Five-Fold Variation Among Surgeons and Hospitals in the Use of Secondary Palate Surgery

Cleft Palate Repair Postoperative Management: Current Practices in the United States

OBJECTIVE

To describe current postoperative management practices following cleft palate repair.

DESIGN

A survey was administered to cleft surgeons to collect information on their demographic characteristics, surgical training, surgical practice, and postoperative management preferences.

SETTING

Eighteen tertiary referral hospitals across the United States.Participants: Surgeons (n = 67) performing primary cleft palate repair.

RESULTS

Postoperative diet restrictions were imposed by 92% of surgeons; pureed foods were allowed at one week after surgery by 90% of surgeons; a regular diet was allowed at one month by 80% of surgeons. Elbow immobilizers and/or mittens were used by 85% of surgeons, for a median duration of two weeks. There was significant disagreement about postoperative use of bottles (61% allow), sippy cups (68% allow), pacifiers (29% allow), and antibiotics (45% prescribe). Surgeon specialty was not associated with any aspect of postoperative management (p > 0.05 for all comparisons). Surgeon years in practice, a measure of surgeon experience, was associated only with sippy cup use (p < 0.01). The hospital at which the surgeon practiced was associated with diet restrictions (p < 0.01), bottle use (p < 0.01), and use of elbow immobilizers or mittens (p < 0.01); however, many hospitals still had disagreement among their surgeons.

CONCLUSIONS

Surgeons broadly agree on diet restrictions and the use of elbow immobilizers or mittens following palate repair. Almost all other aspects of postoperative management, including the type and duration of diet restriction as well as the duration of immobilizer use, are highly individualized.

Choosing a Multidisciplinary Cleft and Craniofacial Team: Medical, Surgical, and Social Considerations

Cleft and craniofacial conditions often present with a variety of functional and esthetic sequelae optimally treated by a multidisciplinary approach. Diagnosis of such conditions pre- or postnatally may evoke parental uncertainty and anxiety, and an important primary consideration is the selection of a cleft and craniofacial team. Identifying an optimal team may be particularly important for developing long-term relationships with clinicians who will ideally work intimately with the family from diagnosis to adulthood. While families, parents, and providers should consider several factors, a dearth of evidence-based suggestions preclude critical appraisal of cleft and craniofacial teams. In this article, the authors summarize medical, surgical, and social considerations for selecting a cleft and craniofacial team to optimize patient outcomes and the family/caregiver experience.

Characterizing Speech Phenotype in Individuals With Craniofacial Microsomia: A Scoping Review

INTRODUCTION

Craniofacial microsomia (CFM) is a complex congenital condition primarily affecting the ear, mandible, facial nerve and muscles, and tongue. Individuals with CFM are at increased risk of hearing loss, obstructive sleep apnea, and feeding/swallowing difficulties. The purpose of this scoping review was to summarize evidence pertaining to speech production in CFM.

METHOD

All articles reporting any characteristic of speech production in CFM were included and screened by two independent reviewers by title, abstract, and full text. Data charting captured details related to study population and design, CFM diagnostic criteria, speech outcome measurement, and key findings. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist guided reporting of results. Our protocol was registered on the Open Science Framework (https://osf.io/npr94/) and published elsewhere.

RESULTS

Forty-five articles were included in the detailed review. Most articles originated from the United States, were published in the past decade, and utilized case report/series study design. A speech-language pathologist authored 29%. The prevalence of velopharyngeal insufficiency ranged from 19% to 55% among studies. Oral distortion of alveolar and palatal fricatives and affricates primarily characterized articulation errors. Studies identified increased disordered speech and lower intelligibility in adolescents with CFM compared to unaffected peers. Evidence pertaining to phonatory and respiratory speech findings is limited.

CONCLUSIONS

Evidence supports that individuals with CFM are at increased risk of both velopharyngeal and articulatory speech differences. Additional information is needed to develop speech screening guidelines for children with CFM. Heterogeneity in study design and outcome measurement precludes comparisons across studies.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24424555.

Six-year Burden of Care for Nonsyndromic Unilateral Cleft Lip and Palate Patients: A Comparison Between Cleft Centers and Noncleft Centers

OBJECTIVE

To determine differences in burden of care between nonsyndromic patients with unilateral cleft lip and palate undergoing treatment at American Cleft Palate-Craniofacial Association (ACPA)-accredited centers and nonaccredited centers in New York State.

DESIGN

A retrospective review of the New York Statewide Planning and Research Cooperative System database from January 2001 to December 2014 was performed using ICD-9 and CPT coding.

PATIENTS, PARTICIPANTS

This study included patients with unilateral cleft lip and palate who underwent both lip and palate repairs during their first  6 years of life. Exclusion criteria included orofacial cleft syndromes, follow-up under  6 years, and one-stage combined cleft lip and palate repairs.

RESULTS

Eighty-eight patients were treated at cleft centers, and 29 patients at nonaccredited centers (  n = 117). Age at primary palatoplasty (13.0 months vs 18.1 months;   p = .019), total number of cleft operations (2.3 vs 2.7;   p = .012), and total number of primary cleft-specific procedures (2.2 vs 2.5;   p = .0049) were significantly lower for patients treated in cleft centers. Age at primary cheiloplasty (4.8 months vs 4.6 months;   p = .865), post-cheiloplasty length of stay (1.2 days vs 1.2 days;   p = .673), post-palatoplasty length of stay (1.5 days vs 1.9 days;   p = .211), average hospital admissions (2.2 vs 2.3; p = 0.161), and total complication rates (34.1% vs 21.1%; p = 0.517) did not differ significantly between cleft centers and noncenters.

CONCLUSIONS

This data demonstrates some significant differences in overall 6 year burden of care for nonsyndromic patients with unilateral cleft lip and palate treated at ACPA-accredited cleft centers versus nonaccredited centers.

A Preliminary Study of Anatomical Changes Following the Use of a Pedicled Buccal Fat Pad Flap During Primary Palatoplasty

OBJECTIVE

The purpose of this study was to examine the surgical impact of the pedicled buccal fat pad (BFP) flap on the levator veli palatini (LVP) muscle and surrounding velopharyngeal (VP) anatomy following primary palatoplasty using magnetic resonance imaging (MRI).

DESIGN

Observational, prospective.

SETTING

MRI studies were completed at 3 different facilities. All participants with BFP flap were operated on by the same surgeon.

PARTICIPANTS

Five pediatric participants with cleft palate with or without cleft lip (CP±L) who underwent primary palatoplasty with BFP flap placement. Comparison groups consisted of 10 participants: 5 with CP±L who did not receive the BFP flap and 5 healthy controls.

INTERVENTIONS

All participants underwent nonsedated MRI 2 to 5 years postoperatively.

MAIN OUTCOMES AND MEASURES

Anatomical measures of the velopharynx and LVP among the 3 participant groups.

RESULTS

Median values were significantly different among groups for velar length (P = .042), effective velar length (P = .048), effective VP ratio (P = .046), LVP length (P = .021), extravelar LVP length (P = .009), and LVP origin-origin distance (P = .030). Post hoc analysis revealed a statistically significant difference between the BFP and traditional repair groups for effective VP ratio (P = .040), extravelar LVP length (P = .033), and LVP length (P = .022).

CONCLUSIONS

This study provides preliminary support that the BFP flap creates a longer velum, with increased distance between the posterior hard palate and the LVP, and a larger effective VP ratio compared to traditional surgical techniques. Future research is needed to determine whether this procedure provides a more favorable mechanism for VP closure.

Complications and the Need for Long-Term Follow-Up after Secondary Speech Surgery: A National and Longitudinal Claims Analysis

BACKGROUND

Although most patients attain normal speech after cleft palate repair, up to 20 percent require secondary speech surgery. Despite the frequency of these procedures, complications and rates of subsequent revisions of secondary speech surgery after all procedure types have never been reviewed using national, longitudinal data.

METHODS

The authors examined insurance claims from Clinformatics Data Mart between 2001 and 2017. Cases were categorized as palatalprocedures (i.e., palatoplasty, revision palatoplasty, secondary lengthening, palatal island flap) or pharyngeal procedures (i.e., pharyngeal flap, dynamic sphincter pharyngoplasty) (n = 846). Continuous enrollment from 180 days before to 30 days after surgery was required. Patients were excluded if they underwent palatoplasty, or any surgery at less than 3 years of age, without a speech diagnosis. Outcomes included 30-day complications and rates of subsequent revision secondary speech surgery. Multivariable logistic regression was used to evaluate the relationship between procedure type and complications.

RESULTS

In this cohort, 52.5 percent underwent pharyngeal procedures, and 47.5 percent underwent palatal procedures. Complications occurred in 10.9 percent of patients and included respiratory complications (4.0 percent), bleeding (1.2 percent), dehiscence (3.6 percent), and critical care episodes (3.0 percent). There was no difference in complications between procedure types (OR, 0.87; 95 percent CI, 0.56 to 1.37; p = 0.56). The subsequent revision rate was 12.7 percent, but was 21.7 percent in patients with 3 years of postoperative enrollment.

CONCLUSIONS

Although complication rates were comparable to those in recent literature, rates of subsequent revisions of secondary speech procedures were high in patients with longer postoperative enrollment. Thus, these patients merit prolonged follow-up, as velopharyngeal dysfunction may recur over time.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Oral Flora and Perioperative Antimicrobial Interventions in Cleft Palate Surgery: A Review of the Literature

BACKGROUND

The role of perioperative antibiotics in cleft palate remains a topic of debate. Advocates stress their importance in preventing local and systemic infections and decreasing the incidence of oronasal fistula formation. However, few studies to date have directly evaluated the role of antibiotics and other antimicrobial measures in cleft palate surgery.

OBJECTIVE

The aim of this review is to evaluate the evidence surrounding the use of perioperative antibiotics and other antimicrobial interventions in cleft palate surgery. Additionally, we review the literature on the oral flora unique to the cleft palate patient population.

METHODS

This was accomplished utilizing PubMed, Medline, and the Cochrane Library with MeSH and generic terms. Articles were selected based on predefined inclusion and exclusion criteria.

RESULTS

This review highlights the lack of higher level evidence on perioperative antibiotic use and other antimicrobial interventions in cleft palatoplasty and calls for further research on the matter.

CONCLUSIONS

The literature appears to support the use of preoperative antibiotics for cleft palatoplasty, but the benefits of prolonged postoperative antibiotic use remain questionable.

Cleft Palate Repair by Otolaryngologist-Head and Neck Surgeons: Risk Factors for Postoperative Fistula

OBJECTIVES/HYPOTHESIS

To assess the incidence of palatal fistula after primary repair of the cleft palate among two cohorts of Otolaryngologist-Head and Neck Surgeons and to identify patient and surgeon characteristics that may predict fistula development.

STUDY DESIGN

Retrospective case series with chart review.

METHODS

Children who underwent primary repair of cleft palate at one of two multidisciplinary cleft centers over a 10 year period were identified. Charts were reviewed for the presence of palatal fistula; chi square test and multivariate logistic regression analysis were performed to determine variables associated with fistula formation.

RESULTS

From 2007 to 2017, 477 patients underwent primary repair of cleft palate by one of 6 Otolaryngologist-Head and Neck Surgeons. Twenty-four children had incomplete charts, allowing 453 patients to be included in the final analysis. The pooled mean incidence of palatal fistula was 6.6% (P = .525) and varied significantly by cleft type. Logistic regression analysis controlling for multiple variables, showed that Veau IV classification had the highest risk of fistula (OR = 10.582; P = .004). Repair by a specific surgeon was not a significant risk factor for fistula development (P > .07 for each surgeon).

CONCLUSIONS

Among six Otolaryngologist-Head and Neck Surgeons with fellowship training in cleft palate repair postoperative fistula rates were consistent and compared favorably to standards in the Cleft and Craniofacial surgery literature established by other surgical specialties. Consistent with larger database studies involving multiple surgical specialties, Veau IV classification was the strongest predictor of palatal fistula development, even after adjusting for multiple variables, including differing levels of experience.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1281-1285, 2021.

Provision and Utilization of Team- and Community-Based Operative Care for Patients With Cleft Lip/Palate in North Carolina

OBJECTIVE

To characterize operative care for cleft lip and/or palate (CL/P) based on location (ie, from American Cleft Palate Craniofacial Association [ACPA]-approved multidisciplinary teams or from community providers).

DESIGN

Cross-sectional analysis of Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery & Services Database databases for North Carolina from 2012 to 2015.

SETTING/PATIENTS AND MAIN OUTCOME MEASURES

Clinical encounters for children with CL/P undergoing operative procedures were identified, classified by location as "Team" versus "Community," and characterized by demographic, geographic, clinical, and procedural factors. A secondary evaluation reviewed concordance of team and community practices with an ACPA guideline related to coordination of care.

RESULTS

Three teams and 39 community providers performed a total of 3010 cleft-related procedures across 2070 encounters. Teams performed 69.7% of total volume and performed the majority of cleft procedures, including cleft lip repair, palate repair, alveolar bone grafting, and correction of velopharyngeal insufficiency. Community locations principally offered myringotomy and rhinoplasty. Team care was associated with higher guideline concordance.

CONCLUSIONS

American Cleft Palate Craniofacial Association -approved team-based care accounts for the majority of cleft-related care in North Carolina; however, a substantial volume of cleft-related procedures was provided by community providers, with 3 providers accounting for the vast majority of community cases.

Oronasal Fistula Risk After Palate Repair

OBJECTIVE

To assess risk factors for oronasal fistula, including 2-stage palate repair.

DESIGN

Retrospective analysis.

SETTING

Tertiary children's hospital.

PATIENTS

Patients with non-submucosal cleft palate whose entire cleft repair was completed at the study hospital between 2005 and 2013 with postsurgical follow-up.

INTERVENTIONS

Hierarchical binary logistic regression assessed predictive value of variables for fistula. Variables tested for inclusion were 2 stage repair, Veau classification, sex, age at surgery 1, age at surgery 2, surgeon volume, surgeon, insurance status, socioeconomic status, and syndrome. Variables were added to the model in order of significance and retained if significant at a .05 level.

MAIN OUTCOME MEASURE

Postoperative fistula.

RESULTS

Of 584 palate repairs, 505 (87%) had follow-up, with an overall fistula rate of 10.1% (n = 51). Among single-stage repairs (n = 211), the fistula rate was 6.7%; it was 12.6% in 2-stage repairs (n = 294, P = .03). In the final model utilizing both single-stage and 2-stage patient data, significant predictors of fistula were 2-stage repair (odds ratio [OR]: 2.5, P = .012), surgeon volume, and surgeon. When examining only single-stage patients, higher surgeon volume was protective against fistula. In the model examining 2-stage patients, surgeon and age at hard palate repair were significant; older age at hard palate closure was protective for fistula, with an OR of 0.82 (P = .046) for each additional 6 months in age at repair.

CONCLUSIONS

Two-stage surgery, surgeon, and surgeon volume were significant predictors of fistula occurrence in all children, and older age at hard palate repair was protective in those with 2-stage repair.

Increased Risk of Velopharyngeal Insufficiency in Patients Undergoing Staged Palate Repair

OBJECTIVE

To evaluate the association of 2-stage cleft palate (CP) surgery on velopharyngeal insufficiency (VPI) incidence, speech surgeries, and cleft-related surgical burden.

DESIGN

Retrospective cohort with follow-up of 4 to 19 years.

SETTING

Academic, tertiary children's hospital.

PATIENTS

Patients who underwent CP surgery between 2000 and 2017. Exclusions included submucous CP or age at last contact under 3.9.

INTERVENTIONS

Cleft palate surgery, completed in either a single-stage or 2-stage repair.

MAIN OUTCOME MEASURE(S)

Rates of VPI diagnosis and speech surgery and total cleft surgeries; t tests, tests of proportion, and linear and logistic regression were performed. Total cleft-related surgeries were examined in a subset (n = 418) of patients with chart reviews.

RESULTS

A total of 1047 patients were included; 59.6% had 2-stage CP repair, 40.4% had single-stage repair. Approximately 32% of children with 2-stage CP repair were diagnosed with VPI, as opposed to 22% of single-stage patients (P < .001). Children with 2-stage CP repair were 1.8 times as likely to be diagnosed with VPI (P < .001). Speech surgery rates were similar across groups. Patients who had 2-stage repair received an average of 2.3 more cleft-related procedures, when excluding prosthesis management procedures.

CONCLUSION

Our data show an increased risk of VPI diagnosis and increased surgical burden among patients receiving 2-stage CP repair.

Marked Variation Exists Among Surgeons and Hospitals in the Use of Secondary Cleft Lip Surgery

OBJECTIVE

To identify child-, surgeon-, and hospital-specific factors at the time of primary cleft lip repair that are associated with the use of secondary cleft lip surgery.

DESIGN

Retrospective cohort study.

SETTING

Forty-nine pediatric hospitals.

PARTICIPANTS

Children who underwent cleft lip repair between 1999 and 2015.

MAIN OUTCOME MEASURE

Time from primary cleft lip repair to secondary lip surgery.

RESULTS

By 5 years after primary lip repair, 24.0% of children had undergone a secondary lip surgery. In multivariable analysis, primary lip repair before 3 months had a 1.22-fold increased hazard of secondary surgery (95% confidence interval [CI]: 1.02-1.46) compared to repair at 7 to 12 months of age, and children with multiple congenital anomalies had a 0.77-fold decreased hazard of secondary surgery (95% CI: 0.68-0.87). After adjusting for cleft type, age at repair, presence of multiple congenital anomalies, and procedure volume, there remained substantial variation in secondary surgery use among surgeons and hospitals (P < .01). For children with unilateral cleft lip repaired at 3 to 6 months of age, the predicted proportion of children undergoing secondary surgery within 5 years of primary repair ranged from 4.9% to 21.8% across surgeons and from 4.5% to 24.7% across hospitals.

CONCLUSIONS

There are substantial differences among surgeons and hospitals in the rates of secondary lip surgery. Further work is needed to identify causes for this variation among providers.

On the Frequency of Oronasal Fistulation After Primary Cleft Palate Repair

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.