The Rate of Oronasal Fistula Following Primary Cleft Palate Surgery: A Meta-Analysis

Utilization of a Decellularized Skin Scaffold for Repair of a Cleft Palate in a Dog: A Case Report

Cleft palates are oral deformities that mostly affect puppies. They are frequently extensive and characterized by bone and palatal mucosa malformation. This deformity is a serious condition that may result in the death of the dog, therefore surgical treatment is recommended. Tissue bioengineering has emerged as a valuable option to treat cleft palates by applying acellular biological scaffolds as grafts. This case report proposed a new approach for surgical correction of canine cleft palate through a grafting technique using a decellularized scaffold. A decellularized portion of skin was implanted to correct a large cleft palate in a 3-month-old female Pug dog. The skin fragment was obtained from a dog cadaver and a decellularization protocol was performed. Under general anesthesia, a bilateral mucoperiosteal separation of the entire length of cleft margins was performed, and the scaffold was then positioned between the tissue and the bone palate. The interaction of the grafted scaffold with the oral mucosa and palatine layers resulted in total cleft closure, without postsurgical rejection or infection, indicating the applicability of this technique in dog's cleft palate correction. This is the first reported case demonstrating this new technique, which resulted in full cleft closure and healing.

Early Cleft Palate Repair by a Modified Technique Without Relaxing Incisions

OBJECTIVE

This study sought to evaluate a modified palatoplasty technique (MPT) concerning the postoperative outcomes and associated influencing factors.

DESIGN

A retrospective cohort study.

PARTICIPANTS AND SETTING

One hundred forty-three consecutive patients with non-syndromic cleft palate, who received MPT before one year of age within an oral and maxillofacial surgery department of a university-affiliated tertiary hospital between 2011-2017, were reviewed.

MAIN MEASURES

The postoperative wound healing and velopharyngeal function (VPF) were the primary outcome measures. The sex, age at surgery, cleft type, cleft width, palatal width, soft palate length, pharyngeal cavity depth, and operation duration were preselected as influencing factors. Univariate and multivariate analyses were conducted.

RESULTS

The mean age at surgery was 9 ± 1.31 months (5-11), and the average cleft width was 9.03 ± 2.41 mm (4-15). The rate of incomplete cleft palate was 84.6% while the complete cleft palate was 15.4%. Complete wound healing was reported in 96.5% while the others (3.5%) had persistent oronasal fistula. About 90.2% of cases have shown normal velopharyngeal function whereas the others (9.8%) had sustained velopharyngeal insufficiency. The wound healing appeared to be significantly impacted by cleft width and pharyngeal cavity depth (P = .015 and 0.049, respectively). However, none of the factors had a significant association with VPF.

CONCLUSIONS

The present modified palatoplasty technique has obtained a low fistula rate and appropriate speech outcome. Therefore, this MPT could be promoted for early repairing cleft palate of different severities.

Two-stage palatal repair in non-syndromic CLP patients using anterior to posterior closure is associated with minimal need for secondary palatal surgery

OBJECTIVE

The aim of the present study was to assess the need for secondary palatal corrective surgery in a concept of palate repair that uses a protocol of anterior to posterior closure of primary palate, hard palate and soft palate.

METHODS

A data base of patients primarily operated between 2001 and 2021 at the Craniofacial and Cleft Care Center of the University Goettingen was evaluated. Cleft lips had been repaired using Tennison Randall and Veau-Cronin procedures in conjunction with alveolar cleft repair. Cleft palate repair in CLP patients was accomplished in two steps with repair of primary palate and hard palate first using vomer flaps at the age of 10-12 months and subsequent soft palate closure using Veau/two-flap procedures 3 months later. Isolated cleft palate repair was performed in a one-stage operation using Veau/two-flap procedures. Data on age, sex, type of cleft, date and type of surgery, occurrence and location of oronasal fistulae, date and type of secondary surgery performed for correction of oronasal fistula (ONF)and / or Velophyaryngeal Insufficiency (VPI) were extracted. The rate of skeletal corrective surgery was registered as a proxy for surgery induced facial growth disturbance.

RESULTS

In the 195 patients with non-syndromic complete CLP evaluated, a total number of 446 operations had been performed for repair of alveolar cleft and cleft palate repair (Veau I through IV). In 1 patient (0,5%), an ONF occurred requiring secondary repair. Moreover, secondary surgery for correction of VPI was required in 1 patient (0,5%) resulting in an overall rate of 1% of secondary palatal surgery. Skeletal corrective surgery was indicated in 6 patients (19,3%) with complete CLP in the age group of 15 - 22 years (n = 31).

CONCLUSIONS

The presented data have shown that two-step sequential cleft palate closure of primary palate and hard palate first followed by soft palate closure has been associated with minimal rate of secondary corrective surgery for ONF and VPI at a relatively low need for surgical skeletal correction.

Unraveling a Major Burden of Orofacial Clefts Analyses: Classification of Cleft Palate Fistulas by Cleft Surgeons

OBJECTIVE

The objective of this study was to investigate how cleft surgeons classify palatal fistulas. We focused on three different anatomical locations (ie, hard palate, soft palate, junction hard/soft palate) to analyze agreement/disagreement at various anatomical locations.

DESIGN

Cross-sectional survey study.

PARTICIPANTS

Participants in an international webinar that focused on palatal fistula treatment were included.

INTERVENTION

Participants were presented with a survey pre- and post-webinar.

MAIN OUTCOMES

Frequency of used classification systems for classifying oronasal fistulas and the inter-rater reliability of the Pittsburgh classification system.

RESULTS

A total of 141 participants completed the questionnaires prior to the webinar and 109 participants completed the survey after the webinar. In total, four classification systems were used (ie, Pittsburgh, Pakistan Comprehensive Fistula Classification [PCFC], anatomical and 'other'). The Pittsburgh classification was the most commonly used system in all cases. However, Pittsburgh inter-rater reliability was low (κ = 0.136 pre-webinar, and κ = 0.174 post-webinar). Surprisingly, a substantial shift was observed from the anatomical to Pittsburgh classification after the webinar, indicating increased awareness of the usability of the Pittsburgh classification system.

CONCLUSIONS

This study demonstrates a large heterogeneity with regards to the classification of cleft palate fistulas. Interestingly, a shift was observed from the anatomical to Pittsburgh classification after the webinar. However, the inter-rater reliability for using the Pittsburgh classification was low. Classifying palatal fistulas in a homogenous fashion could enhance comparison of primary palate repair and could improve treatment of palatal fistulas.

Evaluation of postoperative outcomes in palatoplasty with three soft palate cleft repairs

The aim of this study was to compare the postoperative clinical and functional outcomes of palatoplasty with three soft palate cleft repairs and analyse the factors potentially impacting these outcomes. A retrospective analysis was conducted on a consecutive series of 337 patients who underwent primary cleft palate repair by palatoplasty modified with either Furlow Z-plasty (P-FZP, n = 77), intravelar veloplasty (P-IVV, n = 110), or combined intravelar veloplasty-Furlow Z-plasty (P-IVV-FZP, n = 150). The postoperative outcomes evaluated included wound healing (complete closure/fistula) and velopharyngeal function. Demographic and surgical data were analysed using both univariate and multivariate analysis. There was no significant difference between the groups with regard to the sex distribution, age at repair, cleft width, cleft type, or follow-up duration. However, relaxing incisions were significantly more common with P-FZP (26.0%) and P-IVV (29.1%) compared to P-IVV-FZP (10%) (P = 0.002 and <0.001, respectively). The complete wound closure rate was significantly higher with P-IVV-FZP (97.3%) compared to P-FZP (88.3%) (P = 0.012) and P-IVV (90%) (P = 0.015). The normal velopharyngeal function rate was comparable for P-IVV-FZP (86.7%) and P-FZP (83.1%), and both rates were significantly better than the rate with P-IVV (73.6%) (P = 0.039 and 0.029, respectively). The cleft type and width were identified as factors influencing postoperative outcomes. In conclusion, it may be appropriate to prioritize the palatoplasty with combined intravelar veloplasty-Furlow Z-plasty whenever feasible.

Revision Palate Surgery

Oronasal fistulae and velopharyngeal insufficiency are common and interdependent complications after cleft palate surgery. Bone grafting can complement cleft habilitation. Early identification and intervention are vital for optimal outcomes. Collaboration with experienced healthcare professionals is crucial to develop a comprehensive treatment plan which considers speech therapy, prosthetic devices, and surgery. This article aims to review the current literature on the management of VPI and oronasal fistulae following cleft palate surgery and additionally highlight the role of alveolar bone grafting to improve outcomes for these patients.

Evidence-Based Practices in Cleft Palate Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications.

SUMMARY

Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft palate; surgical techniques for palatoplasty and perioperative patient management; and complications of palatoplasty.

Anatomical Study of Domain Rescue of Palatal Length in Patients With a Wide Cleft Palate: Buccal Flap Reconstruction in Primary Palatoplasty

BACKGROUND

This study characterizes the potential loss of velar length in patients with a wide cleft and rescue of this loss of domain by local flap reconstruction, providing anatomic evidence in support of primary lengthening of the soft palate during palatoplasty.

METHODS

A retrospective review was conducted of all patients with a cleft palate at least 10mm in width, who underwent primary palatoplasty with a buccal flap prior to 18 months of age over a 2-year period. All patients underwent primary palatoplasty with horizontal transection of the nasal mucosa, which was performed after nasal mucosa repair, but prior to muscular reconstruction. The resulting palatal lengthening was measured and the mucosal defect was reconstructed with a buccal flap.

RESULTS

Of the 22 patients included, 3 (13.6%) had a history of Pierre Robin sequence, and 5 (22.7%) had an associated syndrome. No patients had a Veau I cleft, 7 (31.8%) had a Veau II, 12 (54.5%) had a Veau III, and 3 had (13.6%) a Veau IV cleft. All patients had a right buccal flap during primary palatoplasty. The mean cleft width at the posterior nasal spine was 10.6  ±  2.82mm, and mean lengthening of the velum after horizontal transection of the nasal mucosa closure was 10.5  ±  2.23mm. There were 2 (9.1%) fistulas, 1 (4.5%) wound dehiscence, 1 (4.5%) 30-day readmission, and no bleeding complications.

CONCLUSIONS

Patients with a wide cleft palate have a potential loss of 1cm velar length. The buccal flap can rescue the loss of domain in palatal length, and potentially improve palatal excursion.

Comparison of Furlow's Double Opposing Z-plasty and Straight-Line Intravelar Veloplasty as Methods of Cleft Palate Repair

Background One of the common craniofacial abnormalities is cleft lip and palate. Various surgical procedures have been employed to repair the cleft. However, immediate post-operative complications and formation of palatal fistula post surgery are common in surgical procedures. The study aims to compare the fistula rate, soft palate lengthening, and immediate complications of cleft palate repair of Furlow's Z-plasty and straight-line intravelar veloplasty techniques. Method Fifty Patients with isolated or unilateral cleft palate and lip with age between 9-18 months were randomly divided into two groups. One group underwent Furlow's Z-plasty while the other underwent straight-line intravelar veloplasty procedures. Post surgery, after discharge, the patients were followed up at 2 weeks, 1 month, and 3 months intervals. Immediate post-operative complications and fistula formation rate were compared along with other parameters like fistula width, duration of the procedure, intra-operative soft palate length, etc. Results Straight-line procedures took less time as compared to Furlow's Z-plasty. Bleeding (N=2, 8%) and dehiscence (N=1, 4%) of the wound were the immediate post-operative complications found in the straight-line group. Bleeding was also present in the Furlow's group (N=1, 4%). At 1-month follow-up, in the straight-line group (N=3, 12%) patients had fistula while (N=2, 8%) had minimal nasal regurgitation of liquids when compared to the Furlow's group. At 3-month follow-up, patients in the straight-line procedure group (three out of N=25, 12%) exhibited fistula, whereas in the Furlow's group, fistula occurrence was observed in one out of N=25 participants (4%). Intra-operative soft palate lengthening was 6.44 ± 0.768 mm and 1.64 ± 0.952 mm in the Furlow and straight-line groups, respectively. Conclusion Furlow's Z-plasty was observed to be the better surgical procedure for cleft repair as it had low immediate post-operative complications, and fistula development and had higher intra-operative soft palate lengthening.

Impact of a Palatal Fistula After Cleft Palate Repair on Velopharyngeal Closure

PURPOSE

A palatal fistula is an adverse outcome of cleft palate repair. It is unknown if a palatal fistula will influence velopharyngeal closure, even after repair of the fistula. This study determines the effect of a soft palate fistula on the risk of developing velopharyngeal insufficiency.

METHODS

A retrospective chart review was conducted on patients who underwent primary cleft palate repair between 2000 and 2015, with complete records at 4 years of age. Fistulae involving the secondary palate following primary palatoplasty were classified as the soft or hard palate. A forced-entry multivariate logistic regression model was built to detect predictors of velopharyngeal dysfunction.

RESULTS

Records of 329 patients were analyzed with a mean follow-up of 8.7 years. A palatal fistula was identified in 89/329 patients (27%) and 29/329 patients (9%) underwent an independent fistula repair. Of the patients with fistula, 44% were located in the hard palate only and 56% had soft palate involvement. Compared to patients without a fistula, rates of velopharyngeal dysfunction were significantly higher in patients with a fistula involving the soft palate (OR 3.875, CI: 1.964-7.648, P < .001) but not in patients with a hard palate fistula (OR 1.140, CI: 0.497-2.613, P = .757). Veau class, age at primary repair, and syndromic status were not significant predictors of VPI (0.128≤P ≤ .975).

CONCLUSIONS

A palatal fistula involving the soft palate is a significant predictor for development of velopharyngeal dysfunction after primary palatoplasty. Surgical intervention, at the time of fistula repair, to add vascularized tissue may be indicated to prophylactically decrease the risk of velopharyngeal dysfunction.

Interposition grafting of collagen-gelatin sponge impregnated with basic fibroblast growth factor in primary palatoplasty

INTRODUCTION

An oronasal fistula is a challenging post-operative complication of palatoplasty due to impaired velopharyngeal function or its high recurrence rate. Muscle repositioning, a key procedure in palatoplasty, causes dead space at the junction between the hard and soft palates. Consequently, thin oral and nasal mucosae are prone to break down and form fistulas. In this study, we used basic fibroblast growth factor-impregnated collagen gelatin sponge (bFGF-CGS) in primary palatoplasty to reduce fistula formation.

METHODS

This retrospective study assessed the complications and efficacy of bFGF-CGS to reduce fistula formation. Patients who underwent primary palatoplasty with bFGF-CGS were included. The same number of patients who underwent primary palatoplasty without bFGF-CGS was included as a control group. The outcomes included post-operative oronasal fistula formation, delayed healing, bleeding, and infection.

RESULTS

Both groups included 44 patients. Except for age at palatoplasty, there were no statistically significant demographic differences between the two groups; however, the rates of fistula formation in the study and control group were 2.3% and 13.6%, respectively. There were no infections among the patients.

CONCLUSIONS

The grafting of bFGF-CGS in primary palatoplasty was safe and probably effective in reducing post-operative oronasal fistula formation.

Long-term Follow-up of Bilateral Cleft Lip and Palate: Incidence of Speech-Correcting Surgeries and Fistula Formation

While bilateral cleft lip and palate (BCLP) constitutes a clinical challenge for the whole cleft team, the ideal surgical protocol remains obscure. This study presents the long-term burden of care in terms of secondary surgeries, defined as fistula repair and speech-correcting surgeries (SCS), in a single center. Outcomes of two surgical protocols utilized over the years were also compared.

A retrospective single-center analysis of 81 non-syndromic children with complete BCLP born between 1990 and 2010. Two surgical protocols comprising single-stage and two-stage (delayed hard palate closure) procedures were compared. Outcome was analyzed at the time of alveolar bone grafting (ABG) and post-ABG.

Altogether 54 children (66.7%) had underwent secondary surgery by the time of bilateral ABG. At this point, 38.3% (n = 31) of patients had received SCS and 49.4% (n = 40) had undergone fistula repair. The corresponding incidences at the end of follow-up were 46.9% (n = 38) and 53.1% (n = 43). No significant difference emerged in SCS incidence between the 2 protocols; however, prior to ABG the single-stage protocol had a significantly lower need for fistula repair. Regarding the location of fistulas, some differences were observed, with the single-stage procedure more associated with anterior fistulas.

BCLP has a high surgical burden of care in terms of secondary surgeries, defined as SCS and fistula repair. In our experience, the single-stage protocol, particularly the two-flap technique, offers better results in the management of BCLP than the two-stage approach with a short delay in hard palate closure.

Secondary surgery techniques to optimise functional and aesthetic outcomes in orofacial clefting

Although the goal of primary surgery is to avoid the need for secondary surgery, in a proportion of patients this is not always possible. Secondary, or revisional, surgery is frequently undertaken in patients with orofacial clefts and may present a complex and challenging problem for the multidisciplinary team. There are a broad range of functional and aesthetic issues that secondary surgery might aim to address. These include palatal fistulae (that may be symptomatic for air, fluid or food), velopharyngeal insufficiency (typically manifesting with decreased intelligibility or nasal regurgitation), suboptimal cleft lip scars (that can significantly impact upon the psychosocial wellbeing of the patient), and nasal asymmetry (that is frequently accompanied by nasal airway concerns). Unilateral and bilateral clefts are each associated with a characteristic nasal deformity that requires a tailored surgical approach. Suboptimal maxillary growth in repaired orofacial clefts may impact negatively on both appearance and function; surgical correction through orthognathic surgery can be transformational for the patient. The general dental practitioner, cleft orthodontist and restorative dentist all play a critical role in this process.

Nasal Septal Flaps for Repair of Large or Recurrent Palatal Fistula: Report of Technique and 4-Year Experience

SUMMARY

Large or multiply recurrent oronasal fistulas following cleft palate repair present a challenging problem. Nasal septal mucoperichondrial flaps have been widely used for repair of skull base defects; however, their use in the repair of oronasal cleft palate fistulas has not previously been described. In this pilot study, the authors describe anterior palatal fistula repair using a nasal septal flap and review their experience with this technique over 4 years. Fourteen patients with anterior palatal fistulas not amenable to repair using local palatal flaps were included for analysis. The mean size of the fistula was 12 mm in maximum dimension. Flap healing with complete or near-complete closure of fistula was achieved in 13 patients (93%). Five of these patients had a small, slit-like residual fistula that was asymptomatic. Nasal septal flaps are a new technique for repair of large or recurrent palatal fistulas. The procedure is well-tolerated with minimal side effects, high success rate, and low incidence of recurrence.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Triple Layer Oronasal Fistula Repair Using Local Endonasal Flaps: Case Series of Three Patients

Oronasal fistula (ONF) is a common complication encountered after palatoplasty. Repair is indicated when symptoms impact speech and swallowing. In spite of the variety of surgical approaches described to repair these defects, recurrence rates remain high. Traditionally, successful closure is said to be achieved in using a double-layered approach due to the three-dimensional aspect of the defect. The extent of the fistula into the nasal cavity has incited an increased curiosity in using local endonasal flaps. In recent years, endonasal reconstructive procedures have seen increased interest and application, from cranial base defect repairs to orbital reconstruction and beyond. The nasoseptal (NSF) and inferior turbinate flaps (ITF) possess a robust arterial supply and an exceptional reach with excellent results demonstrated in large defect repair. However, the use of these flaps in ONF repair is scarcely discussed in the literature, and their effectiveness is relatively undetermined. In this manuscript, we present a series of three patients who underwent a triple layer ONF closure, with the oral portion incorporating a turn-in mucosal flap plus a local palate rotation flap or greater palatine artery pedicled-rotation flap, and a NSF or an ITF for the nasal portion of the defect.

Tongue Flap for Management of Large Palatal Fistulas

ABSTRACT

One of the worst complications after a primary palatoplasty is the lesion of the neurovascular bundle, results into a type of flap necrosis, having as a final consequence a residual palatine fistula.In our institution the authors usually use tongue flap to repair large fistulas.The authors retrospectively reviewed all patients with large palatal fistulas that were repaired with tongue flap at Fundacion Gantz between January 2002 and December 2020.Fundacion Gantz has 1.067 patients with palatal surgeries, with an incidence of 5,8% for palatal fistulas and 3,2% (n = 2) were considered large.Surgery was done on 24 patients with large residual palatal fistula, all of them with tongue flaps as outpatient surgery. Fifteen were girls and 9 were boys, between 13 and 40 years.The average size of the fistula was 2,5 cm and 100% are localized in the anterior palate.The incidence of complications with tongue flap was 12, 5%: 2 dehiscences and 1 persistent residual fistula. The authors had no complications in phonation due to the lingual donor area.The authors consider that this outpatient surgery, is a reprodutible and safe technique, with a low rate of complications, which allows us to recommend it for the treatment of large palatal fistulas.

Secondary Alveolar Bone Grafting in Patients with Unilateral and Bilateral Complete Cleft Lip and Palate: A Single-Institution Outcomes Evaluation Using Three-Dimensional Cone Beam Computed Tomography

BACKGROUND

Secondary alveolar bone grafting of autologous bone from the iliac crest is a widely accepted modality for repair of residual alveolar cleft in patients with mixed dentition with previously repaired complete cleft lip and palate. There remains debate regarding surgical timing and preoperative, perioperative, and postoperative management of these cases.

METHODS

This retrospective study reviewed patient demographic information in addition to preoperative, perioperative, and postoperative course to evaluate how patient and practice factors impact graft outcomes as assessed by three-dimensional cone beam computed tomographic evaluation at the 6-month postoperative visit.

RESULTS

On univariate analysis, age at operation older than 9 years, history of oronasal fistula, history of cleft lip or palate revision, and history of international adoption were all found to significantly increase likelihood of graft failure (p < 0.05). On multivariate analysis, age older than 9 years was found to be the single most significant predictor of graft failure (p < 0.05). There was no significant difference in graft outcomes between patients with unilateral or bilateral cleft lip and palate, and no single variable was found to significantly correlate to increased complication rates. The graft success rate overall of the authors' practice was 86.2 percent, with a complication rate of 7.7 percent.

CONCLUSIONS

Secondary alveolar bone grafting is an integral part of the cleft lip and palate surgical treatment series; this study identified several outcome predictors for both graft failure and adverse events, the most significant of which was age at operation. Although the mixed dentition phase often extends to 12 years of age, it is recommended that bone grafting be performed before 9 years of age to optimize outcomes.

CLINICAL QUESTIONS/LEVEL OF EVIDENCE

Risk, III.

Palatoplasty Using Alveolar Ridge Incisions: A Novel Approach for Addressing Cleft Palate Deformities

Background:

Traditionally, plastic surgeons have performed palatoplasties using mucoperiosteal flaps with lateral incisions that are medial to the alveolar ridge. However, narrow flaps can cause limitations in some cases. To construct larger and wider flaps and minimize exposed bone after closure, we propose a novel technique that entails creating the lateral incisions at the top of the alveolar ridge, instead of the base of the alveolar ridge, to capture more tissue when repairing the hard palate.

Methods:

A retrospective chart review was conducted for patients undergoing cleft palate repair with the aforementioned technique. Information collected included basic demographic and diagnostic factors related to cleft palate deformity and history of previous facial surgeries. Operative report details and postoperative complications were analyzed.

Results:

Nineteen patients with hard palate clefts were included in the analysis, with the majority being women (68%). There was a balanced representation of patients with Veau classifications of II (47%) and III (42%). The majority of patients had an isolated cleft palate (74%) and incomplete deformity (63%), with no other craniofacial deformities. One (5%) had postoperative self-limited oronasal fistula managed conservatively.

Conclusions:

We present a novel approach for repairing cleft palate deformities by extending the lateral incision to the top of the alveolar ridge to create larger mucosal flaps. Further longitudinal studies are needed to evaluate how this unique approach compares to traditional methods—with respect to impact on maxillary growth processes, requirement for subsequent surgeries beyond two years of follow-up, and ultimately normalized speech over time.

Steroid Use in Palatoplasty: A Single Surgeon Comparative Retrospective Cohort Study

BACKGROUND

Fistula rates in cleft palate repair vary by technique, surgeon, and institution. Although steroids are commonly used in airway surgery, many plastic surgeons are reluctant to use steroids because of concerns with wound healing. This study aims to assess outcomes and safety of steroid use in Furlow palatoplasty and determine its impact on fistula formation.

METHODS

A retrospective cohort study was done of all cleft palate surgeries performed by a single surgeon between 2010 and 2014. Data reviewed included demographics, type of cleft, steroid use, length of surgery, length of stay, and fistula formation rate.

RESULTS

One hundred thirty-five patients underwent palatoplasty, of which 101 received steroids and 34 did not. The mean age was 4.6 years. A total of 42.2% of patients underwent primary palatoplasty, 48.1% underwent submucous cleft palatoplasty, and 9.7% underwent conversion palatoplasty. The overall fistula rate was 1.5% and was comparable between the 2 groups (steroids = 2.0%, no steroids = 0.0%, P = 0.558), and all occurred in primary palatoplasty patients. The average length of stay in the hospital was shorter among patients receiving steroids (steroids = 2.0 days, no steroids = 2.5 days, P < 0.05).

CONCLUSIONS

Steroid use in cleft palate surgery appears to be safe and likely not associated with impaired wound healing or increased fistula formation. It may also shorten length of hospitalization.

Long-term Results of Three-layered Closure of Oronasal Fistula: A Case Report

An oronasal fistula is an interconnection between the oral and nasal cavities. It interferes with normal functioning and affects quality of life by impeding eating and speech. The most common management strategy is surgical treatment. The aim of our study was to present the results of a long-term follow-up of effective treatment of a case of oronasal fistula that occurred without any cause and comorbidities. A 46-year-old woman reported the sudden appearance of a painless oronasal fistula. She demonstrated nasal regurgitation—that is, loss of fluids through the nose while drinking—and slurred‚ nasal speech. Clinical examination revealed a soft tissue defect (diameter: 5 mm) on the left side of the palate. Computed tomography revealed a gap in the hard palate bone, measuring 25 × 30 mm. No complications were noted following the procedure, nor at 10-year follow-up. It seems that the use of bone substitute and palatal flap for spontaneous oronasal fistula closure was fully justified. The patient may have had an undiagnosed congenital defect of the hard palate, and the deficit may have appeared due to bone loss occurring in her forties. However, no consensus exists regarding the best treatment management for oronasal fistulae located in the palatal region, and further comparative studies between the existing techniques are needed.

Five-year prospective fistula audit in a single center. TIG training negates consultant learning curve, but surgeons should beware the mid-range palatal defect

The aim of primary palatoplasty is to achieve optimum speech with minimal morbidity. Symptomatic fistulae are well-recognised complications of palatoplasty and may require additional surgical intervention, increasing the burden of care. Our aims were to better understand fistula experience in our unit and compare fistula rates between an established consultant and a newly appointed training interface group (TIG) trained consultant. Post-operative fistulae were prospectively and independently recorded by Cleft Clinical Nurse Specialists as part of routine 6-week post-operative reviews. Cleft type and intra-operative hard-soft palate junction (HSPJ) width were prospectively recorded by operating surgeons. Data were collated and analysed using Microsoft Excel. Between 1 January 2014 and 31 December 2018, 250 primary palatoplasties were performed. The overall fistula rate was 8% (0% SMCP, ICP 7%, UCLP 8%, BCLP 22%). Fistulae clustered in clefts with a mid-range HSPJ width of 12-16 mm. Numerically, fistula rates remained similar over time despite increased unit activity (doubling of primary surgeries in 2017 and 2018). There was no significant difference in fistulae rates between surgeons (P > 0.05). Overall fistulae rate compared favourably with published data. TIG fellowships were designed in the context of cleft surgery to address issues relating to steep operative learning curves. These data demonstrate that results from a newly appointed TIG-trained surgeon are comparable to that of an established TIG-trained surgeon. Data also suggest surgeons should be aware of the risk of fistulae in the mid-range palatal defect and in HSPJ widths of 12-16 mm.

Comparison of recurrence rate and speech outcome between two different techniques for cleft palatal fistula closure: A retrospective cohort study

The aim of this retrospective cohort study was to compare the recurrence rate and speech outcomes between two techniques for palatal fistula closure of cleft palate (CP). Patients with CP who underwent secondary palatal fistula closure using the single hinge-flap method with double-breasted mattress suture (hinge-flap group) and those who were treated with the conventional sliding palatal flap method (sliding-flap group) were retrospectively evaluated for demographic and perioperative variables. Recurrence rate of palatal fistula, perceptual speech outcomes, and nasalance scores were further reviewed in patients who met the inclusion criteria. A total of 31 patients, 21 in the hinge-flap group and 10 in the sliding-flap group, were included in this study. The fistula recurrence rate in the hinge-flap group (0%) was significantly lower than that in the sliding-flap group (30.0%) (P = 0.027). In the speech assessment, hypernasality and nasalance scores decreased post-operatively in both groups and significance was observed in the hinge-flap group (P = 0.013, P < 0.001, respectively). Articulation disorders were significantly improved in the hinge-flap group (P = 0.001). Within the limitations of the study it seems that the single hinge-flap method with double-breasted mattress suture should be preferred whenever appropriate.

Impact of Cleft Palate on Tongue-Based Upper Airway Obstruction in Pierre Robin Sequence: Implications for Mandibular Distraction Osteogenesis and Timing of Cleft Palate Repair

INTRODUCTION

The objectives of this study are to analyze the impact of cleft palate (CP) on upper airway obstruction using polysomnography in patients with Pierre Robin Sequence (PRS) undergoing mandibular distraction osteogenesis (MDO) and subsequent CP repair.

METHODS

A single-surgeon, retrospective chart review was performed of all patients with nonsyndromic PRS treated with MDO. Severity of upper airway obstruction was evaluated pre- and post-distraction via polysomnography. Details of MDO and CP repair were collected and any complications recorded.

RESULTS

Twenty-one nonsyndromic PRS patients with CP and 6 patients without CP met inclusion criteria. There was no significant difference in predistraction apnea-hypopnea index between the 2 groups (53.4 ± 42.1 versus 34.4 ± 18.9; P = 0.3). Patients with CP had significantly higher predistraction SpO2 saturation (94.5 ± 1.6% versus 91.0% ± 4.8%; P = 0.01), SpO2 nadir (74.5% ± 9.1% versus 63.6% ± 11.6%; P = 0.03) and lower percentage time spent below 90% SpO2 (6.0% ± 7.2% versus 23.6% ± 29.9%; P = 0.04). The rate of oronasal fistulas formation was 38%. The time between MDO and CP repair was shorter for patients with complications (250.8 ± 3.3 versus 370.8 ± 191.9 days; P = 0.08). Five patients experienced relapse of respiratory difficulties after CP repair.

CONCLUSIONS

The presence of CP in nonsyndromic PRS patients decreases the severity of obstructive sleep apnea by oxygen parameters on PSG. Palatal fistulas and relapse of respiratory distress are common complications of CP repair following MDO. Delaying CP repair may help to decrease complication rates.

Predictive Factors for Velopharyngeal Insufficiency Following Primary Cleft Palate Repair

OBJECTIVE

Velopharyngeal insufficiency (VPI) remains a known complication of primary palatoplasty. We sought to identify factors associated with the incidence of VPI and create a predictive model for VPI development in our population.

DESIGN

A single-institution, retrospective review.

SETTING

Multidisciplinary clinic in a tertiary academic institution.

PATIENTS

A total of 453 consecutive patients undergoing primary palatoplasty from 1999 to 2016 were reviewed. Inclusion required follow-up past age 5. Patients who were non-verbal, and thus unable to undergo speech evaluation, were excluded.

MAIN OUTCOME MEASURES

Primary outcome was VPI, defined as revision palatoplasty or recommendation by speech-language pathology.

RESULTS

Of 318 patients included, 179 (56%) were male. Median age at primary repair was 1.0 years (0.9-1.1) with a median age of 8.8 years at last follow-up. One hundred nineteen (37%) patients developed VPI at a median age of 5.0 years (3.8-6.5). Higher rates were seen with posterior fistula (65% vs 14%, P <.01) and straight-line repair (41% vs 9%, P <.01), with lower rates in patients with Veau I clefts (22% vs 39%, P <.05). Patients with VPI were older at last follow-up. Following multivariate regression, factors remaining significant were posterior fistula (odds ratio [OR]: 11.3, 95% CI: 6.1-22.0), primary Furlow repair (OR: 0.18, 95% CI: 0.03-0.68), genetic diagnoses (OR: 2.92, 95% CI: 1.1-7.9), and age at last follow-up (OR: 1.11, 95% CI: 1.01-1.2).

CONCLUSIONS

Length of follow-up, posterior fistulae, and genetic diagnoses are associated with VPI formation. Furlow repair may protect against formation of VPI. Use of allograft, Veau class, birth type, birth weight, and race are not independently associated with VPI formation.

Prevention and management of oronasal fistulas

PURPOSE OF REVIEW

The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients.

RECENT FINDINGS

Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication.

SUMMARY

Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review.

Evaluation of Prognostic Factors for Palatal Fistulae after Cleft Lip and Palate Surgery in a North-Western Romanian Population over a 10-Year Period

Cleft lip and palate is the most frequent birth anomaly, with increasing reported rates of complications, such as palate fistulae. Current studies concerning the occurrence rate of cleft lip and palate (CLP) report 2 to 10 cases in 10,000 births. The purpose of this study was to investigate the existence of factors that could predict the occurrence of fistulae after cleft lip and palate surgery. A retrospective study was performed by collecting and analyzing data from all patients who were operated for cleft lip and/or palate in the Maxillo-Facial Department of the Emergency Clinical County Hospital of Cluj-Napoca, Romania, between 2010 and 2020. We investigated the existing evidence for possible links between the number of fistulae observed after the primary palatoplasty and the age at which the primary palatoplasty was performed, the sex of the patient, the type of cleft, the timing of the surgical corrections, and the presence of comorbidities. A total of 137 cases were included for analysis. A significant link between the number of fistulae and the type of cleft was found (with fistulae occurring more frequently after the surgical correction of CLP—p < 0.001). No evidence was found for the existence of significant links between the number of fistulae and the patient’s sex, the timing of surgery, or the presence of comorbidities. This study concluded that the incidence of palatal fistulae appears to be influenced by the type of cleft (CLP), but not by the sex of the patient, the timing of surgery, or the presence of comorbidities.

Is Risk of Secondary Surgery for Oronasal Fistula Following Primary Cleft Palate Repair Associated With Hospital Case Volume and Cost-to-Charge Ratio?

OBJECTIVE

This study assesses the association between risk of secondary surgery for oronasal fistula following primary cleft palate repair and 2 hospital characteristics-cost-to-charge ratio (RCC) and case volume of cleft palate repair.

DESIGN

Retrospective cohort study.

SETTING

This study utilized the Pediatric Health Information System (PHIS) database, which consists of clinical and resource-utilization data from >49 hospitals in the United States.

PATIENTS AND PARTICIPANTS

Patients undergoing primary cleft palate repair from 2004 to 2009 were abstracted from the PHIS database and followed up for oronasal fistula repair between 2004 and 2015.

MAIN OUTCOME MEASURE(S)

The primary outcome measure was whether patients underwent oronasal fistula repair after primary cleft palate repair.

RESULTS

Among 5745 patients from 45 institutions whom met inclusion criteria, 166 (3%) underwent oronasal fistula repair within 6 to 11 years of primary cleft palate repair. Primary palatoplasty at high-RCC facilities was associated with a higher rate of subsequent oronasal fistula repair (odds ratio [OR] = 1.84 [1.32-2.56], adjusted odds ratio [AOR] = 1.81 [1.28-2.59]; P ≤ .001). Likelihood of surgery for oronasal fistula was independent of hospital case volume (OR = 0.83 [0.61-1.13], P = .233; AOR = 0.86 [0.62-1.20], P = .386). Patients with complete unilateral or bilateral cleft palate were more likely to receive oronasal fistula closure compared to those with unilateral-incomplete cleft palate (AOR = 2.09 [1.27-3.56], P = .005; AOR = 3.14 [1.80-5.58], P < .001).

CONCLUSIONS

Subsequent need for oronasal fistula repair, while independent of hospital case volume for cleft palate repair, increased with increasing hospital RCC. Our study also corroborates complete cleft palate and cleft lip as risk factors for oronasal fistula.

Administration of Single-Dose Antibiotic Does Not Decrease Oronasal Fistula Rates After Primary Palatoplasty

OBJECTIVE

Oronasal fistula (ONF) is a known complication after primary palatoplasty (PP). Studies investigating the effect of perioperative antibiotics on fistula rates after PP are limited by inadequate sample size or reliance on self-reporting through national databases. In this study, the authors evaluated the association between single-dose perioperative antibiotics and postoperative fistula rates after PP at a single institution.

DESIGN

A retrospective study.

PARTICIPANTS

Children younger than 2 years who underwent PP from April 2009 to September 2019 were included.

INTERVENTIONS

Patients were divided into 2 categories: Group 1 received a single intraoperative dose of IV antibiotic, while group 2 did not.

MAIN OUTCOME MEASURE(S)

Outcome measures included ONF formation, length of stay (LOS), and 30-day readmission rates. Multivariable firth logistic regression, quantile regression, and χ² tests were performed.

RESULTS

Of the 424 patients, 215 and 209 patients were in groups 1 and 2, respectively. The overall ONF rate was 1.9% among all patients. Patients in group 1 experienced an ONF rate of 3.3%, while patients in group 2 had an ONF rate of 0.5%. After correcting for confounding variables, the difference in ONF rates was not statistically different (P = .68). Median LOS was 35.7 hours and 35.5 hours (P = .17), while the rate of readmission within 30 days was 4.7% and 2.4% for group 1 and 2, respectively (P = .96).

CONCLUSIONS

Administration of a single-dose perioperative antibiotic did not decrease fistula formation after PP, nor did it affect the patient's LOS or 30-day readmission rate.

The Lima Surgical Protocol for Cleft Palate Repair

BACKGROUND

A cleft team experience addressing non-syndromic cleft palate and cleft lip and palate is presented. The purpose of the present study is to compare surgical outcomes using 2 different protocols for cleft palate repair provided by a cleft team in Lima, Perú.

METHODS

This is a comparative study between 2 groups of patients with non-syndromic cleft palate who were operated using different surgical protocols from 1999 to 2014. One hundred twenty-four children with non-syndromic isolated cleft palate and cleft lip and palate treated from 2007 to 2014 using a surgical protocol developed by our cleft team in Lima, Perú were compared with 145 children with cleft palate and cleft lip and palate treated by the same team using different protocol from 1999 to 2007. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency (VPI) and postoperative complications.

RESULTS

Statistical significant differences were observed between the 2 groups regarding the development of flap necrosis in favor of the Lima protocol. No significant difference in palatal fistula and VPI rate between the 2 protocols was found.

CONCLUSIONS

The Lima Surgical Protocol for cleft palate repair is an alternative strategy which uses the strengths of different surgical techniques based on the severity of the cleft. We observed better surgical outcomes using the Lima protocol with regards to postoperative complications in patients with non-syndromic cleft palate.

Orthodontic Management of a Palatal Fistula in a Patient With Pierre Robin Sequence Using 3D Intraoral Scanning and Computer-Aided Design

Pierre Robin sequence (PRS) is a rare congenital abnormality that may be classified as a first branchial arch syndrome. Patients with PRS who present with cleft palate have a deformity to the soft or hard palate of the maxilla that is repaired within the first year of birth. Despite the repair, patients may experience oronasal complications. Surgical repair is usually necessary if palatal fistula presents, and prosthetic obturators are used to provide temporary relief prior to surgery. This case report outlines the steps in the successful fabrication of a custom-fitted temporary vacuum-formed prosthetic obturator using computer-aided design technology to provide a more comfortable and effective treatment option for the patient.

Patients With a History of Oronasal Fistula Repair Exhibit Lower Oral Health Measured With Patient-Centric Outcomes Measures

INTRODUCTION

Oronasal fistulae following palatoplasty may affect patients' quality of life by impacting their ability to eat, speak, and maintain oral hygiene. We aimed to quantify the impact of previous oronasal fistula repair on patients' quality of life using patient-reported outcome psychometric tools.

METHODS

A cross-sectional study of 8- to 9-year-old patients with cleft palate and/or lip was completed. Patients who had a cleft team clinic between September 2018 and August 2019 were recruited. Participants were divided into 2 groups (no fistula, prior fistula repair). Differences in the individual CLEFT-Q and Child Oral Health Impact Profile-Short Form 19 (COHIP-SF 19) Oral Health scores between the 2 groups were evaluated using a multivariate analysis controlling for Veau classification and syndromic diagnosis.

RESULTS

Sixty patients with a history of cleft palate were included. Forty-two (70%) patients had an associated cleft lip. Thirty-two (53.3%) patients had no history of fistula and 28 (46.7%) patients had undergone a fistula repair. CLEFT-Q Dental, Jaw, and Speech Function were all higher in patients without a history of a fistula repair; however, none of these differences were statistically significant. The COHIP-SF 19 Oral Health score demonstrated a significantly lower score in the fistula group, indicating poorer oral health (P = .05).

CONCLUSIONS

One would expect that successful repair of a fistula would result in improved function and patient satisfaction, but the consistent trend toward lower CLEFT-Q scores and significantly increased COHIP-SF 19 Oral Health scores in our study group suggests that residual effects linger and that the morbidity of a fistula may not be completely treated with a secondary correction.

Oronasal Fistula Incidence Associated With Vomer Flap Repair of Cleft Palate: A Systematic Review and Meta-Analysis

OBJECTIVES

To determine the incidence of oronasal fistulas (ONF) associated with primary repair of the anterior palate using a single-layered, superiorly based, vomer mucoperiosteal flap.

DESIGN

A systematic review of MEDLINE, PubMed, Cochrane, and Web of Science databases using the keywords: "vomer flap" and "cleft palate repair" were carried out. A meta-analysis was performed using random effect modeling with stratified analysis by syndromic diagnosis, number of surgeons, and mean age.

MAIN OUTCOME MEASURE(S)

Incidence of ONFs.

RESULTS

The meta-analysis included 9 studies with a total of 464 children who met inclusion criteria. The overall ONF rate was 3.0% (95% CI: 1.0-9.0). Fistula rates were not significantly different in studies that included syndromic patients compared to studies that did not, 5.0% (95% CI: 1.0-24.0) versus 3.0% (95% CI: 1.0-6.0), respectively. There was no significant difference between studies in which there was a single surgeon versus multiple surgeons, 3.0% (95% CI: 1.0-13.0) versus 4.0% (95% CI: 1.0-8.0), respectively. Age at the time of cleft repair showed no statistically significant difference in fistula rate when comparing children with a mean age less than 12 months to those greater than 12 months, 3.0% (95% CI: 1.0-5.0) versus 5.0% (95% CI: 1.0-28.0), respectively.

CONCLUSIONS

The vomer flap technique in cleft palate repair appears to be associated with a low ONF rate unaffected by syndromic diagnosis, number of surgeons, or patient age at time of 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.

Efficacy of Staged Oronasal Fistula Reconstruction and Improved Bone Graft Survival in Cleft Patients Undergoing Secondary Reconstruction

OBJECTIVE

To evaluate the efficacy of the senior author's technique of staged reconstruction in patients with recalcitrant oronasal fistulas.

DESIGN

A retrospective review of the Pediatric Plastic Surgery Cleft & Craniofacial Surgery Database of cases from September 2013 to December 2018 was conducted.

PATIENTS

A total of 31 patients who had previously undergone >1 surgical attempt to repair a fistula or patients who have failed >1 attempt at bone graft were included in this study. All patients were referrals from outside facilities.

MAIN OUTCOME MEASURES

Primary outcomes examined included fistula recurrence, infection rates, ability to proceed with second stage bone grafting after first stage fistula takedown and reconstruction, and bone graft loss.

RESULTS

Charts of 1053 patients were reviewed and 31 (2.94%) cases met inclusion criteria for this study. Nineteen (61.3%) of these patients proceeded with the second stage of reconstruction and 100% did not experience any graft loss. Seven patients who completed the first stage are undergoing orthodontic optimization prior to bone grafting. The remaining 5 are adult patients not interested in pursuing bone grafting. All 31 patients with recurrent and recalcitrant fistulas had successful fistula reconstruction with our approach, despite multiple previous failed reconstructions.

CONCLUSIONS

The 2-staged reconstructive approach described herein effectively resulted in resolution of prior recurrent recalcitrant fistulas and resulted in eventual bone grafting. By employing this technique, we report successful fistula repair and bone grafting in patients who had previously undergone multiple surgical reconstructions.

Malnutrition as a Risk Factor in Cleft Lip and Palate Surgery

OBJECTIVES/HYPOTHESIS

To assess the prevalence of acute and chronic malnutrition at the time of surgery in patients with cleft lip and/or palate (CLP) at our institution, and to quantify nutrition as a risk factor for postsurgical complications following CLP surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Retrospective review of 855 children undergoing initial cleft lip or palate surgery, or revision surgery after fistula/dehiscence of initial cleft repair. We measured acute and chronic malnutrition using World Health Organization Z-scores of weight-for-age and height-for-age, respectively, and noted any postsurgical fistula or dehiscence.

RESULTS

Among patients with cleft lip, 22.3% were at least moderately chronically malnourished at the time of initial repair, and 17.5% were at least moderately acutely malnourished. Among patients undergoing initial repair of cleft palate, 20.9% were at least moderately chronically malnourished, and 8.1% were at least moderately acutely malnourished. Increasing nutritional status, as measured by height-for-age, predicts decreased odds of fistula (OR 0.78, P = .01) after cleft palate surgery.

CONCLUSIONS

Chronic malnutrition significantly increases the risk of fistula formation in patient with cleft palate. Preoperative strategies to manage this risk and influence surgical timing can avoid morbid and costly postoperative complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2060-E2065, 2021.

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.

A Toolbox of Surgical Techniques for Palatal Fistula Repair

OBJECTIVE

To provide an inventory of oronasal fistula repair techniques alongside expert commentary on which techniques are appropriate for each fistula type.

DESIGN

A 4-stage approach was used to develop a consensus on surgical techniques available for fistula repair: (1) in-person discussion of oronasal fistula cases among cleft surgeons, (2) development of a schema for fistula management using transcripts of the in-person case discussion, (3) evaluation of the preliminary schema via a web-based survey of additional cleft surgeons, and (4) revision of the management schema using survey responses.

PARTICIPANTS

Six cleft surgeons participated in the in-person case discussion. Eleven additional surgeons participated in the web-based survey. Participants had diverse training experiences, having completed residency and fellowship at 20 different hospitals.

RESULTS

A schema for fistula management was developed, organized by fistula location. The schema catalogues all viable approaches for each location. For fistulae involving the soft palate, the schema stresses the importance of evaluating for velopharyngeal insufficiency (VPI) and incorporating VPI management into fistula repair. For fistulae involving the hard palate, the schema separately enumerates the techniques available for nasal lining repair and for oral lining repair in each region. The schema also catalogues the diversity of approaches to lingual- and labioalveolar fistula, including variation in timing, orthodontic preparation, and simultaneous alveolar bone grafting.

CONCLUSIONS

This study employed consensus methods to create a comprehensive inventory of available fistula repair techniques and to identify preferential techniques among a diverse group of surgeons.

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.

Revision Surgery of the Cleft Palate

Cleft palate repairs often require secondary surgeries and/or revisions for a variety of reasons. The most common causes are symptomatic oronasal fistulas and velopharyngeal insufficiency. Complications from primary surgery, such as wound dehiscence, infection, and hematomas, contribute to the relatively high rate of revision surgery. Prevention of postoperative complications that may lead to fistula or velopharyngeal insufficiency is key, and many techniques have been described that have reportedly decreased the incidence of secondary surgery. Management varies depending on the nature of the fistulous defect and the type of velopharyngeal insufficiency. Numerous surgical options exist to fix this deficiency.

Analysis of the Intrinsic Predictors of Oronasal Fistula in Primary Cleft Palate Repair Using Intravelar Veloplasty

Introduction:

The purpose of the present study was to investigate various factors of cleft palate and to analyze their effect on fistula occurrence following palatal muscle repair using intravelar veloplasty.

Methods:

A retrospective review of patients who underwent palatoplasty was performed. Primary palatoplasty was performed by a single surgeon in a single center. A total of 165 patients who underwent palatoplasty were enrolled. Primary palatoplasty with levator veli palatini muscle repair using intravelar veloplasty was performed. Three extrinsic factors (age, gender, and body weight) and 6 intrinsic factors (cleft width, ratio of cleft width to intermaxillary tuberosity distance, cleft anterior margin shape, uvula position, cleft lip, and radical intravelar veloplasty) were analyzed.

Results:

Palatal fistula occurred in 11 (6.67%) patients. The occurrence of fistula was significantly correlated with a specific Veau classification, that is, type II ( P = .041). Fistula tended to occur more frequently with a wide cleft palate ( P = .063), and the high-risk cutoff value of the width was 7.75 mm.

Conclusions:

A larger cleft width tended to increase the occurrence of fistula. Close observation and information about the higher risk of fistula formation should be given to patients with a large cleft width who underwent intravelar veloplasty.

Three-Dimensional Morphological Changes of the True Cleft under Passive Presurgical Orthopaedics in Unilateral Cleft Lip and Palate: A Retrospective Cohort Study

The aim of this cohort study was to quantify the morphological changes in the palatal cleft and true cleft areas with passive plate therapy using a new analysis method based on three-dimensional standardized reproducible landmarks. Forty-five casts of 15 consecutive patients with complete unilateral cleft lip and palate were laser scanned and investigated retrospectively. The landmarks and the coordinate system were defined, and the interrater and intrarater measurement errors were within 1.0 mm. The morphological changes of the cleft palate area after a period of 8 months of passive plate therapy without prior lip surgery are presented graphically. The median decrease in cleft width was 38.0% for the palatal cleft, whereas it was 44.5% for the true cleft. The width of the true and palatal cleft decreased significantly over a period of 8 months. The true cleft area decreased by 34.7% from a median of 185.4 mm² (interquartile range, IQR = 151.5-220.1) to 121.1 mm² (IQR = 100.2-144.6). The palatal cleft area decreased by 31.5% from a median of 334 mm² (IQR = 294.9-349.8) to 228.8 mm². The most important clinical considerations are the reproducibility and reliability of the anatomical points, as well as the associated morphological changes. We propose using the vomer edge to establish a validated measuring method for the width, area, and height of the true cleft.

Large Anterior Oronasal Fistula Repair Using Pedicled Buccal Fat Pad and Fibroepithelial Tissue

Oronasal fistula (ONF) is the most common complication after palatoplasty in patients with cleft lip and palate (CLP). When left untreated, it may negatively affect the quality of life, leading to development of other comorbidities. This study reports for the first time, the use of a portion of a hyperplasic tissue associated with pedicled buccal fat pad flap to repair a large anterior ONF in a 60-year-old man. The hyperplasic tissue may have developed due to the combination of a loose fitting upper denture and long-term use of dihydropyridine calcium channel blocker (amlodipine besylate). There is controversy in the literature about use of pedicled buccal fat pad flap in the anterior region. However, in this study, we report successful repair of a large anterior ONF using a portion of a fibroepithelial hyperplasic tissue associated with pedicled buccal fat pad flap.

The Use of Prophylactic Antibiotics before Primary Palatoplasty Is Not Associated with Lower Fistula Rates: An Outcome Study Using the Pediatric Health Information System Database

BACKGROUND

Previous attempts to study the effect of prophylactic antibiotics on the outcomes of cleft palate surgery have been hampered by the need for a very large sample size to provide adequate power to discern a potentially small therapeutic effect. This limitation can be overcome by querying large databases created by health care governing bodies.

METHODS

Data from the Pediatric Health Information System database were used for this analysis. Patients, aged 6 to 18 months, who had undergone primary palatoplasty (International Classification of Diseases, Ninth Revision, code 27.62) between 2004 and 2009 were included. Subsequent repair of an oronasal fistula between 2004 and 2015 was identified by International Classification of Diseases, Ninth Revision, procedure code 21.82. Pharmacy billing records were used to determine antibiotic administration. Associations between antibiotic administration and fistula repair were assessed using random-intercept logistic regression adjusting for age, sex, race, and cleft type.

RESULTS

Seven thousand one hundred sixty patients were available for analysis; of these, 460 (6.4 percent) had a subsequent repair of an oronasal fistula. Fistula rates were 5.9, 11.4, and 5.2 percent among patients given preoperative antibiotics, only postoperative antibiotics, and no antibiotics, respectively (p < 0.001). Multivariable analysis results showed that the odds of having an oronasal fistula among patients who were administered preoperative antibiotics did not differ significantly (statistically) from patients who did not receive antibiotics (OR, 0.88; 95 percent CI, 0.59 to 1.31).

CONCLUSIONS

The treatment goal of primary palatoplasty is the successful repair of the cleft without an oronasal fistula. Administration of preoperative antibiotics did not significantly reduce the odds of subsequent fistula repair within the same Pediatric Health Information System institution following primary palatoplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Closer to the Truth on National Fistula Prevalence After Unilateral Complete Cleft Lip and Palate Repair? The Cleft Care UK Study

Objectives:

To (1) determine the prevalence of nonperialveolar palatal fistula up to age 5 following repair of unilateral cleft lip and palate (UCLP) in the United Kingdom, (2) examine the association of palatoplasty techniques with fistula occurrence, and (3) describe the frequency of fistula repairs and their success.

Design:

Cross-sectional study.

Setting:

All 11 centralized regional cleft centers in the United Kingdom.

Participants:

Two hundred sixty-eight children born between 2005 and 2007 recruited by Cleft Care UK, a nationwide cross-sectional study of all 5-year-old children born with nonsyndromic UCLP.

Main Outcome Measure:

Nonperialveolar palatal fistula prevalence up to age 5.

Results:

Fistulas were found in 72 children (31.3%, 95% confidence interval: 25.4%-37.7%) and had no significant association with palate repair sequences. Twenty-four fistulas were repaired by age 5, 12 of which had data showing 10 (83.3%) successful repairs.

Conclusion:

The prevalence of nonperialveolar fistulas following primary palatoplasty of UCLP in the United Kingdom was higher than previously reported. This information should be part of the preoperative discussion with families. Prospective collection of the presence of fistulas will be necessary before we can associate the occurrence of fistulas with a surgeon, institution, surgical technique, or protocol of care.

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.