A theoretical cause of nasal obstruction in patients with repaired cleft palate

Characteristics of Neuropeptide-Containing Innervation, Tissue Remodeling, Growth, and Vascularity in Noses of Patients With Cleft Lip and Palate

OBJECTIVE

To detect the appearance and distribution of factors regulating remodeling, innervation, growth, and vascularity of the nasal tissue affected by cleft lip and palate (CLP).

DESIGN

Morphological analysis of human tissue.

SETTING

Cleft and craniofacial center.

PARTICIPANTS

Fifteen patients who underwent CLP rhinoplasty, 7 control patients.

INTERVENTIONS

Rhinoplasty.

MAIN OUTCOME MEASURES

Immunohistochemistry was performed with protein gene product (PGP) 9.5, transforming growth factor β1 (TGFβ1), vascular endothelial growth factor (VEGF), cluster of differentiation 34 (CD34), matrix metalloproteinase 2 (MMP2), MMP9, and tissue inhibitor of metalloproteinase 2 (TIMP2). The results were evaluated semiquantitatively. Spearman rank order correlation coefficient and Mann-Whitney U test were used for statistical analysis.

RESULTS

Cleft lip and palate-affected tissue revealed dense and loose connective tissue, adipose cells, and hyaline cartilage, along with numerous CD34-positive endotheliocytes and regions of VEGF-positive neoangiogenesis. We observed moderate to numerous PGP 9.5-positive nerve fibers. Transforming growth factor β1, MMP2, MMP9, and TIMP2 were found in cartilage and connective tissue. Cleft lip and palate-affected tissue compared to control samples showed a statistically significant difference in PGP 9.5 (P = .006), VEGF (P = .001), MMP2 (P = .002), MMP9 (P = .013), and TIMP2 (P < .001) expression. We observed a strong, positive correlation between VEGF and MMP9 (P = .027; r _S = 0.705).

CONCLUSIONS

The moderate expression of TGFβ1 and increased distribution of VEGF, MMP2, MMP9, and TIMP2 demonstrate an active extracellular matrix remodeling and angiogenesis, performed by proteases. The cartilaginous septum of the nose is an example of balance between tissue degradation and its suppression, demonstrated by the relationship between MMPs and TIMPs and the presence of VEGF.

Incidence of positive screening for obstructive sleep apnea in patients with isolated cleft lip and/or palate

OBJECTIVE

To determine the incidence of obstructive sleep apnea (OSA) in children with isolated cleft lip and/or palate (CL/P).

METHODS

The present prospective study was performed at a pediatric tertiary care centre. Consecutive patients evaluated at the cleft clinic from January 2011 to August 2013 were identified. Patients' families prospectively completed the Pediatric Sleep Questionnaire (PSQ), a validated tool used to predict moderate to severe OSA. Patients with CL/P and an underlying syndrome or other craniofacial diagnosis were excluded. A positive OSA screen was recorded if the ratio of positive to total responses was >0.33. Risk factors associated with a positive screen were identified using the Student's t or ANOVA test.

RESULTS

A total of 867 patients completed the PSQ, 489 of whom with isolated CL/P met inclusion criteria. The mean age was 8.4 years. The overall incidence of positive screening was 14.7%. The most commonly reported symptoms among positive screeners were 'fidgets with hands or feet' (73.6%), 'interrupts others' (69.4%) and 'mouth breather during the day' (69.4%). The most sensitive items were 'stops breathing during the night' and 'trouble breathing during sleep', with positive predictive values of 0.78 and 0.67, respectively. Sex, body mass index, ancestry and cleft type were not significantly associated with increased risk for positive screening.

CONCLUSION

One in seven children with isolated CL/P screened positively for OSA according to the PSQ. This finding highlights the potential importance of routine screening in this at-risk group.

Incidence of positive screening for obstructive sleep apnea in patients with isolated cleft lip and/or palate

Objective

To determine the incidence of obstructive sleep apnea (OSA) in children with isolated cleft lip and/or palate (CL/P).

Methods

The present prospective study was performed at a pediatric tertiary care centre. Consecutive patients evaluated at the cleft clinic from January 2011 to August 2013 were identified. Patients' families prospectively completed the Pediatric Sleep Questionnaire (PSQ), a validated tool used to predict moderate to severe OSA. Patients with CL/P and an underlying syndrome or other craniofacial diagnosis were excluded. A positive OSA screen was recorded if the ratio of positive to total responses was >0.33. Risk factors associated with a positive screen were identified using the Student's t or ANOVA test.

Results

A total of 867 patients completed the PSQ, 489 of whom with isolated CL/P met inclusion criteria. The mean age was 8.4 years. The overall incidence of positive screening was 14.7%. The most commonly reported symptoms among positive screeners were ‘fidgets with hands or feet’ (73.6%), ‘interrupts others’ (69.4%) and ‘mouth breather during the day’ (69.4%). The most sensitive items were ‘stops breathing during the night’ and ‘trouble breathing during sleep’, with positive predictive values of 0.78 and 0.67, respectively. Sex, body mass index, ancestry and cleft type were not significantly associated with increased risk for positive screening.

Conclusion

One in seven children with isolated CL/P screened positively for OSA according to the PSQ. This finding highlights the potential importance of routine screening in this at-risk group.

The effect of steroid injection of the tongue base on reducing postoperative airway obstruction in cleft palate repair

Upper airway obstruction (UAO) is a well known complication of cleft palate repair. The aim of this study was to evaluate the efficacy of local tongue base steroid injection in preventing or reducing the lingual oedema that can cause UAO following palatoplasty. Thirty children with unilateral complete cleft palate were included. They were randomly divided into two equal groups. Children in group I received intravenous dexamethasone whilst children in group II received both intravenous dexamethasone and local betamethasone injected at the tongue base. Both groups underwent the same technique of palatoplasty, postoperative breathing was assessed and UAO was rated as mild, moderate or severe. Postoperative UAO developed in six cases (40%) in group I and in two cases (13%) in group II. In group I, it was mild in three cases, moderate in one case, and severe in two cases. In group II, it was mild in one case and moderate in another case. Despite the differences in the number and severity of the condition in both groups, comparison was statistically insignificant. Local steroid injection of the tongue base during cleft palate surgery reduced the incidence and severity of post-palatoplasty UAO.