Cleft lip and palate: current management

Can a Predetermined Grid and Multidisciplinary Consultation Improve the Description of Cleft lip with or Without Cleft Palate?

OBJECTIVE

Evaluate the two-dimensional (2D) ultrasound (US) grid and multidisciplinary consultation (maxillofacial surgeon-sonographer) during prenatal US imaging to improve the sensitivity of prenatal description for cleft lip (CL) with or without alveolar cleft (CLA) or +/- cleft palate (CLP).

DESIGN

Retrospective study of children with CL/P in a tertiary children's Hospital.

SETTING

Single-center cohort study conducted in a tertiary pediatric Hospital.

PATIENTS/PARTICIPANTS

Fifty-nine cases of prenatally diagnosed CL +/-CA or CP between January 2009 and December 2017 were analyzed.

MAIN OUTCOME MEASURES

The correlation was analyzed between prenatal US and postnatal data with regard to eight 2D US criteria (upper lip, alveolar ridge, median maxillary bud, homolateral nostril subsidence, deviated nasal septum, hard palate, tongue movement, nasal cushion flux) in order to propose them in a grid, as well as the presence of the maxillofacial surgeon during the US examination.

RESULTS

Among the 38 cases included, the results were considered satisfied for 87%. Sixty five percent of the US criteria were described when the final diagnosis was correct (5.2 criteria) versus (vs) 45% (3.6 criteria); [OR = 2.28; IC95% (1.10-4.75) P = .022 < 0.05]. This study also highlighted a more in-depth description when the maxillofacial surgeon was present with 68% of 2D US criteria fulfilled (5.4 criteria) vs 47.5% (3.8) when the sonographer was alone [OR = 2.32; IC95% (1.34-4.06) P < .001].

CONCLUSION

This US grid with eight criteria has considerably contributed to a more precise prenatal description. In addition, the systematic multidisciplinary consultation seemed to optimize it and lead to better prenatal information on pathology and postnatal surgical techniques.

Middle-ear effusion in children with cleft palate: congenital or acquired?

Objective

Cleft palates are one of the most common congenital malformations. Because of the loss of Eustachian tube function, middle-ear ventilation is reduced. The aim of this study was to determine if middle-ear effusions were present at birth or at the three-month audiological evaluation.

Method

A total of 53 children with a cleft palate were included. Data review included the results of newborn hearing screening, microscopic findings, a tympanometry, a free field audiometry and intra-operative findings.

Results

A total of 58.4 per cent of patients had a median, 26.4 per cent had a bilateral, 11.3 per cent had a unilateral and 3.8 per cent had a limited soft palate cleft. Newborn hearing screening showed a pass in 83.1 per cent of newborns bilaterally. The first ear microscopy showed a bilateral middle-ear effusion in 90.6 per cent of cases. During cleft surgery, bilateral paracentesis was performed in all cases, and in 90.6 per cent middle-ear effusion was sucked out.

Conclusion

The majority of children with a cleft palate do not present with middle-ear effusion at birth. It develops within several days or weeks of life.

Changes in the Oral Health-Related Quality of Life in Infants With Cleft Lip and/or Palate Before and After Surgical Treatment

OBJECTIVE

To assess oral health-related quality of life (OHRQoL) changes before and after the primary surgical treatment in infants with cleft lip and/or palate (CL/P).

DESIGN

Quasi-experimental study.

METHODS

A total of 106 infants with CL/P younger than 2 years undergoing primary surgical treatment in the Plastic Surgery Service of the Instituto Nacional de Salud del Niño in Peru. The parent/caregiver answered a questionnaire about OHRQoL named the Peruvian version of the Early Childhood Oral Health Impact Scale (P-ECOHIS) in the pretreatment (baseline) and follow-up post-treatment. The total score of P-ECOHIS and their 2 sections (child impact and family impact) in the baseline and each follow-up period post-treatment scores were assessed. As well as, the type of the CL/P on OHRQoL, standardized effect sizes (ES) based on mean total change scores (difference between baseline and 12th month) were analyzed.

RESULTS

Improvements in infant's OHRQoL after treatment were reflected in each follow-up period P-ECOHIS score compared to the baseline score. The total P-ECOHIS scores decreased significantly from 28.07 (baseline) to 7.7 (12th month; P < .0001), as did the individual domain scores (P < .0001). There were significant differences in the baseline and follow-up post-treatment scores of infants who reported improvement of the OHRQoL (P < .0001). The ES was large (3.79). The cleft lip had an improvement in the OHRQoL at 12th month post-treatment (P < .0001).

CONCLUSIONS

Primary surgical post-treatment resulted in significant improvement of the infant's OHRQoL with CL/P.

A Scarless Healing Tale: Comparing Homeostasis and Wound Healing of Oral Mucosa With Skin and Oesophagus

Epithelial tissues are the most rapidly dividing tissues in the body, holding a natural ability for renewal and regeneration. This ability is crucial for survival as epithelia are essential to provide the ultimate barrier against the external environment, protecting the underlying tissues. Tissue stem and progenitor cells are responsible for self-renewal and repair during homeostasis and following injury. Upon wounding, epithelial tissues undergo different phases of haemostasis, inflammation, proliferation and remodelling, often resulting in fibrosis and scarring. In this review, we explore the phenotypic differences between the skin, the oesophagus and the oral mucosa. We discuss the plasticity of these epithelial stem cells and contribution of different fibroblast subpopulations for tissue regeneration and wound healing. While these epithelial tissues share global mechanisms of stem cell behaviour for tissue renewal and regeneration, the oral mucosa is known for its outstanding healing potential with minimal scarring. We aim to provide an updated review of recent studies that combined cell therapy with bioengineering exporting the unique scarless properties of the oral mucosa to improve skin and oesophageal wound healing and to reduce fibrotic tissue formation. These advances open new avenues toward the ultimate goal of achieving scarless wound healing.

Emotional and Behavioral Problems in Children With a Cleft Lip With or Without Palate or an Infantile Hemangioma

OBJECTIVE

Life can be challenging for children with a visible difference due to a medical condition, and they might be at risk for emotional and behavioral problems. This study examines emotional and behavioral problems in children with a cleft lip with or without palate (CL ± P) or an infantile hemangioma (IH) in relation to the visibility of the condition, the presence of additional condition-related problems, and parental affect.

SETTING

This cross-sectional study took place in an academic medical hospital in the Erasmus MC Sophia Children's Hospital, the Netherlands.

PARTICIPANTS

A total of 309 parents (mean age = 40.34, 44.00% male) of 182 children with CL ± P and 48 parents (mean age = 39.21, 37.50% male) of 33 children with an IH completed questionnaires. Children were 1.5 to 12 years old.

RESULTS

Parents reported fewer child emotional and behavioral problems compared to normative data. Problems reported were mainly related to learning difficulties and parent gender, while visibility of the condition had no significant influence. Parental negative affect was related to child internalizing problems. Parental positive affect was not related to any of the outcome measures.

CONCLUSIONS

Parents reported fewer problems for their children compared to normative data. This is inconsistent with previous research, showing similar or worse scores for these children compared to peers. Our findings may be explained by a protective parenting style, a response shift in parents, or problems developing at a later point in life.

The Psychosocial Patient-Reported Outcomes of End of Pathway Cleft Surgery: A Systematic Review

OBJECTIVE

To identify and review the literature on the psychosocial patient-reported outcomes (PROs) of surgery at the end of the cleft treatment pathway.

DESIGN

A systematic literature search was performed using electronic databases (Medline, PubMed, EMBASE, PsycInfo, Web of Science, and Science Direct) from database inception to September 2017, to identify studies measuring and reporting the psychosocial PROs of end of pathway cleft surgery.

RESULTS

Of 263 identified papers, 22 studies were eligible for inclusion. Apart from one randomized controlled study, studies were largely observational and adopted a cross-sectional or retrospective design. The majority (n = 16) were small-scale studies. The methodological quality was variable in terms of what, how, and when psychosocial outcomes were measured and reported. None of the studies utilized a psychosocial PRO measure validated in the cleft population, and few studies measured outcomes prospectively. A high proportion of studies utilized bespoke measures of patient satisfaction. Taken together, findings from the included studies are tentative but seem to suggest patients derive some benefit from undergoing end of pathway cleft surgery, in terms of increased satisfaction, quality of life, social interactions, and decreased appearance-related distress.

CONCLUSIONS

Due to methodological challenges and the heterogeneity of what, how, and when outcomes are measured and currently reported, it is difficult to determine the psychosocial PROs of end of pathway cleft surgeries. Consequently, this review advocates the conduct of well-designed, longitudinal studies using cleft-sensitive tool/s to capture the psychosocial PROs of end of pathway cleft surgery at various time points.

Is There a Correlation Between Nasolabial Appearance and Dentoalveolar Relationships in Patients With Repaired Unilateral Cleft Lip and Palate?

OBJECTIVE

To determine whether a relationship exists between the aesthetic scores given to photographic records of the nasolabial region of patients with repaired unilateral cleft lip and palate (UCLP) and the 5-Year Olds' Index scores of study models for the same participants.

DESIGN

Retrospective study.

SETTING

University of Bristol Dental Hospital, United Kingdom.

PARTICIPANTS

Patients with nonsyndromic UCLP previously enrolled in the Cleft Care UK (CCUK) Study.

METHODS

The CCUK participants, who had both study models and photographs (frontal and worm's eye view), were identified and their records retrieved. These were rated by 2 consultants and 2 senior registrars in orthodontics. The 5-Year Olds' Index was used to score the study models, and at a separate sitting, a 5-point Likert scale was used to score the cropped frontal and worm's eye view photographs of the same children. The results were analyzed using intraclass correlation coefficients and Cohen κ.

MAIN OUTCOME MEASURES

Correlation between the aesthetic scores of the photographic views and the concordant 5-Year Olds' Index scores of the study models.

RESULTS

The intraclass correlation coefficient scores showed very poor agreement between the photographic views and their concordant study models. The level of inter- and intra-rater reliability was strongest when scoring the study models.

CONCLUSIONS

There was no agreement between the scores given to various photographic views and their corresponding study models. Scoring the study models using the 5-Year Olds' Index was the most reliable outcome measure for this age-group.

Outcomes of Primary Palatoplasty: An Analysis Using the Pediatric Health Information System Database

BACKGROUND

Previous attempts at reporting oronasal fistula development and secondary speech surgery following cleft palate surgery have been limited to single-center case series. This limitation can be overcome by querying large databases created by health care governing bodies or health care alliances. The authors examined the effect of cleft type and demographic variables on the clinical outcomes.

METHODS

Data from the Pediatric Health Information System database were queried for patients, aged 6 to 18 months, who had undergone primary palatoplasty between 2004 and 2009. Subsequent repair of an oronasal fistula and/or secondary speech surgery between 2004 and 2015 was identified by procedure codes. Logistic regression models were used to assess the associations between cleft type with oronasal fistula and with secondary speech surgery.

RESULTS

Seven thousand three hundred twenty-five patients were identified, and 6.4 percent (n = 468) had a subsequent repair of an oronasal fistula and 18.5 percent (n = 1355) had a secondary speech operation. Adjusted for age, sex, and race, patients with cleft lip and palate have increased odds of oronasal fistula (OR, 5.60; 95 percent CI, 4.44 to 7.07) and secondary speech surgery (OR, 2.32; 95 percent CI, 2.05 to 2.63).

CONCLUSIONS

Using a large, multi-institution billing database, the authors were able to estimate the prevalence of oronasal fistula and surgically treated velopharyngeal insufficiency following primary palatoplasty in the United States. In addition, the authors demonstrated that patients with isolated cleft palate develop fewer oronasal fistulas and require less secondary speech surgery than patients with cleft lip and palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The prenatal diagnosis and classification of cleft palate: the role and value of magnetic resonance imaging

OBJECTIVE

The aim of this study was to evaluate the value of MRI in the prenatal diagnosis and classification of cleft palate (CP).

METHODS

We collected 94 fetal cases that were suspected of cleft palate with or without cleft lip by prenatal ultrasound (US) and then carried out further MRI to examine the entire body of each fetus within 1 week. The diagnoses resulting from MRI and US examination were compared separately with the final diagnoses obtained from postnatal physical examination or fetal autopsy. The diagnostic accuracy between MRI and US was then determined.

RESULTS

During the follow-up period, the results for 6 fetuses (6.38%) were lost. Of the remaining 88 cases, the final diagnoses identified 23 cases of cleft lip (CL), 45 cases of unilateral cleft lip with cleft palate (UCLP), 4 cases of median cleft lip with cleft palate (MCLP), 12 cases of bilateral cleft lip with cleft palate (BCLP), 3 cases of unilateral cleft lip and cleft alveolus (CLA), and 1 case of isolated cleft palate (CPO). The total accuracy rate of US was 59.09%, while that of MRI was 92.05%. More importantly, 81 cases were accurately identified by MRI; the accuracy rate for CL, UCLP, MCLP, BCLP, CLA, and CPO was 86.96%, 95.56%, 100%, 91.67%, 66.67%, and 100%, respectively.

CONCLUSION

Our results suggest that MRI could be a useful adjunct to US examination in the prenatal diagnosis of fetuses with cleft palate, and further demonstrates the classification and degree of involvement of the cleft palate.

KEY POINTS

• MRI is a useful adjunct to prenatal ultrasound. • MRI has a higher accuracy rate for CP. • The accurate classification of CP diagnosed by MRI can guide clinical management.

Increased Risk for Neurodevelopmental Disorders in Children With Orofacial Clefts

OBJECTIVE

Children with orofacial clefts (OFC) may have an increased risk of poor mental health. This study aimed to investigate the risk of psychiatric diagnoses in individuals with OFC, stratified by cleft type.

METHOD

A nationwide register-based cohort of all individuals born with nonsyndromic OFC in Sweden between 1973 and 2012 (n = 7,842) was compared to a matched cohort (n = 78,409) as well as to their unaffected siblings (n = 9,637). The risk of psychiatric diagnoses, suicide attempts, and suicides was examined by crude and adjusted Cox regression models. Effect modification by sex was investigated with interaction terms in the models.

RESULTS

Children with cleft lip (CL) had a significantly higher risk of any psychiatric disorder, intellectual disability, and language disorders; children with cleft lip and palate (CLP) had, in addition, an increased risk of autism spectrum disorder (ASD). Children with cleft palate only (CPO) had risk increases for the same diagnoses as children with CL and CLP, but with higher hazard ratios, and also for psychotic disorders, attention-deficit/hyperactivity disorder (ADHD), and other behavioral or emotional disorders in childhood. Sex stratification indicated higher risk increases among females in CL and CLP but not in CPO. Siblings without OFC were less likely to be diagnosed with any psychiatric disorder, intellectual disability, language disorder, ASD, or ADHD compared to their siblings with OFC.

CONCLUSION

Children with nonsyndromic clefts had a significantly higher risk of neurodevelopmental disorders. This risk is unlikely to be explained by familial influences such as inherited genetic or shared environmental factors.

A comparative study of immediate wound healing complications following cleft lip repair using either absorbable or non-absorbable skin sutures

Objectives

The aim of the study was to compare wound healing complications following the use of either absorbable or non-absorbable sutures for skin closure in cleft lip repair.

Materials and Methods

This was a randomized controlled trial conducted at the Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Idi Araba, Lagos State, Nigeria. Sixty subjects who required either primary or secondary cleft lip repair and satisfied all the inclusion criteria were recruited and randomized into two groups (Vicryl group or Nylon group). The surgical wounds in all subjects were examined on 3rd, 7th, and 14th postoperative days (POD) for presence or absence of tissue reactivity, wound dehiscence, and local wound infection.

Results

Hemorrhage, tissue reactivity, wound dehiscence, and local wound infection were identified as wound healing complications following cleft lip repair. The incidence of postoperative wound healing complications on POD3 was 33.3%. Tissue reactivity was more common throughout the evaluation period with the use of an absorbable (Vicryl) suture compared to a non-absorbable (Nylon) suture, although the difference was statistically significant only on POD7 (P=0.002). There were no significant differences in the incidences of wound dehiscence and infection between the two groups throughout the observation period.

Conclusion

There were no statistically significant differences in the incidences of wound dehiscence and surgical site wound infection following the use of either Vicryl or Nylon for skin closure during cleft lip repair. However, more cases of tissue reactivity were recorded in the Vicryl group than in the Nylon group on POD7. Particular attention must be paid to detect the occurrence of wound healing complications, most especially tissue reactivity, whenever a Vicryl suture is used for skin closure in cleft lip repair.

The impact of nonsyndromic cleft lip with or without cleft palate on oral health-related quality of life

Nonsyndromic cleft lip with or without cleft palate (NSCL±P) compromises oral health, leading to missing or malformed teeth, and hampering oral hygiene. Apart from anatomic damages, NSCL±P also culminates in an impact on the routine quality of life with social privation and psychological embarrassment.

Sociodemographic Predictors of Missed Appointments Among Patients With Cleft Lip and Palate

Objective:

To identify disparities in compliance of and care for patients with cleft lip and/or palate (CL/P) by determining the impact of sociodemographic variables on the rate of missed appointments and Child Protective Services (CPS) involvement.

Design:

A retrospective, noninterventional quality assessment and quality improvement study were designed.

Setting:

This institutional study was performed at the University of Michigan in Ann Arbor, Michigan.

Patients:

All patients born between January 1, 2011, and December 31, 2014, who underwent surgical CL/P repair, excluding those with fewer than 5 appointments (n = 178).

Main Outcome Measure:

The rate of missed appointments, calculated as the total number of no-show appointments divided by the total number of scheduled appointments. All appointments from CL/P diagnosis to data collection were considered, including those outside of plastic surgery.

Results:

The average patient was 4.5 years of age and had 49 total scheduled appointments. The overall rate of missed appointments was 9.6%, with 66.8% of patients missing at least 1 scheduled visit. Patients who were black ( P = .04), not affiliated with a religion ( P = .01), Medicaid users ( P = .01), from an unstable social background ( P = .01), or received need-based financial assistance ( P = .00) were significantly more likely to miss appointments. Child Protective Services was involved with 3.9% of patients.

Conclusions:

Disparities exist in attendance rates among patients with CL/P, and at-risk patient populations have been identified. The allocation of cleft care resources must be efficiently planned in order to enhance the quality of care for at-risk individuals.

Effects of Infant Cleft Lip on Adult Gaze and Perceptions of “Cuteness”

Objective:

Early mother-infant interactions are impaired in the context of infant cleft lip and are associated with adverse child psychological outcomes, but the nature of these interaction difficulties is not yet fully understood. The aim of this study was to explore adult gaze behavior and cuteness perception, which are particularly important during early social exchanges, in response to infants with cleft lip, in order to investigate potential foundations for the interaction difficulties seen in this population.

Methods:

Using an eye tracker, eye movements were recorded as adult participants viewed images of infant faces with and without cleft lip. Participants also rated each infant on a scale of cuteness.

Results:

Participants fixated significantly longer on the mouths of infants with cleft lip, which occurred at the expense of fixation on eyes. Severity of cleft lip was associated with the strength of fixation bias, with participants looking even longer at the mouths of infants with the most severe clefts. Infants with cleft lip were rated as significantly less cute than unaffected infants. Men rated infants as less cute than women overall but gave particularly low ratings to infants with cleft lip.

Conclusions:

Results demonstrate that the limited disturbance in infant facial configuration of cleft lip can significantly alter adult gaze patterns and cuteness perception. Our findings could have important implications for early interactions and may help in the development of interventions to foster healthy development in infants with cleft lip.

A comparative study of quality of life of families with children born with cleft lip and/or palate before and after surgical treatment

Objectives

The aim of this study was to compare the quality of life (QoL) of parents/caregivers of children with cleft lip and/or palate before and after surgical repair of an orofacial cleft.

Materials and Methods

Families of subjects who required either primary or secondary orofacial cleft repair who satisfied the inclusion criteria were recruited. A preoperative and postoperative health-related QoL questionnaire, the ‘Impact on Family Scale’ (IOFS), was applied in order to detect the subjectively perceived QoL in the affected family before and after surgical intervention. The mean pre- and postoperative total scores were compared using paired t-test. Pre- and postoperative mean scores were also compared across the 5 domains of the IOFS.

Results

The proportion of families whose QoL was affected before surgery was 95.7%. The domains with the greatest impact preoperatively were the financial domain and social domains. Families having children with bilateral cleft lip showed QoL effects mostly in the social domain and 'impact on sibling' domain. Postoperatively, the mean total QoL score was significantly lower than the mean preoperative QoL score, indicating significant improvement in QoL (P<0.001). The mean postoperative QoL score was also significantly lower than the mean preoperative QoL score in all domains. Only 3.2% of the families reported affectation of their QoL after surgery. The domains of mastery (61.3%) with a mean of 7.4±1.8 and finance (45.1%) with a mean score of 7.2±1.6 were those showing the greatest postoperative impact. The proportion of families whose QoL was affected by orofacial cleft was markedly different after treatment (95.7% preoperative and 3.2% postoperative).

Conclusion

Caring for children with orofacial clefts significantly reduces the QoL of parents/caregivers in all domains. However, surgical intervention significantly improves the QoL of the parents/caregivers of these children.

On Cuteness: Unlocking the Parental Brain and Beyond

Cuteness in offspring is a potent protective mechanism that ensures survival for otherwise completely dependent infants. Previous research has linked cuteness to early ethological ideas of a 'Kindchenschema' (infant schema) where infant facial features serve as 'innate releasing mechanisms' for instinctual caregiving behaviours. We propose extending the concept of cuteness beyond visual features to include positive infant sounds and smells. Evidence from behavioural and neuroimaging studies links this extended concept of cuteness to simple 'instinctual' behaviours and to caregiving, protection, and complex emotions. We review how cuteness supports key parental capacities by igniting fast privileged neural activity followed by slower processing in large brain networks also involved in play, empathy, and perhaps even higher-order moral emotions.

Use of autologous platelet-rich plasma in complete cleft palate repair

OBJECTIVES/HYPOTHESIS

Evaluate the effect of topical application of autologous platelet-rich plasma (PRP) in primary repair of complete cleft palate and then compare the result with another group of patients using the same surgical technique, without application of PRP with regard to the incidence of oronasal fistula, velopharyngeal closure, and grade of nasality.

STUDY DESIGN

Case control study.

METHODS

This study was carried on 44 children with complete cleft palate with age range from 12 to 23 months. The children were divided into two age- and gender-matched groups: All children were subjected to the same technique of V-Y pushback repair of the complete cleft palate. In group A (22 children), the PRP prepared from the patient was topically applied between the nasal and oral mucosa layer during palatoplasty, whereas in group B (22 children) the PRP was not applied.

RESULTS

All cases were recovered smoothly without problems. In group A, no oronasal fistula was reported, whereas in group B three patients (13.6%) had postoperative fistulae and two patients (9.1%) needed revision palatoplasty. At 6 months postoperative assessment, group A (with PRP application) showed significantly better grade of nasality (P = 0.024) and better endoscopic velopharyngeal closure (P = 0.016) than group B.

CONCLUSION

Usage of autologous PRP in complete cleft palate repair is simple; effective; can decrease the incidence of oronasal fistula; and also significantly improves the grade of nasality and velopharyngeal closure, which decreases the need of further surgical intervention in cleft palate patients.

LEVEL OF EVIDENCE

3b. Laryngoscope, 126:1524-1528, 2016.

Comparison of Outcome of Modified Millard's Incision and Delaire's Functional Method in Primary Repair of Unilateral Cleft Lip: A Prospective Study

BACKGROUND

Certain preoperative anatomical features may lead the surgeon to choose one particular incision pattern in preference to another. No one technique of cleft lip repair consistently produces ideal aesthetic and functional results.

OBJECTIVES

This study was conducted to compare the outcomes attained using two different designs of skin incision used for surgical correction of unilateral cleft lip.

MATERIALS AND METHODS

Modified Millard's incision and Delaire's functional method techniques were performed and evaluated on 18 patients who received primary unilateral cleft lip repair. Soft-tissue measurements of the lip and nose were recorded preoperatively. Analysis was based on postoperative assessment of the white roll, vermilion border, scar, Cupid's bow, lip length, and nostril symmetry and appearance of the alar dome and base. Chi-square and Fisher exact test, Student t test (two tailed, independent) and Student t test (two tailed, dependent) were used for statistical analysis of study parameters at 5 % level of significance.

RESULTS

Preconceptions that one particular technique was better suited to certain preoperative cleft anatomical forms were not proven statistically. The outcome of our surgical methods was good and suggested quantitative changes with progressive diminution of asymmetry of the cleft and non cleft sides.

CONCLUSION

Lip length improvement was better in case of modified Millard's incision. The Delaire's functional method of cleft lip repair results in improved nasal symmetry due to correction of the abnormal insertions of the underlying musculature.

Prevalence, demographics, and complications of cleft palate surgery

INTRODUCTION

Current published data on the demographics of cleft lip and palate is sparse and differs intranationally in reported incidence, demographics, and complication rates, making accurate local data both valuable and useful. We investigate the prevalence, demographics, and complications of cleft palate correction surgery in the inpatient setting over a 15-year period.

METHODS

A retrospective review of The California Hospital Discharge Data sets of all pediatric patients who underwent cleft palate repair or cleft palate revision from 1997 to 2011. Children's hospitals (CHs) were analyzed as a separate group. For each record, age, gender, ethnicity, length of stay, total charges, principal payer, complications, and disposition were analyzed.

RESULTS

10,450 correction surgeries were performed during 1997-2011. This was an annual case-volume of 697 and annual population-adjusted rate of 2.0, neither of which changed over time (p=0.9 and 0.06, respectively). Of all surgeries, 21.5% were revisions, 48.3% were performed in CHs, 56.2% were performed on males, and 65.5% were performed on Caucasians. The median length of stay was 1 day, which did not change over time (p=1.0). The median total charges increased from $9.074 to $35,643 over the studied period (p<0.001). Admission to CHs was associated with shorter stay (1-3 days vs. 1-4 days) and higher total charges ($15,560 vs. $13,242; both p<0.001). Complications occurred in 393 (3.8%) of the surgeries. This percentage did not change over time (p=0.2). The most common complication was fistula/abscess/infection, which occurred in 159 cases (1.5%). Respiratory complications requiring ventilation occurred 66 cases (0.6%). Complications were more common in CHs (4.8% vs. 2.8%; p<0.001). Mortality rate was <0.1%.

CONCLUSIONS

Our study constitutes the entire surgical cohort within a state, allowing for an accurate representation of the true perioperative complication rate of these procedures. The prevalence, demographics, and outcomes of the cleft palate correction surgery have remained unchanged during 1997-2011. Collectively, our data suggest that primary and secondary palatoplasty present low perioperative risk.

Understanding the human parental brain: a critical role of the orbitofrontal cortex

The bond between a parent and an infant often appears to form effortlessly and intuitively, and this relationship is fundamental to infant survival and development. Parenting is considered to depend on specific brain networks that are largely conserved across species and in place even before parenthood. Efforts to understand the neural basis of parenting in humans have focused on the overlapping networks implicated in reward and social cognition, within which the orbitofrontal cortex (OFC) is considered to be a crucial hub. This review examines emerging evidence that the OFC may be engaged in several phases of parent-infant interactions, from early, privileged orienting to infant cues, to ongoing monitoring of interactions and subsequent learning. Specifically, we review evidence suggesting that the OFC rapidly responds to a range of infant communicative cues, such as faces and voices, supporting their efficient processing. Crucially, this early orienting response may be fundamental in supporting adults to respond rapidly and appropriately to infant needs. We suggest a number of avenues for future research, including investigating neural activity in disrupted parenting, exploring multimodal cues, and consideration of neuroendocrine involvement in responsivity to infant cues. An increased understanding of the brain basis of caregiving will provide insight into our greatest challenge: parenting our young.

Minor structural abnormalities in the infant face disrupt neural processing: a unique window into early caregiving responses

Infant faces elicit early, specific activity in the orbitofrontal cortex (OFC), a key cortical region for reward and affective processing. A test of the causal relationship between infant facial configuration and OFC activity is provided by naturally occurring disruptions to the face structure. One such disruption is cleft lip, a small change to one facial feature, shown to disrupt parenting. Using magnetoencephalography, we investigated neural responses to infant faces with cleft lip compared with typical infant and adult faces. We found activity in the right OFC at 140 ms in response to typical infant faces but diminished activity to infant faces with cleft lip or adult faces. Activity in the right fusiform face area was of similar magnitude for typical adult and infant faces but was significantly lower for infant faces with cleft lip. This is the first evidence that a minor change to the infant face can disrupt neural activity potentially implicated in caregiving.

X-linked markers in the Duchenne muscular dystrophy gene associated with oral clefts

As part of an international consortium, case-parent trios were collected for a genome-wide association study of isolated, non-syndromic oral clefts, including cleft lip (CL), cleft palate (CP), and cleft lip and palate (CLP). Non-syndromic oral clefts have a complex and heterogeneous etiology. Risk is influenced by genes and environmental factors, and differs markedly by gender. Family-based association tests (FBAT) were used on 14,486 single nucleotide polymorphisms (SNPs) spanning the X chromosome, stratified by type of cleft and racial group. Significant results, even after multiple-comparisons correction, were obtained for the Duchenne muscular dystrophy (DMD) gene, the largest single gene in the human genome, among CL/P (i.e., both CL and CLP combined) trios. When stratified into groups of European and Asian ancestry, stronger signals were obtained for Asian subjects. Although conventional sliding-window haplotype analysis showed no increase in significance, selected combinations of the 25 most significant SNPs in the DMD gene identified four SNPs together that attained genome-wide significance among Asian CL/P trios, raising the possibility of interaction between distant SNPs within the DMD gene.

[Facial coloboma: report of an exceptional prenatal case and interest of three-dimensional ultrasonography]

We report a rare case of Tessier no. 4 craniofacial cleft diagnosed by ultrasound imaging at 10 weeks' gestation. Tessier no. 4 craniofacial cleft is a very rare and complex congenital abnormality, characterized by an oblique orbitomaxillary facial cleft. Prenatal diagnosis of orofacial clefting is usually done at midtrimester of pregnancy, based on careful sonographic examination of the fetal face. However conventional 2D ultrasound is limited in screening isolated cleft palate and defects of the secondary palate. Thus, 3D ultrasound shows a greater sensitivity in a referred population and antenatal evaluation of facial clefs.