Incorporating Cleft Lip Simulation Into a "Bootcamp-Style" Curriculum

INTRODUCTION

The traditions of surgical education have changed little over the years. However, the increasing focus on patient safety and duty hour restrictions mandates that residents start developing complex skill sets earlier to ensure they graduate with procedural competency. Surgical training is poised to exploit high-fidelity simulation technology to mitigate these pressures.

METHODS

By revisiting principles of adult learning theory, the authors created a "bootcamp-style" cleft lip curriculum that sought to (1) maximize educational impact and (2) pilot a high-fidelity procedural trainer permitting resident operative autonomy as part of that curriculum. Trainees participated in small group educational sessions comprised of a standard cleft didactic lecture, augmented by instructional video. Participants immediately processed knowledge from the lecture/video by "operating" on the simulator, allowing opportunities for questions and self-reflection, completing the learning cycle. A self-assessment survey was taken before and after each component of the session, including a self-confidence survey to conclude the session. Anthropometric measures of lip/nasal symmetry were assessed.

RESULTS

Sixteen trainees participated in the program. Little increase in self-assessed knowledge/skill was seen after the lecture, but significant increases in most aspects of cleft lip repair were seen after simulation. The greatest increase in self-assessment was seen for the program as a whole, with significant differences across all aspects of the self-assessment. Higher levels of training were associated with both higher self-assessment scores and better lip symmetry. Regardless of level of training, all participants strongly agreed that simulation helped them actively engage in learning and should be a required aspect of training, whereas 94% (n = 15) thought simulation was much more effective than standard preparation alone.

CONCLUSIONS

This pilot curriculum illustrates a mechanism to incorporate lessons from adult learning theory into plastic surgery training using a high-fidelity simulator for deliberate practice of cleft lip repair. Further evaluation is warranted to determine whether this didactic model can accelerate the acquisition of the complex skill set required for cleft lip repair and other surgical procedures.

Does the Nostril Shape Change After Le Fort I Advancement in Patients With Unilateral Complete Cleft Lip?

PURPOSE

Patients with unilateral cleft lip and palate (UCLP) may require Le Fort I advancement to correct maxillary hypoplasia after reaching skeletal maturity. The underlying cleft anatomy, previous operations, and scarring can affect nostril changes after maxillary advancement. The purpose of the present study was to determine whether Le Fort I advancement affects the nostril configuration (ie, width, axis, shape) in patients with UCLP. The specific aims were to (1) compare cleft and noncleft nostrils in patients with UCLP after maxillary advancement and (2) compare the changes in nostril configuration in patients with UCLP with those in noncleft controls after Le Fort advancement.

PATIENTS AND METHODS

A retrospective case-control study of nonsyndromic, skeletally mature patients with UCLP and a case-matched control group without UCLP who had undergone single-piece Le Fort I advancement with alar cinch suture from 2010 to 2014. Patients were included if they had undergone pre- and postoperative 3-dimensional photogrammetry without intervening nasal revision. Three-dimensional anthropometry was used to evaluate changes in nostril axis and width, soft triangle angle, columellar show, and nasal width after orthognathic correction.

RESULTS

The present study included 19 patients with UCLP (11 males; mean age, 18.0 years) and 19 noncleft controls (11 males; mean age, 18.7 years; P = .276). The mean sagittal advancement in the patients with UCLP and noncleft controls was 7.5 mm and 6.3 mm, respectively (P = .143). On average, the nostrils widened, the soft triangles flattened, and the columellar show increased. No significant difference was found in the changes to the nostril configuration between the cleft and noncleft sides in the patients with UCLP. No significant differences were found in the nostril changes between patients with UCLP and noncleft controls.

CONCLUSIONS

Baseline nostril asymmetry is not altered by Le Fort osteotomy in patients with UCLP because both nostrils respond similarly to the deforming forces of maxillary advancement. Similarly, no differences were found in the nostril changes between the cleft and noncleft controls. These findings can aid proper surgical planning for cleft nasal revisions.

Impact of Obstructive Sleep Apnea on Optic Nerve Function in Patients With Craniosynostosis and Recurrent Intracranial Hypertension

PURPOSE

Assessment of combined impact of intracranial hypertension (ICH) and obstructive sleep apnea (OSA) on optic nerve function in children with craniosynostosis (CS).

DESIGN

Retrospective cross-sectional study.

METHODS

Patients treated at Boston Children's Hospital for CS who had an ophthalmic examination that included pattern reversal (pr)VEP (2013-2014) and history of ICH based on direct measurement, papilledema, or classic features on neuroimaging and during cranial vault expansion were included. History of OSA was determined by polysomnography and associated conditions, including apnea and (adeno)tonsillectomy. Subjects were divided into 4 groups: group 1, resolved ICH absent history of OSA; group 2, resolved ICH with history of OSA; group 3, recurrent ICH absent history of OSA; and group 4, recurrent ICH with history of OSA. Predictor variables included latency of P100 component of pattern-reversal visual evoked potential, best-corrected visual acuity, optic nerve appearance, visual fields, and global retinal nerve fiber layer. Primary outcome was association of prolonged P100 latency with resolved vs recurrent ICH and OSA.

RESULTS

Twenty-eight children met inclusion criteria (mean age 11.6 ± 6.9 years): group 1 (n = 3), group 2 (n = 6), group 3 (n = 8), and group 4 (n = 11). P100 latencies were not prolonged in groups 1 and 2. Three of 8 in group 3 and 9 of 11 in group 4 had prolonged P100 latency. Group 4 was significantly worse than group 3 (P = .005).

CONCLUSIONS

History of OSA, in addition to recurrent ICH, is associated with greatest risk of optic neuropathy with CS. Ophthalmologists should encourage early management of OSA as well as ICH to optimize ophthalmic outcomes.

Can Robin Sequence Be Predicted From Prenatal Ultrasonography?

PURPOSE

Prenatal diagnosis of Robin sequence (RS) could promote safe delivery and improve perinatal care. The purpose of this study was to evaluate the correlation between prenatal ultrasonography (US) and magnetic resonance imaging (MRI) studies for assessing micrognathia to determine if US alone can be used to reliably screen for RS.

MATERIALS AND METHODS

This was a retrospective case-control study of fetuses evaluated in the Advanced Fetal Care Center at Boston Children's Hospital from 2002 to 2017. To be included, 1) prenatal MRI and US must have been performed during the same visit, 2) the infant must have been live-born, and 3) the diagnosis must have been confirmed postnatally. Patients with images of inadequate quality for analysis were excluded. Patients were divided into 4 groups based on postnatal diagnosis: 1) RS (micrognathia, glossoptosis, and airway obstruction) (RS group), 2) micrognathia without RS (micrognathia group), 3) cleft lip and palate (CLP) without micrognathia (CLP group), and 4) gestational age-matched controls with normal craniofacial morphology (control group). The inferior facial angle (IFA) was measured using both imaging modalities and compared. Receiver operating characteristic curves were applied to identify a threshold for the diagnosis of RS from US. The sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio were calculated.

RESULTS

A total of 94 patients were included (mean gestational age at imaging, 24.9 ± 5.2 weeks), with 25 in the RS group (26.6%), 29 in the micrognathia group (30.9%), 23 in the CLP group (24.5%), and 17 in the control group (18.1%). The IFA was significantly smaller in the RS group than in all other groups on both US and MRI (P < .001). A moderate correlation was found between IFA measurements on US and MRI (intraclass correlation coefficient, 0.729). An IFA threshold on US of 45.5° maximized sensitivity (84%) and specificity (81%) for the diagnosis of RS.

CONCLUSIONS

We suggest incorporating the IFA into routine prenatal US and referring patients for confirmatory MRI when the US IFA is lower than 45.5°.

Retropalatal Cross-Sectional Area Is Predictive of Obstructive Sleep Apnea in Patients With Syndromic Craniosynostosis

OBJECTIVE

There is a high rate of obstructive sleep apnea (OSA) in patients with syndromic craniosynostosis (SCS). Little is known about the airway anatomy in this population. The purpose of this study is to characterize the 3 dimensional (3D) upper airway in patients with SCS with and without OSA.

DESIGN

This is a retrospective study of patients with SCS treated at Boston Children's Hospital from 2000 to 2015. Patients were divided into OSA and no-OSA groups based on polysomnography. Predictor variables included age, sex, body mass index (BMI), and 3D upper airway measurements. The primary outcome variable was the presence or absence of OSA. Secondary outcome variables were apnea-hypopnea index and oxygen saturation nadir. Descriptive and bivariate statistics were computed, and significance was set as P < .05.

RESULTS

There were 24 patients: 16 in the OSA group and 8 in the no-OSA group. The 2 groups did not differ significantly by age, BMI, or syndromic diagnosis. The presence of OSA was associated with a smaller minimum retropalatal cross-sectional area (minRPCSA; P < .001). In a logistic regression model controlling for age, sex, and upper airway length, minRPCSA was the primary predictor of OSA (P ≤ .002). Receiver operating characteristic analysis determined minRPCSA = 55.3 mm² to be the optimal diagnostic threshold for OSA, with sensitivity = 100% and specificity = 87.5% (P < .001).

CONCLUSION

A minRPCSA ≤55.3 mm² is predictive of the presence of OSA in patients with SCS.

Schneiderian Membrane Thickness Is Increased in Patients With Cleft Lip and Palate

OBJECTIVE

Patients with cleft lip and palate (CLP) are more likely to have sinusitis. The purpose of this study is to determine whether patients with CLP have thickening of the Schneiderian membrane. Specific aims were to (1) compare Schneiderian membrane thickness in patients with CLP to noncleft controls, (2) evaluate whether membrane thickening is associated with cleft side in patients with unilateral cleft lip and palate (UCLP), and (3) evaluate if age and sex are predictors of mucosal thickening.

DESIGN

Case-control study.

SETTING

Tertiary care center.

PATIENTS

Patients with CLP and controls.

MAIN OUTCOME MEASURE

The primary outcome variable was maximum Schneiderian membrane thickness measured on cone beam computed tomography. The primary predictor variable was the presence of a cleft. Additional variables were cleft phenotype, age, and sex.

RESULTS

There were 225 patients with CLP and 93 controls. Median mucosal thickness was 2.4 mm in cleft group and 0.0 mm in controls (P = .006). In cleft group, 56.7% of sinuses had mucosal thickness >2.0 mm compared to 38.2% in controls (P = < .004). Pathologic membrane thickening (>4.0 mm) was significantly higher in cleft group (P = .005). No statistically significant difference in mucosal thickness between cleft and noncleft sides in patients with UCLP. Linear regression showed no association between age or sex and Schneiderian membrane thickness.

CONCLUSION

Schneiderian membrane thickening is more common in patients with CLP and is not associated with the side of the cleft in patients with UCLP.

Do Oral and Maxillofacial Surgeons Over-Prescribe Opioids After Extraction of Asymptomatic Third Molars?

PURPOSE

Opioid abuse is a public health concern. Oral opioids are prescribed after removal of third molars, but the amount needed for adequate postoperative analgesia is unknown. The purpose of this study was to quantify opioid need after third molar extractions.

MATERIALS AND METHODS

This is a prospective cohort study of consecutive patients who had asymptomatic third molars extracted with intravenous sedation at the Boston Children's Hospital (Boston, MA) from June through October 2018 by 3 attending surgeons. To be included, patients had to have had 4 third molars removed. Patients were excluded if they had a concomitant procedure, preoperative infection, postoperative inflammatory complication, chronic pain condition, or did not complete the study. Postoperative prescriptions and instructions included 1) oxycodone 5-mg tablets with 1 tablet taken every 6 hours as needed (dispensed, 6); 2) ibuprofen 600-mg tablets with 1 tablet taken every 6 hours as needed (dispensed, 20); and 3) acetaminophen 325-mg tablets with 2 tablets taken every 6 hours as needed (dispensed, 40). Participants reported medication use by electronic questionnaire each day for 7 postoperative days (PODs). Descriptive statistics were calculated.

RESULTS

Eighty-one patients (56% female; mean age, 19.4 ± 7.7 yr) were included. The average number of oxycodone tablets used was 0.04 ± 0.24, and the highest daily use of oxycodone was on POD 2 (1.0 ± 0.0 tablet). Oxycodone was taken by 3 patients (4%) on POD 1, 4 (5%) on POD 2, 2 (3%) on PODs 3 and 4, and 0 on PODs 5 to 7. Seventy-five patients (93%) used no postoperative oxycodone; 466 prescribed oxycodone tablets remained unfilled or unused. Ibuprofen 600 mg was used for 4.6 ± 2.2 PODs and acetaminophen 650 mg was used for 3.4 ± 1.9 PODs.

CONCLUSIONS

Oral opioid use after third molar extractions is minimal. Caution is necessary to avoid over-prescribing.

Is Amniotic Fluid Level a Predictor for Syndromic Diagnosis in Robin Sequence?

OBJECTIVE

The purpose of this study was to determine whether gestational amniotic fluid level abnormalities were associated with postnatal syndromic status in a series of patients with Robin sequence (RS).

DESIGN

Retrospective study of participants with RS at Boston Children's Hospital from 1967 to 2017. Participants were divided into syndromic and nonsyndromic groups. The primary predictor variable was postnatal syndromic diagnosis (yes/no). Additional predictor variables included gestational age at birth, birthweight, sex, presence of cleft palate, and other congenital anomalies. The primary outcome variable was amniotic fluid level (normal, oligohydramnios, or polyhydramnios). Descriptive statistics were computed and logistic regression was used to analyze amniotic fluid level as a predictor for syndromic diagnosis. Statistical significance was set at P < .05.

RESULTS

Sixty-five (54%) syndromic and 56 (46%) nonsyndromic RS participants were included. An abnormal amniotic fluid level was seen significantly more frequently in the syndromic group (49.2% vs 25.0%; P = .001). Abnormal amniotic fluid level was associated with a 2.9-fold increased likelihood of a syndromic diagnosis (P = .007). Polyhydramnios, which was seen more frequently than oligohydramnios, predicted a 4.18 times increased likelihood of a syndromic diagnosis (P = .003).

CONCLUSIONS

Abnormal amniotic fluid level, particularly polyhydramnios, is associated with an increased likelihood of a syndromic diagnosis in patients with RS.

Evaluation of Andrews' Analysis as a Predictor of Ideal Sagittal Maxillary Positioning in Orthognathic Surgery

PURPOSE

There is no universally accepted method for determining the ideal sagittal position of the maxilla in orthognathic surgery. In "Element II" of "The Six Elements of Orofacial Harmony," Andrews used the forehead to define the goal maxillary position. The purpose of this study was to compare how well this analysis correlated with postoperative findings in patients who underwent bimaxillary orthognathic surgery planned using other guidelines. The authors hypothesized that the Andrews analysis would more consistently reflect clinical outcomes than standard angular and linear measurements.

MATERIALS AND METHODS

This is a retrospective cohort study of patients who had bimaxillary orthognathic surgery and achieved an acceptable esthetic outcome. Patients with no maxillary sagittal movement, obstructive sleep apnea, cleft or craniofacial diagnoses, or who were non-Caucasian were excluded. Treatment plans were developed using photographs, radiographs, and standard cephalometric measurements. The Andrews analysis, measuring the distance from the maxillary incisor to the goal anterior limit line, and standard measurements were applied to end-treatment records. The Andrews analysis was statistically compared with standard methods.

RESULTS

There were 493 patients who had orthognathic surgery from 2007 through 2014, and 60 (62% women; mean age, 22.1 ± 6.8 yr) met the criteria for inclusion in this study. The mean Andrews distances were -4.8 ± 2.9 mm for women and -8.6 ± 4.6 mm for men preoperatively and -0.6 ± 2.1 mm for women and -1.9 ± 3.4 mm for men postoperatively. For women, the Andrews analysis was closer to the goal value (0 mm) postoperatively than any standard measurement (P < .001). For men, the linear distance from the A point to a vertical line tangent to the nasion from the McNamara analysis performed best (P < .001), followed by the Andrews analysis.

CONCLUSION

The Andrews analysis correlated well with the final esthetic sagittal maxillary position in the present sample, particularly for women, and could be a useful tool for orthognathic surgical planning.

In Utero Glossoptosis in Fetuses With Robin Sequence

Objective:

Glossoptosis causes airway obstruction in patients with Robin sequence (RS), but little is known about the in-utero tongue. The purpose of this study was to assess shape and position of the fetal tongue on prenatal magnetic resonance imaging (MRI) to determine if this is predictive of postnatal RS.

Design:

Retrospective case-control study including fetuses with prenatal MRIs performed from 2002 to 2017. Inclusion criteria were (1) prenatal MRI of adequate quality, (2) live born and evaluated postnatally for craniofacial findings. Subjects were divided into groups based on postnatal findings: (1) RS, (2) micrognathia without RS, and (3) a gestational-age-matched control group with normal craniofacial morphology. Outcome variables were based on the prenatal MRI and included fetal tongue height, length, and width, tongue shape index (TSI, ratio of height to length), and observation of tongue touching the posterior pharyngeal wall.

Results:

A total of 116 subjects with mean gestational age at MRI of 25.6 ± 5.1 weeks were included: RS, n = 27 (23%); micrognathia, n = 35 (30%); control, n = 54 (47%). Tongue length was significantly shorter ( P = .009) and TSI was significantly larger in the RS group ( P < .0001). The tongue touched the posterior pharyngeal wall in 5 (19%) of the RS group and in no subjects in the other groups ( P < .0001).

Conclusion:

In utero tongue shape and position were significantly different in fetuses with postnatal RS compared to those with isolated micrognathia and controls. Prenatal MRI tongue characteristics may be predictors for postnatal RS.

Pathogenesis of Cleft Palate in Robin Sequence: Observations From Prenatal Magnetic Resonance Imaging

PURPOSE

The etiology of the palatal cleft in Robin sequence (RS) is unknown. The purpose of this study was to assess the position of the fetal tongue at prenatal magnetic resonance imaging (MRI) and to suggest a potential relation between tongue position and development of the cleft palate seen in most patients with RS.

MATERIALS AND METHODS

This is a retrospective case-and-control study including fetuses with prenatal MRIs performed in the authors' center from 2002 to 2017. Inclusion criteria were 1) prenatal MRI of adequate quality, 2) liveborn infant, and 3) postnatal diagnosis of RS (Robin group) or cleft lip and palate (CLP group). Patients with postnatal RS without a palatal cleft were excluded. A control group with normal facial morphology was matched by gestational age. The outcome variable was tongue position at fetal MRI, described as within the cleft, along the floor of the mouth (normal), other, or indeterminate.

RESULTS

One hundred twenty-two patients with mean gestational age at MRI of 25.8 ± 4.9 weeks were included (Robin, n = 21 [17%]; CLP, n = 47 [39%]; control, n = 54 [44%]). The tongue was visualized within the palatal cleft in 76.2% of the Robin group and 4.3% of the CLP group. The tongue was found along the floor of the mouth (normal) in the remainder of the Robin and CLP groups and in 100% of the control group.

CONCLUSION

These findings suggest a relation between in utero tongue position and the development of cleft palate in RS.

Micrognathia and Oropharyngeal Space in Patients With Robin Sequence: Prenatal MRI Measurements

PURPOSE

Micrognathia is the initiating feature of Robin sequence (RS) and leads to airway obstruction. Prenatal identification of micrognathia is currently qualitative and has not correlated with postnatal findings in previous studies. Oropharyngeal airway space has not been evaluated prenatally. The purposes of this study were to 1) quantitate mandibular characteristics and oropharyngeal size at prenatal magnetic resonance imaging (MRI) and 2) identify differences in fetuses with postnatal RS compared with those with micrognathia (without RS) and normal controls.

MATERIALS AND METHODS

This is a retrospective case-control study of fetuses with prenatal MRIs performed from 2002 through 2017 who were live born and evaluated postnatally for craniofacial findings. Postnatal findings were used to divide patients into 3 groups: 1) RS (micrognathia, glossoptosis, and airway obstruction), 2) micrognathia without RS ("micrognathia"), and 3) a gestational-age matched control group with normal craniofacial morphology ("control"). Inferior facial angle (IFA), jaw index, and oropharyngeal space (OPS) were calculated and compared among groups.

RESULTS

Of 116 patients in this study, 27 had RS (23%), 35 had micrognathia (30%), and 54 were control subjects (47%). IFA, jaw index, and OPS were statistically significantly smaller in the RS group compared with the comparison groups (P < .0001).

CONCLUSIONS

Prenatal MRI measurements of micrognathia and OPS are considerably different in patients with RS compared with other groups, including those with micrognathia alone. These measurements might serve as reliable prenatal predictors of RS.