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Chernov ES, Taniguchi AN, Nguyen SA, Sutton SR, Pecha PP, Patel KG, Montiel M, Carroll WW. Surgical outcomes and revision rates for velopharyngeal insufficiency (VPI) in syndromic and non-syndromic children: A systematic review and meta-analysis. Am J Otolaryngol 2024; 45:104341. [PMID: 38754293 DOI: 10.1016/j.amjoto.2024.104341] [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: 02/27/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE To evaluate pre- and post-operative resonance, surgical technique, revision rate, and revision indication among syndromic and non-syndromic children with velopharyngeal insufficiency (VPI). MATERIALS AND METHODS A systematic review was conducted through July 2022. Children surgically treated for VPI were included. A meta-analysis of single means, proportions, comparison of proportions, and mean differences with 95 % confidence interval [CI] was conducted. RESULTS Twenty-three articles (n = 1437) were included in the analysis. The most common surgery was Sphincter Pharyngoplasty (SP), 62.6 % [31.3-88.9] for syndromic and 76.3 % [37.5-98.9] for non-syndromic children. Among all surgical techniques, for syndromic and non-syndromic children, 54.8 % [30.9-77.5] and 73.9 % [61.3-84.6] obtained normal resonance post-operatively, respectively. Syndromic patients obtained normal resonance post-operatively in 83.3 % [57.7-96.6] of Combined Furlow Palatoplasty and Sphincter Pharyngoplasty (CPSP), 72.6 % [54.5-87.5] of Pharyngeal Flap (PF), and 45.1 % [13.2-79.8] of Sphincter Pharyngoplasty (SP) surgeries. Non-syndromic patients obtained normal resonance post-operatively in 79.2 % [66.4-88.8] of PF and 75.2 % [61.8-86.5] of SP surgeries. The revision rate for syndromic and non-syndromic patients was 19.9 % [15.0-25.6] and 11.3 % [5.8-18.3], respectively. The difference was statistically significant, 8.6 % [2.9-15.0, p = 0.003]. Syndromic patients who underwent PF were least likely to undergo revision surgery as compared to SP and CPSP, 7.7 % [2.3-17.9] vs. 23.7 % [15.5-33.1] and 15.3 % [2.8-40.7], respectively. CONCLUSIONS Syndromic children had higher revision rates and were significantly less likely to obtain normal resonance following primary surgery than non-syndromic patients. Among syndromic children, PF and CPSP have been shown to improve resonance and reduce revision rates more so than SP alone.
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Affiliation(s)
- Evan S Chernov
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA; SUNY Upstate Medical University, School of Medicine, 766 Irving Ave, Syracuse, NY 13210, USA
| | - April N Taniguchi
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA; University of Central Florida, School of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, USA
| | - Shaun A Nguyen
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA.
| | - Sarah R Sutton
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA; University of Nevada, Reno, School of Medicine, 1664 N Virginia St, Reno, NV 89557, USA
| | - Phayvanh P Pecha
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA
| | - Krishna G Patel
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA
| | - Melissa Montiel
- Medical University of South Carolina, Department of Speech Language Pathology, 135 Rutledge Avenue, Charleston, SC 29425, USA
| | - William W Carroll
- Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, 135 Rutledge Avenue, Charleston, SC 29425, USA
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Wang AT, Hseu AF, Staffa SJ, Clark RE, Meara JG, Nuss RC, Ganske IM, Rogers-Vizena CR. Comparative Study of Pharyngeal Flap Outcomes between Children with 22q11.2 Deletion Syndrome and Nonsyndromic Cleft Lip and Palate. Plast Reconstr Surg 2024; 154:151-160. [PMID: 37337330 DOI: 10.1097/prs.0000000000010854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Management of velopharyngeal insufficiency (VPI) in 22q11.2 deletion syndrome is challenging. The authors compared pharyngeal flap outcomes in children with 22q11.2 deletion syndrome to those with nonsyndromic cleft lip and palate (CLP) to assess risk of poor speech outcomes and negative sequelae. METHODS Children with 22q11.2 deletion syndrome or CLP treated with pharyngeal flap through a multidisciplinary VPI clinic between 2009 and 2020 were retrospectively reviewed. Preoperative and postoperative speech assessments, perioperative characteristics, and complications were identified. RESULTS Thirty-six children with 22q11.2 deletion syndrome and 40 with CLP were included. Age at surgery ( P = 0.121), preoperative velopharyngeal competence score ( P = 0.702), and preoperative resonance ( P = 0.999) were similar between groups. Pharyngeal flaps were wider ( P = 0.038) and length of stay longer in the 22q11.2 deletion syndrome group ( P = 0.031). On short-term follow-up 4 months after surgery, similar speech outcomes were seen between groups. At long-term follow-up greater than 12 months after surgery, 86.7% of 22q11.2 deletion syndrome versus 100% of CLP ( P = 0.122) children had improvement in velopharyngeal function; however, fewer children with 22q11.2 deletion syndrome (60.0%) achieved a completely "competent" velopharyngeal competence score compared with those with CLP (92.6%) ( P = 0.016). Nasal regurgitation improved for both groups, with a greater improvement in those with 22q11.2 deletion syndrome ( P = 0.026). Revision rate ( P = 0.609) and new-onset obstructive sleep apnea ( P = 0.999) were similar between groups. CONCLUSIONS Children with 22q11.2 deletion syndrome have improved speech after pharyngeal flap, but they may be less likely to reach normal velopharyngeal function over the long term than those with CLP; however, negative sequelae do not differ. Improvement in nasal regurgitation is a uniquely positive outcome in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
| | - Anne F Hseu
- From Harvard Medical School
- the Departments of Otolaryngology and Communication Enhancement
| | - Steven J Staffa
- From Harvard Medical School
- Surgery
- Anesthesiology, Critical Care, and Pain Medicine
| | | | - John G Meara
- From Harvard Medical School
- Plastic and Oral Surgery, Boston Children's Hospital
| | - Roger C Nuss
- From Harvard Medical School
- the Departments of Otolaryngology and Communication Enhancement
| | - Ingrid M Ganske
- From Harvard Medical School
- Plastic and Oral Surgery, Boston Children's Hospital
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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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Ghanem AM, Ghorbanian S, Borg TM, Sell D, Sommerlad BC. Submucous Cleft Palate (SMCP): Indications and Outcomes of Radical Muscle Dissection Palatoplasty in Children Under 4 Years of Age. Cleft Palate Craniofac J 2022:10556656221088170. [PMID: 35306868 DOI: 10.1177/10556656221088170] [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: 11/15/2022] Open
Abstract
To delineate the indications, referral sources and outcomes of radical muscle dissection palate repair in the first 4 years of life for patients with submucous cleft palate (SMCP). This study presents a retrospective analysis of a single surgeon's management. All children were treated at Great Ormond Street Hospital, United Kingdom. Twenty-three children with nonsyndromic SMCP were included in this study. All participants underwent radical muscle dissection repair before their fourth birthday. Parameters analyzed included: referral sources, indications for referral, extent of anatomical abnormality, and postoperative outcomes. Paediatricians provided the largest proportion of referrals to the cleft lip and palate clinic (39%) due to the presence of cleft lip/palate on prenatal scans or during neonatal examination. Over half (n = 12, 52%) of patients had severe anatomical anomalies being in grade IV (score 8-9), with the classical triad present to some extent in all but 2 of the patients. The main indication for surgery was nasal regurgitation of food and liquid (n = 9, 35%) followed by hypernasality (n = 6, 21%), difficulty feeding (n = 3, 8%), and severe anatomical defect (n = 2; 4%). Postoperatively, the presenting complaint improved in the majority of cases. Nonsyndromic SMCP is often missed, though may present with nasal regurgitation, feeding problems, and/or hypernasality, though may be missed in nonsyndromic children. Early radical muscle dissection repair in the first 4 years of life is safe and effective, facilitating normal speech development.
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Affiliation(s)
- Ali M Ghanem
- 4952Barts and the London School of Medicine and Dentistry, London, UK
| | - Samim Ghorbanian
- 4952Barts and the London School of Medicine and Dentistry, London, UK
| | | | - Debbie Sell
- 4956Great Ormond Street Hospital for Children NHS Trust, London, UK
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Kimia R, Elden L, Dailey J, Kodavatiganti M, Crowley TB, McGinn DE, Bailey A, Zackai EH, McDonald-McGinn DM, Jackson OA. Magnetic resonance angiography (MRA) in preoperative planning for patients with 22q11.2 deletion syndrome undergoing craniofacial and otorhinolaryngologic procedures. Int J Pediatr Otorhinolaryngol 2020; 138:110236. [PMID: 32890936 DOI: 10.1016/j.ijporl.2020.110236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/28/2020] [Accepted: 06/28/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with 22q11.2 deletion syndrome (22q11.2DS) have a variety of anatomic anomalies. For surgeons operating in proximity to the retropharynx, the most pertinent is medial displacement of the internal carotid arteries. The purpose of this study is to describe the preoperative use of magnetic resonance angiography (MRA) in surgical planning and update the incidence rate of medial carotid displacement in patients with 22q11.2DS. METHODS This is a retrospective cohort study of patients with a confirmed diagnosis of 22q11.2 deletion and preoperative MRA <18 years old who underwent tonsillectomy, adenoidectomy, Furlow palatoplasty (FPP), posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), or submucosal cleft palate (SMCP) repair between January 1st, 2008 and December 31st, 2019. RESULTS Ninety patients who met the inclusion criteria underwent 133 procedures. The majority identified as Caucasian (84.4%); 52.2% were female. Cervical MRA was more likely to be ordered before a PPF (80.9%) and tonsillectomy (72.7%) over a FPP (47.6%) or adenoidectomy (11.1%). Carotid medialization was visualized in 23 patients (25.6%) and was mild in 11 cases, moderate in 7 cases, and significant in 5 cases. There was no association between sex, race/ethnicity, or genetic diagnosis with carotid medialization. Flap shortening was necessary in 20% of PPF cases to avoid injuring the medialized vessel. CONCLUSION Patients with 22q11.2DS may have higher rates of medialization of the carotid arteries than previously thought. Given the risk for complications in these patients during pharyngeal operations, there may be a critical place for MRA in surgical planning for patients with 22q11.2DS.
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Affiliation(s)
- Rotem Kimia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa Elden
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julia Dailey
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mallika Kodavatiganti
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - T Blaine Crowley
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel E McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alice Bailey
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elaine H Zackai
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Donna M McDonald-McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Fleming J, Morrell N, Zavala H, Chinnadurai S, Roby BB. Submucous Cleft Palate Repair in Patients With 22q11.2 Deletion Syndrome. Cleft Palate Craniofac J 2020; 58:84-89. [PMID: 32700562 DOI: 10.1177/1055665620942436] [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: 11/17/2022] Open
Abstract
OBJECTIVE To determine whether surgical intervention for submucous cleft palate (SMCP) is more common in children with 22q11.2 deletion syndrome (22q DS) compared to children without 22q DS. DESIGN Retrospective chart review. SETTING Tertiary pediatric hospital and 22q11.2 DS specialty clinic. PARTICIPANTS One hundred forty-two children seen at the tertiary hospital or clinic during a 20-year period (June 1999-June 2019) with documented SMCP with and without 22q DS. MAIN OUTCOME MEASURE Percentage of children with SMCP with and without 22q DS requiring surgical intervention for velopharyngeal insufficiency. RESULTS Patients with 22q DS had a significantly higher frequency of SMCP repair than those without 22q DS (89.7% vs 32.0%, P < .001, χ2 = 37.75). The odds of requiring SMCP repair were 18.6 times higher in those with 22q DS compared to those without (odds ratio = 18.6, CI = 6.1-56.6). CONCLUSIONS This study provides new evidence suggesting patients with 22q DS require SMCP surgical repair for velopharyngeal insufficiency at a significantly higher rate than those without 22q DS. As the majority of patients with 22q DS with SMCP require surgical intervention, future prospective studies looking at early versus late repair of SMCP in patients with 22q DS are needed to guide the surgical repair timeline in this population.
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Affiliation(s)
- Jenna Fleming
- University of Minnesota Medical School Twin Cities, Minneapolis, MN, USA
| | - Noelle Morrell
- Pediatric ENT and Facial Plastic Surgery, 14539Children's Hospital of Minnesota, St Paul, MN, USA
| | - Hanan Zavala
- Pediatric ENT and Facial Plastic Surgery, 14539Children's Hospital of Minnesota, St Paul, MN, USA
| | - Siva Chinnadurai
- Pediatric ENT and Facial Plastic Surgery, 14539Children's Hospital of Minnesota, St Paul, MN, USA
| | - Brianne Barnett Roby
- Pediatric ENT and Facial Plastic Surgery, 14539Children's Hospital of Minnesota, St Paul, MN, USA.,Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, MN, USA
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Roche L, Campbell L, Heussler H. Communication in 22q11.2 Deletion Syndrome: a Brief Overview of the Profile, Intervention Approaches, and Future Considerations. CURRENT DEVELOPMENTAL DISORDERS REPORTS 2020. [DOI: 10.1007/s40474-020-00208-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Optimizing speech outcomes for cleft palate. Curr Opin Otolaryngol Head Neck Surg 2020; 28:206-211. [PMID: 32520757 DOI: 10.1097/moo.0000000000000635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Cleft lip with or without palate is one of the most common pediatric birth anomalies. Patients with cleft palate often have speech difficulties from underlying anatomical defects that can persist after surgery. This significantly impacts child development. There is a lack of evidence exploring, which surgical techniques optimize speech outcomes. The purpose of this update is to report on recent literature investigating how to optimize speech outcomes for cleft palate. RECENT FINDINGS The two-flap palatoplasty with intravelar veloplasty (IVVP) and Furlow double-opposing Z-plasty has the strongest evidence for optimizing speech. One-stage palatal repair is favored at 10-14 months of age, while delays are associated with significant speech deficits. For postoperative speech deficits, there is no significant difference between the pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. Surgical management should be guided by closure pattern and velopharyngeal gap but few studies stratify by these characteristics. SUMMARY According to recent evidence, the two-flap palatoplasty with IVVP and Furlow palatoplasty result in the best speech. The pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation are all viable techniques to correct residual velopharyngeal insufficiency. Future research should focus on incorporating standardized measures and more robust study designs.
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