Predictors of Adverse Outcomes Following Cleft Palate Repair: An Analysis of Over 2500 Patients Using International Smile Train Data

OBJECTIVE

The objective of this study was to use data from Smile Train's global partner hospital network to identify patient characteristics that increase odds of fistula and postoperative speech outcomes.

DESIGN

Multi-institution, retrospective review of Smile Train Express database.

SETTING

1110 Smile Train partner hospitals.

PATIENTS/PARTICIPANTS

2560 patients.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURE(S)

Fistula occurrence, nasal emission, audible nasal emission with amplification (through a straw or tube) only, nasal rustle/turbulence, consistent nasal emission, consistent nasal emission due to velopharyngeal dysfunction, rating of resonance, rating of intelligibility, recommendation for further velopharyngeal dysfunction assessment, and follow-up velopharyngeal dysfunction surgery.

RESULTS

The patients were 46.6% female and 27.5% underweight by WHO standards. Average age at palatoplasty was 24.7 ± 0.5 months and at speech assessment was 6.8 ± 0.1 years. Underweight patients had higher incidence of hypernasality and decreased speech intelligibility. Palatoplasty when under 6 months or over 18 months of age had higher rates of affected nasality, intelligibility, and fistula formation. The same findings were seen in Central/South American and African patients, in addition to increased velopharyngeal dysfunction and fistula surgery compared to Asian patients. Palatoplasty technique primarily involved one-stage midline repair.

CONCLUSIONS

Age and nutrition status were significant predictors of speech outcomes and fistula occurrence following palatoplasty. Outcomes were also significantly impacted by location, demonstrating the need to cultivate longitudinal initiatives to reduce regional disparities. These results underscore the importance of Smile Train's continual expansion of accessible surgical intervention, nutritional support, and speech-language care.

Feeding Management and Palate Repair Timing in Infants with Cleft Palate with and without Pierre Robin Sequence: A Multisite Study

OBJECTIVES

Compare the feeding management practices in infants with cleft palate with and without Pierre Robin sequence (PRS) and determine if specific feeding difficulties or interventions predict delayed palate repair.

DESIGN

Retrospective cross-sectional study.

SETTING

Seventeen cleft palate teams contributed data.

PATIENTS

414 infants were included in this study: 268 infants with cleft palate only and 146 infants with cleft palate and PRS.

PROCEDURES

Data were collected via parent interview and electronic health records.

MAIN OUTCOME MEASURES

Outcomes for the primary objective included categorical data for: history of poor growth, feeding therapy, milk fortification, use of enteral feeding, and feeding difficulties. The outcome for the secondary objective was age in months at primary palate repair.

RESULTS

Infants with PRS had a significantly higher prevalence of feeding difficulties (81% versus 61%) and poor growth (29% versus 15%) compared to infants with cleft palate only. Infants with PRS received all feeding interventions-including feeding therapy, milk fortification, and enteral feeding-at a significantly higher frequency. Infants with PRS underwent primary palate repair at a mean age of 13.55 months (SD = 3.29) which was significantly (P < .00001) later than infants with cleft palate only who underwent palate repair at a mean age of 12.05 months (SD = 2.36). Predictors of delayed palate repair included diagnosis of PRS as well as Hispanic ethnicity and a history of poor growth.

CONCLUSIONS

These findings can be used to establish clinical directives focused on providing early, multimodal feeding interventions to promote optimal growth and timely palate repair for infants with PRS.

A systematic review of differences in outcome between one and two stage palate repair in cleft lip and palate

The aim of this systematic review was to determine whether one-stage palatoplasty for children born with cleft lip and palate shows overall advantages in outcome compared with two-stage palatoplasty. The included studies were controlled studies of syndromic and non-syndromic children born with unilateral cleft lip and palate, bilateral cleft lip and palate, or isolated cleft palate. The interventions studied were one-stage palatoplasty and two-stage palatoplasty starting with the soft palate. The outcomes were facial growth, speech, hearing, presence of fistulae, other complications related to surgery, health-related quality of life, and health economics. In total, 14 original studies were included. Results were dichotomized into showing advantage for one- or two-stage palatoplasty for the respective outcome and compared with the results from six included systematic reviews. No overall advantage for either surgical strategy was found for any of the outcome measures. The certainty of evidence was highest for the presence of fistulae, followed by facial growth and speech. For several outcomes, the quality of the existing evidence was too low to allow for any conclusions to be drawn. Neither one- nor two-stage palatoplasty showed significant advantages in clinical outcomes compared with the other. Other aspects such as ethics, economics, or surgeon's preference might hence be of more importance. Homogenous choices of outcome measures and defined minimal clinically important differences would facilitate further research.

Velopharyngeal Insufficiency Following Furlow Versus Straight Line Repair With Intravelar Veloplasty: A Single-institution Experience

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 χ2 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.

The Life Cycle of Orofacial Cleft Operations

Patients with cleft lip and palate must undergo various surgical interventions at appropriate times to achieve optimal outcomes. While guidelines for the timing of these operations are well known, it has not yet been described if national surgical practice reflects these recommendations. This study evaluates whether orofacial operations are performed in time frames that align with advised timing. Time-to-event analyses were performed using the 2012-2020 Pediatric National Surgical Quality Improvement Program database on the ages at time of orofacial operations. Outliers with an absolute Z-score of 3.29 or greater were excluded. Cleft lip (N=9374) and palate (N=13,735) repairs occurred earliest at mean ages of 200.99±251.12 and 655.08±694.43 days, respectively. Both operations clustered along the later end of recommended timing. 69.0% of lip versus 65.1% of palate repairs were completed within the advised age periods. Cleft lip (N=2850) and palate (N=1641) revisions occurred at a mean age of 7.73±5.02 and 7.00±4.63 years, respectively. Velopharyngeal insufficiency operations (N=3026), not including palate revision, were performed at a delayed mean age of 7.58±3.98 years, with only 27.7% of operations occurring within the recommended time frame. Finally, 75.8% of alveolar bone grafting cases (N=5481) were found to happen within the advised time period, with a mean age of 10.23±2.63 years. This study suggests that, with the exception of VPI procedures, orofacial operations reliably cluster near their recommended age periods. Nevertheless, primary lip repair, palatoplasty, and velopharyngeal insufficiency procedures had a mean age that was delayed based on advised timing.

Advances in Cleft Lip and Palate Surgery

Cleft lip with or without cleft palate is one of the most common congenital malformations, with an average prevalence of 1 in 1000 live births. Cleft lip and/or palate is incredibly phenotypically diverse, with constant advancements and refinements in how we care for patients. This article presents an in-depth review of the latest advances and current evidence in cleft lip and palate surgery. This includes presurgical infant orthopedics, perioperative practice patterns including use of enhanced recovery after surgery (ERAS) protocols, patient-reported outcome measures, and the latest adjuncts in cheiloplasty and palatoplasty.

Associations Between Medicaid Expansion and Timely Repair of Cleft Lip and Palate

The expansion of Medicaid under the Affordable Care Act (ACA) increased access to health care for many low-income children. However, the impact of this expansion on the timing of primary cleft lip and palate repair remains unclear. This study aimed to evaluate whether Medicaid expansion improved access to timely cleft lip and palate repair and whether it reduced preexisting ethnoracial disparities. Using a quasi-experimental design, the study analyzed data from 44 pediatric surgical centers across the United States. The results showed that Medicaid expansion was associated with a 9.0 percentage-point increase in delayed cleft lip repairs, resulting in an average delay of 16 days. Non-White patients were disproportionately affected by this delay, experiencing a 14.8 percentage-point increase compared with a 4.9 percentage-point increase for White patients. In contrast, Medicaid expansion had no significant effect on the timing of palate repair or on ethnoracial disparities in palate repair. The study underscores the importance of monitoring unintended consequences of large-scale health system changes, especially those affecting disadvantaged populations. Delayed cleft lip repair can lead to worse outcomes for patients, and the disproportionate impact on non-White patients is concerning. Further research is needed to identify the reasons for this delay and to mitigate its effects. Overall, the study highlights the need for ongoing vigilance to ensure that health care policies and interventions do not inadvertently worsen health disparities.

Timing of Primary Surgery for Cleft Palate

BACKGROUND

Among infants with isolated cleft palate, whether primary surgery at 6 months of age is more beneficial than surgery at 12 months of age with respect to speech outcomes, hearing outcomes, dentofacial development, and safety is unknown.

METHODS

We randomly assigned infants with nonsyndromic isolated cleft palate, in a 1:1 ratio, to undergo standardized primary surgery at 6 months of age (6-month group) or at 12 months of age (12-month group) for closure of the cleft. Standardized assessments of quality-checked video and audio recordings at 1, 3, and 5 years of age were performed independently by speech and language therapists who were unaware of the trial-group assignments. The primary outcome was velopharyngeal insufficiency at 5 years of age, defined as a velopharyngeal composite summary score of at least 4 (scores range from 0 to 6, with higher scores indicating greater severity). Secondary outcomes included speech development, postoperative complications, hearing sensitivity, dentofacial development, and growth.

RESULTS

We randomly assigned 558 infants at 23 centers across Europe and South America to undergo surgery at 6 months of age (281 infants) or at 12 months of age (277 infants). Speech recordings from 235 infants (83.6%) in the 6-month group and 226 (81.6%) in the 12-month group were analyzable. Insufficient velopharyngeal function at 5 years of age was observed in 21 of 235 infants (8.9%) in the 6-month group as compared with 34 of 226 (15.0%) in the 12-month group (risk ratio, 0.59; 95% confidence interval, 0.36 to 0.99; P = 0.04). Postoperative complications were infrequent and similar in the 6-month and 12-month groups. Four serious adverse events were reported (three in the 6-month group and one in the 12-month group) and had resolved at follow-up.

CONCLUSIONS

Medically fit infants who underwent primary surgery for isolated cleft palate in adequately resourced settings at 6 months of age were less likely to have velopharyngeal insufficiency at the age of 5 years than those who had surgery at 12 months of age. (Funded by the National Institute of Dental and Craniofacial Research; TOPS ClinicalTrials.gov number, NCT00993551.).

Outcomes of Tympanoplasty After Cleft Palate Repair: A Systematic Review and Meta-analysis

OBJECTIVE

To analyze graft success rates and hearing outcomes in patients with a history of cleft palate (CP) repair undergoing tympanoplasty.

DATA SOURCES

PubMed, Scopus, and CINAHL.

REVIEW METHODS

Per PRISMA guidelines, the databases were searched from date of inception through December 14, 2021. Studies of patients with previous CP repair who underwent tympanoplasty were included. Meta-analysis of proportions, continuous measures, odds ratios (ORs), and meta-regression were used to analyze graft success and hearing outcomes after tympanoplasty.

RESULTS

A total of 323 patients with CP repair and 1169 controls were included. The proportion of graft success was 86.7% (95% CI, 76.1%-94.5%) in patients with CP repair and 88.8% (95% CI, 76.9-96.8) in controls. There was no difference in odds of graft success between patients with CP repair and controls (OR, 1.0 [95% CI, 0.5-1.8]; P = .870). Age was not a significant moderator of graft success in patients with CP repair (r = 0.1 [95% CI, -0.2 to 0.3]; P = .689) or controls (r = -0.0 [95% CI, -0.1 to 0.1]; P = .952). Comparing mean differences between pre- and postoperative air-bone gap was not statistically significant in patients with CP repair and controls (0.2 dB [95% CI, -3.1 to 3.4]; P = .930). Odds of functional success (postoperative air-bone gap <20 dB) were not different between the groups (OR, 0.8 [95% CI, 0.5-1.4]; P = .450).

CONCLUSION

This meta-analysis does not endorse anatomic or functional differences between patients with CP repair and controls after tympanoplasty. However, there is a paucity of evidence for younger children. Further studies are warranted to elucidate specific risk factors for tympanoplasty outcomes in young patients with previous CP repair.

Number and timing of primary cleft lip and palate repair surgeries in England: whole nation study of electronic health records before and during the COVID-19 pandemic

OBJECTIVE

To quantify differences in number and timing of first primary cleft lip and palate (CLP) repair procedures during the first year of the COVID-19 pandemic (1 April 2020 to 31 March 2021; 2020/2021) compared with the preceding year (1 April 2019 to 31 March 2020; 2019/2021).

DESIGN

National observational study of administrative hospital data.

SETTING

National Health Service hospitals in England.

STUDY POPULATION

Children <5 years undergoing primary repair for an orofacial cleft Population Consensus and Surveys Classification of Interventions and Procedures-fourth revisions (OPCS-4) codes F031, F291).

MAIN EXPOSURE

Procedure date (2020/2021 vs 2019/2020).

MAIN OUTCOMES

Numbers and timing (age in months) of first primary CLP procedures.

RESULTS

1716 CLP primary repair procedures were included in the analysis. In 2020/2021, 774 CLP procedures were carried out compared with 942 in 2019/2020, a reduction of 17.8% (95% CI 9.5% to 25.4%). The reduction varied over time in 2020/2021, with no surgeries at all during the first 2 months (April and May 2020). Compared with 2019/2020, first primary lip repair procedures performed in 2020/2021 were delayed by 1.6 months on average (95% CI 0.9 to 2.2 months). Delays in primary palate repairs were smaller on average but varied across the nine geographical regions.

CONCLUSION

There were significant reductions in the number and delays in timing of first primary CLP repair procedures in England during the first year of the pandemic, which may affect long-term outcomes.

Sommerlad-Furlow modified palatoplasty: A retrospective study

The purpose of this study was to introduce the surgical process of Sommerlad-Furlow modified (S-F) palatoplasty and compare its surgical and functional outcomes with conventional Sommerlad (S) palatoplasty. Patients with non-syndromic cleft palate who had undergone either S-F palatoplasty or S palatoplasty were retrospectively reviewed. Data on the outcomes of velopharyngeal function and postsurgical palatal fistula incidence were collected for all patients. Data for preselected factors, including gender, age at palatoplasty, and cleft type, were also collected. Chi-square tests were conducted. 1254 patients were included. The postsurgical velopharyngeal competence (VPC) rate after S-F palatoplasty was significantly higher than after S palatoplasty (total, 70.5% vs 57.9%, p < 0.0001; age ≤ 1, 87.0% vs 69.2%, p < 0.0001; 1 < age ≤ 2, 78.3% vs 69.3%, p = 0.0479). With regard to different types of cleft palate, the postsurgical VPC rates after S-F palatoplasty were all significantly higher than for S palatoplasty in all patients younger than 2 years of age (complete cleft palate, 78.7% vs 62.4%, p = 0.0016; hard and soft palate cleft, 84.4% vs 74.8%, p = 0.0172; submucosal cleft and soft palate cleft, 96.6% vs 68.4%, p = 0.0114). The postoperative fistula rate after S-F palatoplasty was 4.3%. This modified palatoplasty technique provided adequate cleft palate closure, with satisfactory speech outcomes and low fistula rates, while older age at palatoplasty may affect the postsurgical outcomes. Within the limitations of the study it seems that the Sommerlad-Furlow modified technique is an option for cleft palate repair.

Racial and Ethnic Disparities in Primary Cleft Lip and Cleft Palate Repair

OBJECTIVE

To examine the impact of race/ethnicity on timing and postoperative outcomes of primary cleft lip (CL) and cleft palate (CP) repair.

DESIGN

Cross-sectional analysis of the National Surgical Quality Improvement Program Pediatric (NSQIP-P) database from 2013 to 2018.

PATIENTS AND MAIN OUTCOME MEASURES

Patients under 2 years of age who underwent primary CL or CP repair were identified in the NSQIP-P. Outcomes were the timing of surgery and 30-day readmission and reoperation rates stratified by race and ethnicity.

RESULTS

In total, 6021 children underwent CL and 6938 underwent CP repair. Adjusted rates of CL repair over time were 10% lower in Hispanic children (95%CI: 0.84-0.96) and 38% lower for Asian children (95%CI: 0.55-0.70) compared with White infants. CP repair rates over time were 13% lower in Black (95%CI: 0.79-0.95), 17% lower in Hispanic (95%CI: 0.77-0.89), and 53% lower in Asian children (95%CI: 0.43-0.53) than in White infants. Asian patients had the highest rates of delayed surgical repair, with 19.3% not meeting American Cleft Palate-Craniofacial Association (ACPA) guidelines for CL (P < .001) and 28.2% for CP repair (P< .001). Black and Hispanic children had 80% higher odds of readmission following primary CL repair (95%CI: 1.16-2.83 and 95%CI: 1.27-2.61, respectively).

CONCLUSIONS

This study of a national database identified several racial/ethnic disparities in primary CL and CP, with reduced receipt of cleft repair over time for non-White children. Asian patients were significantly more likely to have delayed cleft repair per ACPA guidelines. These findings underscore the need to better understand disparities in cleft repair timing and postoperative outcomes.

Cleft Palate Repair in Robin Sequence following Mandibular Distraction Osteogenesis Compared to Tongue-Lip Adhesion

OBJECTIVE

To evaluate the timing and safety of cleft palate (CP) repair in patients with Robin sequence (RS) treated with mandibular distraction osteogenesis (MDO) or tongue-lip adhesion (TLA) for airway obstruction.

DESIGN

Retrospective cohort study.

SETTING

Tertiary Pediatric Hospital during 2004-2020.

PATIENTS

148 patients with RS underwent MDO, 66 met inclusion by having MDO and followed by palatoplasty. 26 patients with RS underwent TLA, 14 met inclusion by having TLA and followed by palatoplasty.

MAIN OUTCOME MEASURES

Patient characteristics, hospital/operative details, postoperative complications, and polysomnographic (PSG) data were compared.

RESULTS

Groups were well-matched except more patients with syndromes underwent MDO (N = 27, 41%, P ≤ .002). In the MDO and TLA cohorts, mean CP repair age was 12.8 ± 1.9 months and 14.6 ± 1.6 months, respectively (P ≤ .002). Despite the earlier CP repair in the MDO group, there were no differences in peri-operative complication rates after palatoplasty in either group. All sleep respiratory parameters improved after MDO/TLA prior to palatoplasty P ≤ .050. All PSG parameters remained significantly improved after palatoplasty compared to preoperative values, P ≤ .043. Obstructive apnea hypopnea index and Oxygen saturation nadir further improved after palatoplasty within the MDO group, P ≤ .050, while no changes in the TLA group, P ≥ .500.

CONCLUSIONS

MDO was associated with earlier age at palatoplasty than TLA with a similar perioperative risk profile. In those patients with pre- and post-palatoplasty PSG data, palatoplasty was not associated with a deterioration in PSG parameters, and in fact in the MDO group, PSG data improved.

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.

Speech Outcomes following Mandibular Distraction Osteogenesis for Robin Sequence: Midchildhood Results

BACKGROUND

The aim of this study was to compare midchildhood speech outcomes in patients with nonsyndromic Robin sequence with cleft palate (RSCP) treated with mandibular distraction osteogenesis (MDO) to patients with nonsyndromic Veau class I and Veau class II cleft palate (CP).

METHODS

The authors performed a retrospective review of patients with nonsyndromic Robin sequence from 2000 to 2017, comparing those who underwent MDO to patients with nonsyndromic CP. Demographics, operative details, length of hospital stay, complications, and Pittsburgh Weighted Speech Scale scores were collected.

RESULTS

Thirty-three patients met inclusion criteria in the MDO group with 127 patients as controls. Despite similar median age (RSCP, 4.5 years; CP only, 4.6 years) and Veau cleft type at early evaluation, there was a significant increase in composite Pittsburgh Weighted Speech Scale score within the MDO cohort ( P ≤ 0.002); specifically, with worse visible nasal emission ( P ≤ 0.007), hypernasality ( P ≤ 0.001), and compensatory articulation ( P ≤ 0.015). However, these differences were not present at age-matched midchildhood evaluation (median, RSCP, 6.5; CP only, 7.1; P ≥ 0.092). Median age-matched follow-up was 6.4 years in the MDO group and 7.1 years in the control group ( P ≥ 0.136). There was also no difference in the rate of secondary speech surgery at midchildhood evaluation ( P ≥ 0.688).

CONCLUSIONS

The authors' retrospective comparison of speech outcomes in RSCP versus CP only demonstrates no difference in midchildhood speech, conflicting with recent reports. Although patients with Robin sequence treated with MDO had worse visible nasal emission, hypernasality, and compensatory articulation in early childhood, this appears to have resolved in the interim without additional intervention. Longitudinal follow-up is needed to fully understand the speech ramifications of RSCP.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Cleft Palate Repair: A History of Techniques and Variations

Orofacial clefting is a common reconstructive surgical condition that often involves the palate. Cleft palate repair has evolved over three centuries from merely achieving anatomical closure to prioritizing speech development and avoiding midface hypoplasia. Despite centuries of advancements, there is still substantial controversy and variable consensus on technique, timing, and sequence of cleft palate repair procedures. Furthermore, evaluating the success of various techniques is hindered by a lack of universal outcome metrics and difficulty maintaining long-term follow-up. This article presents the current controversies of cleft palate repair and details how the history of cleft palate repair has influenced current techniques commonly used worldwide. Our review highlights the need for a global consortium on cleft care to gather expert opinions on current practices and outcomes and to standardize technique classifications. An understanding of global protocols is crucial in an attempt to standardize technique and timing to achieve anatomical closure with optimal velopharyngeal competence, while also minimizing the occurrence of maxillary hypoplasia and palatal fistulae.

Primary palatoplasty: A comparison of results by various techniques - A retrospective study

Introduction:

To identify a better method for primary cleft palate (CP) repairs with respect to velopharyngeal function.

Materials and Methods:

A retrospective, longitudinal review of medical charts of patients with congenital CP who underwent four different techniques of palatoplasty, performed by three different surgeons in the Department of Maxillofacial Surgery of the National Center for Maternal and Child Health. Nasopharyngoscopy (NPS) was used for velopharyngeal function evaluation. CP was classified according to the Veau system and the “Golding-Kushner” scale for NPS results was used for assessing the patient’s velopharyngeal function and its association with cleft types and the primary palatoplasty techniques. Pearson’s Chi-square analysis and binary logistic regression were used for statistical analysis.

Results:

A total of 335 patients were included in the study. The mean age at primary palate repair was 22.9 ± 13.6 months. There were 56, 42, 177, and 60 patients with Veau-I, Veau-II, Veau-III, and Veau-IV types, respectively, whereas for primary palatoplasty 65 patients underwent Furlow, 148 patients – Mongolian, 108 patients – two flap, 34 patients – von Langenbeck technique. NPS assessment of adequate velopharyngeal function was followed by Furlow’s technique in 89.4% of cases, Mongolian technique in 62.2% of cases but by “two flap” only in 48.1% and von Langenbeck in 47.1% of cases.

Discussion:

The Furlow and Mongolian techniques were superior for maintaining velopharyngeal function after primary palatoplasty.

Predictors of Success After Furlow Palatoplasty for Repair of Cleft Palate: Does Syndrome Matter?

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.

Correlation between surgical protocols for palatoplasty and midfacial growth in cleft lip and palate patients: A long-term, single centre study

To evaluate and compare the outcomes of two different surgical protocols for palatoplasty for midfacial growth in patients with cleft lip and palate. A retrospective observational cohort study was conducted in 80 patients with cleft lip and palate, who were divided into two groups. Group 1 comprised patients who underwent operation between 9 and 11 months of age using the Bardach two-flap technique without a palatal pushback. Group 2 comprised patients who had undergone operation between 18 and 20 months of age using either a Bardach two-flap technique with a palatal pushback or a von Langenbeck technique. Patient follow-up was done between 8 and 9 years of age when they reported to the centre for secondary alveolar bone grafting. Post-surgical cephalometric measurements were taken for midfacial growth analysis. Group 1 underwent palatoplasty at significantly younger ages than Group 2 (p < 0.01). A statistically significant difference(p < 0.01) was found between the two groups of patients on comparison of cephalometric parameters such as SNA, ANB, CoA, NperpA ANS-PNS, N-ANS, N-Me, Witt's (AO-BO). Group 2 had more positive cephalometric values as compared to Group 1, thereby implying that there was less incidence of midfacial hypoplasia in patients treated at the age of 18-20 months. Between the types of palatoplasty techniques within Group 2, i.e., Bardach two-flap and von Langenbeck, there was no statistical difference found in the post-opertative cephalometric values, i.e., SNA, ANB, CoA, ANS-PNS, N-ANS, N-Me, Witt's (AO-BO) except for Nperp-A, which showed a statistical difference (p = 0.03). Within the limitations of the study which is only a single center experience it seems that palatal closure should be carried out at 18-20 months of age for better midfacial growth, leading to decreased incidence of maxillary hypoplasia at a later stage in life. Repair at less than 18 months of age is also associated with mid-facial hypoplasia.

A Closer Look at Delayed Primary Cleft Surgery and Unrepaired Cleft Lip and/or Palate in 5 UK Cleft Centers

BACKGROUND

There may be many reasons for delays to primary cleft surgery. Our aim was to investigate the age of children undergoing primary cleft lip or primary cleft palate repair in 5 cleft centers within the United Kingdom. Identify the reasons for delayed primary cleft lip repair (beyond 6 months) and delayed primary palate repair (beyond 13 months). Identify children who had a cleft lip and/or palate (CL±P) that was intentionally unrepaired and the reasons for this.

METHODS

A retrospective, multicenter review of patients born with a CL±P between December 1, 2012, and December 31, 2016. Three regional cleft centers, comprising of 5 cleft administrative units in the United Kingdom participated.

RESULTS

In all, 1826 patients with CL±P were identified. Of them, 120 patients had delayed lip repair, outside the expected standard of 183 days. And, 178 patients in total had delayed palate repair, outside the expected standard of 396 days. Twenty (1%) patients had an unrepaired cleft palate.

CONCLUSIONS

This large retrospective review highlights variations between centers regarding the timing of lip and palate surgery and details the reasons stated for delayed primary surgery. A small number of patients with an unrepaired cleft palate were identified. All had complex medical problems or comorbidities listed as a reason for the decision not to operate and 50% had a syndromic diagnosis. The number of patients receiving delayed surgery due to comorbidities, being underweight or prematurity, highlights the importance of the cleft specialist nurse and pediatrician within the cleft multidisciplinary team.

Readability of Online Patient Information Relating to Cleft Palate Surgery

OBJECTIVE

It is important for health care education materials to be easily understood by caretakers of children requiring craniofacial surgery. This study aimed to analyze the readability of Google search results as they pertain to "Cleft Palate Surgery" and "Palatoplasty." Additionally, the study included a search from several locations globally to identify possible geographic differences.

DESIGN

Google searches of the terms "Cleft Palate Surgery" and "Palatoplasty" were performed. Additionally, searches of only "Cleft Palate Surgery" were run from several internet protocol addresses globally.

MAIN OUTCOME MEASURES

Flesch-Kincaid Grade Level and Readability Ease, Gunning Fog Index, Simple Measure of Gobbledygook (SMOG) index, and Coleman-Liau Index.

RESULTS

Search results for "Cleft Palate Surgery" were easier to read and comprehend compared to search results for "Palatoplasty." Mean Flesch-Kincaid Grade Level scores were 7.0 and 10.11, respectively (P = .0018). Mean Flesch-Kincaid Reading Ease scores were 61.29 and 40.71, respectively (P = .0003). Mean Gunning Fog Index scores were 8.370 and 10.34, respectively (P = .0458). Mean SMOG Index scores were 6.84 and 8.47, respectively (P = .0260). Mean Coleman-Liau Index scores were 12.95 and 15.33, respectively (P = .0281). No significant differences were found in any of the readability measures based on global location.

CONCLUSIONS

Although some improvement can be made, craniofacial surgeons can be confident in the online information pertaining to cleft palate repair, regardless of where the search is performed from. The average readability of the top search results for "Cleft Palate Surgery" is around the seventh-grade reading level (US educational system) and compares favorably to other health care readability analyses.

Speech and Audiology Outcomes After Single-Stage Versus Early 2-Stage Cleft Palate Repair

PURPOSE

The timing and management of patients with cleft palates have been controversial. Early soft palate closure at the time of cleft lip repair followed by hard palate closure at a second stage has been hypothesized to improve speech and audiology outcomes. This study compares cleft palate patients who have undergone single-stage versus 2-stage cleft palate repairs and the outcomes on speech and hearing.

METHODS

A retrospective chart review identified patients with diagnosis of cleft lip with complete cleft palate who underwent either single or 2-stage repair from 2006 to 2012. Data collected included age at each surgery, necessity of further speech surgery for velopharyngeal insufficiency, frequency of tympanostomy tube placement, presence of hearing loss, and speech assessment data graded per the validated Americleft speech scale.

RESULTS

A total of 84 patients were identified and subdivided into groups of single-stage and 2-stage repair. The mean age at the time of single-stage palate repair was 13.3 months. For the 2-stage group, the mean ages were 4.2 and 11.8 months for the soft palate and hard palate repairs, respectively. Comparing the single-stage versus 2-stage palate repairs, there was no significant difference in all speech parameters including hypernasality, hyponasality, nasal air emission, articulation, expressive language, receptive language, speech intelligibility, and speech acceptability for both unilateral and bilateral cleft lip/palate patients. Two-stage repair was associated with increased number of tympanostomy tube placement compared with single-stage repair (relative risk, 1.74; P = 0.009), and the first set of tubes was performed at a statistically significantly younger age, 4.5 months in the 2-stage repair compared with 16.9 months in the single-stage (P = 0.012) with 87.5% performed with first stage of repair. However, there was no difference in the types, degrees of hearing loss, or the presence of at least mild conductive hearing loss at latest follow-up audiograms between the groups.

CONCLUSIONS

There was no significant benefit with respect to speech or hearing outcomes between single-stage and 2-stage cleft palate repairs. This advocates for surgeon and family preference in the timing of cleft palate repair.

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.

Optimizing speech outcomes for cleft palate

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.