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Riklin E, Choi DG, Trotter C, Lasky S, Kato RM, Davidson Ward SL, Magee WP, Hammoudeh JA, Urata MM, Johns AL. Polysomnogram Findings and Psychosocial and Academic Concerns in Children With Cleft Palate With or Without Cleft Lip. J Craniofac Surg 2024:00001665-990000000-01808. [PMID: 39141811 DOI: 10.1097/scs.0000000000010504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/26/2024] [Indexed: 08/16/2024] Open
Abstract
Children born with a cleft palate with or without a cleft lip (CP±L) are at risk for sleep-disordered breathing, particularly obstructive sleep apnea (OSA). While OSA and CP±L have both been associated with higher risk for psychosocial and academic concerns, their combined risk has been understudied. This paper aimed to describe polysomnography findings and psychosocial and academic concerns among children with isolated (iCP±L) and syndrome-associated (sCP±L) clefts who had undergone primary palatoplasty. Medical records were reviewed from 2004 to 2022 for demographics, medical history, polysomnography results, and family-reported psychosocial and academic variables. Of the 694 patients with CP±L who had a palatoplasty, 147 had a polysomnogram and 82 had at least one follow-up polysomnogram. Across time points, only 19% to 27% of participants had normal polysomnograms and the most frequent finding was mild OSA for 30% to 35% of patients. For children with iCP±L, more frequent oxygen desaturations were significantly associated with receiving special education services and family-reported academic concerns and OSA was associated with a history of receiving mental health services. Children with sCP±L had a significantly higher Obstructive Apnea-Hypopnea Index and a greater proportion of all-day special education classroom placements relative to youth with iCP±L. Study results suggest that cleft providers should monitor for OSA and sleep-disordered breathing symptoms, collaborate with pulmonologists for evaluation and treatment of sleep concerns, and address possible sleep-associated psychosocial and academic issues.
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Affiliation(s)
- Eric Riklin
- Behavioral Health Institute, Children's Hospital Los Angeles
| | - Dylan G Choi
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles
| | - Collean Trotter
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles
| | - Sasha Lasky
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles
| | - Roberta M Kato
- Division of Pediatric Pulmonary and Sleep Medicine, Children's Hospital Los Angeles
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Sally L Davidson Ward
- Division of Pediatric Pulmonary and Sleep Medicine, Children's Hospital Los Angeles
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - William P Magee
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jeffrey A Hammoudeh
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Mark M Urata
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alexis L Johns
- Behavioral Health Institute, Children's Hospital Los Angeles
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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Kimia R, Solot CB, McCormack SM, Cohen M, Blum JD, Villavisanis DF, Vora N, Valenzuela Z, Taylor JA, Low DW, Jackson OA. Speech Outcomes Following Operative Management of Velopharyngeal Dysfunction (VPD) in Non-Syndromic Post-Palatoplasty Cleft Palate Patients. Cleft Palate Craniofac J 2024; 61:1007-1017. [PMID: 36749038 DOI: 10.1177/10556656231154808] [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: 02/08/2023] Open
Abstract
OBJECTIVE Approximately 30% of patients with a history of repaired cleft palate (CP) go on to suffer from velopharyngeal dysfunction (VPD). This study discusses the operative management of VPD and postoperative speech outcomes in a cohort of CP patients. SETTING An academic tertiary pediatric care center. METHODS Retrospective cohort study. PATIENTS Patients with history of repaired CP (Veau I-IV) who underwent operative management of VPD between January 1st, 2010 and December 31st, 2020. Operative modalities were posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), Furlow palate re-repair, and buccal myomucosal flap palate lengthening (PL). OUTCOME MEASURES The primary outcome measure is postoperative speech improvement evaluated by the Pittsburgh Weighted Speech Scale (PWSS). RESULTS 97 patients met inclusion criteria. 38 patients with previous straight-line primary palatoplasty underwent Furlow re-repair; these patients were significantly younger (7.62 vs 11.14, P < .001) and were more likely to have severe VPD per PWSS (OR 4.28, P < .01, 95% CI 1.46-12.56) when compared to VPD patients with previous Furlow repair. 21.1% of these patients required an additional non-revisional VPD procedure. The remaining patients underwent a non-revision procedure (26 PPF, 22 SPP, 11 PL); all experienced significant (P < .001 on paired t-test) reductions in PWSS total and subgroup VPD severity scores without difference in improvement between operation types. SPP was statistically associated with all-cause complication (OR 2.79, 95% CI 1.03-7.59, P < .05) and hyponasality (OR 3.27, 95% CI 1.112-9.630, P < .05). CONCLUSION Furlow re-repair reduced need for additional VPD operations. Speech outcomes between non-revisional operations are comparable, but increased complications were seen in SPP.
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Affiliation(s)
- Rotem Kimia
- Division of Plastic and Reconstructive Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Cynthia B Solot
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan M McCormack
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marilyn Cohen
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Speech-Language Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jessica D Blum
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dillan F Villavisanis
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nisha Vora
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary Valenzuela
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David W Low
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Hattori Y, Lo CC, Chen YJ, Saito T, Chou PY, Lu TC, Chang CS, Lo LJ. Comparison of modified Furlow palatoplasty using small double-opposing Z-plasty and conventional Furlow palatoplasty: A long-term outcome study. J Plast Reconstr Aesthet Surg 2024; 93:261-268. [PMID: 38723512 DOI: 10.1016/j.bjps.2024.04.058] [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: 10/20/2023] [Revised: 04/02/2024] [Accepted: 04/21/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND The aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing post-operative complications. This study aimed to compare the long-term outcomes of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center. METHODS A retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included. RESULTS A total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were included in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% vs. 4.6%, p = 0.01), and the VPI prevalence was not significantly different (9.2% vs. 7.9%, p = 0.62). Patients who developed fistula had a significantly higher likelihood of developing VPI than patients without oronasal fistula (50.0% vs. 7.1%, respectively; p < 0.01), with an odds ratio of 13.0. CONCLUSION Both modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension lowered the risk of oronasal fistula.
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Affiliation(s)
- Yoshitsugu Hattori
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Chin Lo
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Jen Chen
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Takafumi Saito
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Pang-Yun Chou
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Ting-Chen Lu
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Shin Chang
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lun-Jou Lo
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan.
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Ovadia SA, Smartz T, Thaller SR. Management of Velopharyngeal Insufficiency Associated With Cleft Palate: Sphincter Pharyngoplasty and Pharyngeal Flap. J Craniofac Surg 2024:00001665-990000000-01432. [PMID: 38578098 DOI: 10.1097/scs.0000000000010098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/29/2024] [Indexed: 04/06/2024] Open
Affiliation(s)
- Steven A Ovadia
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Taylor Smartz
- Division of Plastic, DeWitt-Daughtry Family Department of Surgery, Aesthetic and Reconstructive Surgery, University of Miami, Leonard Miller School of Medicine, Miami, FL
| | - Seth R Thaller
- Division of Plastic, DeWitt-Daughtry Family Department of Surgery, Aesthetic and Reconstructive Surgery, University of Miami, Leonard Miller School of Medicine, Miami, FL
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Boynuyoğun E, Çırak A, Atak F, Tığrak TK, Çalış M, Günaydın RÖ, Karaosmanoğlu A, Süslü AE, Kayıkçı MEK, Özgür F. Pharyngeal flap outcomes for velopharyngeal insufficiency: Evaluation of speech, obstructive sleep apnea, and velopharyngeal anatomy. J Plast Reconstr Aesthet Surg 2024; 88:397-406. [PMID: 38086325 DOI: 10.1016/j.bjps.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 01/02/2024]
Abstract
The purpose of this study was to evaluate the speech outcomes, reveal postoperative rates of obstructive sleep apnea, and characterize changes in the pharyngeal flap and velopharyngeal anatomy following pharyngeal flap surgery for velopharyngeal insufficiency. A retrospective chart was reviewed for patients with clefts who underwent pharyngeal flap surgery between November 2020 and November 2021. The data collected included age, gender, cleft palate type, age at pharyngeal flap surgery, postoperative complications, age and type of primary palatoplasty, preoperative and postoperative speech assessments, magnetic resonance imaging findings, and obstructive sleep apnea outcomes. The authors included 72 nonsyndromic patients who underwent pharyngeal flap surgery following cleft palate repair. The mean age at pharyngeal flap surgery was 10.6 ± 6.2 years. There was a significant improvement in the Pittsburgh Weighted Speech Score Hypernasality Component and the nasalance scores of oral syllables (p < 0.001). The obstructive sleep apnea rate after pharyngeal flap surgery was 6.9%. Compared to preoperatively, the velar angle was more acute (p < 0.001), the velar length was longer (p < 0.001), the distance of the velum tip to the posterior pharyngeal wall was shorter (p < 0.001), the size of velopharyngeal gap was narrower (p < 0.001), and the pharyngeal flap atrophied (p < 0.001) at 6 months postoperatively. The pharyngeal flap improved speech outcomes in patients with velopharyngeal insufficiency with a relatively low incidence of obstructive sleep apnea (6.9%). The velum is positioned more superiorly and posteriorly, and the size of the velopharyngeal gap is substantially reduced after pharyngeal flap surgery. In addition, the pharyngeal flap partially atrophied over time.
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Affiliation(s)
- Etkin Boynuyoğun
- Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey.
| | - Alaz Çırak
- Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey
| | - Fırat Atak
- Hacettepe University Faculty of Medicine, Department of Radiology, Ankara, Turkey
| | - Tuğçe Karahan Tığrak
- Hacettepe University Faculty of Health Sciences, Department of Speech and Language Therapy, Ankara, Turkey
| | - Mert Çalış
- Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey
| | - Rıza Önder Günaydın
- Hacettepe University Faculty of Medicine, Department of Otorhinolaryngology, Ankara, Turkey
| | - Ayça Karaosmanoğlu
- Hacettepe University Faculty of Medicine, Department of Radiology, Ankara, Turkey
| | - Ahmet Emre Süslü
- Hacettepe University Faculty of Medicine, Department of Otorhinolaryngology, Ankara, Turkey
| | - Maviş Emel Kulak Kayıkçı
- Hacettepe University Faculty of Health Sciences, Department of Speech and Language Therapy, Ankara, Turkey
| | - Figen Özgür
- Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey
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Chin MG, Roca Y, Huang KX, Moghadam S, LaGuardia JS, Bedar M, Wilson LF, Lee JC. Long-term outcomes of sphincter pharyngoplasty in patients with cleft palate. J Plast Reconstr Aesthet Surg 2024; 88:24-32. [PMID: 37950988 PMCID: PMC11144360 DOI: 10.1016/j.bjps.2023.10.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/13/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate long-term outcomes of sphincter pharyngoplasties, including speech outcomes, revision surgeries, and postoperative incidence of obstructive sleep apnea (OSA). DESIGN Retrospective matched-cohort study SETTING: Two craniofacial centers in Los Angeles, CA PATIENTS: Patients (n = 166) with cleft lip and palate (CLP) or isolated cleft palate (iCP) who underwent sphincter pharyngoplasty from 1992 to 2022 were identified. An age- and diagnosis-matched control group of 67 patients with CLP/iCP without velopharyngeal insufficiency (VPI) was also identified. INTERVENTIONS The pharyngoplasty group underwent sphincter pharyngoplasty, whereas the non-VPI group had no history of VPI surgery or sphincter pharyngoplasty. MAIN OUTCOME MEASURES Postoperative speech outcomes, revision surgeries, and incidence of OSA were evaluated. Multivariable regression was used to evaluate independent predictors of OSA. RESULTS Among the patients in the pharyngoplasty cohort, 63.9% demonstrated improved and sustained speech outcomes after a single pharyngoplasty, with a median postoperative follow-up of 8.8 years (interquartile range [IQR], 3.6-12.0 years). One-third of the patients who underwent pharyngoplasty required a revision surgery, with a median time to primary revision of 3.9 years (IQR, 1.9-7.0 years). OSA rates increased significantly among the pharyngoplasty cohort, from 3% before surgery to 14.5% after surgery (p < 0.001). The average time from sphincter pharyngoplasty to OSA diagnosis was 4.4 ± 2.4 years. Multivariable analysis results indicated that sphincter pharyngoplasty surgery was independently associated with a fourfold increase in OSA (p = 0.03). CONCLUSIONS Although sphincter pharyngoplasty remains successful in improving long-term speech outcomes, persistent OSA is a sequela that should be monitored beyond the immediate postoperative period.
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Affiliation(s)
- Madeline G Chin
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Yvonne Roca
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Kelly X Huang
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Shahrzad Moghadam
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Jonnby S LaGuardia
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Meiwand Bedar
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Libby F Wilson
- Craniofacial/Cleft Palate Program, Orthopaedic Institute for Children, Los Angeles, CA, United States
| | - Justine C Lee
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States.
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Hattori Y, Pai BCJ, Saito T, Chou PY, Lu TC, Chang CS, Chen YR, Lo LJ. Long-term treatment outcome of patients with complete bilateral cleft lip and palate: a retrospective cohort study. Int J Surg 2023; 109:1656-1667. [PMID: 37073546 PMCID: PMC10389451 DOI: 10.1097/js9.0000000000000406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/06/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Patients with cleft lip and palate have functional and esthetic impairment and typically require multiple interventions in their life. Long-term evaluation following a treatment protocol, especially for patients with complete bilateral cleft lip and palate (BCLP), is important but was rarely reported in the literature. PATIENTS AND METHODS A retrospective review was conducted on all patients with complete BCLP born between 1995 and 2002 and treated at our center. Inclusion criteria were having adequate medical records and receiving continuous multidisciplinary team care at least until 20 years of age. Exclusion criteria were lack of regular follow-up and congenital syndromic abnormalities. The medical records and photos were reviewed, and facial bone development was evaluated using cephalometric analysis. RESULTS A total of 122 patients were included, with a mean age of 22.1 years at the final evaluation in this study. Primary one-stage cheiloplasty was performed in 91.0% of the patients, and 9.0% underwent two-stage repair with an initial adhesion cheiloplasty. All patients underwent two-flap palatoplasty at an average of 12.3 months. Surgical intervention for velopharyngeal insufficiency was required in 59.0% of patients. Revisional lip/nose surgery was performed in 31.1% during growing age and in 64.8% after skeletal maturity. Orthognathic surgery was applied in 60.7% of patients with retruded midface, of which 97.3% underwent two-jaw surgery. The average number of operations to complete the treatment was 5.9 per patient. CONCLUSION Patients with complete BCLP remain the most challenging group to treat among the cleft. This review revealed certain suboptimal results, and modifications have been made to the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.
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Affiliation(s)
- Yoshitsugu Hattori
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Betty C.-J. Pai
- Department of Craniofacial Orthodontics and Craniofacial Research Center, Chang Gung Memorial Hospital, Kwei Shan, Taoyuan, Taiwan
| | - Takafumi Saito
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Pang-Yun Chou
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Ting-Chen Lu
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Chun-Shin Chang
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Yu-Ray Chen
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
| | - Lun-Jou Lo
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
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Suzzi C, Di Gennaro G, Baylon H, Captier G. A Master Mind Game Code Algorithm Approach to Help Surgical Decision-Making between Retropharyngeal Fat Grafting and Pharyngoplasty for the Treatment of Velopharyngeal Incompetence. Int Arch Otorhinolaryngol 2023; 27:e351-e361. [PMID: 37125364 PMCID: PMC10147477 DOI: 10.1055/s-0043-1763501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 10/09/2022] [Indexed: 03/31/2023] Open
Abstract
Abstract
Introduction Velopharyngeal insufficiency (VPI) is a controversial pathology with many surgical options.
Objective To compare pharyngoplasty and retropharyngeal fat grafting and to build a prognostic tool to achieve perfect speech.
Methods Retrospective observational cohort study of 114 patients operated for VPI from 1982 to 2019 in a single tertiary center. The instrumental assessment was made using an aerophonoscope and nasofibroscopy. The variables sex, age, genetic syndromes, and type of diagnosis were analyzed with logistic regression model adjusted with propensity score. To generalize results and to build a surgical predictive tool, a marginal analysis concludes the study.
Results Among the patients (median [range] age 7 [4–48]), 63 (55.26%) underwent pharyngoplasty and 51 (44.74%) graft. The graft group had no complication, but it had a failure rate of 7.84%. The pharyngoplasty group had no failure, but one patient had postoperative obstructive sleep apnea. The marginal analysis demonstrated that age lower than 7 years, cleft lip and palate, absence of syndrome, and intermittent VPI were important predictive factors of good result regardless of surgical technique.
Conclusions Without a statistical demonstration of the superiority of pharyngoplasty over graft, and in the uncertainty of literature background, our perfect-speech patient profile represents an important tool for a postoperative forecast of results in which, like in the Master Mind game, every feature has to be considered not individually but as a pattern of characteristics whose association contributes to the outcome.
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Cancelliere S, Heung T, Fischbach S, Klaiman P, Bassett AS. Adult-onset obstructive sleep apnea and pediatric pharyngoplasty in 22q11.2 deletion syndrome. Sleep Med 2023; 104:49-55. [PMID: 36889031 DOI: 10.1016/j.sleep.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/27/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVE/BACKGROUND We aimed to evaluate adult-onset obstructive sleep apnea (OSA) and related risk factors, including history of pediatric palatal/pharyngeal surgery to remediate velopharyngeal dysfunction, in 22q11.2 deletion syndrome (22q11.2DS). PATIENTS/METHODS Using a retrospective cohort design and standard sleep study-based criteria, we determined presence of adult-onset OSA (age ≥16 years) and relevant variables through comprehensive chart review in a well-characterized cohort of 387 adults with typical 22q11.2 microdeletions (51.4% female, median age 32.3, interquartile range 25.0-42.5, years). We used multivariate logistic regression to identify independent risk factors for OSA. RESULTS Of the 73 adults with sleep study data, 39 (53.4%) met criteria for OSA at median age 33.6 (interquartile range 24.0-40.7) years, indicating a minimum OSA prevalence of 10.1% in this 22q11.2DS cohort. History of pediatric pharyngoplasty (odds ratio 2.56, 95% confidence interval 1.15-5.70) was a significant independent predictor of adult-onset OSA, while accounting for other significant independent predictors (asthma, higher body mass index, older age), and for male sex. An estimated 65.5% of those prescribed continuous positive airway pressure therapy were reported as adherent. CONCLUSIONS In addition to factors of known importance in the general population, delayed effects of pediatric pharyngoplasty may contribute to risk of adult-onset OSA in individuals with 22q11.2DS. The results support increased index of suspicion for OSA in adults with a 22q11.2 microdeletion. Future research with this and other homogeneous genetic models may help to improve outcomes and to better understand genetic and modifiable risk factors for OSA.
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Affiliation(s)
- Sabrina Cancelliere
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Tracy Heung
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; The Dalglish Family 22q Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Simone Fischbach
- Department of Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada; Department of Plastic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paula Klaiman
- Department of Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada; Department of Plastic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anne S Bassett
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; The Dalglish Family 22q Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, Toronto, Ontario, Canada; Department of Mental Health, University Health Network, Toronto, Ontario, Canada; Toronto Congenital Cardiac Centre for Adults, Division of Cardiology, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, Toronto, Ontario, Canada.
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Bruce MK, Zhang C, Vodovotz L, Irgebay Z, Maliha S, Pfaff M, Ford M, Goldstein JA, Losee JE. Revision Pharyngoplasty in Cleft Palate and Velopharyngeal Insufficiency: Management and Outcomes. Ann Plast Surg 2022; 88:S152-S155. [PMID: 35513313 DOI: 10.1097/sap.0000000000003198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Velopharyngeal insufficiency (VPI), a stigmatizing hallmark of palatal dysfunction, occurs in a wide spectrum of pediatric craniofacial conditions. The mainstays for surgical correction include palate repair and/or pharyngeal surgery. However, primary pharyngoplasty has a failure rate of 15% to 20%. Although revision pharyngoplasty may be necessary in those with persistent VPI, little is known regarding the indications for and outcomes after such procedures. The purpose of this study is to describe the authors' experience with indications for and outcomes after revision pharyngoplasty. METHODS A single-center retrospective review was performed of all patients undergoing revision pharyngoplasty between 2002 and 2019. Demographic data and Pittsburgh Weighted Speech Scores, diagnoses, comorbidities, and complications were tabulated. Two-tailed Student t test was used, and a P value of 0.05 or less was considered statistically significant. RESULTS Thirty-two patients (65.6% male) met inclusion criteria for this study. The most common diagnoses included cleft palate (68.8%), submucous cleft palate (SMCP, 18.8%), and congenital VPI (6.3%, likely occult SMCP). Most patients (84.4%) underwent palatoplasty before their initial pharyngoplasty. The primary indication for initial pharyngoplasty was VPI (mean age 7.1 ± 4.6 years). The most common indication for revision pharyngoplasty (mean age 11.2 ± 5.1 years) included persistent VPI (n = 22), followed by obstructive sleep apnea (OSA) (n = 11). Persistent VPI (n = 8) and OSA (n = 6) were the most common complications after secondary pharyngoplasty. Thirteen patients (40.6%) within the revision pharyngoplasty cohort required additional surgical intervention: 4 underwent tertiary pharyngoplasty, 4 underwent takedown for OSA (n = 3) or persistent VPI (n = 1), 3 underwent takedown and conversion Furlow for persistent VPI (n = 2), OSA (n = 2) and/or flap dehiscence (n = 1), and 2 underwent palatal lengthening with buccal myomucosal flaps for persistent VPI. Of the 4 patients who required a tertiary pharyngoplasty, the mean age at repair was 6.6 ± 1.1 years and their speech scores improved from 13.5 to 2.3 after tertiary pharyngoplasty (P = 0.11). The overall speech score after completion of all procedures improved significantly from 19 to 3.3. CONCLUSION Patients who fail primary pharyngoplasty represent a challenging population. Of patients who underwent secondary pharyngoplasty, nearly half required a tertiary procedure to achieve acceptable speech scores or resolve complications.
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Affiliation(s)
- Madeleine K Bruce
- From the Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Casey Zhang
- From the Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Lena Vodovotz
- From the Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Zhazira Irgebay
- From the Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Samantha Maliha
- From the Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Matthew Ford
- From the Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jesse A Goldstein
- From the Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Joseph E Losee
- From the Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
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