The Incidence and Outcomes for Children with Cleft Palate and/or Lip and CHARGE Syndrome

OBJECTIVES

Published literature on children with cleft palate and/or lip (CP + /-L) and CHARGE syndrome (CS) is limited. This study investigated cleft characteristics including surgery, and feeding and communication outcomes in children identified with CP + /-L and CS.

DESIGN

Retrospective cross-sectional review.

SETTING

Regional Referral Centre for Paediatric Cleft Surgery.

PATIENTS

All children diagnosed with CP + /-L and CS (based on clinical features and/or CHD7 mutation testing) between 1989-2019.

MAIN OUTCOME MEASURES

Cleft type, timing of CP + /-L repair, reasons for 'delayed' repair, feeding methods and communication modality.

RESULTS

Twenty-two children with CP + /-L and CS were identified. Cleft sub-types (%) were: Eleven (50%) had bilateral cleft lip and palate (BCLP), six (27%) had unilateral cleft lip and palate (UCLP) and five (23%) had cleft palate (CP). Cleft repair was delayed compared to protocol care for non-syndromic children with CP + /-L. Median age for lip repair + /- vomerine flap was 9 months (range 4-22 months), and palate repair was 21 months (range 11-40 months). Median age for isolated CP repair was 13 months (range 7-23). Surgery for cardiac anomalies (36%) before cleft repair, and (59%) were classed as having severe systemic disease at the time of cleft surgery. Only 27% of the children in this study had both full oral feeding and verbal communication.

CONCLUSIONS

Children with CP + /-L and CS had severe cleft types and complex medical problems leading to delayed cleft surgery. Feeding and speech outcomes were better in the children aged over ten years.

Effectiveness of ventilation tube insertion for conductive hearing loss in children with chronic otitis media with effusion and non-syndromic cleft palate: a systematic review protocol

OBJECTIVE

This review will investigate the efficacy of ventilation tube insertion versus non-surgical options in the management of chronic otitis media with effusion in children with non-syndromic cleft palate by assessing the degree of conductive hearing loss.

INTRODUCTION

Chronic otitis media with effusion is common in children with cleft palate due to associated eustachian tube dysfunction. It can lead to impaired hearing and can hinder speech and language development. The main treatment options are drainage of effusion with ventilation tubes, surveillance, or amplification with hearing aids. Each of these approaches has its advantages but there is currently no consensus on the most appropriate management in children with cleft palate.

INCLUSION CRITERIA

Eligible studies will include children (<18 years) with cleft palate not associated with a genetic syndrome, diagnosed with chronic otitis media with effusion, who have undergone insertion of ventilation tubes compared with either surveillance or amplification with hearing aids.

METHODS

A comprehensive search of MEDLINE, CINAHL, Embase, and Scopus will be conducted to find published literature. Gray literature searches will be conducted through the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and ProQuest Dissertations and Theses Global. Two reviewers will screen studies, conduct critical appraisal of eligible studies, assess the methodological quality, and extract the data. Where possible, studies will be pooled in statistical meta-analysis, with heterogeneity of data being assessed using the standard χ 2 and I2 tests.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021255861.

High prevalence of deleterious mutations in concomitant nonsyndromic cleft and outflow tract heart defects

Our previous work demonstrating enrichment of outflow tract (OFT) congenital heart disease (CHD) in children with cleft lip and/or palate (CL/P) suggests derangements in common underlying developmental pathways. The current pilot study examines the underlying genetics of concomitant nonsyndromic CL/P and OFT CHD phenotype. Of 575 patients who underwent CL/P surgery at Children's Hospital Los Angeles, seven with OFT CHD, negative chromosomal microarray analysis, and no recognizable syndromic association were recruited with their parents (as available). Whole genome sequencing of blood samples paired with whole‐blood‐based RNA sequencing for probands was performed. A pathogenic or potentially pathogenic variant was identified in 6/7 (85.7%) probands. A total of seven candidate genes were mutated (CHD7, SMARCA4, MED12, APOB, RNF213, SETX, and JAG1). Gene ontology analysis of variants predicted involvement in binding (100%), regulation of transcription (42.9%), and helicase activity (42.9%). Four patients (57.1%) expressed gene variants (CHD7, SMARCA4, MED12, and RNF213) previously involved in the Wnt signaling pathway. Our pilot analysis of a small cohort of patients with combined CL/P and OFT CHD phenotype suggests a potentially significant prevalence of deleterious mutations. In our cohort, an overrepresentation of mutations in molecules associated with Wnt‐signaling was found. These variants may represent an expanded phenotypic heterogeneity within known monogenic disease genes or provide novel evidence of shared developmental pathways. The mechanistic implications of these mutations and subsequent developmental derangements resulting in the CL/P and OFT CHD phenotype require further analysis in a larger cohort of patients.

Cleft Lip and Palate in Infants With Prenatal Opioid Exposure

OBJECTIVE

This study examines phenotypic presentation and perioperative outcomes of cleft-related procedures for infants with cleft lip and/or palate (CL/P) and prenatal opioid exposure.

DESIGN

This is a retrospective review of infants with prenatal opioid exposure treated for CL/P from 2008 to 2018.

SETTING

Patients cared for at a tertiary center from 2008 to 2018.

PATIENTS/PARTICIPANTS

Eighteen patients with documented prenatal opioid exposure and CL/P had primary repairs in our unit.

MAIN OUTCOME MEASURE(S)

The phenotypes of CL/P were characterized. Demographic data regarding additional exposures, as well as associated medical and social comorbidities were recorded. Outcome variables included operative delays, perioperative complications, and loss of follow-up.

RESULTS

Isolated cleft palate (CP; 67%) was overrepresented among patients with prenatal opioid exposure and CL/P, as was Robin sequence (50% in isolated CP). Fifty-six percent had exposure to additional substances. A majority (67%) had other medical conditions or anomalies, and 17% had known genetic syndromes. Seventy-two percent were in state custody. Thirty-nine percent of exposed patients had delays in their planned operative dates due to medical and/or social factors. There were no postoperative readmissions following cleft procedures. Lack of follow-up was noted in 33% of patients.

CONCLUSIONS

Infants with CL/P who have prenatal opioid exposure are likely to have additional medical conditions and complex social challenges.

[Ultrasound scan of a fetus with facial cleft must be done from the lip to the uvula: What's new?]

Facial cleft are the most frequent craniofacial anomalies with an incidence of one for 1000 births, all births combined, and require specialized multidisciplinary care. Since 2005, the systematic realization of two ultrasound views (nose-lip and profile) is recommended for the exploration of the fetal face in the 2nd trimester of pregnancy. Application of these recommendations should allow screening of the majority of cleft lip and palate. However, cleft palates, without labiomaxillary involvement, are currently largely underdiagnosed at prenatal ultrasound, although they can be associated with a syndromic diagnosis in up to 30% of cases. The aim of this work is to describe, from embryology to surgical consultation, the complete ultrasound examination of a fetus with a classic facial cleft.

Outcomes in Velopharyngeal Dysfunction Treatment: Comparing Two Approaches for Pharyngeal Flaps

BACKGROUND

The most common surgical intervention to treat velopharyngeal dysfunction in the US is the posterior pharyngeal flap (PPF). In this retrospective study, the authors compare surgical and speech outcomes across 2 PPF surgical approaches: the palatal split (PS) and fish mouth (FM) techniques.

METHODS

An Institutional Review Board approved retrospective chart review was performed for PPF cases performed by a single surgeon between 2008 and 2016. Overall, 40 patients received the PS technique and 47 received the FM technique. Age at surgery, operative length, length of stay (LOS), revisional surgery, and pain medication administration were measured. Speech outcomes were measured based on the Universal Parameters for Reporting Speech Outcomes and included Speech Language Pathologist ratings of hypo- and hypernasality, speech acceptability, and audible nasal emission. Two sample t-tests and multivariable-mixed effects logistic regression were used to analyze the data.

RESULTS

Comparing the 2 groups (PS versus FM), there were statistically significant differences among the operative approaches across multiple measures: LOS (32.86 hours versus 26.20 hours, P = 0.01), acetaminophen use (1523.54 mg versus 805.74 mg, P = 0.01), revisional surgery rate (17.5% versus 2.10%, P = 0.02), and degree of postoperative hypernasality (0.61 versus 0.29, P = 0.03). Syndromic patients were more likely to receive the FM technique (PS: 15% versus FM: 29.8%; P = 0.05). The odds ratio for revision surgery with the FM technique was -2.32 (CI: -4.32 to -0.35, P = .04).

CONCLUSIONS

In this study, the FM technique offered a shorter LOS, lower revision rate, less acetaminophen administration, and more favorable speech outcomes when compared to the PS technique.

Cleft Lip and Palate in Ectodermal Dysplasia

OBJECTIVE

Ectodermal dysplasia (ED) comprises multiple syndromes that affect skin, hair, nails, and teeth, and sometimes are associated with orofacial clefting. The purpose of this study is to (1) identify the prevalence and characteristics of cleft lip and/or palate (CL/P) in patients with ED and (2) describe the management and outcomes.

DESIGN

Retrospective review from 1990 to 2019.

PATIENTS

All patients with ED treated at Boston Children's Hospital.

MAIN OUTCOMES MEASURES

Prevalence of CL/P was calculated and clinical details recorded: phenotypic anomalies, cleft type, operative treatment, and results of repair.

RESULTS

Of 170 patients with a purported diagnosis of ED, 24 (14%) had CL/P. Anatomic categories were bilateral CL/P (67%), unilateral CL/P (8%), and cleft palate only (25%). The most common ED syndrome (37%) was ectrodactyly, ectodermal dysplasia, and cleft lip/palate (EEC). Pathogenic variants in TP63 were the most frequent finding in the 11 patients who had genetic testing. Aberrations from a typical clinical course included failure of presurgical dentofacial orthopedics, dehiscence of nasolabial adhesion, and total palatal absence requiring free-flap construction. Two patients had prolonged postoperative admission for respiratory infection. High fistula (8%) and velopharyngeal insufficiency (33%) rates reflected the predominance of bilateral complete forms.

CONCLUSIONS

As in other types of syndromic CL/P, cleft phenotypic expression in ED is more severe than the general cleft population. Further studies are needed to correlate genotype and phenotype for the distinct syndromes included in the ED spectrum.

CHARGE syndrome: genetic aspects and dental challenges, a review and case presentation

Background

CHARGE syndrome (CS) is a rare genetic condition (OMIM #214800). The condition has a variable phenotypic expression. Historically, the diagnosis of CHARGE syndrome was based on the presence of specific clinical criteria. The genetic aetiology of CS has since been elucidated and attributed to pathogenic variation in the CHD7 gene (OMIM 608892) at chromosome locus 8q12.

Case presentation

A South African female of mixed ancestry heritage, aged 4 years, was referred for dental assessment to the Faculty of Dentistry, University of the Western Cape, in 2018. She had a diagnosis of CHARGE syndrome confirmed by a Medical Geneticist from the Division of Molecular Biology and Human Genetics at the University of Stellenbosch.

The patient had a long prior history of health and developmental problems, with the correct diagnosis becoming apparent over time. She presented with many oral and craniofacial features warranting consideration by the dentist including micrognathia, hypoplastic nasal bones, cranial nerve dysfunction, bruxism, craniofacial anomalies and compromised sensory perception. The treatment was mainly preventive and, although she fed through a percutaneous endoscopic gastrostomy tube (PEG), maintenance of her oral hygiene was necessitated.

Conclusion: CS is a multisystem condition and the optimal care for an individual is with a specialist multidisciplinary team. The numerous systemic problems affecting these individuals take precedence in their care, and often there is neglect of their dental concerns. Given the abnormalities frequently present in the oral and craniofacial region, the authors recommend that a team of dental and other medical specialists be involved in the management of individuals with CS.