Association of Pediatric Patient Demographic Factors and Scar Anatomic Features With Scar Outcomes After Surgical Repair of Cleft Lip

Importance

Scar outcomes following cleft lip repair are an important component of pediatric patient and family satisfaction and indicate the need for future surgical interventions.

Objective

To assess the association of pediatric patient demographic factors and scar anatomic features with scar outcomes following cleft lip surgical repair.

Design, Setting, and Participants

A case-control study was conducted involving 58 pediatric patients who underwent surgical repair of a cleft lip from October 31, 2008, to August 4, 2016, at a tertiary care pediatric specialty hospital. Data on patient demographic factors, cleft type, and the surgical technique used were collected and analyzed from June 11, 2009, to November 21, 2017. Scar outcomes were subjectively rated by 3 physicians at 6-month and 12-month postoperative intervals.

Main Outcomes and Measures

Overall scar outcomes at 6-month and 12-month postoperative intervals were based on rating of scar appearance, color, width, height, and alignment by using a subjective, 5-point scar-assessment scale in which 1 indicated the poorest aesthetic appearance and 5, the ideal aesthetic appearance.

Results

A total of 58 pediatric patients who underwent cleft lip repair were evaluated; mean (SD) age at time of repair, 4.8 (3.0) months. Of these, 44 (76%) were male and 14 (24%) were female, 37 (64%) were white, 11 (19%) were black, 7 (12%) were Hispanic, 2 (3%) were Asian, and 1 (2%) was of another race/ethnicity. Scores on the Cohen κ interrater test indicated either a substantial or almost perfect strength of agreement among the physicians grading the scar outcomes. At 12 months, patients with black skin type had worse overall scar outcomes than patients with white skin type (odds ratio [OR], -0.31; 95% CI, -1.15 to -0.14; P = .03). A depressed scar height (OR, -0.54; 95% CI, -1.32 to -0.49; P < .001), and hypopigmented scar color (OR, -0.45; 95% CI, -1.34 to -0.32; P = .002) were associated with worse scar outcomes at 12 months following surgery. The overall median lip scar outcome significantly improved between the 6-month and 12-month follow-up assessments (scar-assessment scale score, 3.3; interquartile range [IQR], 2.7-4.0 vs 4.0; IQR, 3.3-4.3; P < .001). No association was observed between the anatomic type and severity of the cleft lip and scar outcomes (unilateral vs bilateral cleft, complete vs incomplete or microform cleft, and lip height ratio of the unilateral noncleft to cleft lip).

Conclusions and Relevance

This study's findings suggest that, compared with white pediatric patients, black pediatric patients exhibited worse overall scar outcomes. A depressed scar and a hypopigmented scar also were associated with overall worse scar appearance after surgical repair. Cleft lip scar outcomes were not significantly associated with the type and severity of the cleft lip.

Masseteric Nerve Transfer for Facial Nerve Paralysis: A Systematic Review and Meta-analysis

Importance

A review of the role of masseteric nerve transfer is needed to guide its use in facial reanimation.

Objective

To systematically review the available literature, and, when applicable, analyze the combined outcomes of masseteric nerve transfer to better define its role in reanimation and to guide further research.

Data Sources

Two independent researchers conducted the review using PubMed-NCBI and Scopus literature databases for studies on masseteric nerve transfer for facial nerve paralysis.

Study Selection

Studies that examined masseter nerve transfer with additional cranial nerve transposition/coaptation or muscle flap were excluded.

Data Extraction and Synthesis

Literature review and data extraction followed established PRISMA guidelines. Two researchers extracted data independently.

Main Outcomes and Measures

The main planned outcomes for the study were quantitative results of facial nerve movement after nerve transfer including oral commissure movement and time to nerve recovery.

Results

A total of 13 articles met inclusion criteria with a total of 183 patients undergoing masseteric nerve transfer. From those studies, there were a total of 183 patients who underwent masseteric nerve transfer. There were 85 men and 98 women with a mean (SD) age of 43 (12.2) years and mean (SD) follow up examination after surgery of 22 (7.6) months. Mean (SD) duration of nerve paralysis was 14 (6) months. Most common cause of paralysis was cerebellopontine angle tumors (81%). Six studies coapted the masseteric nerve to the main facial nerve trunk, whereas 7 used distal branches (buccal or zygomatic). Four studies used interposition nerve grafts with great auricular nerve. Two measures, improvement in oral commissure excursion and length from reanimation to facial movement, were measured consistently across the studies. Pooled analysis showed time from surgery to first facial movement, described in 10 studies, to be 4.95 months (95% CI, 3.66 to 6.24). Distal branch coaptation improved time to recovery vs main branch coaptation, 3.76 vs 5.76 months (95% CI, -0.33 to 4.32), but mean difference was not significant. The use of interposition graft significantly delayed time of nerve recovery, 6.24 vs 4.06 months (95% CI, 0.20 to 4.16). When controlled for main trunk coaptation only, interposition nerve graft delayed recovery but difference was no longer statistically significant, 6.24 vs 4.75 months (95% CI, -0.94 to 3.92). Reported complications were minor and rare occurring in only 6.5% (12 of 183) of patients.

Conclusions and Relevance

The masseteric nerve was found to be a good option for nerve transfer in this patient population, and showed favorable results in both time to nerve recovery and improvement in oral commissure excursion.

Level of Evidence

NA.

Trigeminal Trophic Syndrome-A Unique Clinical Presentation of a Rare Condition

This study describes a unique clinical presentation of trigeminal trophic syndrome (TTS), which is not well described within the otolaryngology literature. Trigeminal trophic syndrome classically presents with a triad of symptoms: trigeminal anesthesia, facial paresthesias, and crescent-shaped ulceration of the lateral nasal ala. The patient discussed in this report had a self-induced, waxing and waning ulceration of the frontal scalp for 7 years and was evaluated and treated ineffectively by multiple physicians, including otolaryngologists, before TTS was diagnosed and a targeted treatment was initiated. Although extranasal presentation is uncommon, this condition must be considered when ulcers are encountered in the trigeminal dermatome. This case highlights the variability in presentation and the importance of awareness of this rare syndrome. We aim to facilitate more prompt diagnosis and expedite the initiation of appropriate treatment for TTS in the field of otolaryngology.

Efficacy of Upper Airway Stimulation on Collapse Patterns Observed during Drug-Induced Sedation Endoscopy

OBJECTIVE

To describe upper airway collapse patterns observed on drug-induced sedation endoscopy (DISE) during screening for a clinical trial and to evaluate the impact of collapse patterns found on preoperative DISE on response rates to upper airway stimulation (UAS) therapy.

STUDY DESIGN

Retrospective review of an ongoing prospective multi-institutional cohort study.

SETTING

Twenty-two participating institutions of the STAR trial.

SUBJECTS AND METHOD

In total, 222 subjects were screened with DISE to determine eligibility for an implantable UAS device. Supine laryngoscopy was performed during moderate sedation (propofol and/or midazolam). Airway collapse pattern and severity were graded at 4 levels, including velum, oropharynx, tongue base, and epiglottis (VOTE classification). Patients with complete concentric collapse (CCC) at the velum were excluded from implantation.

RESULTS

The CCC at the velum was observed in 52 (23%) of screened subjects, and these subjects were subsequently excluded from implantation. Of the 170 subjects without CCC at the velum, 126 (77%) underwent implantation: 121 (96%) had multilevel collapse and 5 (4%) had single-level collapse. When comparing preimplantation DISE findings, UAS responders at 12 months had lower baseline VOTE scores compared with therapy nonresponders.

CONCLUSION

Drug-induced sedation endoscopy is an efficient and safe method for determining UAS eligibility and has the potential to identify UAS nonresponders. Most patients had multilevel airway collapse, illustrating the limitations of single-level upper airway surgery in treating obstructive sleep apnea. Upper airway stimulation is effective therapy for most patients with multilevel airway collapse; however, patients with complete anterior-posterior or lateral soft palate and/or epiglottic collapse may be at increased risk of therapy failure.

TranQuill sling snoreplasty for snoring: A single-arm pilot study for safety and effectiveness

OBJECTIVES/HYPOTHESIS

Determine safety and efficacy of the TranQuill Sling Snoreplasty (TSS) (Surgical Specialties Corp., Vancouver, BC, Canada) for the treatment of snoring in adults with benign snoring or mild obstructive sleep apnea.

STUDY DESIGN

Prospective, unblinded, single-center pilot study.

METHODS

From February 2014 to July 2014, 20 adult patients with chronic, disruptive snoring assessed by bed partner were recruited to undergo TSS. Subjects with apnea hypopnea index < 15, minimum oxygen saturation > 85%, and body mass index (BMI) < 32 were included. Outcomes were assessed comparing the results of quality-of-life questionnaires, bed partner-assessed snoring, pain visual analog scales, WatchPAT (Itamar Medical Ltd, Caesarea Ind. Park, Israel) home sleep studies, and flexible endoscopy at baseline and 90-day follow-up.

RESULTS

Thirteen males and seven females were enrolled. Average age was 49.1 (range 31-67) and BMI of 25.8 ± 2.66. TranQuill Sling Snoreplasty significantly reduced snoring symptom scores from 8.70 ± 4.27 to 6.42 ± 4.14, P = 0.012. Snoring visual analog scores demonstrated reduction of 17.8 mm (59.4 mm ± 22.1 to 41.6 mm ± 29.2), P = 0.0184. Thirty-five percent (7/20) of subjects reported complications related to the trial, with no serious adverse events.

CONCLUSION

TranQuill Sling Snoreplasty is a safe therapy that improves snoring symptoms in most adult subjects with benign snoring or mild sleep apnea. Further study is required to better identify patients likely to respond to the therapy.

The Effect of Glossectomy for Obstructive Sleep Apnea

Objective

Determine the effect of glossectomy as part of multilevel sleep surgery on sleep-related outcomes in patients with obstructive sleep apnea.

Data Sources

PubMED, Scopus.

Review Methods

Two independent researchers conducted the review using PubMed-NCBI and Scopus literature databases. Studies on glossectomy for obstructive sleep apnea that reported pre- and postoperative apnea-hypopnea index (AHI) score with 10 or more patients were included.

Results

A total of 18 articles with 522 patients treated with 3 glossectomy techniques (midline glossectomy, lingualplasty, and submucosal minimally invasive lingual excision) met inclusion criteria. Pooled analyses (baseline vs post surgery) showed a significant improvement in AHI (48.1 ± 22.01 to 19.05 ± 15.46, P < .0001), Epworth Sleepiness Scale (ESS; 11.41 ± 4.38 to 5.66 ± 3.29, P < .0001), snoring visual analog scale (VAS; 9.08 ± 1.21 to 3.14 ± 2.41, P < .0001), and Lowest O2 saturation (76.67 ± 10.58 to 84.09 ± 7.90, P < .0001). Surgical success rate was 59.6% (95% CI, 53.0%-65.9%) and surgical cure was achieved in 22.5% (95% CI, 11.26%-36.26%) of cases. Acute complications occurred in 16.4% (79/481) of reported patients. Glossectomy was used as a standalone therapy in 24 patients. In this limited cohort, significant reductions in AHI (41.84 ± 32.05 to 25.02 ± 20.43, P = .0354) and ESS (12.35 ± 5.05 to 6.99 ± 3.84, P < .0001) were likewise observed.

Conclusion

Glossectomy significantly improves sleep outcomes as part of multilevel surgery in adult patients with OSA. Currently, there is insufficient evidence to analyze the role of glossectomy as a standalone procedure for the treatment of sleep apnea, although the evidence suggests positive outcomes in select patients.