management in infancy correlated with speech outcomes in patients with PRS. METHODS A retrospective review was performed of all nonsyndromic patients with clefts of the palate only who underwent repair between 1981 and 2006 at The Children's Hospital of Philadelphia using the modified Furlow technique. Patient outcomes were evaluated by the rate of postoperative oronasal fistula, speech scores at a minimum of age 5 years using the Pittsburgh Weighted Values for Speech Symptoms Associated with VPI, and the need for secondary pharyngeal surgery for VPI. RESULTS Fifty-five patients with PRS and 129 without PRS were included in this study. There was no significant difference in oronasal fistula rate between groups. Speech outcomes were worse in patients with PRS with 52.7% demonstrating a competent velopharyngeal mechanism, and 30.9% a borderline mechanism, compared to 72.1% and 19.4% in the non-PRS group, respectively (P = 0.035). In addition, only 76.3% of patients with PRS had no or mild hypernasality compared to 91.5% of patients without PRS (P = 0.01). The rates of nasal emission, articulation errors associated with VPI, and secondary surgery for VPI did not differ between groups. Of the patients with PRS, 36 were managed in infancy with positioning alone and 15 underwent surgical intervention for airway obstruction, and there were no significant differences in speech scores or rates of secondary surgery for VPI between these subgroups. CONCLUSIONS Nonsyndromic patients with PRS had worse speech outcomes after modified Furlow cleft palate repair, but no significant differences were seen in the rates of secondary surgery for VPI or postoperative oronasal fistula. In addition, initial airway management in patients with PRS did not correlate with speech outcomes.
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Caouette-Laberge L, Borsuk DE, Bortoluzzi PA. Subperiosteal Release of the Floor of the Mouth to Correct Airway Obstruction in Pierre Robin Sequence: Review of 31 Cases. Cleft Palate Craniofac J 2012; 49:14-20. [DOI: 10.1597/10-173] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The purpose of this study was to evaluate subperiosteal release of the floor of the mouth (SRFM) musculature to correct neonatal airway obstruction in children with Pierre Robin sequence and to compare this procedure with other surgical options available. Methods A retrospective chart review of patients who underwent a SRFM for neonatal severe airway obstruction unresponsive to conservative management was performed. Preoperative and postoperative oxygenation parameters, sleep studies, feeding difficulties, and long-term evolution were documented. Results Thirty-one consecutive patients between 1995 and 2009, 19 boys and 12 girls, had an SRFM procedure to alleviate severe neonatal airway obstruction. Eight children were syndromic, 15 had associated malformations, and eight had an isolated Pierre Robin sequence. The airway obstruction was corrected with SRFM alone in 26 children (84%), three patients remained dependent on nasopharyngeal airway, and two required subsequent mandibular osteogenic distraction procedures following the SRFM to manage persistent obstruction. No patient required a tracheostomy. The average age at SRFM was 33 days, and the patients were kept intubated for an average of 6 days postoperatively. Average hospital stay after the surgery was 45 days, and 10 patients went home with gavage feeding. Conclusions The SRFM is effective for the treatment of severe airway obstruction in patients with Pierre Robin sequence. The procedure is simple and has fewer complications and secondary procedures than other surgical options for correction of the airway obstruction.
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Affiliation(s)
- Louise Caouette-Laberge
- University of Montreal, Division of Plastic and Reconstructive Surgery, CHU Sainte-Justine, Montreal, Quebec
| | - Daniel E. Borsuk
- Division of Plastic Surgery, University of Montreal, Montreal, Quebec
| | - Patricia A. Bortoluzzi
- University of Montreal, Division of Plastic and Reconstructive Surgery, CHU Sainte-Justine, Montreal, Quebec
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Bookman LB, Melton KR, Pan BS, Bender PL, Chini BA, Greenberg JM, Saal HM, Taylor JA, Elluru RG. Neonates with Tongue-Based Airway Obstruction. Otolaryngol Head Neck Surg 2011; 146:8-18. [DOI: 10.1177/0194599811421598] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. In this systematic review, the authors summarize the current evidence in the literature regarding diagnosis, treatment, and long-term outcomes in neonates with tongue-based airway obstruction (TBAO) and assess the level of evidence of included studies. Data Sources. The terms Pierre Robin syndrome/sequence, micrognathia, retrognathia, and cleft palate were combined with airway obstruction, treatment, tongue-lip plication, and osteogenesis distraction to perform an Ovid literature search, yielding 341 references. The authors excluded references containing patients with isolated choanal/nasal obstruction, patients older than 12 months, and expert opinion papers, yielding 126 articles. Review Methods. The authors searched 3 electronic databases and reference lists of existing reviews from 1980 to October 2010 for articles pertaining to the diagnosis, treatment, and outcomes of TBAO. Reviewers assigned a level of evidence score based on Oxford’s Centre for Evidence Based Medicine scoring system and recorded relevant information. Results. Most studies were case studies and single-center findings. The lack of standardization of diagnostic and treatment protocols and the heterogeneity of cohorts both within and between studies precluded a meta-analysis. There was little evidence beyond expert opinion and single-center evaluation regarding diagnosis, treatment, and long-term outcomes of neonates with TBAO. Conclusions. The variability in the phenotype of the cohorts studied and the absence of standardized indications for intervention preclude deriving any definitive conclusions regarding diagnostic tools to evaluate this patient population, treatment choices, or long-term outcomes. A coordinated multicenter study with a standardized diagnostic and treatment algorithm is recommended to develop evidence for the diagnosis and treatment of neonates with TBAO.
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Affiliation(s)
- Laurel B. Bookman
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kristin R. Melton
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Brian S. Pan
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Barbara A. Chini
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Howard M. Saal
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jesse A. Taylor
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Subperiosteal Release of the Floor of the Mouth in Airway Management in Pierre Robin Sequence. J Craniofac Surg 2008; 19:609-15. [DOI: 10.1097/scs.0b013e31816aab0b] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Thieme V, Selzer G, Günther L, Rustemeyer J, Bremerich A. Pierre-Robin-Sequenz — postoperative Komplikationen nach Gaumenspaltverschluss. ACTA ACUST UNITED AC 2005; 9:306-11. [PMID: 16136349 DOI: 10.1007/s10006-005-0637-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In a 25-year retrospective review of 1976-2000, the postoperative course after cleft palate surgery and pharyngeal flap surgery in 87 children with Pierre Robin sequence was studied. PATIENTS AND METHODS The study comprised 114 interventions with 87 primary palatoplasties; 17 patients required palatal fistulae repair and 10 children were treated with secondary pharyngoplasty procedures. All children were divided into three postnatal risk groups according to the severity of their symptoms at birth and in the course of the early months of life. RESULTS A direct correlation was seen between the incidence of early postnatal difficulties and the postoperative obstructive complications after cleft palate surgery and pharyngeal flap surgery. Thus, children experiencing obstructive problems at birth (high postnatal risk group) displayed more severe complications at the time after cleft palate repair. In children undergoing pharyngeal flap surgery not only early postoperative obstruction but also late obstructive sleep apnea can occur.
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Affiliation(s)
- V Thieme
- Klinik für Mund-, Kiefer- und Gesichtschirurgie, Plastische Operationen und Spezielle Schmerztherapie, Klinikum Bremen-Mitte.
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Abstract
OBJECTIVE AND METHODS Between February 1987 and September 1997, 247 patients underwent primary repair of a cleft of the secondary palate by one surgeon, using the double-opposing Z-plasty (Furlow) technique. This retrospective study reviews perioperative and postoperative airway compromise among these patients. The purposes of this study were to identify factors associated with airway obstruction following palatoplasty and to analyze the management of those patients. Although infants experiencing airway problems following Wardill-Kilner and Von Langenbeck palatoplasty have been described, airway complications in a group of Furlow repair patients has not been previously reported. RESULTS Fourteen patients (5.7%) had airway problems. The average age of these patients was 18 months, which was not significantly different from those without airway problems. Airway obstruction occurred as late as 48 hours after the completion of surgery. Twelve of the 14 patients had severe airway compromise requiring continued postoperative intubation, reintubation, or tracheostomy (one). There were no deaths. Thirteen of the 14 patients with postoperative airway problems (93%) had other congenital anomalies in addition to clefting, a named congenital disorder, or both. Seven of those 13 had Pierre Robin sequence. In contrast, only 40 of the 233 patients without airway problems (17%) had additional congenital anomalies or named disorders. Presence of other congenital anomalies was associated with a significantly increased risk of airway obstruction (p =.005). CONCLUSION Patients with cleft palate with the Pierre Robin sequence or other additional congenital anomalies had an increased risk of airway problems following palatoplasty. Awareness of this risk permits identifying those patients prior to surgery so that they can be monitored and managed appropriately, minimizing the likelihood of major complications or death.
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Affiliation(s)
- Anuja K Antony
- University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599-7195, USA
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Abramson DL, Marrinan EM, Mulliken JB. Robin sequence: obstructive sleep apnea following pharyngeal flap. Cleft Palate Craniofac J 1997; 34:256-60. [PMID: 9167078 DOI: 10.1597/1545-1569_1997_034_0256_rsosaf_2.3.co_2] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE We reviewed 24 children with Robin sequence who underwent cleft palate repair. METHOD All patients were 5 years of age or older at the time of review, allowing for accurate assessment of speech in relation to velopharyngeal function. All infants had palatal closure between 9 and 14 months of age, either V-Y repair (n = 16) or von Langenbeck repair (n = 8). RESULTS Only 1 of 16 children who had V-Y repair had borderline velopharyngeal dysfunction (VPD). For reasons that are unclear, in the von Langenbeck repair group, six of eight children had VPD, and four of six underwent pharyngeal flap. Three additional patients with nonsyndromic Robin sequence had palatoplasty and subsequent pharyngeal flap. Six of the combined total of seven children with nonsyndromic Robin sequence developed obstructive sleep apnea and require flap take-down. CONCLUSION Since conventional pharyngeal flap for VPD in nonsyndromic Robin sequence children resulted in a high incidence of obstructive sleep apnea, alternative management should be considered: modification of the standard pharyngeal flap, palatal lengthening (V-Y or double-opposing Z-plasty), or construction of a speech bulb.
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Affiliation(s)
- D L Abramson
- Department of Otolaryngology and Communication Disorders, Children's Hospital, Boston, Massachusetts, USA
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Witt PD, Marsh JL, Muntz HR, Marty-Grames L, Watchmaker GP. Acute obstructive sleep apnea as a complication of sphincter pharyngoplasty. Cleft Palate Craniofac J 1996; 33:183-9. [PMID: 8734716 DOI: 10.1597/1545-1569_1996_033_0183_aosaaa_2.3.co_2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
This report describes postoperative airway compromise following sphincter pharyngoplasty (SP) for treatment of post-palatoplasty velopharyngeal dysfunction. A retrospective review of 58 SPs performed for post-palatoplasty velopharyngeal dysfunction, on 30 male, and 28 female patients, over a 5-year study period was undertaken at a tertiary referral academic institution (Washington University School of Medicine), at the St. Louis Children's Hospital, Cleft Palate and Craniofacial Deformities Institute. Eight patients were identified who had the following inclusion criteria: overt perioperative and/or postoperative airway dysfunction, identifiable syndromes, or microretrognathia. Items reviewed were patient demographic factors, associated medical problems, genetics evaluations, nasendoscopic characteristics of velopharyngeal closure, anesthetic evaluation of the patients, and the incidence and severity of perioperative complications. Particular attention was paid to factors contributing to the airway obstruction. Of the eight subjects with perioperative and/or postoperative upper airway dysfunction following SP, five patients had Pierre Robin sequence/micrognathia, while three patients had a history of perinatal respiratory and/or feeding difficulties without micrognathia or an identified genetic disorder. All but two episodes of airway dysfunction resolved within 3 days postoperatively. These patients were discharged home with apnea monitors; both were readmitted with recurrent airway dysfunction. Continuous positive airway pressure (CPAP) was utilized successfully in all instances, and no patients required take-down of the SP to relieve airway dysfunction. CPAP is an effective, noninvasive treatment strategy for management of iatrogenically induced apnea following SP, without sacrificing the surgical benefit of improved speech intelligibility.
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Affiliation(s)
- P D Witt
- Department of Surgery, Plastic and Reconstructive, Washington University School of Medicine, St. Louis, Missouri, USA
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