Cleft lip and palate

Newly Identified Developmental Delays in a Large Population of Children With Nonsyndromic Cleft Lip and Palate

Background

Nonsyndromic cleft lip and/or palate (NSCLP) is the most common congenital craniofacial anomaly. Early recognition of developmental delays associated with NSCLP is critical for counseling and management. This study investigates developmental delays in a large population of children with NSCLP.

Methods

This is an institutional review board-approved, retrospective analysis of children 5-21 years of age with a diagnosis of NSCLP. Demographic and clinical variables were collected for patients and a control group without NSCLP from the 2018 National Survey of Children's Health (NSCH) database.

Results

A total of 617 patients with NSCLP subjects and 29,147 NSCH participants were included. Among orofacial clefts, 45.2% were unilateral cleft lip and palate, followed by isolated cleft palate (30%), bilateral cleft lip and palate (16.4%), and isolated cleft lip (8.4%). NSCLP children with isolated cleft lip (odds ratio [OR]: 3.97), unilateral cleft lip and palate (OR: 2.17) and bilateral cleft lip and palate (OR: 2.91) had significantly higher odds of being diagnosed with attention-deficit hyperactivity disorder than the NSCH cohort. Rates of autism/pervasive developmental disorder were higher in children with isolated cleft lip than cleft lip and palate (11.5% versus 4.7%, P = 0.06), but this association was not significant. Children with isolated cleft palate had higher rates of intellectual disability, speech delay, global developmental delay, cerebral palsy, and hearing loss compared with the NSCH cohort (P < 0.05).

Conclusions

Higher rates of attention disorders and developmental delays in children with NSCLP highlight the importance of proper risk assessment and multidisciplinary management for this population.

Evolution of Cleft Lip and Palate Surgery and the Pursuit for Consensus on Standardized Algorithms of Care

Cleft lip and palate (CLP) surgery has evolved over centuries in an attempt to achieve anatomical closure while optimizing speech and limiting fistulas and midface hypoplasia. Masters of cleft surgery and early pioneers inspired generations of surgical innovators to refine techniques and timing to improve surgical outcomes. Constant modification has resulted in significant diversity of cleft surgical protocols across institutions. Unlike many other surgical conditions, there is no gold-standard algorithm of care for CLP. Several international consortiums, including Eurocleft, Americleft, and Scandcleft, aimed to investigate the ideal cleft care protocol. Despite the inclusion of multiple institutions and attempts at long-term follow-up, these studies were limited by small sample sizes, lack of diversity in patient population, poor long-term follow-up, lack of standardized measurement tools, and inability to control for confounders such as severity. This article aimed to present the findings of these early pioneer consortiums in their pursuit for the optimal CLP surgical protocol and recommend a direction for future research with a global consortium of experts in cleft care.

Spanish Terms for Cleft Lip Within the United States

ObjectiveTo examine Spanish terms used for "cleft lip" within the United States. Perceived acceptability of these terms was also considered.DesignAn online survey was distributed to Spanish-speaking medical interpreters, clinicians, and parents of children with cleft lip. Survey questions probed demographics, language use, preferred term for "cleft lip," and perceived acceptability of terms for cleft lip.ResultsThere were 158 respondents. Significant differences were observed with profession (P < .001) as 62.5% of medical providers used labio hendido, while 71.8% of interpreters preferred labio leporino. Perceived acceptability of terms was consistent with the term use patterns reported by respondent groups. Significant differences were also observed with geographical region (P = .001) as 90% of respondents from the Northeast United States employed labio leporino, compared to 60% to 70% of respondents from other regions.ConclusionsSelection and perception of Spanish terms for "cleft lip" may differ across regions and professions. Cleft teams should invite stakeholders to discuss what terms best suit their community.

Treatment Outcomes of Lip Taping in Patients with Non-syndromic Cleft Lip and/or Palate: A Systematic Review and Meta-analysis

OBJECTIVE

To conduct a systematic review of the data in peer-reviewed medical literature and evaluate the effectiveness of lip taping as a pre-surgical naso-alveolar molding (NAM) technique in infants with cleft lip and/or palate.

DESIGN

An electronic search of various databases for relevant studies, regardless of date, from inception to June 2023 was carried out and evaluated. After completing the electronic search and applying our inclusion/exclusion criteria, 6 studies-2 randomized control trials, 2 non-randomized studies, and 2 case series-were included. Data extraction of relevant articles was done independently by 2 authors. Quality assessment was done using the JBI prevalence critical appraisal tool and certainty of evidence was carried out by GRADE approach.

MAIN OUTCOME MEASURES

Nasolabial Aesthetics, Dentoalveolar Relationship.

RESULTS

A total of six studies were included in the current review. Meta-analysis was carried out, and forest plots were obtained for a single mean from the lip-taping group. 3 studies had a low risk of bias, while 3 studies displayed a serious risk of bias. Significant improvement in various outcome measures was noted with lip taping when compared with the control group although the certainty of evidence was very low.

CONCLUSION

When compared to no therapy, lip taping appears to ameliorate dentoalveolar measurements and nasolabial aesthetics. To increase our knowledge of lip taping, more research will be needed in the future, as there are not many studies to prove lip taping is better than other treatment approaches.

Healthcare use and direct medical costs in a cleft lip and palate population: an analysis of observed and protocolized care and costs

This study was performed to describe observed healthcare utilization and medical costs for patients with a cleft, compare these costs to the expected costs based on the treatment protocol, and explore the additional costs of implementing the International Consortium for Health Outcomes Measurement (ICHOM) Standard Set for Cleft Lip and Palate (CL/P). Forty patients with unilateral CL/P between 0 and 24 years of age, treated between 2012 and 2019 at Erasmus University Medical Center, were included. Healthcare services (consultations, diagnostic and surgical procedures) were counted and costs were calculated. Expected costs based on the treatment protocol were calculated by multiplying healthcare products by the product prices. Correspondingly, the additional expected costs after implementing the ICHOM Standard Set (protocol + ICHOM) were calculated. Observed costs were compared with protocol costs, and the additional expected protocol + ICHOM costs were described. The total mean costs were highest in the first year after birth (€5596), mainly due to surgeries. The mean observed total costs (€40,859) for the complete treatment (0-24 years) were 1.6 times the expected protocol costs (€25,198) due to optional, non-protocolized procedures. Hospital admissions including surgery were the main cost drivers, accounting for 42% of observed costs and 70% of expected protocol costs. Implementing the ICHOM Standard Set increased protocol-based costs by 7%.

The Life Cycle of Orofacial Cleft Operations

Patients with cleft lip and palate must undergo various surgical interventions at appropriate times to achieve optimal outcomes. While guidelines for the timing of these operations are well known, it has not yet been described if national surgical practice reflects these recommendations. This study evaluates whether orofacial operations are performed in time frames that align with advised timing. Time-to-event analyses were performed using the 2012-2020 Pediatric National Surgical Quality Improvement Program database on the ages at time of orofacial operations. Outliers with an absolute Z-score of 3.29 or greater were excluded. Cleft lip (N=9374) and palate (N=13,735) repairs occurred earliest at mean ages of 200.99±251.12 and 655.08±694.43 days, respectively. Both operations clustered along the later end of recommended timing. 69.0% of lip versus 65.1% of palate repairs were completed within the advised age periods. Cleft lip (N=2850) and palate (N=1641) revisions occurred at a mean age of 7.73±5.02 and 7.00±4.63 years, respectively. Velopharyngeal insufficiency operations (N=3026), not including palate revision, were performed at a delayed mean age of 7.58±3.98 years, with only 27.7% of operations occurring within the recommended time frame. Finally, 75.8% of alveolar bone grafting cases (N=5481) were found to happen within the advised time period, with a mean age of 10.23±2.63 years. This study suggests that, with the exception of VPI procedures, orofacial operations reliably cluster near their recommended age periods. Nevertheless, primary lip repair, palatoplasty, and velopharyngeal insufficiency procedures had a mean age that was delayed based on advised timing.

Velopharyngeal Insufficiency Following Furlow Versus Straight Line Repair With Intravelar Veloplasty: A Single-institution Experience

BACKGROUND

Measurements of postoperative velopharyngeal dysfunction (VPD) can be used to determine the efficacy of a palatoplasty operation. Hypernasality and audible nasal air emission are typical manifestations of VPD during speech. We aimed to longitudinally compare VPD outcomes in postpalatoplasty patients who underwent Furlow repair versus straight line repair with intravelar veloplasty (IVVP). Additionally, we examined the relationship between VPD outcomes and select pre-existing patient characteristics.

METHODS

Retrospective chart review was performed to identify primary palatoplasty patients treated from April 2012 to March 2021. Variables collected included gender, syndromic status, primary language, Veau cleft type, type of speech assessment, age at time of surgery, degree of hypernasality, presence of audible nasal air emission, and overall adequacy of velopharyngeal function. Pearson χ 2 test and multivariable t tests were used to analyze variables. Logistic regression was used to control for statistically significant variables.

RESULTS

Of the 118 patients included, 38 received a Furlow procedure and 80 received a straight line with IVVP procedure. Audible nasal air emission was present in 57.3% of straight line with IVVP patients and 42.9% of Furlow patients, with no statistically significant difference between groups. Clinically significant hypernasality was present in 42.1% of straight line with IVVP patients and 22.9% of Furlow patients ( P= 0.05). Velopharyngeal function was classified as adequate in 63.5% of straight line with IVVP patients and 83.3% of Furlow patients ( P= 0.03). However, after stratifying by syndromic versus nonsyndromic status, there was no statistically significant difference between straight line with IVVP and Furlow patients for postoperative hypernasality and velopharyngeal function.

CONCLUSIONS

This study suggests that there are no statistically significant differences between straight line with IVVP and Furlow palatoplasty techniques regarding speech outcomes including hypernasality, audible nasal air emission, and overall VP function. Furthermore, select patient characteristics such as gender, primary language, syndromic status, age at repair, and Veau cleft type do not significantly impact postoperative speech outcomes.

Comparative Study between Modified Millard and White Roll Vermilion Flap Techniques in Unilateral Lip Repair: A Randomised Controlled Study

BACKGROUND

Cleft lip and palate, which affects 0.5-1.6 out of every 1000 live births, is the most prevalent congenital defect of the head and neck. Several approaches, including quadrangular flaps, triangular flaps and rotation-advancement procedures, White Roll Vermilion Turn Down Flap (WRV flap) from the lateral lip element were employed by Mishra to modify Millard's technique to create the vermilion and white roll on the medial lip segment. This study aimed to use the anthropometric measurements taken pre- and post-operation to evaluate quantitative assessment of modified Millard technique compared with WRV flap technique in unilateral cleft lip (UCL) repair.

MATERIALS AND METHODS

Prospective, randomised controlled study recruited infants scheduled for UCL repair. Infants aged 3-6 months, either complete or incomplete deformity. A total of 42 patients were randomized in 1:1 ratio to undergo either WRV flap technique (group A) or modified Millard technique (group B) and another control included 21 age-matched healthy children. We compared WRV flap procedure to Modified Millard's procedure in terms of both qualitative (another surgeon's opinion) and quantitative (anthropometric) evaluation.

RESULTS

Vertical lip length and philtral lip height significantly longer in Millard group (B) than WRV flap group (A) in immediate postoperative assessment and nasal width was significantly wider in WRV flap group (A) than Millard group (B) in 3-month post-operative assessment. The lip shape, the vermilion shape was better in Millard technique than WRV flap technique; however, this was statistically insignificant. However, no major difference in the overall results between the WRV flap and Millard rotation-advancement repairs.

CONCLUSION

Anthropometric measurement of surgical outcome evaluates the surgical technique used and helps to compare between cleft and non-cleft side showing the degree of deformity and we used subjective assessment to analyse facial aesthetics. Overall results demonstrate no significant differences between modified Millard technique and WRV flap technique.

The Outcomes of Modified Millard Technique Versus Tennison-Randall Technique in Unilateral Cleft Lip Repair: A Comparative Trial

BACKGROUND

This study aimed to use anthropometric measurements taken pre- and post-operation to evaluate quantitative assessment of modified Millard technique compared with Tennison-Randall technique in unilateral cleft lip (UCL) repair.

MATERIALS AND METHODS

Prospective randomised controlled study recruited infants scheduled for UCL repair. Infants aged 2-6 months, either complete or incomplete deformity. A total of 68 patients were randomised in 1:1 ratio to undergo either modified Millard technique (Group I) or Tennison-Randall technique (Group II).

RESULTS

Group I had significantly longer operative time than Group II (85.7 ± 7.4 vs. 68.7 ± 8.8 min, respectively; P < 0.001). Group I has less post-operative wound infection, wound dehiscence and wound scarring than Group II, but Group II has less post-operative lip notch. In Group I, greater increases in post-operative horizontal lip length and vertical lip height were observed, compared to Group II, without statistically significant difference. Group I showed a greater reduction in nasal width and total nasal width than Group II, without statistically significance. Group II had a greater increase in philtral height. However, only post-operative Cupid's-bow width was significantly different between two groups (P = 0.041).

CONCLUSION

Overall results demonstrate no significant differences between modified Millard technique and Tennison-Randall technique.

Development of Artificial Neural Network-Based Prediction Model for Evaluation of Maxillary Arch Growth in Children with Complete Unilateral Cleft Lip and Palate

INTRODUCTION

Cleft lip and palate (CLP) are the most common congenital craniofacial deformities that can cause a variety of dental abnormalities in children. The purpose of this study was to predict the maxillary arch growth and to develop a neural network logistic regression model for both UCLP and non-UCLP individuals.

METHODS

This study utilizes a novel method incorporating many approaches, such as the bootstrap method, a multi-layer feed-forward neural network, and ordinal logistic regression. A dataset was created based on the following factors: socio-demographic characteristics such as age and gender, as well as cleft type and category of malocclusion associated with the cleft. Training data were used to create a model, whereas testing data were used to validate it. The study is separated into two phases: phase one involves the use of a multilayer neural network and phase two involves the use of an ordinal logistic regression model to analyze the underlying association between cleft and the factors chosen.

RESULTS

The findings of the hybrid technique using ordinal logistic regression are discussed, where category acts as both a dependent variable and as the study's output. The ordinal logistic regression was used to classify the dependent variables into three categories. The suggested technique performs exceptionally well, as evidenced by a Predicted Mean Square Error (PMSE) of 2.03%.

CONCLUSION

The outcome of the study suggests that there is a strong association between gender, age, and cleft. The difference in width and length of the maxillary arch in UCLP is mainly related to the severity of the cleft and facial growth pattern.

Environmental factors in non-syndromic orofacial clefts: A review based on meta-analyses results

Non-syndromic orofacial clefts (NSOFCs) are prevalent birth defects with a complex etiology where several interacting genetic and environmental factors have been observed. This narrative review describes maternal exposures that have been significantly associated with protective effects or risk factors. The statistically significant information reported here was found in meta-analysis studies, taking advantage of their precision in defining intervention effects and their management of heterogeneity between studies. In addition, I propose a hypothesis explaining the biological basis for the results of the meta-analyses. This review aims to improve the evidence available in parent counseling, to prevent the occurrence of orofacial clefts by suggesting lifestyle changes.

Rasch Analysis of Patient- and Parent-Reported Outcome Measures in the International Consortium for Health Outcomes Measurement Standard Set for Cleft Lip and Palate

OBJECTIVES

The aim of this study was to evaluate the psychometric performance of the patient- and parent-reported measures in the International Consortium for Health Outcomes Measurement (ICHOM) Standard Set for Cleft Care, and to identify ways of improving concept coverage.

METHODS

Data from 714 patients with cleft lip and/or palate, aged 8 to 9, 10 to 12.5, and 22 years were collected between November 2015 and April 2019 at Erasmus University Medical Center, Boston Children's Hospital, Duke Children's Hospital, and from participating sites in the CLEFT-Q Phase 3 study. The Standard Set includes 9 CLEFT-Q scales, the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, the Child Oral Health Impact Profile-Oral Symptoms Scale (COHIP-OSS), and the Intelligibility in Context Scale (ICS). Targeting, item-fit statistics, thresholds for item responses, and measurement precision (PSI) were analyzed using Rasch measurement theory.

RESULTS

The proportion of the sample to score within each instruments range of measurement varied from 69% (ICS) to 92% (CLEFT-Q teeth and COHIP-OSS). Specific problems with individual items within the NOSE and COHIP-OSS questionnaires were noted, such as poor item fit to the Rasch model and disordered thresholds (6 of 10). Reliability measured with PSI was above 0.82 for the ICS and all but one CLEFT-Q scale (speech distress). PSIs were lowest for the COHIP-OSS (0.43) and NOSE questionnaire (0.35).

CONCLUSION

The patient- and parent-reported components within the facial appearance, psychosocial function, and speech domains are valid measures; however, the facial function and oral health domains are not sufficiently covered by the CLEFT-Q eating and drinking, NOSE, and COHIP-OSS, and these questionnaires may not be accurate enough to stratify cleft-related outcomes.

Osteocalcin and regulatory cytokine imbalance in children with congenital cleft lip and palate

The aim of the work was a comprehensive assessment of the cytokine system and peripheral blood osteocalcin with the establishment of features of their interconnections in children with congenital cleft lip and palate (CCLP) in comparison with corresponding controls at different age periods. Levels of IL17, IL4, IL6, IL1β, IFNγ and osteocalcin were analyzed by enzyme immunoassay in the peripheral blood of 80 children (0-12 months, 1-3 years, 4-9 years, 10-15 years) with CCLP and age-appropriate control of healthy individuals (40 people). An analysis of the obtained data shows that in children with CCLP we revealed significant differences between pro-inflammatory (IL1β, IL6, IL17), regulatory (IFNγ), anti-inflammatory (IL4) cytokines and osteocalcin compared with controls. Differences were found in the content of IL17, IFNγ, IL4 and osteocalcin in healthy children and in children with CCLP in postnatal ontogenesis. Cytokine deregulation of immunosteogenesis in CCLP, leading to a significant deficit of osteocalcin in the first year of life due to imbalance of the cytokine profile: discordant IL17, IFNγ and IL4 were detected. Obtained data are undoubtedly important in the future for developing new strategies for targeted therapy aimed at normalizing osteocalcin levels at different age periods in children with CCLP.

Prospective evaluation of the effect of early nasal layer closure on definitive repair in cleft palate patients

Introduction

The cleft palate is one of the most common congenital anomalies treated by plastic surgeons. The cleft width increases the tension of repair and necessitates excessive dissection that might affect maxillary growth. Decreasing the width of cleft minimize tension, dissection and may limit the impact on maxillary growth.

Objectives

The purpose of the study was to evaluate the effect of nasal layer closure of the hard palate at the time of cleft lip repair in patients with complete cleft lip and palate, to demonstrate the efficacy of narrowing the gap and to reduce the incidence of fistulae or other complications.

Methods

Thirty patients less than 1 year of age were included in this prospective observational study. A superiorly based vomer flap was used to repair the nasal layer of the cleft hard palate at the time of primary cleft lip repair. 12–14 weeks after the vomer flap, the cleft soft and hard palate was definitively repaired. Alveolar and palatal gaps were recorded during the 1st and 2nd operations to demonstrate the reduction of the gap defect.

Results

The mean reduction of the alveolar cleft width in patients who had a vomer flap in the first stage was 4.067 mm and the mean reduction of the palatal gap was 4.517 mm. Only 3 patients developed small fistula on the repaired nasal layer that was discovered and corrected during definitive palatoplasty.

Conclusion

Nasal layer closure is a simple surgical technique that can be used to close the hard palate at the time of cleft lip repair. It is a valuable addition to cleft lip and palate repair that may prevent some cleft palate surgical complications.

Classification of Mouth Corners in Asian Women

BACKGROUND

There is increasing interest in mouth corner lift (MCL), as well as lip augmentation. Procedures for lip corner lifting to create smiling lips include botulinum toxin, injectable filler, and surgery. However, there is no proper system to classify mouth corners, thereby causing difficulties in patient counseling, treatment planning, and communicating with medical staff. We developed a new classification system to analyze the shape of mouth corners in Asian women.

METHODS

Lip shapes were classified as types I (arched upper lip) and II (flat upper lip), each of which was further classified as subtypes a (upturned mouth corner) and b (flat or downturned mouth corner). Atypical cases were classified as type III. The anterior-posterior view of facial photographs were taken of female patients aged 20-40 years who visited HB Plastic Surgery Clinic between January 2017 and December 2018. Patients who visited for surgery other than lip plastic surgery (group A) and those who visited for MCL (group B) were compared. Changes in mouth corner type across age were examined.

RESULTS

The most common type was IIb in group A and Ib in group B. IIa and IIb were more common in group A, whereas Ib was more common in group B, at a statistically significant level. With increasing age, the proportions of IIb and III tended to increase, and Ia and IIa tended to decrease.

CONCLUSION

This relatively simple classification system for mouth corners might be helpful in patient counseling and communication with medical staff during plastic surgery.

Correlation between Type of Clefting and the Incidence of Otitis Media among Children with Lip and/or Palate Clefts

INTRODUCTION

Otitis media is a frequent condition among children with high morbidity. Orofacial clefts are undoubtedly one of the most well-established risk factors for otitis media during childhood. The clinical spectrum of disease in orofacial clefting is broad according to the subtype of malformation. This study aims to correlate the occurrence of otitis media among lip and/or palate cleft children with clinical and epidemiological parameters, in particular with the subtypes of malformation diagnosed.

METHODS

This is a clinical, retrospective, case-control type of study. Epidemiological and clinical data were obtained from medical records of children born between 2005 and 2008 and attending a multidisciplinary center for cleft patients.

RESULTS

53% of the patients had registers of middle ear disorder during follow-up, and secretory otitis media was the most frequently diagnosed condition. Five children (1.39%) had chronic otitis media during the study period. Those patients with malformations including involvement of structures located posteriorly to the incisive foramen were more frequently diagnosed with otitis media than those with isolated pre-foramen cleft (p value < 0.001, odds ratio: 5.33). Gender and bilateral malformations did not correlate with increased occurrence of middle ear disease (p value > 0.05).

CONCLUSION

Otitis media is frequent among lip and/or palate cleft children, although the grade of middle ear involvement seems to vary widely within this population. Post-foraminal malformations are clearly associated with increased incidence of otitis media, as well as with more severe diseases.

Unilateral cleft lip repair: a comparison of treatment outcome with two surgical techniques using quantitative (anthropometry) assessment

OBJECTIVES

The unilateral cleft lip (UCL) repair technique has evolved extensively over the past century into its modern form and has been identified as an important determinant of treatment outcome. The aim of this study was to evaluate and compare treatment outcomes following repair of UCL using either the Tennison-Randall (triangular) technique or the Millard rotation-advancement technique.

MATERIALS AND METHODS

This was a prospective randomized controlled study conducted at the Lagos University Teaching Hospital between January 2013 and July 2014. A total of 48 subjects with UCL presenting for primary surgery and who satisfied the inclusion criteria were recruited for the study. The subjects were randomly allocated into two surgical groups through balloting. Group A underwent cleft repair with the Tennison-Randall technique, while group B underwent cleft repair with the Millard rotation-advancement technique. Surgical outcome was assessed quantitatively according to anthropometric measurements, using a method described by Cutting and Dayan (2003).

RESULTS

Our 48 enrolled subjects were evenly divided into the two surgery groups (n=24 for both group A and group B). Twenty-seven subjects were male (56.3%) and 21 were female (43.8%), making a sex ratio of 1.3:1. The Millard group showed a greater increase in postoperative horizontal length and vertical lip height and a greater reduction in nasal width and total nasal width. Meanwhile, the Tennison-Randall group showed better reduction of Cupid's-bow width and better philtral height.

CONCLUSION

We did not find any significant differences in the surgical outcomes from the two techniques. The expertise of the surgeon and individual patient preferences are the main factors to consider when selecting the technique for unilateral cleft repair.

Early Placement of Ventilation Tubes in Infants with Cleft Lip and Palate: A Systematic Review

Objective

Studies have shown that the majority of cleft lip and palate (CLP) children have middle ear fluid present at the time of lip repair (3-4 months). Despite hearing loss, the majority of children do not undergo ventilation tube treatment if required until the time of palate repair (9-12 months). We aimed to examine the effectiveness and potential complications of early ventilation tube placement prior to palatoplasty in infants with cleft lip and palate.

Data Sources

Medline (1946-2015), Embase (1980-2015), and EBM Reviews (Cochrane Central Register of Controlled).

Review Methods

Data sources were searched for publications that described the results of early ventilation tube placement in children with CLP prior to cleft palate repair. Two independent reviewers appraised the selected studies.

Results

Of 226 studies identified, 6 studies met the inclusion criteria. Early ventilation tube insertion in CLP gave similar speech and audiology outcomes to non-CLP children undergoing ventilation tube insertion and better outcomes than those children with CLP having later ventilation tube insertion at or after the time of palate closure. The main reported side effect was otorrhea, being higher for children with CLP having early ventilation tube insertion (67% vs 33%), with a reduction in otorrhea with increasing age. Larger studies with longer-term outcome reporting are required to fully address the study objectives.

Conclusion

Published data are limited but appear to support early insertion of ventilation tubes in children with CLP to restore middle ear function and maximize audiologic and speech outcomes.

Correlation between Nasoalveolar Molding and Surgical, Aesthetic, Functional and Socioeconomic Outcomes Following Primary Repair Surgery: a Systematic Review

OBJECTIVES

The authors performed a systematic review to evaluate the potential beneficial effects of the nasoalveolar molding appliance on nonsyndromic unilateral clefts of the lip and/or palate prior to primary lip repair.

MATERIAL AND METHODS

A literature search was performed using three electronic databases (PubMed, Embase, Web of Science) and three journals ("Cleft Palate-Craniofacial Journal", "Plastic and Reconstructive Surgery Journal" and "American Journal of Orthodontics and Dentofacial Orthopaedic") from January 1980 to April 2017. Data extraction was performed with tables treating different subjects: surgical, aesthetical, functional, socio-economical effects of nasoalveolar molding (NAM) appliances and the evolution of NAM appliances, especially three-dimensional technology.

RESULTS

Of the 145 articles retrieved in the literature surveys, 28 were qualified for the final analysis and 20 studies were excluded because of their small sample size (less than 10 patients) and/or too long follow-up (exceeded 18 months). Four randomized controlled trials were available. Although literature allowed discussing the short-term benefits of NAM appliance and the three-dimensional technology, scientific evidence is lacking.

CONCLUSIONS

Based on the results, nasoalveolar molding appliances have positive surgical, aesthetical, functional and socio-economical effects on unilateral clefts of the lip and/or palate treatment before the primary repair surgeries. Three-dimensional technology results in a more efficient and predictable nasoalveolar molding appliance treatment. However, nasoalveolar molding appliance effect in a short term remains unclear with the available literature. Further studies that integrate three-dimensional technology in a large scale are still needed.

The pivotal role of CCN2 in mammalian palatogenesis

Mammalian palatogenesis is a complex process involving a temporally and spatially regulated myriad of factors. Together these factors control the 3 vital processes of proliferation, elevation and fusion of the developing palate. In this study, we show for the first time the unequivocally vital role of CCN2 in development of the mammalian palate. We utilized CCN2 knockout (KO) mice and cranial neural crest derived mesenchymal cells from these CCN2 KO mice to investigate the 3 processes crucial to normal palatogenesis. Similar to previously published reports, the absence of CCN2 inhibits proliferation of cells in the palate specifically at the G1/S transition. Absence of CCN2 also inhibited palatal shelf elevation from the vertical to horizontal position. CCN2 KO mesenchymal cells demonstrated deficiencies in adhesion and spreading owing to an inability to activate Rac1 and RhoA. On the contrary, CCN2 KO mesenchymal cells exhibited increased rates of migration compared to WT cells. The addition of exogenous CCN2 to KO mesenchymal cells restored their ability to spread normally on fibronectin. Finally, utilizing an organ culture model we show that the palatal shelves of the CCN2 KO mice demonstrate an inability to fuse when apposed. Together, these data signify that CCN2 plays an indispensible role in normal development of the mammalian palate and warrants additional studies to determine the precise mechanism(s) responsible for these effects.

Evolution of Obstructive Sleep Apnea in Infants with Cleft Palate and Micrognathia

STUDY OBJECTIVES

Children with craniofacial anomalies are a heterogeneous group at high risk for obstructive sleep apnea (OSA). However, the prevalence and structural predictors of OSA in this population are unknown. We hypothesized that infants with micrognathia would have more significant OSA than those with isolated cleft palate ± cleft lip (ICP), and those with ICP would have more significant OSA than controls. We postulated that OSA severity would correlate with reduced mandibular size, neurodevelopmental scores, and growth.

METHODS

Prospective cohort study. 15 infants with ICP, 19 with micrognathia, and 9 controls were recruited for polysomnograms, neurodevelopmental testing, cephalometrics (ICP and micrognathia groups) at baseline and a follow-up at 6 mo.

RESULTS

Baseline apnea-hypopnea index (AHI) [median (range)] of the micrognathia group [20.1 events/h (0.8, 54.7)] was greater than ICP [3.2 (0.3, 30.7)] or controls [3.1 (0.5, 23.3)] (p = 0.001). Polysomnographic findings were similar between ICP and controls. Controls had a greater AHI than previously reported in the literature. Cephalometric measures of both midface hypoplasia and micrognathia correlated with OSA severity. Neurodevelopment was similar among groups. OSA improved with growth in participants with ICP and postoperatively in infants with micrognathia.

CONCLUSIONS

Micrognathia, but not ICP, was associated with more significant OSA compared to controls. Both midface and mandibular hypoplasia contribute to OSA in these populations. OSA improved after surgical correction in most infants with micrognathia, and improved without intervention before palate repair in infants with ICP.

Furlow palatoplasty for previously repaired cleft palate with velopharyngeal insufficiency

OBJECTIVE

Velopharyngeal insufficiency (VPI) is a common complication after cleft palate repair, it may be due to lack of levator sling reconstruction and/or palatal shortening. Furlow palatoplasty has the advantages of retro-positioning of levator palati muscles and palatal lengthening. The aim of this study was to assess the efficacy of Furlow palatoplasty in the treatment of VPI in patients who undergone previous palatoplasty.

METHODS

Twenty-three children with post-palatoplasty VPI were included in the study. Furlow technique which was not used in the primary repair, has been used as a secondary corrective surgery. Preoperative and postoperative evaluation of velopharyngeal function was performed, using auditory perceptual assessment (APA) and nasometry for speech, and flexible nasopharyngoscopy for velopharyngeal closure.

RESULTS

Significant improvement of APA and nasalance score for oral and nasal sentences was achieved. Flexible nasopharyngoscopy showed complete velopharyngeal closure in 19 patients (82%) postoperatively.

CONCLUSION

Furlow palatoplasty is considered a useful treatment option for VPI in patients with previously repaired cleft palate, it improves the speech and velopharyngeal closure.

A 35-year experience with syndromic cleft palate repair: operative outcomes and long-term speech function

BACKGROUND

Associated comorbidities can put syndromic patients with cleft palate at risk for poor speech outcomes. Reported rates of velopharyngeal insufficiency (VPI) vary from 8% to 64%, and need for secondary VPI surgery from 23% to 64%, with few studies providing long-term follow-up. The purpose of this study was to describe our institutional long-term experience with syndromic patients undergoing cleft palatoplasty.

METHODS

A retrospective review was conducted of all patients with syndromic diagnoses undergoing primary Furlow palatoplasty from 1975 to 2011. Outcomes included postoperative oronasal fistula (ONF) and need for secondary VPI surgery. Speech scores for verbal patients 5 years or older were collected via the Pittsburgh scale for speech assessment. Aggregate scores categorized the velopharyngeal mechanism as competent, borderline, or incompetent. Outcomes were analyzed by patient and operative factors.

RESULTS

One hundred thirty-two patients were included with average age at repair of 20.7 months. Cleft type was 9% submucosal, 16% Veau class I, 50% class II, 12% class III, and 13% class IV. Forty-five syndromes were recorded, most commonly Stickler syndrome (n = 32) and 22q11.2 deletion syndrome [22q11.2DS (n = 19)]. Forty-four patients also had associated Pierre Robin sequence (PRS). The overall ONF rate was 4.5% and was highest in Veau class IV clefts (P = 0.048). Seventy-six patients were included in speech analysis, with an average age at last assessment of 10.4 years. Overall, 60.5% of patients had a competent velopharyngeal mechanism, 23.7% borderline, and 15.8% incompetent mechanism. Fifty percent of 22q11.2DS patients had borderline speech and none had competent speech, compared to 73.3% with Stickler syndrome (P = 0.01) and 71.4% of patients with associated PRS (P = 0.02). Secondary VPI surgery was performed in 11.4% of patients overall. Patients with PRS (13.6%) and with Stickler syndrome (15.6%) had secondary VPI surgery, compared to 31.6% of patients with 22q11.2DS (P = 0.01).

CONCLUSIONS

This study demonstrates low rates of postoperative ONF after modified Furlow palatoplasty in syndromic patients. Speech outcomes were comparable to nonsyndromic patients at our institution, but patients with 22q11.2DS consistently had borderline-incompetent speech and a 3-fold higher incidence of secondary VPI surgery.

Exploratory genotype-phenotype correlations of facial form and asymmetry in unaffected relatives of children with non-syndromic cleft lip and/or palate

Family relatives of children with nonsyndromic cleft lip with or without cleft palate (NSCL/P) who presumably carry a genetic risk yet do not manifest overt oral clefts, often present with distinct facial morphology of unknown genetic etiology. This study investigates distinct facial morphology among unaffected relatives and examines whether candidate genes previously associated with overt NSCL/P and left-right body patterning are correlated with such facial morphology. Cases were unaffected relatives of individuals with NSCL/P (n = 188) and controls (n = 194) were individuals without family history of NSCL/P. Cases and controls were genotyped for 20 SNPs across 13 candidate genes for NSCL/P (PAX7, ABCA4-ARHGAP29, IRF6, MSX1, PITX2, 8q24, FOXE1, TGFB3 and MAFB) and left-right body patterning (LEFTY1, LEFTY2, ISL1 and SNAI1). Facial shape and asymmetry phenotypes were obtained via principal component analyses and Procrustes analysis of variance from 32 coordinate landmarks, digitized on 3D facial images. Case-control comparisons of phenotypes obtained were performed via multivariate regression adjusting for age and gender. Phenotypes that differed significantly (P < 0.05) between cases and controls were regressed on the SNPs one at a time. Cases had significantly (P < 0.05) more profile concavity with upper face retrusion, upturned noses with obtuse nasolabial angles, more protrusive chins, increased lower facial heights, thinner and more retrusive lips and more protrusive foreheads. Furthermore, cases showed significantly more directional asymmetry compared to controls. Several of these phenotypes were significantly associated with genetic variants (P < 0.05). Facial height and width were associated with SNAI1. Midface antero-posterior (AP) projection was associated with LEFTY1. The AP position of the chin was related to SNAI1, IRF6, MSX1 and MAFB. The AP position of the forehead and the width of the mouth were associated with ABCA4-ARHGAP29 and MAFB. Lastly, facial asymmetry was related to LEFTY1, LEFTY2 and SNAI1. This study demonstrates that, genes underlying lip and palate formation and left-right patterning also contribute to facial features characteristic of the NSCL/P spectrum.

Prenatal consultation with the pediatric otolaryngologist

OBJECTIVES

To examine the spectrum of fetal head and neck anomalies that may prompt prenatal referral and to determine the frequency of these consultations.

STUDY DESIGN

Case series with chart review.

METHODS

The billing databases of two urban pediatric otolaryngology practices were queried for ICD-9 codes corresponding to fetal anomalies between January 2010 and December 2012. The pediatric otolaryngology practices in this study evaluate all fetal head and neck anomalies referred to their respective institutions, including craniofacial disorders.

RESULTS

Over a three-year period, 53 women presented for fetal otolaryngology consultation, with each practice seeing approximately one consultation every 6 weeks (every 5 weeks (JDS) and every 7 weeks (ARS)). The average maternal and gestational age at presentation were 28.7 years and 27.2 weeks, respectively. 83% of the cases (n = 44) involved some form of cleft lip with or without cleft palate. Other head and neck anomalies included fetal goiter/other congenital neck mass (9% (n = 5)) and micrognathia (6% (n = 3)). Macroglossia (n = 1) and facial cleft (n = 1) each accounted for 2% of cases. Cleft mothers presented earlier in pregnancy (average 26.8 weeks) than those with a neck mass (average 32.3 weeks) (p < 0.05). Only 3 cases (6%) merited ex utero intrapartum treatment.

CONCLUSIONS

Depending on the referral practices at a given medical center, craniofacial surgeons rather than pediatric otolaryngologists may be evaluating the majority of fetal head and neck anomalies, as orofacial clefts account for most prenatal consultations. The wide spectrum of congenital neck masses may or may not demand monitoring of the airway during the peripartum period.

Unilateral cleft lip repair

Modern cleft surgery requires four-dimensional and functional anatomic understanding of the cleft (and noncleft) lip, nose, and alveolus. Some techniques for nasolabial repair rely more on precise anatomic geometry, whereas others afford the surgeon a more flexible design. Consistent anthropometry enables accurate assessment and reporting of long-term outcomes; such reports are needed to guide perioperative care, delineate optimal repair principles, and resolve ongoing controversies.

[Orofacial closure defects: cleft lip and palate. A literature review]

Orofacial clefts are a common problem that can lead to significant healthcare use and costs, as well as suffering on the part of the affected individuals and families. There are several theories explaining their origin, but some of the findings are inconsistent. The most accepted theories involve a major genetic basis that could be modified by the presence of external agents. Understanding the underlying causes could help to prevent its occurrence, an area in which the family physician can play an important role.

Perioperative Risk Factors for Adverse Airway Events in Patients Undergoing Cleft Palate Repair

Objective

To establish the incidence of perioperative airway complications in a large series of pediatric patients undergoing palatoplasty and to identify which specific patient, procedural, and provider factors are associated with increased risk for perioperative adverse airway events (AAEs).

Design

Retrospective chart review.

Setting

Tertiary pediatric hospital.

Patients

Included were 300 patients who underwent primary cleft palate repair using the modified Furlow technique between 2008 and 2011. Patients were 2 years or younger at the time of the operation.

Main Outcome Measure(s)

Charts were reviewed for perioperative AAEs, which were defined as postoperative airway obstruction, oxyhemoglobin saturation ≤85% for ≥45 seconds, bronchospasm, laryngospasm, reintubation, and unplanned admission to the intensive care unit. Patient-specific factors (diagnosis of a craniofacial syndrome, Veau cleft type, preoperative pulmonary and airway history), procedural factors (operative time, anesthesia time, opioid dose, administration and reversal of neuromuscular blockers), and provider factors (experience, number of providers), were documented, and associations with AAEs were investigated.

Results

AAEs occurred in 23% of patients overall and were significantly more common in syndromic patients ( P = .003), patients with jaw or tracheal anomalies ( P = .001), and patients with a history of difficult airway ( P = .001). Other significant factors included prior history of difficult intubation ( P = .05), surgeon ( P = .02) and anesthesiologist experience ( P = .05), and operative time ( P = .02).

Conclusions

Diagnosis of a craniofacial syndrome, a history of preoperative airway problems, and provider inexperience correlated with increased risk for airway complications after palatoplasty. Recognizing patients at risk for AAEs may permit improved preoperative planning to optimize surgical outcomes and minimize complications.

Speech outcome after early repair of cleft soft palate using Furlow technique

OBJECTIVE

The earlier closure of palatal cleft is the better the speech outcome and the less compensatory articulation errors, however dissection on the hard palate may interfere with facial growth. In Furlow palatoplasty, dissection on the hard palate is not needed and surgery is usually limited to the soft palate, so the technique has no deleterious effect on the facial growth. The aim of this study was to assess the efficacy of Furlow palatoplasty technique on the speech of young infants with cleft soft palate.

METHODS

Twenty-one infants with cleft soft palate were included in this study, their ages ranged from 3 to 6 months. Their clefts were repaired using Furlow technique. The patients were followed up for at least 4 years; at the end of the follow up period they were subjected to flexible nasopharyngoscopy to assess the velopharyngeal closure and speech analysis using auditory perceptual assessment.

RESULTS

Eighteen cases (85.7%) showed complete velopharyngeal closure, 1 case (4.8%) showed borderline competence, and 2 cases (9.5%) showed borderline incompetence. Normal resonance has been attained in 18 patients (85.7%), and mild hypernasality in 3 patients (14.3%), no patients demonstrated nasal emission of air. Speech therapy was beneficial for cases with residual hypernasality; no cases needed secondary corrective surgery.

CONCLUSION

Furlow palatoplasty at a younger age has favorable speech outcome with no detectable morbidity.

Protocols in cleft lip and palate treatment: systematic review

Objectives. To find clinical decisions on cleft treatment based on randomized controlled trials (RCTs). Method. Searches were made in PubMed, Embase, and Cochrane Library on cleft lip and/or palate. From the 170 articles found in the searches, 28 were considered adequate to guide clinical practice. Results. A scarce number of RCTs were found approaching cleft treatment. The experimental clinical approaches analyzed in the 28 articles were infant orthopedics, rectal acetaminophen, palatal block with bupivacaine, infraorbital nerve block with bupivacaine, osteogenesis distraction, intravenous dexamethasone sodium phosphate, and alveoloplasty with bone morphogenetic protein-2 (BMP-2). Conclusions. Few randomized controlled trials were found approaching cleft treatment, and fewer related to surgical repair of this deformity. So there is a need for more multicenter collaborations, mainly on surgical area, to reduce the variety of treatment modalities and to ensure that the cleft patient receives an evidence-based clinical practice.

Cleft Lip and Palate

Patients who have cleft lip or palate face significant lifelong communicative and aesthetic challenges and difficulties with deglutition. Management of patients who have orofacial clefting requires an understanding of the anatomy and pathophysiology associated with clefting and the developmental difficulties encountered by these patients. This article describes current surgical concepts and principles of cleft care. Advances in the embryology and genetics of orofacial clefting are also discussed. It is expected that the care of patients who have clefts will continue to evolve because of advances in the fields of tissue engineering, genetics, and fetal surgery.

Treatment of oralfacial clefts by state-affiliated craniofacial centers and cleft palate clinics

BACKGROUND

Oralfacial clefting (OFC) disorders require expedient evaluation and treatment to obtain optimal outcome. In Florida, there is a statewide program targeted to the care of infants with OFC. We therefore sought to determine statewide referral and treatment patterns of children born with OFC identified through the Florida Birth Defects Registry.

METHODS

Using data for 1996 and 1997 and ICD-9 CM codes 749.00 - 749.25, we identified 539 OFC cases. All cases were matched with the evaluation and treatment records of the statewide Children's Medical Services' (CMS) craniofacial centers (CFC) and cleft palate clinics (CPC). The likelihood of CMS contact was examined with respect to demographic and other descriptive data characterizing the OFC cases.

RESULTS

42% (227/539) of OFC cases were evaluated at or known to the CFC or CPC. Children with cleft lip and palate were more likely to have had contact than were those with cleft lip or cleft palate alone. The CFC and CPC programs were most likely to provide evaluation between age 2 months and 3 years. Of 12 counties with occurrences of more than 15 OFC cases, 2 had significantly lower contact rates, suggesting possible problems in accessibility or reporting of services.

CONCLUSIONS

Statewide Birth Defect Registry data can be used in collaboration with statewide treatment programs to gain insight into referral patterns and provision of services. Factors influencing access to services and quality of care, though not addressed by this study, could be prospectively incorporated into such a project.

Prenatal imaging of facial clefts by magnetic resonance imaging with emphasis on the posterior palate

OBJECTIVE

To evaluate the role of Magnetic Resonance Imaging (MRI) in the prenatal diagnosis of facial clefts.

MATERIALS AND METHODS

Six fetuses with a sonographic diagnosis of cleft lip and palate underwent MRI at a median age of 30 weeks (range 28-32). The defect was bilateral in two cases.

RESULTS

Fetal MRI confirmed the presence of a cleft involving at least the anterior palate in all cases. Distinction between unilateral and bilateral clefts could be made in all cases and was always confirmed after birth. Sagittal views of the fetal face were found to be particularly useful in identifying the degree of extension of the cleft into the palate. The diagnosis was confirmed after birth.

CONCLUSION

Our results suggest that MRI may be ancillary to ultrasound in prenatal investigation of a fetus with cleft lip, allowing a better staging of the lesion by demonstrating the degree of involvement of the palate.