Reconstruction of Fistulas Following Cleft Palate Repair.

To determine the degree of weight loss, time to regain lost weight, and impact on postoperative outcomes after primary cleft lip (CL) and cleft palate (CP) repair. Single institution retrospective. Two hundred seven patients who underwent primary CL and/or CP repair procedures. One hundred thirty primary CL repairs (isolated CL = 59; cleft lip and palate [CLP] = 71) and 140 primary CP repairs (isolated CP = 72; CLP = 69): At the first postoperative visit, 21.54% of CL and 57.14% of CP repair patients had not returned to their immediate preoperative weights ( P < .0001). Maximum weight loss after CL repair was 0.44 kg (mean = 0.15 kg; standard deviation [SD]: 0.11) and for CP repair was 0.85 kg (mean = 0.31 kg; SD: 0.21; P = .002). Maximum percentage body weight loss was 6.11% after CL repair (mean = 2.08%; SD: 1.56) and 9.2% after CP repair (mean = 3.10%; SD: 2.13; P = .02). If not returned to preoperative weight by first postoperative visit, CP repair took significantly longer. Median time to return to preoperative weight was CL = 14.08 days (interquartile range [IQR]: 7.26) and CP = 25.37 days (IQR: 21.07; P < .0001). Patients undergoing CP repair with slowed weight recovery had a 22.5% rate of unintentional fistula/partial dehiscence compared to 10.0% of those who recovered quickly ( P = .052). Primary CP repair involves significantly higher risk and degree of postoperative weight loss and slower rates of weight recovery when compared with primary CL repair. Postoperative weight loss is associated with increased risk of complications with palatal healing. Cleft palate repair patients should be monitored closely for weight recovery and considered for nutritional interventions to support improved postoperative outcomes.

Different cleft palate repair techniques have been described to achieve optimum results and minimise complications. Postoperative fistulae are one of the most challenging complications after palate repair. In this clinical study, we reviewed the records of patients who underwent palatoplasty using acellular dermal matrix (ADM) as an addition to facilitate difficult cleft palate and palatal fistula closure. It was a retrospective, comparative, single-centre study, in which records of patients who underwent cleft palate surgeries between 2015 and 2018 were reviewed. Patients who underwent cleft palate or palatal fistula repair with and without ADM were included. Fischer's exact test was used to compare the two groups (primary cleft palate repair with and without ADM) in relation to the rate of fistula occurrence postoperatively. Charts of a total of 31 patients were reviewed. ADM was used in 13 patients; 8(61.5%) were primary repairs and 5(38.5%) were fistula repairs. Eighteen patients were repaired without ADM, of whom 16(88.9%) were primary cleft palate repairs and 2(11.1%) were fistula repairs. The statistical analysis showed no significant difference in fistula formation rate or recurrence in both the groups. ADM is a simple, safe, and helpful tool for augmenting cleft palate repair, mainly in relatively wide and high-tension cleft palate repairs. In our study, a trend showing decreased complications with ADM was observed. Therefore, we recommend a multi-centre study with a larger sample to assess the significance of ADM in cleft palate and palatal fistulae repair.

As healthcare spending within the United States grows, payers have attempted to curb spending through higher cost sharing for patients. For families attempting to balance financial obligations with their children's surgical needs, high cost sharing could place families in difficult situations, deciding between life-altering surgery and bankruptcy. We aim to investigate trends in patient cost sharing and provider payments for cleft lip and palate repair. The IBM® MarketScan® Commercial Database was queried to extract patients younger than 18 years who underwent primary or secondary cleft lip and/or palate repair from 2007 to 2016. Financial variables included gross payments to the provider (facility and/or physician), net payment as reported by the carrier, coordination of benefits and other savings, and the beneficiary contribution, which consisted of patients' coinsurance, copay, and deductible payments. Linear regression was used to evaluate trends in payments over time. Poisson regression was used to trend the proportion of patients with a nonzero beneficiary contribution. All financial values were adjusted to 2016 dollars per the consumer price index to account for inflation. The sample included 6268 cleft lip and 9118 cleft palate repair episodes. Total provider payments increased significantly from 2007 to 2016 for patients undergoing cleft lip (median, $2527.33 vs $5116.30, P 0.008) and palate ($1766.13 vs $3511.70, P < 0.001) repair. Beneficiary contribution also increased significantly for both cleft lip ($155.75 vs $193.31, P < 0.001) and palate ($124.37 vs $183.22, P < 0.001) repair, driven by an increase in deductibles ( P < 0.002). The proportion of cleft palate patients with a nonzero beneficiary contribution increased yearly by 1.6% ( P = 0.002). Higher provider payments and beneficiary contributions were found in the Northeast ( P < 0.001) and South ( P < 0.011), respectively, for both cleft lip and palate repair. The US national data demonstrate that for commercially insured patients with cleft lip and/or palate, there has been a trend toward higher patient cost sharing, most pronounced in the South. This suggests that patients are bearing an increased cost burden while provider payments are simultaneously accelerating. Additional studies are needed to understand the impact of increased cost sharing on parents' decision to pursue cleft lip and/or palate repair for their children.

Objective: To characterize pediatric patients experiencing unplanned intraoperative extubation (UIE) during cleft lip (CL) and cleft palate (CP) repair and assess postoperative outcomes. Design: Retrospective cohort study using the 2019-2023 National Surgical Quality Improvement Program-Pediatric database. Setting: Multicenter surgical registry of pediatric operations. Patients: Children undergoing CL repair (<1 year) or CP repair (<3 years). Interventions: Not applicable. Main Outcome Measure(s): Incidence of UIE, demographic and operative characteristics, and 30-day postoperative complications. Results: Among 17 047 cases, UIE occurred in 0.37% of CL repairs and 0.20% of CP repairs. Patients who experienced UIE had similar baseline characteristics to those without UIE but demonstrated significantly longer operative and anesthesia times for both procedures. Despite these intraoperative events, no cases of death, pneumonia, or unplanned reintubation occurred postoperatively, and overall 30-day complication rates remained low. Conclusions: UIE during CL and CP repair is rare and not associated with major postoperative complications.

Outcomes of Tympanoplasty After Cleft Palate Repair: A Systematic Review and Meta-analysis.

To identify the impact of sociodemographic and health variables on the age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation. A retrospective, noninterventional quality assessment, and quality improvement study was designed. This institutional study was performed at Michigan Medicine in Ann Arbor, MI. All patients born between 2011 and 2014 who received surgical cleft repair, excluded those who were adopted (n = 165). The age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation. Cleft lip repair was performed significantly later for patients identifying as Asian (18 weeks, P = .01), patients with Child Protective Services contact (19 weeks, P = .01), patients with a significant comorbidity (14 weeks, P = .02), and patients who underwent preliminary lip adhesion surgery (19 weeks, P < .01). Cleft palate repair was performed significantly later for patients identifying racially as Asian (19 weeks, P = .03) and other (22 weeks, P = .03). Preliminary speech and language evaluation were performed significantly later for patients identifying as black (55 weeks, P = .03) and patients diagnosed with an isolated cleft lip (71 weeks, P < .01). Timing of cleft lip, cleft palate repair, and primary speech and language evaluation are subject to variation which may be predicted by clinically accessible factors. By identifying race, Child Protective Services contact, and care variables as significant predictors of increased patient age at time of intervention, multidisciplinary cleft care teams can proactively allocate patient support resources.

To assess outcomes from cleft palate repair and define the level of impact of palatal fistula on subsequent velopharyngeal function. A retrospective cohort study. A regional specialist cleft lip and palate center within United Kingdom. Nonsyndromic infants born between 2002 and 2009 undergoing cleft palate primary surgery by a single surgeon with audited outcomes at 5 years of age. Four hundred ten infants underwent cleft palate surgery within this period and 271 infants met the inclusion criteria. Cleft palate repair including levator palati muscle repositioning with or without lateral palatal release. Postoperative fistula development and velopharyngeal function at 5 years of age. Lateral palatal incisions were required in 57% (156/271) of all cases. The fistula rate was 10.3% (28/271). Adequate palatal function with no significant velopharyngeal insufficiency (VPI) was achieved in 79% of patients (213/271) after primary surgery only. Palatal fistula was significantly associated with subsequent VPI (risk ratio = 3.03, 95% confidence interval: 1.95-4.69; P < .001). The rate of VPI increased from 18% to 54% when healing was complicated by fistula. Bilateral cleft lip and palate (BCLP) repair complicated by fistula had the highest incidence of VPI (71%). Cleft palate repair with levator muscle repositioning is an effective procedure with good outcomes. The prognostic impact of palatal fistula on subsequent velopharyngeal function is defined with a highly significant 3-fold increase in VPI. Early repair of palatal fistula should be considered, particularly for large fistula and in BCLP cases.

Measurement of treatment outcome is important in estimating the success of cleft management. The aim of this study was to assess the surgical outcome of cleft lip and palate surgery. The surgical outcome of 131 consecutive patients with cleft lip and palate surgeries between October 2008 and December 2010 were prospectively evaluated at least 4 weeks postoperatively. Data collected included information about the age, sex, type of cleft defects, and type of surgery performed as well as postoperative complications. For cleft lip repair, the Pennsylvania lip and nose (PLAN) score was used to assess the surgical outcome, while the integrity of the closure was used for cleft palate repair. A total of 92 patients had cleft lip repair and 64 had palate repair. Overall, 68.8% cases of cleft lip and palate repair had good outcomes; 67.9% of lip repairs had good lip and nose scores, while 70.2% of palatal repair had a good surgical outcome. Oro-fistula was observed in 29.8% of cleft palate repairs Inter-rater reliability coefficient was substantially significant. The fact that 25.7% of those treated were aged >1 year suggests a continued need to enlighten the public on the availability of cleft lip and palate expertise and treatment. Although an overall good treatment outcome was demonstrated in this study, the nasal score was poorer than the lip score. Complication rate of about 14% following surgical repair is consistent with previous reports in the literature.

To examine the impact of race/ethnicity on timing and postoperative outcomes of primary cleft lip (CL) and cleft palate (CP) repair. Cross-sectional analysis of the National Surgical Quality Improvement Program Pediatric (NSQIP-P) database from 2013 to 2018. Patients under 2 years of age who underwent primary CL or CP repair were identified in the NSQIP-P. Outcomes were the timing of surgery and 30-day readmission and reoperation rates stratified by race and ethnicity. In total, 6021 children underwent CL and 6938 underwent CP repair. Adjusted rates of CL repair over time were 10% lower in Hispanic children (95%CI: 0.84-0.96) and 38% lower for Asian children (95%CI: 0.55-0.70) compared with White infants. CP repair rates over time were 13% lower in Black (95%CI: 0.79-0.95), 17% lower in Hispanic (95%CI: 0.77-0.89), and 53% lower in Asian children (95%CI: 0.43-0.53) than in White infants. Asian patients had the highest rates of delayed surgical repair, with 19.3% not meeting American Cleft Palate-Craniofacial Association (ACPA) guidelines for CL (P < .001) and 28.2% for CP repair (P< .001). Black and Hispanic children had 80% higher odds of readmission following primary CL repair (95%CI: 1.16-2.83 and 95%CI: 1.27-2.61, respectively). This study of a national database identified several racial/ethnic disparities in primary CL and CP, with reduced receipt of cleft repair over time for non-White children. Asian patients were significantly more likely to have delayed cleft repair per ACPA guidelines. These findings underscore the need to better understand disparities in cleft repair timing and postoperative outcomes.

To compare the incidence of otorrhea in a group of infants with cleft palate (CP) and tympanostomy tubes before and after surgical repair of the CP. Prospective observational study. Otolaryngology clinic at a tertiary care children's hospital. Thirty-three infants with CP and middle ear effusions who underwent tympanostomy tube placement. Subjects were observed from the time of tube placement until 6 months after CP repair. Incidence of otorrhea before and after CP repair. Subjects were observed a mean of 6.3 months before CP repair and 6 months after CP repair. Before CP repair, 11 of 33 infants (33%) had no episodes of otorrhea, compared with 22 of 33 (67%) after CP repair (P = .007). Fourteen infants (43%) had 2 or more episodes of otorrhea before CP repair compared with 2 (6%) after CP repair (P = .001). Before CP repair, significantly fewer tubes were patent at the time of the audiologic evaluation compared with after CP repair (39 of 62 [63%] vs 52 of 66 [79%]; P = .048). Average speech reception threshold for the infants with tympanostomy tubes before CP repair was 18.1 dB compared with 12.6 dB after CP repair (P = .01). The incidence of otorrhea after tympanostomy tube placement before CP repair is higher than the incidence after CP repair, although more than half of all infants (19 [58%]) had either 1 or no episodes of otorrhea before CP repair.

In cleft palate repair, anatomically oriented, tension free, atraumatic total closure is the key to achieve a normal speech consecutive to a sufficient velopharyngeal closure and also to prevent postoperative fistula development. In this clinical study, we review our experience with acellular dermal matrix (ADM) which was used as an adjunct to facilitate difficult cleft palate and palatal fistula closure. From October 2009 till December 2013, primary cleft palate and fistula repairs in which ADM was used were culled from the cleft surgery files. Acellular dermal matrix was used as an extra layer in between palatal flaps of primary repairs and as a sandwiched sheet separating the flaps used to repair fistulas. In addition to patient, cleft and fistula demographics, records were evaluated for sizes, fistula development, fistula recurrence, extrusion, exposure, and infection. Acellular dermal matrix was used in 35 patients with palatal clefts of mean size 15 ± 4 mm and in 15 palatal fistulas. Two-flap palatoplasty technique was the dominant technique for the palate repair. Fistula rate for the palate repair was 8.5% and fistula recurrence rate was 20%. Mean follow-up for the palate and fistula repair patients was 29 ± 15 months and 32 ± 11 months, respectively. In two cases of palatoplasty group and in four cases of fistula repair group, ADM was exposed resulting in total extrusion in two fistula cases. In this ongoing experience of application, ADM has been shown to be a simple, safe, and helpful tool to reduce fistula rate mainly in relatively wide and high tension tenuous cleft palate repairs but less favorable in challenging fistula closure attempts particularly along with poorly vascularized surrounding tissues. However, study design and its results are yet far from strongly recommending routine ADM use in cleft palate surgery.

Airway obstruction following palatoplasty of a patient with sleep disturbance

The effect of dexmedetomidine on the duration of sensory blockade has not been studied in humans. We evaluated the effect of adding dexmedetomidine to bupivacaine on the duration of postoperative analgesia in children who underwent repair of a cleft palate. Thirty children who were scheduled for repair of a complete cleft palate using a combination of general anaesthesia and greater palatine nerve block were allocated randomly into one of two equal groups (n = 15). In both groups, the greater palatine nerve block was performed bilaterally using 0.5 ml of solution on each side. The B group received bupivacaine 0.25%, whereas the BD group received bupivacaine 0.25% with 1 microg kg(-1) dexmedetomidine. Heart rate, systolic blood pressure, pain score, the time to the first request for analgesia, and the degree of sedation were recorded. There was no difference in haemodynamic variables between the two groups. The pain score was significantly higher in the B group as compared with the BD group. The time to the first request for analgesia was significantly longer in children in the BD group (mean 22 h, range 20.6-23.7 h) as compared with those who received bupivacaine alone (14.2 h, 13-15 h). Sedation scores in the postoperative period did not differ between the study groups. Greater palatine nerve block with a combination of dexmedetomidine and bupivacaine increased the duration of analgesia after repair of a cleft palate by 50% with no clinically relevant side effects.

SUMMARY Seven foals, 2 horses, and 2 calves were presented to the George D. Widener Hospital for Large Animals at New Bolton Center and the Large Animal Clinic at Auburn University for surgical repair of cleft palate. All animals had preexisting pneumonia. Initial repair of cleft palate in 6 foals, 2 horses, and 2 calves was performed via mandibular symphysiotomy. Primary repair of cleft soft palate in a foal was attempted through a pharyngotomy incision after fracture of the basal hyoid bone; however, exposure was inadequate and mandibular symphysiotomy had to be done. Dehiscence of a portion of the cleft palate occurred in all cases (10 of 11) that survived the immediate postoperative period. A 2nd repair was attempted in 3 foals; however, dehiscence of the palate recurred. Osteomyelitis of the mandibular symphysis developed in 6 animals; dehiscence of the lower lip occurred in 3 animals. Serious complications after surgery led to euthanasia or death of 5 animals. Of the 6 surviving animals, 4 did not grow normally. All survivors experienced chronic nasal discharge often contaminated with food material. Although mandibular symphysiotomy provided adequate exposure for surgical repair of cleft palate, serious complications have not been overcome.

Cleft palate, a pure deformity, has no pathology. Its incidence and the part heredity plays in its production have long been studied by Mr. William F. Blades of the Eugenics Record Office, but no deductions can be drawn from the data as yet collected; so we must pass by this interesting phase of the condition, as well as its anatomic complex. The description of a method for the repair of a cleft palate will be limited to the single sided complete cleft. This is the most common lesion. All technical details applied to it are also applicable to other varieties of the deformity without special indication. The time at which to operate is of initial importance. I wait until the child has passed the first three or four months of life and has established a satisfactory state of health. I advocate and practice operating before the eruption of any teeth.