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Esmailzade Moghimi S, Rezaei P, Sadeghi S, Feizi A, Derakhshandeh F. Outcomes of primary repair of cleft palate using sommerled intravelar veloplasty associated with velocardiofacial syndrome. Int J Pediatr Otorhinolaryngol 2024; 179:111940. [PMID: 38588634 DOI: 10.1016/j.ijporl.2024.111940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/23/2024] [Accepted: 04/01/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVES Velocardiofacial syndrome, a prevalent microdeletion syndrome occurring in 1 in 2000-4000 live births, is marked by speech and language disorders, notably velopharyngeal dysfunction. This study investigates speech outcomes, nasometric and videofluoroscopic results before and after primary repair of cleft palate using the Sommerlad intravelar veloplasty (SIVV) technique within the Isfahan cleft care team for patients with velocardiofacial syndrome. METHODS Employing a quasi-experimental design, 19 participants with velocardiofacial syndrome, who underwent primary cleft palate repair by the Isfahan cleft care team, were included through convenience sampling. Perceptual and instrumental outcomes were assessed pre-and post-operatively. Statistical analysis encompassed paired t-tests and the non-parametric Wilcoxon signed-rank test (p < 0.05). RESULTS The study identified no statistically significant differences between pre-and post-surgical speech outcome parameters and nasalance scores. Nonetheless, a significant distinction emerged in the velopharyngeal closure ratio based on fluoroscopic evaluation (p = 0.038). CONCLUSION The efficacy of the SIVV technique in treating velopharyngeal dysfunction in velocardiofacial syndrome patients is inconclusive, demanding further research. Post-surgical speech outcomes are influenced by surgical technique, hypotonia, apraxia of speech, and surgery timing. Notably, an elevated velopharyngeal valve closure ratio, though anatomically indicative, does not exclusively predict surgical success.
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Affiliation(s)
- Sarah Esmailzade Moghimi
- Faculty of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran; Faculty of Rehabilitation Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Rezaei
- Department of Speech and Language Pathology, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Saba Sadeghi
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Awat Feizi
- Department of Biostatistics, Faculty of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Derakhshandeh
- Craniofacial and Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
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Davis MJ, Roy MG, Burns HR, Yim N, Wilson KD, Moore EE, Buchanan EP, Monson LA. Velopharyngeal Insufficiency Following Furlow Versus Straight Line Repair With Intravelar Veloplasty: A Single-institution Experience. J Craniofac Surg 2024; 35:547-552. [PMID: 37982999 DOI: 10.1097/scs.0000000000009874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/09/2023] [Indexed: 11/21/2023] Open
Abstract
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.
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Affiliation(s)
- Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital
| | - Michelle G Roy
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital
| | - Heather R Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital
| | - Nicholas Yim
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Kristina D Wilson
- Speech, Language, and Learning, Texas Children's Hospital, Houston, TX
| | - Ellen E Moore
- Speech, Language, and Learning, Texas Children's Hospital, Houston, TX
| | - Edward P Buchanan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital
| | - Laura A Monson
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital
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Swanson D, Struyk G, Ba'th F, Chinnadurai S, Roby BB. The Incidence of Velopharyngeal Insufficiency in Stickler Syndrome. Cleft Palate Craniofac J 2024; 61:231-234. [PMID: 36443936 DOI: 10.1177/10556656221140675] [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: 12/27/2023] Open
Abstract
OBJECTIVE Stickler Syndrome (SS) is an inherited collagenopathy characterized by heterogenous orofacial, ocular, auditory, and skeletal abnormalities. The orofacial manifestations are variable and some patients present with cleft palate and velopharyngeal insufficiency (VPI). The incidence of VPI in SS is poorly studied and no studies have compared the incidence of VPI between Type I (COL2A1) and Type II (COL11A1) SS. The objective of this study is to compare the incidence of VPI between SS subtypes and discuss the surgical techniques used to treat them. DESIGN Single-institution, retrospective chart review. SETTING Tertiary pediatric hospital. PATIENTS/PARTICIPANTS Forty-three children were diagnosed with SS between January 2003 and December 2018. Genetic testing results, genetics notes, craniofacial clinic notes, and operative reports were reviewed. Patients without genetic testing or craniofacial/otolaryngologic evaluation were excluded. Thirty-one patients met criteria and were included. MAIN OUTCOME MEASURE Primary outcome was VPI incidence. RESULTS There were 18 patients with Type I SS and 13 with Type II SS. Five (16%) patients had VPI, 2 (11%) with Type I SS compared to 3 (23%) with Type II SS (P > .05). All patients with VPI underwent surgery with either sphincter pharyngoplasty (3) or pharyngeal flap (2). Two patients with Type II SS underwent revision sphincter pharyngoplasty, with one conversion to pharyngeal flap. CONCLUSION VPI is common for patients with SS. In this study, there was no significant difference in the incidence of VPI between SS subtypes. Future studies are needed to confirm these findings, which could be important for patient counseling and treatment planning.
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Affiliation(s)
- Daniel Swanson
- Georgetown University School of Medicine, Washington, DC, USA
| | - Griffin Struyk
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Fadlullah Ba'th
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sivakumar Chinnadurai
- Children's Minnesota ENT and Facial Plastic Surgery, Minneapolis, MN, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Brianne B Roby
- Children's Minnesota ENT and Facial Plastic Surgery, Minneapolis, MN, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
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Hofman L, van Dongen JA, van Rees RCM, Jenniskens K, Haverkamp SJ, Beentjes YS, van der Molen ABM, Paes EC. Speech correcting surgery after primary palatoplasty: a systematic literature review and meta-analysis. Clin Oral Investig 2023; 28:58. [PMID: 38157017 DOI: 10.1007/s00784-023-05391-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES In cleft palate patients, the soft palate is commonly closed using straight-line palatoplasty, Z-palatoplasty, or palatoplasty with buccal flaps. Currently, it is unknown which surgical technique is superior regarding speech outcomes. The aim of this review is to study the incidence of speech correcting surgery (SCS) per soft palatoplasty technique and to identify variables which are associated with this outcome. MATERIALS AND METHODS A systematic literature search was carried out according to the PRISMA guidelines. Inclusion and exclusion criteria were applied to focus on the incidence of SCS after soft palatoplasty. Additional variables like surgical modification, cleft morphology, syndrome, age at palatoplasty, fistula and assessment of velopharyngeal function were reported. A modified New-Ottawa Scale (NOS) was used for quality appraisal. Pooled estimates from the meta-analysis were calculated using a random-effects model. RESULTS One thousand twenty-nine studies were found of which 54 were included in the analysis. The pooled estimate proportion of SCS after straight-line palatoplasty was 19% (95% CI 15-24), after Z-palatoplasty 6% (95% CI 4-9), and after palatoplasty with buccal flaps 7% (95% CI 4-11). CONCLUSIONS A lower SCS rate was found in patients receiving Z-palatoplasty when compared to straight-line palatoplasty. We propose a minimum set of outcome parameters which ideally should be included in future studies regarding speech outcomes after cleft palate repair. CLINICAL RELEVANCE Current literature reports highly heterogenous data regarding cleft palate repair. Our recommended set of parameters may address this inconsistency and could make intercenter comparison possible and of better quality.
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Affiliation(s)
- Lieke Hofman
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands.
| | - Joris A van Dongen
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | | | - Kevin Jenniskens
- Department of Epidemiology & Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sarah J Haverkamp
- Speech and Language Therapy, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Yente S Beentjes
- Utrecht University, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Aebele B Mink van der Molen
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Emma C Paes
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
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Wang C, Shi B, Li J. Management of cleft palate among patients with Pierre Robin sequence. Br J Oral Maxillofac Surg 2023; 61:475-481. [PMID: 37453893 DOI: 10.1016/j.bjoms.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 05/29/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
Pierre Robin Sequence (PRS) is a congenital craniofacial anomaly distinguished by the presence of micrognathia, glossoptosis, and upper airway obstruction. Cleft palate occurs in over 3/4 of patients with PRS. The wide U-shape cleft and airway dysfunction create challenges in clinical management. Currently, disputes exist on the treatment protocol and prognosis of cleft palate management among patients with PRS. This review is focused on the deformity features, intervention timing, technique selection, airway support, and outcome evaluation of cleft palate among patients with PRS, aiming to provide reference to further evolution in the management of PRS-related cleft palate.
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Affiliation(s)
- Chunyi Wang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, PR China
| | - Bing Shi
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, PR China
| | - Jingtao Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, PR China.
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Mao Q, Li J, Yin X. Pearls and pitfalls in contemporary management of marginal velopharyngeal inadequacy among children with cleft palate. Front Pediatr 2023; 11:1187224. [PMID: 37609363 PMCID: PMC10440703 DOI: 10.3389/fped.2023.1187224] [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: 03/15/2023] [Accepted: 06/29/2023] [Indexed: 08/24/2023] Open
Abstract
Marginal velopharyngeal inadequacy (MVPI) is a particular status of velopharyngeal closure after cleft palate repair. The physiological and phonological characteristics of patients with MVPI are significantly different from those with typical velopharyngeal insufficiency. The pathological mechanisms and diagnostic criteria of MVPI are still controversial, and there is limited evidence to guide the selection of surgical and non- surgical management options and a lack of recognized standards for treatment protocols. Based on a systematic study of the relevant literatures, this review identifies specific problems that are currently under-recognized in the diagnosis and treatment of MVPI and provides guidelines for further exploration of standardized and reasonable intervention protocols for MVPI.
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Affiliation(s)
- Qirong Mao
- Department of Oral and Maxillofacial Surgery, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jingtao Li
- Department of Oral and Maxillofacial Surgery, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xing Yin
- Department of Orthodontics, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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Haydon N, Semple H, Ho K, Boorer C. Does pharyngoplasty work? Outcomes of 100 consecutive operations over 10 years. ANZ J Surg 2023; 93:1944-1949. [PMID: 37283293 DOI: 10.1111/ans.18563] [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: 03/14/2023] [Revised: 05/22/2023] [Accepted: 05/28/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Velopharyngeal insufficiency is a commonly encountered problem in Cleft Surgery, with pharyngoplasty being the mainstay of surgical management. In this study we aim to investigate the indications and outcomes of a single institution's experience and compare to international literature. METHODS A retrospective review was performed looking at over 100 consecutive primary pharyngoplasty operations for velopharyngeal dysfunction over a 10-year period at a single institution. Aetiology, peri-operative course and speech outcomes for the cohort between January 2010 through January 2020 were assessed. A comprehensive literature review was performed for comparison and analysis of the studies' data. RESULTS Ninety-seven consecutive patients were included in the study on which 103 operations were performed. Average age at time of surgery was 7.25 years old. Approximately 37% of the patients had a diagnosed syndrome, sequence or chromosomal abnormality. Ninety-seven of the 103 operations were primary pharyngoplasties, 4 were revision pharyngoplasties and 2 return to theatre procedures. Regarding speech outcomes, 51% of the patients that had formal speech assessments were found to have a significant improvement, 42% moderate improvement and 7% had no improvement. 93% of the patients that underwent pharyngoplasty in this study had significant or moderate improvement in speech outcomes. These speech outcomes and post-operative complications such as obstructive sleep apnoea are analysed. CONCLUSION This study demonstrates that pharyngoplasty is a safe procedure for velopharyngeal insufficiency with a good overall success rate. The major outcomes assessed including complications & safety, revision rate and speech outcomes are comparative to previous international studies.
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Affiliation(s)
- Nicholas Haydon
- Department of Plastic & Reconstructive Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Harriet Semple
- Department of Plastic & Reconstructive Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Kevin Ho
- Department of Plastic & Reconstructive Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Catherine Boorer
- Department of Plastic & Reconstructive Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
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Sakran KA, Zhang S, Chen N, Yin J, Alkebsi K, Elayah SA, Al-Rokhami RK, Al-Watary MQ, Telha W, Al-Aroomi M, Shi B, Yin H, Huang H. Development of postoperative velopharyngeal function in patients with cleft palate. Int J Pediatr Otorhinolaryngol 2023; 171:111607. [PMID: 37329703 DOI: 10.1016/j.ijporl.2023.111607] [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: 03/29/2023] [Revised: 05/28/2023] [Accepted: 05/30/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Patients with a cleft palate often experience a velopharyngeal dysfunction known as velopharyngeal insufficiency (VPI). The purpose of this study was to examine the development of velopharyngeal function (VPF) following primary palatoplasty and the factors that are linked to it. METHODS A retrospective study was conducted to examine the medical records of patients who had cleft palate, with or without cleft lip (CP ± L) and underwent palatoplasty at a Tertiary Affiliated Hospital between 2004 and 2017. Postoperative evaluation of VPF was conducted at two follow-up times (T1, T2) and was classified as either normal VPF, mild VPI, or moderate/severe VPI. The consistency of VPF evaluations between the two time points was then assessed, and patients were categorized into either the consistent or inconsistent group. The study collected and analyzed data on gender, cleft type, age at operation, follow-up duration, and speech records. RESULTS The study included 188 patients with CP ± L. Out of these, 138 patients (73.4%) showed consistent VPF evaluations, while 50 patients (26.6%) showed inconsistent VPF evaluations. Among those with VPI at T1 (91 patients), 36 patients (39.6%) had normal VPF at T2. The rate of VPI decreased from 48.40% at T1 to 27.13% at T2, whereas the rate of normal VPF increased from 44.68% at T1 to 68.09% at T2. The consistent group had a significantly younger age at operation (2.90 ± 3.82 vs 3.68 ± 4.02), a longer duration of T1 (1.67 ± 0.97 vs 1.04 ± 0.59), and a lower comprehensive score of speech performance (1.86 ± 1.27 vs 2.60 ± 1.07) than the inconsistent group. CONCLUSIONS It has been verified that there are changes in the development of VPF over time. Patients who underwent palatoplasty at a younger age were more likely to have confirmed VPF diagnosis at the first evaluation. The duration of follow-up was identified as a critical factor that affects the confirmation of VPF diagnosis.
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Affiliation(s)
- Karim Ahmed Sakran
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Yemen
| | - Shiming Zhang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Nan Chen
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jiayi Yin
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Khaled Alkebsi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Yemen
| | - Sadam Ahmed Elayah
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China; Department of Oral and Maxillofacial Surgery, College of Dentistry, Ibb University, Yemen
| | - Remsh Khaled Al-Rokhami
- Department of Orthodontics, School of Stomatology, Nanchang University, Nanchang, Jiangxi, China
| | - Mohammed Qasem Al-Watary
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Wael Telha
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Maged Al-Aroomi
- Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, Shenyang, Liaoning, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Heng Yin
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China.
| | - Hanyao Huang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, and Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, 610041, China.
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Long-term speech outcome in patients with Robin sequence after cleft palate repair and tongue-lip adhesion: A 21-year retrospective analysis. J Craniomaxillofac Surg 2023:S1010-5182(23)00012-4. [PMID: 37117117 DOI: 10.1016/j.jcms.2023.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/21/2022] [Accepted: 01/22/2023] [Indexed: 02/05/2023] Open
Abstract
The purpose of this study was to assess the effect of tongue-lip adhesion (TLA) on the long-term speech and articulation outcomes of patients with Robin sequence (RS) after cleft palate repair. Outcomes were compared to those in patients with RS who required positioning alone and to patients with isolated cleft palate (ICP). All consecutive patients with RS (with or without TLA) versus isolated cleft palate (ICP) who underwent cleft palate repair were retrospectively reviewed. Speech and articulation included all assessments between the age of 3-6 years. Secondary speech operations, velopharyngeal insufficiency (VPI), hypernasality, and articulation errors by cleft-type characteristics (CTC), including 4 categories (passive), non-oral, anterior-oral, and posterior-oral. A total of 41 RS patients and 61 ICP patients underwent repair with sufficient follow-up. Of them, 23 patients underwent a TLA at median age of 12 days. Rates of hypernasality (p = 0.004), secondary speech operations (p = 0.004), and posterior oral CTC (p = 0.042) were higher in RS compared to ICP. Isolated RS had speech outcomes similar to those of ICP; however, syndromic RS patients needed more secondary speech operations compared to isolated RS (p = 0.043). TLA-RS patients did not demonstrate differences in speech outcomes or any CTCs (all p > 0.05) compared to non-TLA-RS patients, except for the anterior oral CTC (74% TLA-RS vs 28% non-TLA-RS, p = 0.005). Within the limitations of the study, it seem that TLA does not affect long-term velopharyngeal function in patients with RS. However, TLA-RS patients demonstrated higher rates of anterior-oral CTC, which might be related to a different positioning of the tongue after TLA. Every effort should be taken to treat patients with RS conservatively instead of with TLA because of this demonstrated a negative effect on one type of articulation error. However, if conservative therapy fails, a TLA is still a valuable adjunct in the treatment of RS, and cleft speech pathologists who treat such patients should be more aware of this phenomenon in order to improve long-term articulation outcomes.
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Letter: Robin Sequence: 5-Year Speech Outcomes-A Case-Control Study. Plast Reconstr Surg 2022; 150:479e-481e. [PMID: 35708683 DOI: 10.1097/prs.0000000000009302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Buccal Fat Pad: Adjunctive Procedure for Lateral Defect Coverage following Primary Palatoplasty. Plast Reconstr Surg 2022; 149:1180-1185. [PMID: 35286291 DOI: 10.1097/prs.0000000000009037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The buccal fat flap is an encapsulated mass originating from a specific fat tissue that is easily accessed and richly vascularized. The aim of this study was to report the effect of using the buccal fat flap on the oronasal fistula rate in primary palatoplasty. METHODS A case-controlled study of 94 patients who underwent primary cleft palate repair. Patients were divided into two groups: (1) two-flap palatoplasty with buccal fat flap for coverage of lateral hard palate defect and (2) conventional two-flap palatoplasty. The incidence of oronasal fistula and postoperative complications were compared between groups. Multivariate analysis was performed to determine the risk factors of oronasal fistula development. RESULT Forty-seven patients in each group demonstrated the same baseline characteristics. The buccal fat group showed a significant lower postoperative oronasal fistula rate (2.13 percent versus 21.28 percent, p = 0.008) and smaller fistula size (2 mm versus 4 mm, p = 0.049). A cleft width wider than 11.5 mm increased the odds ratio of fistula formation by 8.44-fold (p = 0.047), and the use of buccal fat protected against postoperative palatal fistula formation (OR, 0.08, p = 0.019). CONCLUSION The use of buccal fat flaps for lateral hard palatal defect coverage in primary palatoplasty can reduce the rate of postoperative palatal fistula, especially in cases of wide palatal cleft. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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McCrary H, Torrecillas V, Pollard SH, Collingridge DS, Yamashiro D, Skirko JR. Risk of Malocclusion Among Patients Undergoing Single-Stage Versus Two-Stage Cleft Palate Repair. Cleft Palate Craniofac J 2022; 59:1271-1278. [PMID: 34981987 DOI: 10.1177/10556656211044944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Evaluate impact of single-stage versus staged palate repair on the risk of developing malocclusion among patients with cleft palate (CP). DESIGN Retrospective cohort study 2000-2016. SETTING Academic, tertiary children's hospital. PATIENTS Patients undergoing CP repair between 1999-2015. INTERVENTIONS CP repair, categorized as either single-stage or staged. MAIN OUTCOME MEASURE Time to development of Class III malocclusion. RESULTS 967 patients were included; 60.1% had a two-stage CP repair, and 39.9% had single-stage. Malocclusion was diagnosed in 28.2% of patients. In the model examining all patients at ≤5 years (n = 659), patients who were not white had a higher risk of malocclusion (HR 2.46, p = 0.004) and staged repair was not protective against malocclusion (HR 0.98, p = 0.91). In all patients >5 years (n = 411), higher Veau classification and more recent year of birth were significantly associated with higher hazard rates (p < 0.05). Two-staged repair was not protective against developing malocclusion (HR 0.86, p = 0.60). In the model examining patients with staged repair ≤5 years old (n = 414), higher age at hard palate closure was associated with reduced malocclusion risk (HR 0.67, p < 0.001) and patients who were not white had increased risk (HR 2.56, p = 0.01). In patients with staged repair >5 years old, more recent birth year may be associated with a higher risk of malocclusion (HR 1.06, p = 0.06) while syndrome may be associated with lower risk of malocclusion diagnosis (HR 0.46, p = 0.07). CONCLUSION Our data suggests that staged CP repair is not protective against developing Class III malocclusion.
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Affiliation(s)
- Hilary McCrary
- University of Utah Division of Otolaryngology - Head and Neck Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Vanessa Torrecillas
- University of Utah Division of Otolaryngology - Head and Neck Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Sarah Hatch Pollard
- University of Utah Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, Utah, USA
| | | | - Duane Yamashiro
- University of Utah Division of Plastic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Jonathan R Skirko
- University of Arizona College of Medicine Department of Otolaryngology - Head and Neck Surgery, University of Arizona, Salt Lake City, Utah, USA
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Cirillo A, Lioncino M, Maratea A, Passariello A, Fusco A, Fratta F, Monda E, Caiazza M, Signore G, Esposito A, Baban A, Versacci P, Putotto C, Marino B, Pignata C, Cirillo E, Giardino G, Sarubbi B, Limongelli G, Russo MG. Clinical Manifestations of 22q11.2 Deletion Syndrome. Heart Fail Clin 2021; 18:155-164. [PMID: 34776076 DOI: 10.1016/j.hfc.2021.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
DiGeorge syndrome (DGS), also known as "22q11.2 deletion syndrome" (22q11DS) (MIM # 192430 # 188400), is a genetic disorder caused by hemizygous microdeletion of the long arm of chromosome 22. In the last decades, the introduction of fluorescence in situ hybridization assays, and in selected cases the use of multiplex ligation-dependent probe amplification, has allowed the detection of chromosomal microdeletions that could not be previously identified using standard karyotype analysis. The aim of this review is to address cardiovascular and systemic involvement in children with DGS, provide genotype-phenotype correlations, and discuss their medical management and therapeutic options.
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Affiliation(s)
- Annapaola Cirillo
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Michele Lioncino
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Annachiara Maratea
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Annalisa Passariello
- Pediatric Cardiology Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Adelaide Fusco
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Fiorella Fratta
- Pediatric Cardiology Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Emanuele Monda
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Giovanni Signore
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Augusto Esposito
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Anwar Baban
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Viale Di San Paolo, 15, 00165 Rome, Italy
| | - Paolo Versacci
- Department of Pediatrics, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Carolina Putotto
- Department of Pediatrics, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Bruno Marino
- Department of Pediatrics, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Claudio Pignata
- Department of Translational Medical Sciences - Section of Pediatrics, University of Naples Federico II, Via S. Pansini, 5, 80131 Naples, Italy
| | - Emilia Cirillo
- Department of Translational Medical Sciences - Section of Pediatrics, University of Naples Federico II, Via S. Pansini, 5, 80131 Naples, Italy
| | - Giuliana Giardino
- Department of Translational Medical Sciences - Section of Pediatrics, University of Naples Federico II, Via S. Pansini, 5, 80131 Naples, Italy
| | - Berardo Sarubbi
- Adult Congenital Heart Diseases Unit, AORN dei Colli, Monaldi Hospital, Naples
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy
| | - Maria Giovanna Russo
- Pediatric Cardiology Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Via L. Bianchi, 80131 Naples, Italy.
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14
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Evans SS, Bly RA, Paulsgrove K, Perkins JA, Sie K. Predictors of Success After Furlow Palatoplasty for Repair of Cleft Palate: Does Syndrome Matter? Otolaryngol Head Neck Surg 2021; 166:844-849. [PMID: 34491144 DOI: 10.1177/01945998211038928] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine predictors of success following Veau 1 and 2 cleft palate repair in patients with and without syndromes. STUDY DESIGN Retrospective review of prospectively collected data. SETTING Tertiary care children's hospital. METHODS All children <18 months of age undergoing Furlow palatoplasty for Veau 1 and 2 cleft repair between 2000 and 2014 with postoperative perceptual speech assessment (PSA). RESULTS In total, 368 consecutive patients were identified; 95 were excluded, resulting in 273 patients. Median age at surgery was 13.0 months (interquartile range [IQR], 11-15 months) with postoperative PSA at a median of 32.3 months (IQR, 26.3-44.5 months). Fifty patients (18.3%) had syndrome diagnosis; 59 patients (21.6%) had nonsyndromic Robin sequence. Velopharyngeal insufficiency (VPI) occurred in 27 patients (10.5%); 13 underwent secondary speech surgery. Cleft-related speech errors occurred in 46 patients (17.6%). Non-cleft-related speech errors occurred in 155 patients (59.6%) and reduced intelligibility in 127 patients (47.9%). Oronasal fistula occurred in 23 patients (8.8%) and was exclusive to Veau 2 clefts. In multivariate analysis, age >13 months at palatoplasty demonstrated a 6-fold higher rate of VPI (hazard ratio [HR], 6.64; P < .01), worse speech outcomes (HR, 6.04; P < .01; HR, 1.60; P < .01; HR, 1.57; P = .02), and greater speech therapy utilization (HR, 2.18; P < .01). CONCLUSION VPI occurred in 10% of patients undergoing Furlow palatoplasty repair of Veau 1 or 2 clefts. Age <13 months at palatoplasty was associated with improved speech outcomes and lower VPI incidence (2.8% vs 16.2%). Syndromic diagnosis was associated with noncleft speech errors and reduced intelligibility on univariate analysis but not velopharyngeal function after palatoplasty.
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Affiliation(s)
- Sean S Evans
- Otolaryngology Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Randall A Bly
- Otolaryngology-Head and Neck Surgery, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kaylee Paulsgrove
- Speech and Language Services, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jonathan A Perkins
- Otolaryngology-Head and Neck Surgery, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathleen Sie
- Otolaryngology-Head and Neck Surgery, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
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15
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Abstract
BACKGROUND Pierre Robin sequence (Robin sequence) is defined as the triad of micrognathia, glossoptosis, and airway obstruction. It is frequently associated with palatal clefting. In recent years, increased interest in speech outcomes of cleft patients diagnosed with Robin sequence has been shown. METHODS Speech outcomes of cleft patients with Robin sequence were assessed at age 5 in comparison with a cleft palate-only cohort. Speech parameters were evaluated according to the Cleft Audit Protocol for Speech-Augmented and analyzed using the National Audit Standards for Speech (United Kingdom). All patients were treated in the same institution during the same period (2005 to 2012). Subjects who needed nasopharyngeal airway support and those whose airway was managed by positioning only were eligible. RESULTS Fifty-one cleft patients diagnosed with Robin sequence were included in this study. Outcomes were compared to those of 128 nonsyndromic cleft palate-only patients.Patients with Robin sequence were shown to present with a significantly higher rate of cleft speech characteristics in comparison to the reference cohort (p = 0.001). Furthermore, it was shown that Robin sequence is associated with a significantly higher rate of secondary speech surgery for velopharyngeal dysfunction before the age of 5 (p = 0.016). Robin sequence patients with a nasopharyngeal airway presented with a higher rate of cleft speech characteristics compared to Robin sequence patients managed with positioning only. CONCLUSION Cleft patients with Robin sequence are more likely to need further surgery to correct velopharyngeal dysfunction before the age of 5 and are more prone to present with cleft speech characteristics at the age of 5. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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16
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Abstract
BACKGROUND Oronasal fistula (ONF) is a common complication following cleft palate surgery. This study aims to determine the prevalence of ONF and the factors that influence development of ONF following primary palatoplasty. MATERIALS AND METHODS There were 234 patients undergoing primary palatoplasty during 2012 to 2016 included in this cross-sectional study. Patient demographics, surgeon's experience, age at the time of primary palatoplasty, cleft type by Veau classification, cleft width, and operative technique were recorded. The prevalence of fistulae was the primary outcome. Association of age at the time of repair, cleft type, cleft associated with syndromes, cleft width, and surgeon's experience with fistula rate were secondary outcomes. RESULTS There were 234 consecutive patients (128 boys [54.7%] and 106 girls [45.3%]). The mean age at primary palatoplasty was 13 months. Oronasal fistulae occurred in 61 (26.07%) patients. There was a statistically significant association between postoperative oronasal fistulae and the following independent variables: Veau classification (adjusted odds ratio 2.1; 95% confidence interval [CI] = 1.45-3.1, P < 0.01), cleft associated with syndromes (adjusted odds ratio 4.76; 95% CI = 1.48-15.2, P < 0.01) and cleft width more than 11.5 mm (adjusted odds ratio 1.96; 95% CI = 1.00-3.85, P = 0.04). CONCLUSION The overall number of fistulae was moderate in patients who had undergone primary palatoplasty in our center. Cleft severity as defined by the Veau classification, cleft width, and cleft associated with syndromes were predictive factors for development of postoperative fistulae.
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17
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Mamidi IS, Mantilla-Rivas E, Ichiuji BA, Rana MS, Ramirez KI, Stein JR, Aivaz M, Manrique M, McGrath J, Rogers GF, Oh AK. Administration of Single-Dose Antibiotic Does Not Decrease Oronasal Fistula Rates After Primary Palatoplasty. Cleft Palate Craniofac J 2021; 59:14-21. [PMID: 33583204 DOI: 10.1177/1055665621992653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Oronasal fistula (ONF) is a known complication after primary palatoplasty (PP). Studies investigating the effect of perioperative antibiotics on fistula rates after PP are limited by inadequate sample size or reliance on self-reporting through national databases. In this study, the authors evaluated the association between single-dose perioperative antibiotics and postoperative fistula rates after PP at a single institution. DESIGN A retrospective study. PARTICIPANTS Children younger than 2 years who underwent PP from April 2009 to September 2019 were included. INTERVENTIONS Patients were divided into 2 categories: Group 1 received a single intraoperative dose of IV antibiotic, while group 2 did not. MAIN OUTCOME MEASURE(S) Outcome measures included ONF formation, length of stay (LOS), and 30-day readmission rates. Multivariable firth logistic regression, quantile regression, and χ2 tests were performed. RESULTS Of the 424 patients, 215 and 209 patients were in groups 1 and 2, respectively. The overall ONF rate was 1.9% among all patients. Patients in group 1 experienced an ONF rate of 3.3%, while patients in group 2 had an ONF rate of 0.5%. After correcting for confounding variables, the difference in ONF rates was not statistically different (P = .68). Median LOS was 35.7 hours and 35.5 hours (P = .17), while the rate of readmission within 30 days was 4.7% and 2.4% for group 1 and 2, respectively (P = .96). CONCLUSIONS Administration of a single-dose perioperative antibiotic did not decrease fistula formation after PP, nor did it affect the patient's LOS or 30-day readmission rate.
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Affiliation(s)
- Ishwarya Shradha Mamidi
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Brynne A Ichiuji
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Md Sohel Rana
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Karen I Ramirez
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Jason R Stein
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Marudeen Aivaz
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Monica Manrique
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Jennifer McGrath
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Gary F Rogers
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Albert K Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
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18
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Long-term Speech Outcomes of Cleft Palate Repair in Robin Sequence versus Isolated Cleft Palate. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3351. [PMID: 33564582 PMCID: PMC7859383 DOI: 10.1097/gox.0000000000003351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/16/2020] [Indexed: 12/28/2022]
Abstract
Supplemental Digital Content is available in the text. Whether treatment of cleft palate (CP) associated with Robin sequence (RS) should attain outcomes similar to those of isolated cleft palate (ICP) remains unknown. This study compares treatment and outcomes in both conditions and delineates predictors of long-term outcome.
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19
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Gil-da-Silva-Lopes VL, Tacla MA, Sgardioli IC, Vieira TP, Monlleó IL. Brazil's Craniofacial Project: Different approaches on orofacial clefts and 22q11.2 deletion syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2020; 184:912-927. [PMID: 33166033 DOI: 10.1002/ajmg.c.31852] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 12/12/2022]
Abstract
This article reports the present situation of Brazilian health care in genetics for Orofacial Cleft (OFC) and 22q11.2 Deletions Syndrome (22q11.2 DS) based on research conducted by Brazil's Craniofacial Project (BCFP). Established in 2003, BCFP is a voluntary and cooperative network aiming to investigate the health care of people with these diseases and other craniofacial anomalies. The initiatives and research results are presented in four sections: (a) a comprehensive report of the Brazilian public health system in craniofacial genetics; (b) multicentric studies developed on OFC and 22q11.2 DS; (c) education strategies focused on addressing these conditions for both population and health-care professionals; and (d) the nosology through the Brazilian Database on Craniofacial Anomalies (BDCA). Since 2006, BDCA uses a standardized method with detailed clinical data collection, which allows for conducting studies on nosology, genotype-phenotype correlations, and natural history; data can also contribute to public policies. Currently, the BDCA stores data on 1,724 individuals, including 1,351 (78.36%) who were primarily admitted due to OFC and 373 (21.63%) with clinical suspicion of 22q11.2 DS. Chromosomal abnormalities/genomic imbalances were represented by 92/213 (43.19%) individuals with syndromic OFC, including 43 with 22q11.2 DS, which indicates the need for chromosomal microarray analysis in this group. The nosologic diversity reinforces that monitoring clinical is the best strategy for etiological investigation. BCFP's methodology has introduced the possibility of increasing scientific knowledge and genetic diagnosis of OFC and 22q11.2 DS to in turn improve health care and policies for this group of diseases.
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Affiliation(s)
- Vera Lúcia Gil-da-Silva-Lopes
- Faculty of Medical Sciences, Department of Medical Genetics and Genomic Medicine, University of Campinas (Unicamp), Campinas, Sao Paulo, Brazil
| | - Milena Atique Tacla
- Faculty of Medical Sciences, Department of Medical Genetics and Genomic Medicine, University of Campinas (Unicamp), Sao Paulo, Brazil
| | - Ilária Cristina Sgardioli
- Faculty of Medical Sciences, Department of Medical Genetics and Genomic Medicine, University of Campinas (Unicamp), Campinas, Sao Paulo, Brazil
| | - Társis Paiva Vieira
- Faculty of Medical Sciences, Department of Medical Genetics and Genomic Medicine, University of Campinas (Unicamp), Campinas, Sao Paulo, Brazil
| | - Isabella Lopes Monlleó
- Faculty of Medicine, Clinical Genetics Service, University Hospital, Medical Genetics Sector, Federal University of Alagoas-UFAL, Maceió, Alagoas, Brazil
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20
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Kollara L, Baylis AL, Kirschner RE, Bates DG, Smith M, Fang X, Perry JL. Interaction of the craniofacial complex and velopharyngeal musculature on speech resonance in children with 22q11.2 deletion syndrome: An MRI analysis. J Plast Reconstr Aesthet Surg 2020; 74:174-182. [PMID: 32855100 DOI: 10.1016/j.bjps.2020.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/21/2020] [Accepted: 08/01/2020] [Indexed: 01/29/2023]
Abstract
There are limited MRI studies of craniofacial and velopharyngeal features in children with 22q11.2 deletion syndrome (22q11.2DS) and to date, none have explored the potential relationship between these features and the speech phenotype. The purpose of this study was to examine the relationship between craniofacial and related velopharyngeal structures in children with 22q11.2DS and to assess their correlation to resonance features using an unsedated MRI protocol. Fifteen children with 22q11.2DS and 15 age- and sex-matched controls with normal velopharyngeal anatomy (ages 4-12 years) successfully completed the study. Analysis of covariance was used to compare differences between the experimental (22q11.2DS) and control (children with normal anatomy) groups. Correlation analyses and regression models were also utilized. The 22q11.2DS group demonstrated significantly shorter nasion-to-sella, sella-to-basion, and basion-to-opisthion distances. The anterior cranial base angle was significantly more obtuse. The levator veli palatini (levator) muscle was significantly thinner and shorter, with an obtuse angle of origin in the 22q11.2DS group. Levator length was significantly correlated with the sella-to-basion measure and hypernasality was correlated with levator origin-to-origin distance. Preliminary results from this study indicate a significant association between hypernasality and levator origin-to-origin distance. Findings from the present study, provide an insight into the pathophysiology of velopharyngeal dysfunction related to this clinically complex population.
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Affiliation(s)
- Lakshmi Kollara
- School of Communication Sciences and Disorders, University of Central Florida, 4364 Scorpius Street, HPA 2 Suite 101-L, Orlando, FL 32816, United States.
| | - Adriane L Baylis
- Section of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, United States
| | - Richard E Kirschner
- Plastic and Reconstructive Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, United States
| | - D Gregory Bates
- Department of Radiology, Nationwide Children's Hospital, The Ohio State University College of Medicine, United States
| | - Mark Smith
- Department of Radiology, Nationwide Children's Hospital, United States
| | - Xiangming Fang
- Department of Biostatistics, East Carolina University, United States
| | - Jamie L Perry
- Department of Communication Sciences and Disorders, East Carolina University, United States
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21
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Azadgoli B, Munabi NCO, Fahradyan A, Auslander A, McCullough M, Aflatooni N, Davidson Ward SL, Kumar SR, Sanchez-Lara PA, Swanson J, Magee WP. Congenital Heart Disease in Patients With Cleft Lip/Palate and Its Impact on Cleft Management. Cleft Palate Craniofac J 2020; 57:957-966. [DOI: 10.1177/1055665620924915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To evaluate characteristics of congenital heart disease (CHD) in patients with cleft lip and/or palate (CL/P) and assess potential associations with cleft outcomes. Design: Retrospective review of all patients with CL/P who underwent primary cleft treatment from 2009 to 2015. Setting: Children’s Hospital Los Angeles, a tertiary hospital. Patients: Exclusion criteria included microform cleft lip diagnosis, international patients, and patients presenting for secondary repair or revision after primary repair at another institution. Main Outcomes Measured: Patient demographics, prenatal and birth characteristics, CL/P characteristics, syndromic status, postoperative complications, and other outcomes were analyzed relative to CHD diagnoses and management. Patients with CL/P with (+CHD) were compared to those without (−CHD) CHD using χ2 tests and analysis of variance. Results: Among 575 patients with CL/P, 83 (14.4%) had CHD. Congenital heart disease rates were significantly higher in patients with cleft palate (CP) compared to other cleft types (χ2, P = .009). Eighty-one (97.6%) out of 83 +CHD patients were diagnosed prior to initial CL/P surgical assessment. Twenty-three (27.7%) +CHD patients required surgical repair of 10 cardiac anomalies prior to cleft care. Congenital heart disease was associated with delayed CP repair and increased rates of fistula in isolated patients with CP. Conclusions: Congenital heart disease is known to be more prevalent in patients with CL/P. These data suggest the condition is particularly increased in patients with CP. Severe forms of CHD are diagnosed and treated prior to cleft care however postoperative fistula may be more common in patients with CHD. Therefore, careful attention is required for patient optimization and palatal flap dissection in patients with coexisting CHD and CL/P.
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Affiliation(s)
- Beina Azadgoli
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Naikhoba C. O. Munabi
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Artur Fahradyan
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, CA, USA
| | - Allyn Auslander
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, CA, USA
| | - Meghan McCullough
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | | | | | - S. Ram Kumar
- Heart Institute, Children’s Hospital Los Angeles, CA, USA
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | | | - Jordan Swanson
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, CA, USA
- Division of Research and Outcomes, Operation Smile International, Virginia Beach, VA, USA
| | - William P. Magee
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, CA, USA
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22
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Yin H, Huang HY, Guo CL, Wang X, Shi B, Li JT. [Changes of postoperative velopharyngeal function in children with cleft palate under 5 years old]. HUA XI KOU QIANG YI XUE ZA ZHI = HUAXI KOUQIANG YIXUE ZAZHI = WEST CHINA JOURNAL OF STOMATOLOGY 2020; 38:48-53. [PMID: 32037766 DOI: 10.7518/hxkq.2020.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To demonstrate the regularity of velopharyngeal function recovery after primary cleft palatoplasty and its correlation with different surgical procedures, ages, cleft types, and follow-up times. METHODS Patients with cleft palate under 5 years old who had more than two follow-up records were included in this study, and consecutive evaluations of postoperative velopharyngeal function were performed. Univariate and multivariate logistic regression analysis were used to reveal the regularity of postoperative velopharyngeal function and the possible influencing factors. RESULTS A total of 165 patients were included. Inconsistent functions of the velopharyngeal closure were observed in 31 patients, of which velopharyngeal insufficiency (VPI) in the first follow-up converted to velopharyngeal competence (VPC) in the second follow-up, accounting for 18.79% of the total, and 134 patients had consistent velopharyngeal function. The patients in the group who had consistent velopharyngeal function were younger than those in the group who were inconsistent, and the differences between the two groups were statistically significant. The younger the operation age, the patient's velopharyngeal function was more likely to stabilize at the first follow-up. At the time of the first follow-up in 15, 28, and 40 months, the probability that the patients had stable postoperative velopharyngeal function was 80%, 90%, and 95%, respectively. CONCLUSIONS The recovery of velopharyn-geal function after surgery is a dynamic process. The velopharyngeal status of patients can be converted from VPI to VPC. Meanwhile, VPC cannot switch to VPI. The follow-up time is the most important factor affecting the consistency of the evaluation of velopharyngeal function. Choosing appro-priate follow-up time is the key to obtain the stable evaluation of velopharyngeal function.
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Affiliation(s)
- Heng Yin
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Han-Yao Huang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Chun-Li Guo
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Xi Wang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Jing-Tao Li
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
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Tache A, Mommaerts MY. On the Frequency of Oronasal Fistulation After Primary Cleft Palate Repair. Cleft Palate Craniofac J 2019; 56:1302-1313. [DOI: 10.1177/1055665619856243] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: The aims of the study were to assess the postoperative oronasal fistula rate after 1-stage and 2-stage cleft palate repair and identify risk factors associated with its development. Design: Systematic review. Setting: Various primary cleft and craniofacial centers in the world. Patients, Participants: Syndromic and nonsyndromic cleft lip, alveolus, and palate patients who had undergone primary cleft palate surgery. Intervention: Assessment of oronasal fistula frequency and correlation with staging, timing, and technique of repair, gender, and Veau type. The results obtained in this systematic review were compared with those in previous reports. Outcome: The main outcome is represented by the occurrence of the oronasal fistula after 1-stage versus 2-stage palatoplasty. Results: The mean fistula percentage was 9.94%. In the Veau I, II, III, and IV groups, the respective fistula rates were 2%, 7.3%, 8.3%, and 12.5%. Oronasal fistula locations based on the Pittsburgh Fistula Classification System were soft palate (type II), 16.2%; soft palate–hard palate junction (type III), 29.3%; and hard palate (type IV), 37.3%. There were no statistically significant differences between 1-stage and 2-stage palatoplasty, syndromic and nonsyndromic, or male and female patients. Primary palatoplasty timing was not a significant predictor. Conclusion: Some disparities arose when comparing studies, mainly regarding location and types of clefting prone to oronasal fistulation. Interestingly, the fistula rate does not differ between 1- and 2-stage closure, and timing of the repair does not play a role.
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Affiliation(s)
- Ana Tache
- Cleft & Craniofacial Team, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Maurice Y. Mommaerts
- Cleft & Craniofacial Team, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
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Sitzman TJ, Carle AC, Heaton PC, Helmrath MA, Britto MT. Five-Fold Variation Among Surgeons and Hospitals in the Use of Secondary Palate Surgery. Cleft Palate Craniofac J 2019; 56:586-594. [PMID: 30244603 PMCID: PMC6431573 DOI: 10.1177/1055665618799906] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To identify child-, surgeon- and hospital-specific factors at the time of primary cleft palate repair that are associated with the use of secondary palate surgery. DESIGN Retrospective cohort study. SETTING Forty-nine pediatric hospitals. PARTICIPANTS Children who underwent cleft palate repair between 1998 and 2015. MAIN OUTCOME MEASURE Time from primary cleft palate repair to secondary palate surgery. RESULTS By 5 years after the primary palate repair, 27.5% of children had undergone secondary palate surgery. In multivariable analysis, cleft type and age at primary palate repair were both associated with secondary surgery ( P < .01). Children with unilateral cleft lip and palate had a 1.69-fold increased hazard of secondary surgery (95% confidence interval [CI]: 1.54-1.85) compared to children with cleft palate alone. Primary palate repair before 9 months had a 3.99-fold increased hazard of secondary surgery (95% CI: 3.39-4.07) compared to repair at 16 to 24 months of age. After adjusting for cleft type, age at repair, and procedure volume, there remained substantial variation in secondary surgery use among surgeons and hospitals ( P < .01). For children with isolated cleft palate, the predicted proportion of children undergoing secondary surgery within 5 years of primary repair ranged from 8.5% to 46.0% across surgeons and 9.1% to 49.4% across hospitals. CONCLUSIONS There are substantial differences among surgeons and hospitals in the rates of secondary palate surgery. Further work is needed to identify causes for this variation among providers and develop interventions to reduce the need for secondary surgery.
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Affiliation(s)
- Thomas J. Sitzman
- Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, Arizona, and Department of Surgery, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Adam C. Carle
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, College of Medicine, and Department of Psychology, College of Arts and Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Pamela C. Heaton
- James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Michael A. Helmrath
- Division of Pediatric and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Maria T. Britto
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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Jackson O, Crowley TB, Sharkus R, Smith R, Jeong S, Solot C, McDonald-Mcginn D. Palatal evaluation and treatment in 22q11.2 deletion syndrome. Am J Med Genet A 2019; 179:1184-1195. [PMID: 31038278 DOI: 10.1002/ajmg.a.61152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 12/21/2018] [Accepted: 02/27/2019] [Indexed: 01/23/2023]
Abstract
Palatal involvement occurs commonly in patients with 22q11.2 Deletion Syndrome (22qDS), and includes palatal clefting and velopharyngeal dysfunction in the absence of overt or submucous clefts. The reported incidence and distribution of palatal abnormalities vary in the literature. The aim of this article is to revisit the incidence and presenting features of palatal abnormalities in a large cohort of patients with 22qDS, summarize the surgical treatments performed in this cohort, and provide an overview of surgical treatment protocols and management guidelines for palatal abnormalities in this syndrome. Charts of 1,121 patients seen through the 22q and You Center at the Children's Hospital of Philadelphia were reviewed for palatal status, demographic factors, deletion size, and corrective surgical procedures. Statistical analysis was performed using Pearson's chi-squared test to identify differences between gender, deletion size, and palatal abnormality. Of the patients with complete evaluations, 67% were found to have a palatal abnormality. The most common finding was velopharyngeal dysfunction in 55.2% of patients, and in 33.3% of patients, this occurred in the absence of palatal clefting. There was no significant difference in the incidence of palatal abnormalities by gender; however, a difference was noted among race (p < 0.01) and deletion sizes (p < 0.01). For example, Caucasian and Asian patients presented with a much higher prevalence of palatal abnormalities, and conversely those with nested deletions presented with a much lower rate of palatal defects. Overall, 26.9% of patients underwent palatal surgery, and the most common indication was velopharyngeal dysfunction. Palatal abnormalities are a hallmark feature of 22q11.2 Deletion Syndrome; understanding the incidence, presenting features, and treatment protocols are essential for practitioners counseling and treating families affected with this disorder.
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Affiliation(s)
- Oksana Jackson
- Division of Plastic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - T Blaine Crowley
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert Sharkus
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert Smith
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie Jeong
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia Solot
- Department of Speech Language Pathology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Donna McDonald-Mcginn
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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22q11.2 Deletion: Surgical and Speech Outcomes of Patients With Velopharyngeal Insufficiency Treated With a Superiorly Based Pharyngeal Flap as the Primary Surgery. J Craniofac Surg 2018; 29:1480-1485. [PMID: 30052607 DOI: 10.1097/scs.0000000000004859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The most frequent palate diagnoses in patients with chromosome 22q11.2 deletion syndrome are a classic submucous cleft, occult, and velopharyngeal insufficiency without cleft, which generates alterations in speech that require surgery. Surgical protocols are controversial owing to syndrome characteristics that make their handling more complex. Pharyngeal flap pharyngoplasty is effective for this type of patient. The objective of this study is to examine the surgical management of velopharyngeal insufficiency in patients with chromosome 22 deletion, using a pharyngeal flap as the primary surgery. The clinical records of patients with chromosome 22 deletion and velopharyngeal insufficiency between 2015 and 2017 were analyzed retrospectively. Eight patients underwent pharyngeal flap pharyngoplasty as a primary surgery, including 1 with velopharyngeal insufficiency without a cleft, 1 with a classic submucous cleft, and 6 with occult submucous cleft. The pre- and postoperative protocol performed by speech therapists and surgeons included clinical evaluation of the oral cavity; perceptual, video recording, and nasometry speech evaluation; and videonasopharyngoscopy. All perceptual parameters and nasometry results significantly changed. Of the cases, 88% achieved a flap with the expected width and height and complete closure of the velopharyngeal sphincter. One patient required flap revision. Four of the 8 patients achieved normal resonance, and 2 of 8 showed mild hypernasality. Using the pharyngeal flap pharyngoplasty as a primary technique to correct velopharyngeal insufficiency in patients with chromosome 22 deletion provides satisfactory outcomes and decreases the number of surgeries. Preoperative planning must be conducted carefully and needs to be individualized to be successful.
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Gelfoam Interposition Minimizes Risk of Fistula and Postoperative Bleeding in Modified-Furlow Palatoplasty. J Craniofac Surg 2018; 28:1993-1996. [PMID: 28437266 DOI: 10.1097/scs.0000000000003616] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Failure to accomplish a tension-free, watertight closure predisposes the palatoplasty patient to fistula formation. Perioperative bleeding also places the patient at risk for adverse airway events (AAE). This study introduces the incorporation of a hemostatic gelatin sponge (Gelfoam) into layered palatoplasty to minimize adverse postoperative bleeding and fistula formation. A retrospective chart review was performed to identify subjects who underwent Furlow palatoplasty with insertion of Gelfoam from 2010 to 2015. Exclusion criteria include age >3 years, prior palate surgery, <30-day follow-up, immunosuppressive state, and diagnosis of Treacher-Collins or Apert Syndrome. Demographic data include age, sex, cleft laterality, prior surgeries, Veau classification, Pierre Robin status, and tracheostomy dependence. Primary outcome was fistula formation. Secondary outcomes included perioperative metrics and AAE.One hundred subjects met criteria, 45% female. Average age was 14.6 months. Subjects with syndromes comprised 28%, with 16% diagnosed with Pierre Robin. Two subjects were tracheostomy-dependent. Prior cleft and mandibular procedures were performed in 55%. Isolated palatal defects were seen in 46%, unilateral lip and palate in 41%, and bilateral lip and palate in 13%. The majority of defects were Veau II and III (35% and 34%, respectively). Adverse airway events occurred in 2%, one of which resulted in reintubation. One subject (1%) was found to have a postoperative fistula.The incorporation of Gelfoam in the modified-Furlow palatoplasty results in a low rate of oronasal fistula (1%) and low perioperative risk of AAE. Further prospective comparison of this method to others will be the focus of future work.
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Swanson JW, Mitchell BT, Cohen M, Solot C, Jackson O, Low D, Bartlett SP, Taylor JA. The Effect of Furlow Palatoplasty Timing on Speech Outcomes in Submucous Cleft Palate. Ann Plast Surg 2017; 79:156-161. [DOI: 10.1097/sap.0000000000001056] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND A simple algorithm is applied to treat velopharyngeal insufficiency. The purpose of this study was to assess its success rate and complications. METHODS The diagnosis includes speech perceptual assessment and nasopharyngoscopy, focusing on velopharyngeal closure ratio. The treatment is composed of a double-opposing Z-plasty for marginal velopharyngeal insufficiency or a pharyngeal flap for moderate to severe velopharyngeal insufficiency. A retrospective chart review was conducted for 84 consecutive nonsyndromic postpalatoplasty patients undergoing velopharyngeal insufficiency surgery from August of 2007 to December of 2014. The demographic, perioperative, and follow-up data were collected. Statistical analyses were performed. RESULTS Mean age at velopharyngeal insufficiency surgery was 7.0 years. The overall improvement rate for patients was 86.9 percent. Nine patients in the double-opposing Z-plasty group and two patients in the pharyngeal flap group were refractory to velopharyngeal insufficiency surgery. The improvement rates for each surgical group were 80.4 percent for the double-opposing Z-plasty group and 94.7 percent for the pharyngeal flap group. There were no significant differences in postoperative velopharyngeal function between the coronal and noncoronal groups. Airway-associated complications were observed in nine patients (10.7 percent). The complications in the double-opposing Z-plasty group were observed in two patients (4.3 percent), and none of the patients presented obstructive sleep apnea. Seven patients (18.4 percent) in the pharyngeal flap group showed postoperative snoring, and one (2.6 percent) of them presented with obstructive sleep apnea. CONCLUSION The authors' algorithm is a simple patient- and surgeon-friendly strategy to obtain satisfactory improvement of velopharyngeal function for velopharyngeal insufficiency patients, with a low risk of airway complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Cohen SM, Greathouse ST, Rabbani CC, O'Neil J, Kardatzke MA, Hall TE, Bennett WE, Daftary AS, Matt BH, Tholpady SS. Robin sequence: what the multidisciplinary approach can do. J Multidiscip Healthc 2017; 10:121-132. [PMID: 28392703 PMCID: PMC5375645 DOI: 10.2147/jmdh.s98967] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Robin sequence (RS) is a commonly encountered triad of micrognathia, glossoptosis, and airway obstruction, with or without a cleft palate. The management of airway obstruction is of paramount importance, and multiple reviews and retrospective series outline the diagnosis and treatment of RS. This article focuses on the multidisciplinary nature of RS and the specialists’ contributions and thought processes regarding the management of the RS child from birth to skeletal maturity. This review demonstrates that the care of these children extends far beyond the acute airway obstruction and that thorough monitoring and appropriate intervention are required to help them achieve optimal outcomes.
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Affiliation(s)
- Stephanie M Cohen
- Division of Plastic and Reconstructive Surgery, Indiana University School of Medicine, Indianapolis
| | | | | | | | | | | | - William E Bennett
- Section of Children's Health Services Research, Section of Pediatric and Adolescent Comparative Effectiveness Research
| | - Ameet S Daftary
- Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bruce H Matt
- Department of Otolaryngology - Head and Neck Surgery
| | - Sunil S Tholpady
- Division of Plastic and Reconstructive Surgery, Indiana University School of Medicine, Indianapolis
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Jiramongkolchai P, Kumar MS, Sowder D, Chinnadurai S, Wootten CT, Goudy SL. Speech outcomes in children with 22q11.2 deletion syndrome following surgery for velopharyngeal insufficiency. Int J Pediatr Otorhinolaryngol 2016; 88:34-7. [PMID: 27497383 DOI: 10.1016/j.ijporl.2016.06.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/28/2016] [Accepted: 06/28/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The purpose of this study was to identify prognostic factors associated with improved speech outcomes following surgical correction for velopharyngeal insufficiency (VPI) in pediatric patients with 22q11.2 deletion syndrome (22q11DS). METHODS Eighteen patients were identified via retrospective chart review of patients with 22q11DS between 2005 and 2014. Patient characteristics, medical histories, associated comorbidities, surgical procedures, and pre- and postoperative perceptual hypernasality (subjectively rated 1-5 with 5 being the most severe) were gathered for each patient. RESULTS 12 patients (67%) experienced improvement in hypernasality following corrective surgery for VPI. Higher severity of hypernasality preoperatively was found to be indicative of a lower chance of improvement with VPI surgery. Of 8 patients with a preoperative hypernasality score of 5, 3 (38%) showed improvement in hypernasality postoperatively, while 9 out of 10 (90%) of patients with a preoperative hypernasality score less than 5 showed postoperative improvement. Females were also found to have worse speech outcomes compared to males. CONCLUSION 22q11DS patients presenting with severely hypernasal speech preoperatively are less likely to show improvement in hypernasality following corrective surgery for VPI. Those patients with moderate hypernasality are most likely to benefit from surgery.
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Affiliation(s)
- Pawina Jiramongkolchai
- Department of Otolaryngology, Washington University School of Medicine in Saint Louis, 4921 Parkview Place, Suite A, 11th Floor, St. Louis, MO, 63110, USA
| | - Manvinder S Kumar
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA, 30322, USA
| | - Derrick Sowder
- Department of Otolaryngology, Vanderbilt University Medical Center, 1215 21st Avenue South, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Sivakumar Chinnadurai
- Department of Otolaryngology, Vanderbilt University Medical Center, 1215 21st Avenue South, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Christopher T Wootten
- Department of Otolaryngology, Vanderbilt University Medical Center, 1215 21st Avenue South, Medical Center East, South Tower, Nashville, TN, 37232, USA
| | - Steven L Goudy
- Department of Otolaryngology - Head & Neck Surgery, Emory University School of Medicine, 2015 Uppergate Drive, Room 222, Atlanta, GA, 30322, USA.
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Utility of Tongue Stitch and Nasal Trumpet in the Immediate Postoperative Outcome of Cleft Palatoplasty. Plast Reconstr Surg 2016; 138:1080e. [PMID: 27541616 DOI: 10.1097/prs.0000000000002813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Outcomes of Cleft Palate Repair in Patients with Pierre Robin Sequence: A Matched Case-Control Study. Plast Reconstr Surg 2016; 137:927-935. [PMID: 26910675 DOI: 10.1097/01.prs.0000475829.32402.a8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pierre Robin sequence results from a cascade of events that occur during embryologic development and frequently presents with cleft palate. Some studies have shown speech outcomes to be worse in patients with Pierre Robin sequence after cleft palate repair. METHODS A cohort of Pierre Robin sequence patients who all required an airway intervention and nasogastric feeding in the neonatal period were identified and speech outcomes assessed at 5 years of age. A cleft- and sex-matched non-Pierre Robin sequence, cleft palate-only comparison group was also identified from the same institution and study period. RESULTS A total of 24 patients with Pierre Robin sequence that required airway and nutritional support in the neonatal period were matched for age, sex, and cleft type to a group of 24 non-Pierre Robin sequence cleft patients. There was no significant difference in the incidence of oronasal fistula between the groups. Secondary surgery for velopharyngeal incompetence was significantly more (p = 0.017) in the Pierre Robin sequence group, who also had significantly greater nasality (p = 0.031) and cleft speech characteristic (p = 0.023) scores. CONCLUSIONS The authors hypothesize that other factors may exist in Pierre Robin sequence that may lead to poor speech outcomes. The authors would suggest counseling parents of children with Pierre Robin sequence that have required a neonatal airway intervention, that speech development may be poorer than in other children with cleft palate, and that these children will have a significantly higher incidence of secondary speech surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Orthognathic Consequences of Sphincter Pharyngoplasty in Cleft Patients: A 2-Institutional Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e676. [PMID: 27200238 PMCID: PMC4859235 DOI: 10.1097/gox.0000000000000656] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 02/02/2016] [Indexed: 12/16/2022]
Abstract
Background: Understanding long-term sequelae of cleft treatment is paramount in the refinement of treatment algorithms to accomplish optimized immediate and long-term outcomes. In this study, we reviewed sphincter pharyngoplasties as a method of velopharyngeal insufficiency (VPI) treatment in relationship to orthognathic surgery. Methods: Cleft lip/palate and cleft palate patients, 15 years of age and older, were reviewed for demographics, VPI surgery, revisions, and subsequent orthognathic surgery at 2 institutions. Chi-square test, Student’s t test, and logistic regression analyses were performed. Results: In 214 patients reviewed (mean age, 19.5 years), 61.7% were male, 18.2% had isolated cleft palate, 61.2% had unilateral cleft lip and palate, and 20.6% had bilateral cleft lip and palate. A total of 33.6% were diagnosed with VPI and received a sphincter pharyngoplasty (mean age, 11.9 years). When subsequent orthognathic surgery was examined, sphincter pharyngoplasty was not associated with maxillary advancement (P = 0.59) but did correlate with an increase in mandibular surgery from 2.8% to 11.1% (P = 0.02). The indications for mandibular surgery in the pharyngoplasty population were related to congenital micrognathia. When cephalometric analyses were evaluated, sphincter pharyngoplasty resulted in a decreased sella-to-nasion-to-B point angle (mean, 79.0–76.3 degrees, P = 0.02) and a higher incidence of normal to class II maxillomandibular relationships as defined by A point-to-nasion-to-B point angles >0.5 (P = 0.02). Conclusions: Sphincter pharyngoplasty decreases anterior mandibular growth and the discrepancy between maxillomandibular skeletal relationships because of the frequent predisposition of cleft patients to maxillary hypoplasia. In patients with congenital mandibular micrognathia, a small increase in mandibular surgeries may occur.
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Abstract
22q11.2 deletion syndrome (22q11.2DS) is the most common chromosomal microdeletion disorder, estimated to result mainly from de novo non-homologous meiotic recombination events occurring in approximately 1 in every 1,000 fetuses. The first description in the English language of the constellation of findings now known to be due to this chromosomal difference was made in the 1960s in children with DiGeorge syndrome, who presented with the clinical triad of immunodeficiency, hypoparathyroidism and congenital heart disease. The syndrome is now known to have a heterogeneous presentation that includes multiple additional congenital anomalies and later-onset conditions, such as palatal, gastrointestinal and renal abnormalities, autoimmune disease, variable cognitive delays, behavioural phenotypes and psychiatric illness - all far extending the original description of DiGeorge syndrome. Management requires a multidisciplinary approach involving paediatrics, general medicine, surgery, psychiatry, psychology, interventional therapies (physical, occupational, speech, language and behavioural) and genetic counselling. Although common, lack of recognition of the condition and/or lack of familiarity with genetic testing methods, together with the wide variability of clinical presentation, delays diagnosis. Early diagnosis, preferably prenatally or neonatally, could improve outcomes, thus stressing the importance of universal screening. Equally important, 22q11.2DS has become a model for understanding rare and frequent congenital anomalies, medical conditions, psychiatric and developmental disorders, and may provide a platform to better understand these disorders while affording opportunities for translational strategies across the lifespan for both patients with 22q11.2DS and those with these associated features in the general population.
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Swanson JW, Johnston JL, Mitchell BT, Alcorn K, Taylor JA. Perioperative Complications in Posterior Pharyngeal Flap Surgery: Review of the National Surgical Quality Improvement Program Pediatric (NSQIP-PEDS) Database. Cleft Palate Craniofac J 2015; 53:562-7. [PMID: 26402723 DOI: 10.1597/15-154] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Posterior pharyngeal flap (PPF) surgery is effective for treating velopharyngeal insufficiency but has historically been associated with risk of airway compromise. This study aims to identify risk factors for complications from and readmission after PPF using a national database. METHODS Patients who underwent PPF surgery were selected from the 2012 American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-PEDS) database. Patient characteristics, comorbidities, and complication/readmission data were analyzed. RESULTS Among 225 study patients, 12 (5.3%) suffered perioperative complications. The most common complications were pulmonary in nature (5 patients, 2.2%), including prolonged postoperative mechanical ventilation (3 patients, 1.3%). Underlying asthma (P = .024) or any cardiac risk factor (P = .047) conveyed significant complication risk. Further, severe cardiac risk factors were associated with postoperative bleeding (P = .024). Readmission (4 patients, 1.7%) and reoperation (3 patients, 1.3%) occurred at mean intervals of 9 and 10 days after the original procedure. Seventy-nine patients (35%) were discharged postoperatively on an outpatient basis, and this subgroup included only one patient (1.2%) with a complication (P = .038). CONCLUSIONS The overall perioperative complication rate for PPF surgery is low at 5.3%. Patients with underlying cardiac risk factors, severe American Society of Anesthesiologists Physical Status class, and asthma should prompt greater attention given their heightened risk profiles.
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Smarius B, Breugem C. Surgical learning curve in performing palatoplasty: A retrospective study in 200 patients. J Craniomaxillofac Surg 2015; 43:1868-74. [PMID: 26421467 DOI: 10.1016/j.jcms.2015.08.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 08/15/2015] [Accepted: 08/26/2015] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The aim of the study was to assess the influence of the experience of the surgeon on the occurrence of fistulas following palatoplasty. MATERIALS AND METHODS A retrospective review was performed of consecutive children treated between 2006 and 2013 for cleft palate by a single surgeon. Cleft palate repair was performed using the von Langenbeck technique, Furlow palatoplasty, buccal flap or Vomer flap. Data was collected for age, sex, date of birth, syndrome, adoption, cleft palate type, type of repair, cleft width, fistula occurrence and location of fistula. RESULTS A total of 276 operations were performed in 200 children (Veau I, II, III, IV). Mean age at surgery was 21.9 months (range: 6.2 months to 26 years 8.3 months). Postoperatively, palatal fistulas occurred in eight patients (4.0%), however, the incidence was 3.0% in the non-adoption group and 9.7% in the adoption population. In this study there was no statistically significant evidence of a surgical learning curve, and no significant associations between fistula rate and sex, adoption, syndrome, cleft type, cleft width, or type of repair. CONCLUSION AND CLINICAL RELEVANCE This study demonstrates a fistula formation rate of 3.0% for the non-adoption population and 9.7% for the adoption population. There was no statistically significant evidence of a learning curve during the first few years of performing cleft palate repair. No other independent risk factors for postoperative fistula formation were identified; however, the benefit of a vomer flap and subsequent reduction in fistula incidence was demonstrated.
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Affiliation(s)
- Bram Smarius
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
| | - Corstiaan Breugem
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, P.O. Box 85090, 3508 AB Utrecht, The Netherlands; Department of Plastic Surgery Meander Medical Center, 3813 TZ Amersfoort, The Netherlands
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Shkoukani MA, Lawrence LA, Liebertz DJ, Svider PF. Cleft palate: A clinical review. ACTA ACUST UNITED AC 2014; 102:333-42. [DOI: 10.1002/bdrc.21083] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 10/27/2014] [Indexed: 01/30/2023]
Affiliation(s)
- Mahdi A. Shkoukani
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan
- Department of Otolaryngology-Head and Neck Surgery; Division of Craniofacial Surgery, Wayne State University School of Medicine; Detroit Michigan
- Division of Facial Plastic and Reconstructive Surgery; Wayne State University School of Medicine; Detroit Michigan
| | - Lauren A. Lawrence
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan
| | - Daniel J. Liebertz
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan
| | - Peter F. Svider
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan
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