Search

The study aimed to: (1) compare the occurrence of postoperative respiratory difficulties (PRD) following primary cleft palate repair (CPR) in infants with an isolated cleft palate (iCP) and infants with Robin sequence (RS), and (2) describe the possible benefit of preoperative analysis with palatal plate in infants with RS. All consecutive infants with an iCP and infants with RS who underwent CPR between January 2009 and June 2022 in the Wilhelmina Children's Hospital were retrospectively reviewed. A total of 127 infants were included of which 74 infants with an iCP and 53 infants with RS. The group of infants with RS consisted of 35 infants with non-isolated RS (niRS) and 18 infants with isolated RS (iRS). Significant more PRD were seen in infants with RS compared to infants with an iCP (14/53 versus 9/74; p = 0.04). Especially infants with niRS have a significant higher risk of developing PRD in comparison with infants with an iCP (OR = 4.16, 95% CI [1.17–15.99], p = 0.031). The preoperative palatal plate screening in infants with RS (n = 25) did not show abnormalities and had no effect on the perioperative policy. Within the limitations of this study it seems that infants with niRS are more prone to develop PRD following primary CPR when compared to infants with iRS or an iCP. No clear benefit was found in postponing surgery until 12 months or later in infants with RS to avoid PRD. The preoperative palatal plate screening did not demonstrate signs of UAO in infants with RS that developed PRD. These findings suggest that preoperative analysis with palatal plate has a low predictive value. [ABSTRACT FROM AUTHOR]

Background: Bone denudation after conventional relaxing incisions could be a critical factor in inhibiting maxillofacial growth. To address this, alternative relaxing incisions were designed. Thus, this study aimed to compare the effectiveness of palatal relaxing incisions versus nasopharyngeal relaxing incisions in enhancing postoperative outcomes. Materials and methods: A retrospective cohort study was conducted, involving a total of 120 patients divided into three groups: 40 patients have received modified Furlow palatoplasty with nasopharyngeal relaxing incisions (M.F + N.P.I palatoplasty), and 40 patients who received modified Furlow palatoplasty with palatal relaxing incisions (M.F + P.R.I palatoplasty). The other 40 patients received original Furlow palatoplasty without relaxing incisions (F palatoplasty). Data collected included gender, cleft type, cleft width, age at repair, velopharyngeal function, presence of palatal fistula, and follow-up. The chi-square test compared frequencies of sex, cleft type, postoperative fistula, and velopharyngeal outcomes across groups. The Mann–Whitney and independent t-tests compared mean values, with statistical significance set at p < 0.05. Results: The mean age at repair was similar across groups, with follow-up periods ranging from 5 to 11 years. No significant differences were found among the M.F + N.P.I and M.F + P.L.I groups regarding gender, cleft type, cleft width, and age at repair. However, the F group had a significantly narrowest cleft width compared to the other groups. Postoperative outcomes showed no significant differences in velopharyngeal function among the three groups, but the F group had a significantly higher rate of palatal fistula (32.5%) compared to the M.F + P.L.I (10%) and M.F + N.P.I (7.5%) groups. A comparison of the two modified Furlow techniques revealed no significant differences in velopharyngeal closure rates or the incidence of velopharyngeal insufficiency and persistent palatal fistula across different Veau classifications. Conclusions: While both incisions showed similar impacts on palatoplasty outcomes, palatal relaxing incisions may expose more bone and pose a higher risk of secondary healing issues. Therefore, nasopharyngeal relaxing incisions are recommended as an effective and potentially preferable technique in palatoplasty whenever feasible. Clinical relevance: The current study suggests that, whenever feasible, nasopharyngeal relaxing incisions are advised as an effective and potentially superior technique in palatoplasty. [ABSTRACT FROM AUTHOR]

Surgical robotic tools are being developed for a variety of surgical procedures that are executed within small workspaces. Novel designs of miniaturized cable-actuated surgical tools for cleft palate repair have previously been developed. However, the behavior and significance of friction within these tools are largely unknown. A study was conducted to investigate the friction in a pulleyless 3 mm diameter wristed instrument. The wrist utilizes cable guide channels that allow for miniaturization at the cost of increased friction. An experimental rig was developed to measure friction within the wrist link mechanism when the tool is positioned at various pitch angles. A strong relationship between the cable tension and the tool's pitch angle was found as a result of friction. The cable tension increased as the pitch angle approached extreme values (percent increases in the cable tension of 33% and 67.3% at a pitch of 90° and −90°, respectively). However, the resultant cable tension was below the failure strength of the cable, indicating that the design is feasible. The results of this study would be useful to those considering the design of miniature robotic surgical tools that are cable-driven. Significant tool reduction can be achieved by employing static guide channels for the cables, forgoing the use of additional moving components like pulleys while maintaining cable tension well within its break strength. Future work in the design and optimization of novel miniaturized wrist mechanisms should consider frictional effects and their impact on mechanism function. [ABSTRACT FROM AUTHOR]

Background and Objectives: Serous otitis media (SOM), also called otitis media with effusion (OME) or glue ear, is a collection of non-purulent fluid within the middle ear space. Children with cleft palate are more prone to develop this condition. This is caused by impaired eustachian tube function in cleft palate. They may present with hearing loss, delayed speech, and language development or poor social behavior. This is a significant cause of conductive hearing loss in the early speech-forming years of their life. Even after an early surgical repair of palate, speech and language defects are frequently identified during regular postoperative follow-up by speech-language pathologists. When identified, the approach to language delay varies across healthcare systems and includes watchful waiting, providing hearing aids to early otological intervention. The primary objective was to compare the incidence of SOM in children with and without language delay following surgical correction of cleft palate. Materials and Methods: A case-control study involving 63 patients was conducted in a tertiary care hospital with a high-volume cleft lip and palate center from June 2022 to March 2023. Thirty children with language delay were identified and grouped as cases and 33 children without language delay as controls. Tympanogram was conducted after the detailed otoscopic examination. Those with Jerger types B and C were diagnosed with SOM. The incidence of SOM in each group was compared statistically. Results: About 70% of cases and 87.9% of controls had SOM. There is no positive correlation between the incidence of SOM and language delay (P -value > 0.05). Conclusion: SOM cannot be identified as a causal factor for language delay after cleft palate surgery. [ABSTRACT FROM AUTHOR]

Objectives: After cleft lip and/or palate (CL/P) repair, children may develop velopharyngeal insufficiency (VPI) leading to speech imperfections, necessitating additional speech correcting surgery. This study examines the incidence of VPI and speech correcting surgery after Sommerlad’s palatoplasty for CL/P, and its association with various clinical features. Materials and methods: A retrospective cohort study was performed in the Wilhelmina Children’s Hospital in Utrecht and child records from 380 individuals with CL/P registered from 2008 to 2017 were retrospectively reviewed. Inclusion criteria comprised the diagnosis of CL/P, primary palatoplasty according to Sommerlad’s technique, and speech assessment at five years or older. Association between cleft type and width, presence of additional genetic disorders and postoperative complications (palatal dehiscence, fistula) were assessed using odds ratios and chi squared tests. Results: A total of 239 patients were included. The VPI rate was 52.7% (n = 126) and in 119 patients (49.8%) a speech correcting surgery was performed. Severe cleft type, as indicated by a higher Veau classification, was associated with a significant higher rate of speech correcting surgeries (p = 0.033). Significantly more speech correcting surgeries were performed in patients with a cleft width >10 mm, compared to patients with a cleft width ≤10 mm (p < 0.001). Patients with oronasal fistula underwent significantly more speech correcting surgeries than those without fistula (p = 0.004). No statistically significant difference was found in the incidence of speech correcting surgery between patients with and without genetic disorders (p = 0.890). Conclusions/clinical relevance: Variations in cleft morphology, cleft width and complications like oronasal fistula are associated with different speech outcomes. Future research should focus on creating a multivariable prediction model for speech correcting surgery in CL/P patients. [ABSTRACT FROM AUTHOR]

Cleft palate repair is a common reconstructive procedure that can involve significant blood loss. Tranexamic acid (TXA) has been proposed to minimise blood loss during various surgical procedures, but its effectiveness in cleft palate repair remains unclear. This systematic review and meta-analysis aimed to assess the effectiveness of TXA to reduce postoperative blood loss. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search across multiple databases, including PubMed, Cochrane, and Web of Science, to identify relevant studies published up to September 2023. Only randomised controlled trials (RCTs) were included. Primary outcomes measured were total blood loss, transfusion rates, and postoperative complications. We identified four relevant RCTs, which included 275 cleft palate patients with a mean (range) age of 28.7 (6–65) months. The pooled analysis found no significant difference in duration of surgery (MD -18.40 minutes, p = 0.09), preoperative haemoglobin (MD 0.46 g/dl, p = 0.27), or postoperative haemoglobin (MD 0.07 g/dl, p = 0.86) between TXA and control groups. Intraoperative blood loss was lower with TXA, but with TXA, the difference was not statistically significant (MD -16.63 ml, p = 0.15). TXA significantly improved surgical field visibility (p = 0.004). No adverse events occurred with its use. While no significant differences were found in surgical outcomes with TXA, surgical field visibility significantly improved, and TXA showed a promising safety profile. Larger and higher-quality RCTs are still needed to validate these preliminary findings before TXA can be considered as a standard treatment. [ABSTRACT FROM AUTHOR]

Abstract Background Cleft palate repair surgery may result in severe pain in the immediate postoperative period. The aim of this study is to compare the effects of different doses of nalbuphine for postoperative analgesia in children with cleft palate. Methods From November 2019 to June 2021, 90 children (45 males and 45 females, age 9–20 months old, ASA class I—II) were selected for palatoplasty. They were randomly divided into three groups: the control group (Group C), the N1 group (postoperative analgesia with 0.05 mg/kg/h nalbuphine) and the N2 group (postoperative analgesia with 0.075 mg/kg/h nalbuphine). Each group had 30 cases. Nalbuphine was not continuously infused in Group C but was continuously infused in Groups N1 and N2 at rates of 0.05 mg/kg/h and 0.075 mg/kg/h, respectively, for 24 h for postoperative analgesia. The FLACC analgesia score and Ramsay Sedation score were recorded at 10 min (T1), 30 min (T2), 2 h (T3), 12 h (T4) and 24 h (T5) after the operation. Adverse reactions such as nausea, vomiting and respiratory depression were observed and recorded. Results Compared with those in Group C, the FLACC scores in the N1 and N2 groups decreased significantly at T1-T5 (p

Objective: The objective of this study was to compare the incidence of palatal fistula formation between cleft palate (CP) repair with collagen matrix graft and conventional repair without collagen matrix graft. Patients and Methods: This was a preliminary randomized controlled study of patients with CP who underwent primary palatoplasty (two-flap palatoplasty technique) at the Lagos University Teaching Hospital. Patients were randomly allocated to either the test group (palatoplasty with collagen graft) or the control group (palatoplasty without collagen graft). The primary outcome was palatal fistula, and secondary outcomes were wound dehiscence, surgical site inflammation, surgical site infection, and surgeon satisfaction up to 3 months postoperative (PO). Results: Ten patients were recruited, five in each group. Only one patient in the control group developed a palatal fistula at 1 month PO on the soft palate which extended to the junction of hard and soft palate at 3 months PO. Eight patients developed wound dehiscence, five in the test group and three in the control group. Surgical site inflammation persisted up to at least 7 days PO in nine patients (five in the test group and four in the control group). All persistent wound dehiscence and surgical site inflammation resolved at 3 months PO. No patient developed surgical site infection. No significant difference was seen between the study group and wound dehiscence, surgery time, and difficulty of the procedure (P > 0.05 for all associations). Conclusion: Collagen graft may have a protective effect against fistula formation without significantly increasing surgery time and difficulty. However, due to the small sample size, the study failed to draw definite conclusions. Results from this study may inform future designs of larger randomized controlled studies.

Surgical robotic tools are being developed for a variety of surgical procedures that are executed within small workspaces. Novel designs of miniaturized cable-actuated surgical tools for cleft palate repair have previously been developed. However, the behavior and significance of friction within these tools are largely unknown. A study was conducted to investigate the friction in a pulleyless 3 mm diameter wristed instrument. The wrist utilizes cable guide channels that allow for miniaturization at the cost of increased friction. An experimental rig was developed to measure friction within the wrist link mechanism when the tool is positioned at various pitch angles. A strong relationship between the cable tension and the tool’s pitch angle was found as a result of friction. The cable tension increased as the pitch angle approached extreme values (percent increases in the cable tension of 33% and 67.3% at a pitch of 90° and −90°, respectively). However, the resultant cable tension was below the failure strength of the cable, indicating that the design is feasible. The results of this study would be useful to those considering the design of miniature robotic surgical tools that are cable-driven. Significant tool reduction can be achieved by employing static guide channels for the cables, forgoing the use of additional moving components like pulleys while maintaining cable tension well within its break strength. Future work in the design and optimization of novel miniaturized wrist mechanisms should consider frictional effects and their impact on mechanism function.

Objectives: In cleft palate patients, the soft palate is commonly closed using straight-line palatoplasty, Z-palatoplasty, or palatoplasty with buccal flaps. Currently, it is unknown which surgical technique is superior regarding speech outcomes. The aim of this review is to study the incidence of speech correcting surgery (SCS) per soft palatoplasty technique and to identify variables which are associated with this outcome. Materials and methods: A systematic literature search was carried out according to the PRISMA guidelines. Inclusion and exclusion criteria were applied to focus on the incidence of SCS after soft palatoplasty. Additional variables like surgical modification, cleft morphology, syndrome, age at palatoplasty, fistula and assessment of velopharyngeal function were reported. A modified New-Ottawa Scale (NOS) was used for quality appraisal. Pooled estimates from the meta-analysis were calculated using a random-effects model. Results: One thousand twenty-nine studies were found of which 54 were included in the analysis. The pooled estimate proportion of SCS after straight-line palatoplasty was 19% (95% CI 15–24), after Z-palatoplasty 6% (95% CI 4–9), and after palatoplasty with buccal flaps 7% (95% CI 4–11). Conclusions: A lower SCS rate was found in patients receiving Z-palatoplasty when compared to straight-line palatoplasty. We propose a minimum set of outcome parameters which ideally should be included in future studies regarding speech outcomes after cleft palate repair. Clinical relevance: Current literature reports highly heterogenous data regarding cleft palate repair. Our recommended set of parameters may address this inconsistency and could make intercenter comparison possible and of better quality. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to compare the incidence of palatal fistula formation between cleft palate (CP) repair with collagen matrix graft and conventional repair without collagen matrix graft. Patients and Methods: This was a preliminary randomized controlled study of patients with CP who underwent primary palatoplasty (two‑flap palatoplasty technique) at the Lagos University Teaching Hospital. Patients were randomly allocated to either the test group (palatoplasty with collagen graft) or the control group (palatoplasty without collagen graft). The primary outcome was palatal fistula, and secondary outcomes were wound dehiscence, surgical site inflammation, surgical site infection, and surgeon satisfaction up to 3 months postoperative (PO). Results: Ten patients were recruited, five in each group. Only one patient in the control group developed a palatal fistula at 1 month PO on the soft palate which extended to the junction of hard and soft palate at 3 months PO. Eight patients developed wound dehiscence, five in the test group and three in the control group. Surgical site inflammation persisted up to at least 7 days PO in nine patients (five in the test group and four in the control group). All persistent wound dehiscence and surgical site inflammation resolved at 3 months PO. No patient developed surgical site infection. No significant difference was seen between the study group and wound dehiscence, surgery time, and difficulty of the procedure (P > 0.05 for all associations). Conclusion: Collagen graft may have a protective effect against fistula formation without significantly increasing surgery time and difficulty. However, due to the small sample size, the study failed to draw definite conclusions. Results from this study may inform future designs of larger randomized controlled studies. [ABSTRACT FROM AUTHOR]

Objective To observe the effect of different doses of ε-aminocaproic acid （EACA） on wound bleeding in infants undergoing cleft palate repair. Methods One hundred and twenty infants scheduled to undergo cleft palate repair， aged from 6 to 36 months， ASA status Ⅰ or Ⅱ， were randomly divided into the control （group C）， conventional-dose EACA （group E1） and low-dose EACA groups （group E2）， 40 cases in each group. Infants in groups E1 and E2 were administrated with a loading dose of EACA （40 mg/kg） for 20 min before incision， followed by continuous infusion of 30 mg/（kg·h） and 10 mg/（kg·h） in two groups， respectively. In group C， continuous infusion of normal saline was applied. Same anesthesia regimen was delivered for all patients among three groups. Wound bleeding scores during operation， before extubation and 24 h after operation， intraoperative blood loss， anesthesia time， operation time， and fibrinogen concentration before and 24 h after surgery， and the incidence of delayed haemorrhage， deep vein thrombosis and epilepsy were recorded. Results Compared with group C， the wound bleeding scores during operation and before extubation in group E1 and E2 were significantly lower， the amount of intraoperative blood loss was significantly less， and the fibrinogen concentration at postoperative 24 h was significantly increased （all P < 0.05）， while no significant statistical difference was observed between groups E1 and E2 （all P > 0.05）. There were no statistically significant differences in operation time， anesthesia time and the incidence of delayed hemorrhage among three groups （all P > 0.05）. No deep vein thrombosis or epilepsy occurred among three groups. Conclusion The application of EACA in infants with cleft palate repair can mitigate perioperative wound bleeding and lower the incidence of delayed hemorrhage. Low-dose EACA yields favorable hemostatic effect. These findings provide reference for drug use in clinical practice.

Purpose: The current pilot study aimed to collect craniofacial surgeon's personal perspectives regarding the timing of cleft palate surgical repair, medical considerations for surgical repair (i.e., age, weight, type of cleft, and potential for surgical complications), and social considerations (i.e., speech–language development, socioeconomic status, and familial support). Materials and Methods: Fifteen plastic surgeons currently practicing cleft palate repair participated in this study. Surveys were distributed electronically to team coordinators of the American Cleft Palate-Craniofacial Association-accredited craniofacial teams and included a combination of Likert scales, closed multiple-choice questions, and open-ended qualitative questions for free-text responses. Results: Preliminary data obtained in this study suggest that the most common age range for palate repair in nonmedically complex infants is 10–11 months of age (n = 10). Notably, 20% of respondents (n = 3) reported a typical surgical repair time of 7–9 months of age. While medical and social priorities differed, all surgeons rated speech–language development as an important factor when determining the timing of surgical intervention. Conclusion: Given the limited consensus on surgical timing and intervention for children with cleft palate, further research is needed to determine the optimal timing of palate repair that considers both medical safety and near age-appropriate speech sound acquisition and production.

Purpose: The current pilot study aimed to collect craniofacial surgeon's personal perspectives regarding the timing of cleft palate surgical repair, medical considerations for surgical repair (i.e., age, weight, type of cleft, and potential for surgical complications), and social considerations (i.e., speech--language development, socioeconomic status, and familial support). Materials and Methods: Fifteen plastic surgeons currently practicing cleft palate repair participated in this study. Surveys were distributed electronically to team coordinators of the American Cleft Palate-Craniofacial Association-accredited craniofacial teams and included a combination of Likert scales, closed multiple-choice questions, and open-ended qualitative questions for free-text responses. Results: Preliminary data obtained in this study suggest that the most common age range for palate repair in nonmedically complex infants is 10-11 months of age (n = 10). Notably, 20% of respondents (n = 3) reported a typical surgical repair time of 7-9 months of age. While medical and social priorities differed, all surgeons rated speech--language development as an important factor when determining the timing of surgical intervention. Conclusion: Given the limited consensus on surgical timing and intervention for children with cleft palate, further research is needed to determine the optimal timing of palate repair that considers both medical safety and near age-appropriate speech sound acquisition and production. [ABSTRACT FROM AUTHOR]

Objective To observe the effect of different doses of ε-aminocaproic acid (EACA)on wound bleeding in infants undergoing cleft palate repair. Methods One hundred and twenty infants scheduled to undergo cleft palate repair, aged from 6 to 36 months, ASA status Ⅰ or Ⅱ, were randomly divided into the control (group C), conventional-dose EACA (group E1)and low-dose EACA groups (group E2), 40 cases in each group. Infants in groups E1 and E2 were administrated with a loading dose of EACA (40 mg/kg)for 20 min before incision, followed by continuous infusion of 30 mg/(kg · h)and 10 mg/(kg · h)in two groups, respectively. In group C, continuous infusion of normal saline was applied. Same anesthesia regimen was delivered for all patients among three groups. Wound bleeding scores during operation, before extubation and 24 h after operation, intraoperative blood loss, anesthesia time, operation time, and fibrinogen concentration before and 24 h after surgery, and the incidence of delayed haemorrhage, deep vein thrombosis and epilepsy were recorded. Results Compared with group C, the wound bleeding scores during operation and before extubation in group E1 and E2 were significantly lower, the amount of intraoperative blood loss was significantly less, and the fibrinogen concentration at postoperative 24 h was significantly increased (all P < 0.05), while no significant statistical difference was observed between groups E1 and E2 (all P > 0.05). There were no statistically significant differences in operation time, anesthesia time and the incidence of delayed hemorrhage among three groups (all P > 0.05). No deep vein thrombosis or epilepsy occurred among three groups. Conclusion The application of EACA in infants with cleft palate repair can mitigate perioperative wound bleeding and lower the incidence of delayed hemorrhage. Low-dose EACA yields favorable hemostatic effect. These findings provide reference for drug use in clinical practice. [ABSTRACT FROM AUTHOR]

The purpose of this study was to assess the effect of tongue−lip adhesion (TLA) on the long-term speech and articulation outcomes of patients with Robin sequence (RS) after cleft palate repair. Outcomes were compared to those in patients with RS who required positioning alone and to patients with isolated cleft palate (ICP). All consecutive patients with RS (with or without TLA) versus isolated cleft palate (ICP) who underwent cleft palate repair were retrospectively reviewed. Speech and articulation included all assessments between the age of 3–6 years. Secondary speech operations, velopharyngeal insufficiency (VPI), hypernasality, and articulation errors by cleft-type characteristics (CTC), including 4 categories (passive), non-oral, anterior-oral, and posterior-oral. A total of 41 RS patients and 61 ICP patients underwent repair with sufficient follow-up. Of them, 23 patients underwent a TLA at median age of 12 days. Rates of hypernasality (p = 0.004), secondary speech operations (p = 0.004), and posterior oral CTC (p = 0.042) were higher in RS compared to ICP. Isolated RS had speech outcomes similar to those of ICP; however, syndromic RS patients needed more secondary speech operations compared to isolated RS (p = 0.043). TLA-RS patients did not demonstrate differences in speech outcomes or any CTCs (all p > 0.05) compared to non−TLA-RS patients, except for the anterior oral CTC (74% TLA-RS vs 28% non−TLA-RS, p = 0.005). Within the limitations of the study, it seem that TLA does not affect long-term velopharyngeal function in patients with RS. However, TLA-RS patients demonstrated higher rates of anterior-oral CTC, which might be related to a different positioning of the tongue after TLA. Every effort should be taken to treat patients with RS conservatively instead of with TLA because of this demonstrated a negative effect on one type of articulation error. However, if conservative therapy fails, a TLA is still a valuable adjunct in the treatment of RS, and cleft speech pathologists who treat such patients should be more aware of this phenomenon in order to improve long-term articulation outcomes. [ABSTRACT FROM AUTHOR]

Background: Although the United Kingdom (UK) cleft surgeons follow a similar training pathway, and cleft centers adhere to similar protocols regarding the timing of palate surgery and surgical technique, speech outcomes still vary between centers. Objective: To explore the training experiences of consultant cleft lip and palate (CL/P) surgeons, performing a Sommerlad radical intravelar veloplasty (IVVP) and their approach to teaching others. Design: An exploratory, qualitative approach was adopted to understand the views of UK cleft surgeons performing a Sommerlad radical IVVP and discuss what was important during training and upon qualifying as a consultant. Method: A semi-structured interview schedule was designed, interviews were conducted in-person or via videoconferencing, depending on preference and availability, with interested surgeons. The interviews were recorded, transcribed, and checked for accuracy. Analysis involved inductive thematic analysis. Results: Fourteen cleft consultants from the UK participated (3F:11M). Seven of the consultants were trained in plastic surgery and four in maxillofacial surgery. Seven themes were identified from the thematic analysis. Three themes, namely Learning to perform palate repair, Teaching others to perform palate repair, and Ongoing learning as a consultant are discussed. Conclusions: Cleft palate repair is clearly a technically challenging procedure to learn and teach with the potential to cause harm if performed incorrectly. Positive changes have been made to improve exposure to palate surgery, encourage practice away from the patient, and increase supervised practical experience. The role of colleagues in providing mentorship and support appears invaluable. We provide some simple recommendations that may improve the training experience and ensure parity for all trainees. [ABSTRACT FROM AUTHOR]

Cleft lip and palate are the most frequent congenital anomalies of the face. They may be either unilateral or bilateral and involve either lip or palate or both lip and palate. These orofacial clefts can occur as a part of a syndrome or isolated clefts. Multidisciplinary management should be considered in cleft lip and palate patients to fully ensure speech and hearing, the continuation of occlusion and maxillofacial growth. All branches of dentistry treat cleft lip and palate sequentially at various stages of life. [ABSTRACT FROM AUTHOR]

Objective: To determine predictors of success following Veau 1 and 2 cleft palate repair in patients with and without syndromes. Study Design: Retrospective review of prospectively collected data. Setting: Tertiary care children's hospital. Methods: All children <18 months of age undergoing Furlow palatoplasty for Veau 1 and 2 cleft repair between 2000 and 2014 with postoperative perceptual speech assessment (PSA). Results: In total, 368 consecutive patients were identified; 95 were excluded, resulting in 273 patients. Median age at surgery was 13.0 months (interquartile range [IQR], 11-15 months) with postoperative PSA at a median of 32.3 months (IQR, 26.3-44.5 months). Fifty patients (18.3%) had syndrome diagnosis; 59 patients (21.6%) had nonsyndromic Robin sequence. Velopharyngeal insufficiency (VPI) occurred in 27 patients (10.5%); 13 underwent secondary speech surgery. Cleft-related speech errors occurred in 46 patients (17.6%). Non-cleft-related speech errors occurred in 155 patients (59.6%) and reduced intelligibility in 127 patients (47.9%). Oronasal fistula occurred in 23 patients (8.8%) and was exclusive to Veau 2 clefts. In multivariate analysis, age >13 months at palatoplasty demonstrated a 6-fold higher rate of VPI (hazard ratio [HR], 6.64; P <.01), worse speech outcomes (HR, 6.04; P <.01; HR, 1.60; P <.01; HR, 1.57; P =.02), and greater speech therapy utilization (HR, 2.18; P <.01). Conclusion: VPI occurred in 10% of patients undergoing Furlow palatoplasty repair of Veau 1 or 2 clefts. Age <13 months at palatoplasty was associated with improved speech outcomes and lower VPI incidence (2.8% vs 16.2%). Syndromic diagnosis was associated with noncleft speech errors and reduced intelligibility on univariate analysis but not velopharyngeal function after palatoplasty. [ABSTRACT FROM AUTHOR]

Objective: The mainstay of palatal repair in the United Kingdom is the intravelar veloplasty (IVVP). It is not always possible to align the oral mucosa in the midline to achieve tension-free repair. The addition of lateral relieving incisions may aid transposition of the oral mucosa to allow closure. The aim of this study was to explore cleft features that may predispose to a requirement for relieving incisions in order to allow palate closure. Design: We performed a national multiinstitutional retrospective study using data from the UK Cleft Collective cohort study. Patients: The study sample consisted of 474 patients who had undergone IVVP at the time of palatal closure across all 16 of the UK cleft units. Results: We found strong evidence for the requirement for relieving incisions in patients with an increased degree of clefting per the Veau classification (P <.001), increasing palatal soft-edge width (P <.001) and moderate evidence of an associated use in patients with Pierre Robin sequence (P =.015). Insufficient data were available to explore the relationship between intertuberosity distance and the presence of fistula formation with the use of relieving incisions. Conclusions: The results of this study identify cleft features that increase the likelihood for requiring lateral relieving incisions to allow palatal closure. The degree to which the addition of relieving incisions to IVVP affects maxillary growth and speech outcomes is unknown. Further study is required to answer this important question. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the development process and clinical impact of implementing a standardized perioperative clinical care pathway for cleft palate repair. Design: Medical records of patients undergoing primary cleft palate repair prior to pathway implementation were retrospectively reviewed as a historical control group (N = 40). The historical cohort was compared to a prospectively collected group of patients who were treated according to the pathway (N = 40). Patients: Healthy, nonsyndromic infants undergoing primary cleft palate repair at a tertiary care pediatric hospital. Interventions: A novel, standardized pathway was created through an iterative process, combining literature review with expert opinion and discussions with institutional stakeholders. The pathway integrated multimodal analgesia throughout the perioperative course and included intraoperative bilateral maxillary nerve blocks. Perioperative protocols for preoperative fasting, case timing, antiemetics, intravenous fluid management, and postoperative diet advancement were standardized. Main Outcome Measures: Primary outcomes include: (1) length of hospital stay, (2) cumulative opioid consumption, (3) oral intake postoperatively. Results: Patients treated according to the pathway had shorter mean length of stay (31 vs 57 hours, P <.001), decreased cumulative morphine consumption (77 vs 727 μg/kg, P <.001), shorter time to initiate oral intake (9.3 vs 22 hours, P =.01), and greater volume of oral intake in first 24 hours postoperatively (379 vs 171 mL, P <.001). There were no differences in total anesthesia time, total surgical time, or complication rates between the control and treatment groups. Conclusions: Implementation of a standardized perioperative clinical care pathway for primary cleft palate repair is safe, feasible, and associated with reduced length of stay, reduced opioid consumption, and improved oral intake postoperatively. [ABSTRACT FROM AUTHOR]

Highlights: • Economic factors and insufficient information about cleft palate treatment was the primary cause of delayed repairs,except for Parents' education levels. • The essential responsibility of primary care physicians is to provide education on treatment stages to minimize delays. Abstract: Introduction: Optimal time of Cleft palate repair is during the 10 to 12 month of age. In this time produce far natural results in terms of speech because it enabled the maturation of scar tissue postoperatively. The soft palate must function properly before the patient starts learning to talk, otherwise speech disorders such as persistent rhinolalia aperta might arise. In pediatric patients, the role of parents is very important on adherence to therapy. Methods: This is a cross-sectional study. The first study group was parents of patients who had surgical repair before two years old and the second group was the parents of patients who had repair after two years old. We compared age, monthly income, education level, number of children, and residential distance from Surabaya of the two groups. Results: The data of this study were obtained from the medical records of patients with cleft lip surgery at CLP Center Surabaya in 2015th-2017th with total of 358 patients, 172 were female and 186 were male. 52 patients with delayed cleft palate surgery. Patients' parents in both groups were mostly 31- 40 years old, were high school graduated, has one child, earned less than 1.5 million rupiah a month, and lived less than 100 kms from Surabaya. From the statistical results, parent's income has the strongest correlation with the patient's age in cleft palate surgery (-2.7). A negative coefficient means that the less parent's income, the more patient likely had delayed cleft palate surgery. While other factors found weak and very weak correlations. Conclusions:The results form patient's parents' interview, concluded that besides economic factors, the lack of information cleft palate treatment is the key factors that contributed to the delay of cleft palate repair. The education level does not affect the delay in cleft palate surgery, because even in high educated parents, sometimes they don't understand the stages of cleft lip and palate treatment. This study emphasized the necessity to educate about the stages of surgery by primary care physicians, to minimize delays.

Background: Although cleft surgeons in the United Kingdom follow a similar training pathway, and cleft centers adhere to similar protocols regarding timing of palate surgery and surgical technique, speech outcomes still vary significantly between centers. Objective: To explore if differences in technique exist between individual surgeons, performing a Sommerlad radical intravelar veloplasty (IVVP). Design: An exploratory, qualitative approach was adopted to understand the views of UK cleft surgeons performing a Sommerlad radical IVVP for primary cleft palate repair and to discuss what was important in the adoption, adaptation, and evolution of this technique within their own practice. Method: A semistructured interview schedule was designed. Interviews were conducted in person or via videoconferencing, with interested surgeons. The interviews were recorded, transcribed, and checked for accuracy. Analysis involved inductive thematic analysis. Results: Fourteen cleft consultants from the United Kingdom participated (3 females and 11 males). Seven of the consultants were trained in plastic surgery and 4 in oral and maxillofacial surgery. Eight themes were identified from the thematic analysis. One theme--Surgical Variation--is discussed. Conclusions: The findings provide insight into areas of variation seen within one surgical technique of cleft palate repair. These variations may have arisen to accommodate heterogeneity in the patient population or may have evolved in relation to different experiences of training or influences of colleagues. Further work is needed to explore the reasons for these differences in technique and to identify if any of these subtle differences contributed to variability in outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The aim of this study is to compare speech outcomes, fistula rates, and rates of secondary speech surgeries after palatoplasty using Furlow palatoplasty or type 2b intravelar veloplasty for soft palate repair. Patients with unilateral cleft lip and palate who had either Furlow palatoplasty or intravelar veloplasty for soft palate repair were retrospectively evaluated for demographic and perioperative variables and speech outcomes. Fistula rate, secondary surgical intervention for improved speech results, and findings of speech assessment were further reviewed for the patients who met the inclusion criteria. A total of 76 patients, 36 in the Furlow palatoplasty group and 40 in the intravelar veloplasty group, were included in the study. In the speech assessment, nasalance values were statistically similar between the two groups. Also, there was no statistically significant difference between the groups in velopharyngeal motility (p = 0.103). The total rates of secondary surgeries and fistula were statistically similar between the groups (p = 0.347 and 0.105, respectively). The similar outcomes of speech and surgical evaluation between the two groups make the surgeon's preference determinant in the selection of the surgical technique for soft palate repair. [ABSTRACT FROM AUTHOR]

Grisel's syndrome is nontraumatic atlantoaxial subluxation secondary to inflammatory conditions or surgery in the head and neck region due to anomalous head posture. In this case report, a 6-year-old female patient, diagnosed as Grisel's syndrome following the surgery for the repair of cleft palate with velopharyngeal insufficiency is presented. This is to note the importance of perioperative positioning and postoperative stabilization. 6 years old female child, with a weight of 23 kg admitted to the hospital for speech disorders and velopharyngeal insufficiency associated with cleft palate. She underwent surgery for the repair of cleft palate and three weeks after surgery, she was readmitted to the hospital with abnormal head posture, pain and limitation in neck movements. After cervical CT scanning, atlantoaxial subluxation was confirmed. She was diagnosed as Grisel's syndrome and treated with conservative therapy by stabilization of the neck with a hard cervical collar and medical treatment. Extreme head positions are sometimes necessary for cleft lip and palate surgeries. Early diagnosis of Grisel's syndrome is critical for a successful treatment. INSET: 56. [ABSTRACT FROM AUTHOR]

Objective: To increase access to high-quality and multiregional databases in global epidemiology of cleft surgeries through partnership with an NGO. Design: The study retrospectively analyzes 34 801 primary palate surgeries in 70+ countries from the 2016 electronic health records of an non-governmental organization (NGO). The study also utilizes the Kids' Inpatient Database to compare the epidemiology of primary cleft palate surgeries in the United States. Participants: Patient records of those undergoing primary cleft palate surgeries only. Main Outcome Measures: Region, age, sex, type of cleft, laterality of cleft. Results: Key findings show that average age of those receiving primary cleft palate surgery in the low- and middle-income countries (LMICs) was 1.95 years. The distribution of males and females receiving surgery corresponds to the US national data. More hard cleft palates were on the left side (66.18%) than the right side (33.82%), independent of gender and region. Conclusions: Databases from an established NGO can be used to enhance our understanding of the disease characteristics in these regions. By increasing the information available regarding cleft surgeries in the LMIC, we hope to increase awareness of the similarities and differences in surgeries across various regions, as part of an effort to inform the goals set by Global Surgery 2030 initiative by the Lancet Commission. [ABSTRACT FROM AUTHOR]

Objective: To test the feasibility of implementing a high-fidelity cleft palate simulator during a workshop in Santiago, Chile, using a novel video endoscope to assess technical performance. Design: Sixteen cleft surgeons from South America participated in a 2-day cleft training workshop. All 16 participants performed a simulated repair, and 13 of them performed a second simulated repair. The repairs were recorded using a low-cost video camera and a newly designed camera mouth retractor attachment. Twenty-nine videos were assessed by 3 cleft surgeons using a previously developed cleft palate objective structured assessment of technical skill (CLOSATS with embedded overall score assessment) and global rating scale. The reliability of the ratings and technical performance in relation to minimum acceptable scores and previous experience was assessed. Results: The video setup provided acceptable recording quality for the purpose of assessment. Average intraclass correlation coefficient for the CLOSATS, global, and overall performance score was 0.69, 0.75, and 0.82, respectively. None of the novice surgeons passed the CLOSATS and global score for both sessions. One participant in the intermediate group, and 2 participants in the advanced group passed the CLOSATS and global score for both sessions. There were highly experienced participants who failed to pass the CLOSATS and global score for both sessions. Conclusions: The cleft palate simulator can be practically implemented with video-recording capability to assess performance in cleft palate repair. This technology may be of assistance in assessing surgical competence in cleft palate repair. [ABSTRACT FROM AUTHOR]

The prosthodontic rehabilitation of patients postcleft palate repair is an important part of the multidisciplinary approach to solving the many problems related to total health. One such problem is speech difficulties and articulation errors. High-arched palate associated with cleft palate repair affects phonation and articulation by affecting the approximation of its surface with the tongue. This results in unintelligible and hypernasal sound production. Palatogram is a fairly simple, yet highly efficacious clinical technique for the assessment of palatal contours, to improve the existent speech deficiencies of affected sounds. This case report demonstrates a multidisciplinary treatment approach to successfully improve the intelligibility of speech by fabrication of a speech appliance by making a palatogram and customizing the palatal contours. [ABSTRACT FROM AUTHOR]

Backgound Pierre Robin sequence (PRS) has worse speech outcomes than isolated cleft palate. We aimed to search for possible associations of phonological outcomes with PRS status (isolated vs syndromic), clinical severity, soft palate muscles deficiency, or surgical procedure. Methods We designed a retrospective study of 130 children (male/female ratio: 0.4) with isolated (96) or syndromic (34) PRS with cleft palate. Grading systems were used to classify retrognathia, glossoptosis, and respiratory and feeding disorders. Electromyography was used to investigate levator veli palatini muscles. Hard cleft palate was measured using maxillary casts. Intravelar veloplasty was performed using the Sommerlad's technique. Phonological outcomes were assessed using the Borel-Maisonny classification. Results Cleft palate was repaired in one stage (65.5%) or hard palate closure was postponed (34.5%). Velopharyngeal insufficiency was more frequent in syndromic PRS (53%) vs. isolated PRS (30.5%) ( p = 0.01), but was not statistically associated with clinical grade, hard cleft palate width, soft palate electromyography, and surgical procedure. Conclusions In children with PRS, anatomic variables, initial clinical severity, and soft palate muscle deficiency are not predictors of speech prognosis. [ABSTRACT FROM AUTHOR]

Background:The aim of this study was to investigate speech outcomes in children with clefts in the hard and/or soft palate only (CPH/CPS), in order to determine the prevalence of cleft speech characteristics, the change between 5 and 10 years of age, and the difference in occurrence between CPH and CPS. Methods:A consecutive series of 88 children born with CPH or CPS were included in a retrospective cohort. All participants were treated with one-stage palatal repair using a minimal incision technique with muscle reconstruction (mean age 13 months). Twelve children (14%) received a velopharyngeal flap. Cleft speech variables were rated at 5 and 10 years of age independently by three experienced external speech-language pathologists. Inter- and intra-rater agreements were determined, and the prevalence of cleft speech characteristics was calculated. Results:Moderate-to-severe hypernasality and weak pressure consonants were present in 5%–10% of the children at 5 years, with marginal but statistically significant improvement at 10 years of age. Frequently or always occurring audible nasal air leakage was detected in 20% of children at age 5, and increased to ∼35% of the children at 10 years. Ten per cent had compensatory articulation at age 5, and 25% demonstrated s-distortions, whereas few had these problems at age 10. Conclusions:The results demonstrate low occurrence of compensatory articulation problems in this cohort, even by 5 years of age. The high presence of symptoms of velopharyngeal insufficiency at 10 years of age suggests a need for additional secondary velopharyngeal surgery. [ABSTRACT FROM PUBLISHER]

Introduction: Despite the improved techniques of repair of cleft palate, fistula occurrence is still a possibility either due to an error in the surgical technique or due to the poor tissue quality of the patient. Though commonly the fistula closure is established by use of local flaps but at times the site and the size of the fistula make use of local flaps for its repair a remote possibility. The use of tongue flaps because of the central position in the floor of the mouth, mobility and the diversity of positioning the flaps make it a method of choice for closure of anterior palatal fistulae than any other tissues. The aim of this study was to analyse the utility of tongue flap in anterior palatal fistula repair. Materials and Methods: We had 41 patients admitted to our hospital during the period 2006-2012 for repair of palatal fistula and were enrolled into the study. In the entire 41 cases, fistula was placed anteriorly. The size of the fistulae varied from 2 cm × 1.5 cm to 5.5 cm × 3 cm. The flaps were divided after 3-week and final inset of the flap was done. Observation and Result: None of the patients developed flap necrosis, in one case there was the dehiscence of the flap, which was reinset and in one patient there was bleeding. None of our patients developed functional deformity of the tongue. Speech was improved in 75% cases. Conclusion: Leaving apart its only drawback of two-staged procedure and transient patient discomfort, tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulae.

Objective: To compare anthropometric z-scores with incidence of post-operative complications for patients undergoing primary cleft lip or palate repair. Design: This was a retrospective observational analysis of patients from a surgical center in Assam, India, and includes a cohort from a single surgical mission completed before the opening of the center. Setting: Patients included in the study underwent surgery during an Operation Smile mission before the opening of Operation Smile’s Guwahati Comprehensive Cleft Care Center in Guwahati, India. The remaining cohort received treatment at the center. All patients received preoperative assessment and screening; surgery; and postoperative care, education, and follow-up. Patients, Participants: Our sample size included 1941 patients and consisted of all patients with complete information in the database who returned for follow-up after receiving primary cleft lip repair or primary cleft palate repair between January 2011 and April 2013. Interventions: Preoperative anthropometric measurements. Main Outcome Measure(s): Postoperative complications. Results: Anthropometric z-scores were not a significant predictor of adverse surgical outcomes in the group analyzed. Palate surgery had increased risk of complication versus lip repair, with an overall odds ratio of 5.66 (P , .001) for all patients aged 3 to 228 months. Conclusions: Anthropometric z-scores were not correlated with increased risk of surgical complications, possibly because patients were well screened for malnutrition before surgery at this center. Primary palate repair is associated with an approximate fivefold increased risk of developing postoperative complication(s) compared with primary lip repair. [ABSTRACT FROM AUTHOR]

Background: Opioid analgesics used for analgesia are associated with sedation, respiratory depression and post-operative nausea and vomiting. Non-steroidal anti-inflammatory drugs such as diclofenac are a safe and effective alternative with opioid-sparing effect. Objective: To evaluate the effectiveness of pre-operative rectal diclofenac suppository (1 mg/kg) in cleft palate repair for post-operative analgesia and reduction in post-operative opioid requirements. Study Design: A randomized clinical trial. Methods: After obtaining approval from the institutional ethical committee, 60 children were allocated by a computer-generated randomisation into two groups of 30 each; group D (Diclofenac group) and group C (Conventional group). Children in group D and group C were similar in all aspects except for the fact that group D children received 1 mg/kg diclofenac suppository after induction. Pain was evaluated using modification of the objective pain scale by Hannallah and colleagues for 6 h post-operatively by an anaesthesiology resident or nursing staff who was blinded to the group. If the pain score was more than 3, rescue analgesic I.V. fentanyl 0.5 μgm/kg was administered. The pain scores at different intervals, number of doses and quantity of rescue analgesic required were noted. Results: We observed that pre-operative rectal diclofenac provided effective analgesia in the immediate post-operative period, as evidenced by reduced pain scores and reduced opioid requirement (P=0.00002). There was no evidence of any increased perioperative bleeding in the diclofenac group. Conclusion: Pre-operative rectal diclofenac reduces opioid consumption and provides good post-operative analgesia.

The article offers information on economic evaluation of reparing of cleft palate in International Adoptees including payments of Medicaid adjusted physicians. Topics discussed include economic aspects related to hospitality and anesthesiology, family expenditure after adoption, and recommendations of health insurers.

Objective: This study uses the American College of Surgeons Pediatric National Surgical Quality Improvement Program (ACS NSQIP Pediatric), a multicenter database, to identify risk factors for complications after cleft palate repair. Design: Patients undergoing Current Procedural Terminology (CPT) codes 42200 and 42205 were extracted from the 2012 ACS NSQIP Pediatric. Patients older than 36 months or those who had undergone an additional surgery that altered the risk were excluded. Outcome variables were combined to create a complication variable. Fisher's exact, Pearson chi-square, and Wilcoxon rank-sum tests were used for analysis. Results: Eligibility criteria were met by 751 patients. Of these, 192 (25.6%) had unilateral clefts, 146 (19.4%) bilateral, and 413 (55.0%) were unspecified. The average age at time of surgery for those without and with complications was 421.1 ± 184.8 and 433.6 ± 168.0 days, respectively (P = .76). Of the 21 (2.8%) patients with complications, respiratory complications were the most common. Risk factors associated with complications included American Society of Anesthesiologists classification of 3 (P = .003), nutritional support (P = .013), esophageal/gastric/intestinal disease (P = .016), oxygen support (P = .003), structural pulmonary/airway abnormality (P = .011), and impaired cognitive status (P = .009). Patients undergoing concurrent laryngoscopy (P = .048) or other surgeries (P = .047) were also found to be associated with increased complications. The 30-day fistula rate was 0.5%, and the readmission rate was 1.9%. Conclusion: Perioperative complications for primary palatoplasty were 2.8% according to the ACS NSQIP Pediatric. Preoperative patient-related factors as well as concurrent surgeries may affect 30-day complication rates. These results help target those at greater risk for complications and allow for appropriate interventions to mitigate risks. [ABSTRACT FROM AUTHOR]

Summary Cleft palate repair for Pierre Robin Sequence (PRS) patients has always been a challenge for surgeons and anesthetists. The aim of this systematic review is to investigate the outcome of cleft palate repair for PRS patients compared with cleft palate-only patients. All papers published before October 2014 were searched in the databases PubMed and MEDLINE. Search terms included “Pierre Robin Sequence,” “cleft palate repair,” and “speech result.” Additional studies were identified by hand searching the reference lists of the papers retrieved from electronic search. Two independent reviewers assessed the eligibility of studies for inclusion, extracted the data, and assessed the quality of the studies. Six studies met the inclusion criteria. All but one study had multiple deficiencies in study designs. Four studies assessed the fistula rate of both groups, and all studies assessed some aspect of the speech results. Conflicting results and a lack of high-quality and long-term outcomes of reviewed studies provided no conclusive scientific evidence about whether the outcome of cleft palate repair for PRS patients was better or worse than cleft palate-only patients. Further well-designed, well-controlled, and long-term studies are needed. [ABSTRACT FROM AUTHOR]

Palatal and pharyngeal surgeries often require wide visibility and access. Various mouth gags and retractors have been devised and many modifications suggested to optimize these surgeries. The Dingman mouth gag, one of the commonly used retractors, offers a lot of advantages in terms of good mouth opening, tongue retraction, self-retaining cheek retractors, and anchorage for sutures, but it has a main limitation in that it allows only limited visibility of the anterior palate and alveolus. Hence, a modification of the Dingman mouth gag is presented for better visibility of and accessibility to the anterior palate. [ABSTRACT FROM AUTHOR]

Scarring is the primary factor of maxilla growth restriction among people who have undergone cleft palate repair surgery. p38 mitogen-activated protein kinase (p38MAPK) promotes fibrosis in a variety of organs. However, its role in post-surgery scarring on the hard palate has not been fully understood. This study is designed to investigate the role of p38MAPK in scar formation and maxilla growth of rats. We removed the mucosa on the hard palate of rats and applied the p38MAPK silencing adenovirus vector on it two weeks after surgery. Then the scarring tissue and maxilla growth were evaluated by histological and morphological examination. The effect of p38MAPK silencing on scarring-related genes in fibroblasts was also studied. We found that local injection of Ad-p38MAPK-1 in vivo effectively reduces the expression of p38MAPK and scarring-related proteins and weakens the impact of scarring on the width of the hard palate. Mechanistically, p38MAPK silencing inhibits the expression of α-smooth muscle actin (α-SMA) via mediating the production and nuclear localization of myocardin-related transcription factor A (MRTF-A) in fibroblasts. These results reveal a molecular pathway of scar formation involving p38MAPK/MRTF-A stimulation and support targeting p38MAPK as a potentially effective treatment for post-surgery scarring on the hard palate. [ABSTRACT FROM AUTHOR]

Introduction: Despite the improved techniques of repair of cleft palate, fistula occurrence is still a possibility either due to an error in the surgical technique or due to the poor tissue quality of the patient. Though commonly the fistula closure is established by use of local flaps but at times the site and the size of the fistula make use of local flaps for its repair a remote possibility. The use of tongue flaps because of the central position in the floor of the mouth, mobility and the diversity of positioning the flaps make it a method of choice for closure of anterior palatal fistulae than any other tissues. The aim of this study was to analyse the utility of tongue flap in anterior palatal fistula repair. Materials and Methods: We had 41 patients admitted to our hospital during the period 2006-2012 for repair of palatal fistula and were enrolled into the study. In the entire 41 cases, fistula was placed anteriorly. The size of the fistulae varied from 2 cm × 1.5 cm to 5.5 cm × 3 cm. The flaps were divided after 3-week and final inset of the flap was done. Observation and Result: None of the patients developed flap necrosis, in one case there was the dehiscence of the flap, which was reinset and in one patient there was bleeding. None of our patients developed functional deformity of the tongue. Speech was improved in 75% cases. Conclusion: Leaving apart its only drawback of two-staged procedure and transient patient discomfort, tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulae. [ABSTRACT FROM AUTHOR]

Background Wound infiltration with ketamine reduces postoperative pain after tonsillectomy by NMDA receptor blockade and local anesthetic effect. Objectives To evaluate the postoperative analgesia after surgical site infiltration with bupivacaine or ketamine in children undergoing cleft palate surgery. Materials and methods After institutional ethics committee approval and parental consent, 50 ASA-1 children of age 1-6 years undergoing palatoplasty were included in this prospective randomized double-blind study. A standardized technique of general anesthesia was used. The surgical site was infiltrated with either 2 mg·kg−1 of bupivacaine (Group B) or 0.5 mg·kg−1 of ketamine (Group K). Pain (Children Hospital Eastern Ontario Pain Score), sedation, dysphagia, nausea, vomiting, and sleep pattern were assessed postoperatively up to 24 h. Results CHEOPS scores were similar in both the groups up to 12 h but were lower with ketamine compared with bupivacaine at 24 h postoperatively ( P = 0.01). Fewer children required rescue analgesics in Group K (28%) than in Group B (64%; P < 0.01). The time to first rescue analgesic and the amount of analgesics used in 24 h were similar in the two groups. Fewer children suffered from dysphagia in Group K (52%) than in Group B (88%; P < 0.01). More children in Group B had disturbed sleep than in Group K at 6 (88% vs 56%; P = 0.012) and 12 h (60% vs 24%; P = 0.01) postoperatively. None of the children had deep sedation, desaturation or respiratory depression. Conclusion Surgical site infiltration with either bupivacaine or ketamine provides adequate analgesia and is devoid of major side effects. Ketamine is superior to bupivacaine in terms of requirement of rescue analgesic, peaceful sleep pattern and early resumption of feeding. [ABSTRACT FROM AUTHOR]

Background: Opioid analgesics used for analgesia are associated with sedation, respiratory depression and post-operative nausea and vomiting. Non-steroidal anti-inflammatory drugs such as diclofenac are a safe and effective alternative with opioid-sparing effect. Objective: To evaluate the effectiveness of pre-operative rectal diclofenac suppository (1 mg/kg) in cleft palate repair for post-operative analgesia and reduction in post-operative opioid requirements. Study Design: A randomized clinical trial. Methods: After obtaining approval from the institutional ethical committee, 60 children were allocated by a computer-generated randomisation into two groups of 30 each; group D (Diclofenac group) and group C (Conventional group). Children in group D and group C were similar in all aspects except for the fact that group D children received 1 mg/kg diclofenac suppository after induction. Pain was evaluated using modification of the objective pain scale by Hannallah and colleagues for 6 h post-operatively by an anaesthesiology resident or nursing staff who was blinded to the group. If the pain score was more than 3, rescue analgesic I.V. fentanyl 0.5 µgm/kg was administered. The pain scores at different intervals, number of doses and quantity of rescue analgesic required were noted. Results: We observed that pre-operative rectal diclofenac provided effective analgesia in the immediate post-operative period, as evidenced by reduced pain scores and reduced opioid requirement (P=0.00002). There was no evidence of any increased perioperative bleeding in the diclofenac group. Conclusion: Pre-operative rectal diclofenac reduces opioid consumption and provides good post-operative analgesia. [ABSTRACT FROM AUTHOR]

Surgery is an important part of health care worldwide. Without access to surgical treatments, morbidity and mortality increase. Access to surgical treatment is a significant problem in global public health because surgical services are not equally distributed in the world. There is a disproportionate scarcity of surgical access in low-income countries. There are many charitable organizations around the world that sponsor surgical missions to under served nations. One such organization is Operation Smile International, a group with which both authors have volunteered. This paper will describe the purpose and processes involved in Operation Smile and identify some of the key ethical issues that arise in short term medical volunteer work highlighting the importance of sustainability. [ABSTRACT FROM AUTHOR]

An account of the history surrounding the first successful surgical repair of a cleft palate, with excerpts from the patient's narrative. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Oronasal fistula represents a functional problem after cleft palate repair; its closure is technically difficult with a high recurrence rate after primary treatment. The aim of this study was to evaluate the efficacy of closure of oronasal fistula using 2 layers of oral mucoperiosteum in a V–Y manner. Methods: Fourteen patients were subjected for repair of their oronasal fistulas using 2 layers; the first is the oral mucoperiosteum that is elevated and inverted to close the nasal side as a hinge flap, and the second is also the oral mucoperiosteum that is elevated and sutured in a V–Y manner to close the oral side. Results: In all cases, the fistula was completely closed at first attempt, no cases developed operative or postoperative complications. Recurrence with not recorded in any case after a follow-up period of at least 12 months. Conclusion: Closure of oronasal fistula of the hard palate that may develop after cleft palate repair using a two-layer closure in V–Y manner is an easy and ideal method with a high success rate. [ABSTRACT FROM AUTHOR]

Objective: To ascertain the quality of analgesia provided by morphine in comparison to codeine. Design: The study is a prospective, randomized, double-blind trial of analgesic effect employing validated pain scores. Patients: Infants having primary cleft palate repair with informed parental consent to enter the study. Interventions: Infants received one of two analgesics intraoperatively for immediate postoperative pain relief. Morphine was given by intravenous injection and codeine by the intramuscular route. Main Outcome Measure: Pain scores in the immediate postoperative period for 2 hours following surgery; this outcome measure was decided prior to data collection. Results: The pain score and other outcome measures were all blinded. Measurements are all evident from the nature of the results. Conclusions: There was no clinically significant difference observed in the analgesic effect of either drug on the two groups studied. [ABSTRACT FROM AUTHOR]

Objective: To present a new comprehensive and simple classification of vomerine flaps for palatoplasty. Design: This classification has been developed on the basis of a literature search and our clinical experience. The vomerine flaps have been classified into three types, each with A and B subtypes. Patients, Participants: Vomerine tissue has been used in more than 1000 palatoplasties over the past 17 years. The analysis includes 678 cleft palate patients for whom detailed records were available. Type II-A vomerine flaps were used most commonly in unilateral cleft palate patients, whereas Type II-B1 flaps were used in bilateral cleft palate patients. Results: The overall fistula rate at the hard and soft palate junction was 2.95%. Although facial growth pattern was not recorded, obvious midface growth abnormalities were not observed in any of these patients. Conclusions: Vomerine tissue is available in the vicinity of the palatal defect. Raising of the vomerine flap is simple and safe. If properly designed, it can be used judiciously for closure of the nasal and oral defects in the cleft palate. We have used these flaps only to augment the nasal mucosal defect. This comprehensive classification will be useful in understanding, designing, and implementing these small, but very important, flaps. [ABSTRACT FROM AUTHOR]

Objective: We investigated the effect of the bacterial flora of the nose and throat on the outcome of the initial repairs of the cleft palate in the presence of prophylactic antibiotics. Design: A retrospective review of 90 procedures in 66 patients who had cleft palate repair between April 2005 and June 2007 was conducted at Booth Hall Children's Hospital, Manchester, U.K. Both isolated cleft palate and cleft lip and palate patients were included. Exclusion criteria included syndromic cases, other medical disorders, and revisions of previous cleft palate repairs. Nose and throat swabs were taken on admission. Benzyl penicillin and flucloxacillin were given perioperatively. The occurrence of oronasal fistulas was correlated with the bacteria grown on culture. Results: The oronasal fistula rate was 15.9%. The highest fistula rate in procedures with positive swabs was seen with Moraxella catarrhalis.Conclusions: M. catarrhalis has not been previously recognized as a pathogen in cleft palate repairs. This study demonstrates a higher fistula rate in procedures positive for M. catarrhalis. Other factors that may have contributed to the fistula formation include the severity of the initial cleft and technical factors. Further study is required before a definitive link can be established. [ABSTRACT FROM AUTHOR]