[Clinical and nasometric study of velopharyngeal function in two-stage palatoplasty]

Since 1976 children born with complete cleft lip and palate have been treated according to two stage cleft palate repair regime, soft palate at one year of age and hard palate between 3-12 years of age. The objective of this paper is to present the clinical and instrumental speech evaluation and the velopharyngeal function of 41 patients, mean age 8.2 years, 28 unilaterals and 13 bilateral clefts; 7 cases had palatal fistulae larger than 5 mm2. The results showed moderate-severe hypernasality in 20% of cases, persisting articulatory errors with backing in 43% of cases, glotal stops in 2%, the intelligibility was deficient in 7%. The evaluation of the oro-nasal resonance with Nasometry showed suspicious or VPI values in 14 and 20% of cases respectively. Nasendoscopy findings showed same degree of VPI in 35% of cases. Repalatoplasty or fistula closure was needed in 17% and pharyngeal flap in 12% of cases. The great incidence of articulatory errors have promoted us to discontinue this technique.

[Ambulatory pediatric surgery: 25 years of experience]

The objectives of this study are: collect 25 years of experience with ambulatory pediatric surgery in The Pediatric Surgery Service of Hospital de Cruces, present the results of a parents-patient satisfaction survey and show the estimated money savings in the last five years. In the period 1973-1997, 19,934 children (56% of the total surgical cases) were operated with ambulatory surgery, and have been grouped in five quinquenia, showing a constant increase of the percentage of ambulatory surgery. General surgery and ENT are the specialities that more frequently uses this type of surgery (72.4% and 68.6% of the surgical cases of each speciality, respectively, in the last ten years). In general surgery inguinal hernia is the most frequent diagnosis with an increase of orchidopexy in the last five years. ENT is doing ambulatory tonsilectomies in the last ten years. The prolonged recovery stay and unanticipated admissions are rare, usually due to vomiting. The parents satisfaction survey shows great acceptancy, although 13% preferred an overnight postoperative stay. The estimated money saved in the last quinquenia has been important.

[Section of the sublingual frenulum. Are the indications correct?]

OBJECTIVE

To see the relationship of the lingual frenum with speech and other oral functions, evaluating the surgical indications and the results of frenectomy.

MATERIAL AND METHODS

In 1997 we operated 72 children with sublingual frenulum, a telephone questionnaire to the mothers of these patients was done, obtaining data about: age at surgery, professional reasons for referral, preoperative findings, pre-post operative speech therapy, place of surgery and type of anesthesia and mother's impression about the final result.

RESULTS

Fifty valid questionnaires were obtained, the mean age at frenectomy was 3.03 years, 38% of children were sent due to speech problems, 60% due to some degree of tongue-tie and 2% due to dentofacial developmental anomalies. In 70% the patients were sent by a pediatrician and in 14% by a speech therapist. In 20% preoperative speech therapy was done and postoperatively in 30%. In 48% of cases, aged less than 2 years, speech was not possible to be evaluated. In the 11 cases with questionable results, a multidisciplinary reevaluation showed 7 cases with lingual dysfunction and poor tongue control, 4 cases with deglutitory anomalies and 3 cases with orofacial occlusal problems secondary to lingual dysfunction or altered oral habits.

CONCLUSIONS

The presence of a nondisturbing lingual frenulum does not justify its surgical section, the frenectomy is indicated only in presence of altered oro-lingual functions caused by the tongue-tie such as: speech problems, errors of bite and deglutition, lingual dysfunction and anomalous oral habits.

[Results of a questionnaire on the treatment of cleft lip and palate in Spain]

OBJECTIVE

To present the results of a questionnaire done to evaluate the status of the multidisciplinary team treatment of cleft lip and palate in Spain, directed to know the experience and organization of each center.

METHOD

A questionnaire was sent to 34 hospitals asking about the following: existence of multidisciplinary team, number of primary surgical cleft operation in 1997, specialty of the primary surgeon/s, the presence in the hospital staff of: ENT, speech therapist, orthodontist, maxillofacial surgeon; if evaluation of the velopharyngeal function is done, if orthodontist meets with other members of the team, where the speech therapy is performed, how the financial burden of these treatments are covered and if there is a parent group.

RESULTS

Nineteen centers (55.8%) have responded. Only seven centers admit to have a multidisciplinary team, primary surgery is done by pediatric, plastic and maxillofacial surgeons, 36% of the surgeons operate less then 10 cases/year, the absence of a speech therapist and orthodontist in staff was 42% and 84% respectively, instrumental diagnosis of VPI is not performed in 60% of teams, scanty and not uniform cost coverage of these treatments, only 12% of centers admit to have a parent group.

CONCLUSIONS

Deficiencies of organization and staff are present in many centers, there is not a team culture. Centralization of primary surgery is needed. The need of a Spanish Cleft Palate Association is pointed. Eurocleft treatment guidelines are presented.

[Integrated treatment of cleft lip and palate. Organization of a treatment team]

OBJECTIVE

Collect the team experience in the treatment of children with cleft lip and palate, indicating the evolution of the team composition, advantages and improvement aspects, trying to transmit the need of team treatment.

METHOD

The Bilbao cleft palate team was created in 1983, since then a cleft palate clinic, a parents group and a unit of velopharyngeal function has been developed. At present the team is composed by: pediatric reconstructor surgeon, speech therapist, orthodontist, dentist, pediatrician, ENT, maxillofacial surgeon, dismorphologyst, geneticist, nursing.

RESULTS

One of the achievements has been the data unification, obtaining speech cephalometrics, photographic dental casts and video images with prospective view. At this time 403 cleft lip and palate children have been intervened, being essential the transdisciplinar team approach between surgeon, speech therapist and orthodontist. The importance of the team coordinator is pointed. The results of an audit of the two stage cleft palate closure in complete unilateral cleft lip and palate have obligated us to vary our surgical policy. The unresolved aspects are the lack of multidisciplinary team recognition at official level and the non existence of orthodontist in staff, without cost coverage of this treatment by public health system.

CONCLUSIONS

In our experience the team treatment of cleft lip and palate has resulted in improvement of the clinic results, treatment protocols and training.

[Cancellations in pediatric surgery]

Cancellations have an important role in the effectiveness of the surgical schedule.

OBJECTIVE

Analyze the evolution of the cancellations during the years 1994-1997, after institution of several corrective measures.

MATERIAL AND METHOD

We started in 1994 together with the Quality Unit of the Hospital, a program to reduce surgical cancellations. It consisted in improvement of parents information, surgical schedule centralization, and increasing the awareness of the importance of constant improvement. Cancellations have been divided in: inevitables and inevitables, and analyzed for the entire Service and for each speciality.

RESULTS

A significant reduction of cancellations have been obtain (from 12.38% in 1992 to 3.35% in 1997). The inevitable causes (no presentation, inadequate preparation and lack of time in the surgical room) have shown the most improvement. Although the inevitable causes (intercurrent disease) were also significantly improved, after obtaining prior information of the health of the child, by telephone call or parents advise. ENT is the speciality with greatest improvement by significant reduction of the non presentation and intercurrent disease.

CONCLUSION

After corrective measures conjointly with a realistic surgical schedule, prior telephone call and improvement quality concept, have permitted a significant reduction of cancellations.

[Post-adenoidectomy velopharyngeal insufficiency in children with velopalatine clefts]

The influence of adenoidectomy on speech has been well documented, essentially in cleft palate children. A revision of the speech outcome in 7 adenoidectomized cleft palate children reveals 4 cases of deteriorated speech. The need of a preoperative evaluation to look for risk factors is outlined, specially in cases of submucous cleft palate. The evolution of cases with permanent postadenoidectomy velar insufficiency with nasometry, shows increasing severity of nasality .

[Penoscrotal inversion]

A case of a child with complete penoscrotal transposition is presented. Surgical correction was performed in two stages. First, we performed penile elongation with scrotoplasty and partial perineal urethroplasty with the Thiersch Duplay technique, followed by Byars urethroplasty. The surgical techniques commonly used to correct this anomaly and their indications are reviewed. Currently, we recommend correction of hypospadias and transposition in a single stage procedure whenever possible.