Increased Risk of Velopharyngeal Insufficiency in Patients Undergoing Staged Palate Repair

Objective: To evaluate the association of 2-stage cleft palate (CP) surgery on velopharyngeal insufficiency (VPI) incidence, speech surgeries, and cleft-related surgical burden. Design: Retrospective cohort with follow-up of 4 to 19 years. Setting: Academic, tertiary children’s hospital. Patients: Patients who underwent CP surgery between 2000 and 2017. Exclusions included submucous CP or age at last contact under 3.9. Interventions: Cleft palate surgery, completed in either a single-stage or 2-stage repair. Main Outcome Measure(s): Rates of VPI diagnosis and speech surgery and total cleft surgeries; t tests, tests of proportion, and linear and logistic regression were performed. Total cleft-related surgeries were examined in a subset (n = 418) of patients with chart reviews. Results: A total of 1047 patients were included; 59.6% had 2-stage CP repair, 40.4% had single-stage repair. Approximately 32% of children with 2-stage CP repair were diagnosed with VPI, as opposed to 22% of single-stage patients ( P < .001). Children with 2-stage CP repair were 1.8 times as likely to be diagnosed with VPI ( P < .001). Speech surgery rates were similar across groups. Patients who had 2-stage repair received an average of 2.3 more cleft-related procedures, when excluding prosthesis management procedures. Conclusion: Our data show an increased risk of VPI diagnosis and increased surgical burden among patients receiving 2-stage CP repair.

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Risk of Malocclusion Among Patients Undergoing Single-Stage Versus Two-Stage Cleft Palate Repair

The Cleft Palate-Craniofacial Journal ◽

10.1177/10556656211044944 ◽

2022 ◽

pp. 105566562110449

Author(s):

Hilary McCrary ◽

Vanessa Torrecillas ◽

Sarah Hatch Pollard ◽

Dave S. Collingridge ◽

Duane Yamashiro ◽

...

Keyword(s):

Cleft Palate ◽

Outcome Measure ◽

Single Stage ◽

Stage Versus ◽

Class Iii ◽

Class Iii Malocclusion ◽

Two Stage ◽

Increased Risk ◽

Cleft Palate Repair ◽

Palate Repair

Objective Evaluate impact of single-stage versus staged palate repair on the risk of developing malocclusion among patients with cleft palate (CP). Design Retrospective cohort study 2000–2016 Setting Academic, tertiary children’s hospital. Patients Patients undergoing CP repair between 1999–2015. Interventions CP repair, categorized as either single-stage or staged. Main Outcome Measure Time to development of Class III malocclusion. Results 967 patients were included; 60.1% had a two-stage CP repair, and 39.9% had single-stage. Malocclusion was diagnosed in 28.2% of patients. In the model examining all patients at ≤5 years ( n = 659), patients who were not white had a higher risk of malocclusion (HR 2.46, p = 0.004) and staged repair was not protective against malocclusion (HR 0.98, p = 0.91). In all patients >5 years ( n = 411), higher Veau classification and more recent year of birth were significantly associated with higher hazard rates ( p < 0.05). Two-staged repair was not protective against developing malocclusion (HR 0.86, p = 0.60). In the model examining patients with staged repair ≤5 years old ( n = 414), higher age at hard palate closure was associated with reduced malocclusion risk (HR 0.67, p < 0.001) and patients who were not white had increased risk (HR 2.56, p = 0.01). In patients with staged repair >5 years old, more recent birth year may be associated with a higher risk of malocclusion (HR 1.06, p = 0.06) while syndrome may be associated with lower risk of malocclusion diagnosis (HR 0.46, p = 0.07). Conclusion Our data suggests that staged CP repair is not protective against developing Class III malocclusion.

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Incidence of Oronasal Fistulae and Velopharyngeal Insufficiency after Cleft Palate Repair: An Audit of 211 Children Born between 1990 and 2004

The Cleft Palate-Craniofacial Journal ◽

10.1597/06-205.1 ◽

2008 ◽

Vol 45 (2) ◽

pp. 172-178 ◽

Cited By ~ 132

Author(s):

Yun Shan Phua ◽

Tristan de Chalain

Keyword(s):

Cleft Palate ◽

Surgical Repair ◽

Velopharyngeal Insufficiency ◽

Secondary Surgery ◽

Oronasal Fistula ◽

Future Performance ◽

Cleft Palate Repair ◽

Study Population ◽

Palate Repair

Objective: We present an audit of primary cleft palate surgery at our unit, including rates of oronasal fistula development, speech outcomes, and rates of velopharyngeal insufficiency requiring secondary surgery. Design: A retrospective study of patients with all cleft palate types, born between January 1990 and December 2004, who underwent primary palatoplasty at Middlemore Hospital, Auckland, New Zealand. Patients: The study included 211 patients, collectively operated on by five different surgeons. Results: The overall rate of true fistula development was 12.8% over a mean follow-up period of 4 years 10 months. The incidence of true fistulae that required surgical repair was 8.1%. Fistula rates were higher for more severe degrees of clefting but were not affected by gender or type of surgical repair. Overall, 31.8% of the study population had some degree of hypernasality following primary palatoplasty. Secondary surgery for velopharyngeal insufficiency was required in 13.3% of patients. Following surgical correction of velopharyngeal insufficiency, no patients were reported to have appreciable hypernasality and 21.7% were reported to have mild hypernasality, a result comparable to previously published audits. The requirement for secondary surgery was higher in patients with more severe clefts. Conclusion: Our results are comparable to other recent studies. We believe that highly coordinated cleft care helps ensure such outcomes. These data provide a benchmark against which we can measure future performance in our attempts to improve outcomes of cleft repair.

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Non-Interventional Factors Influencing Velopharyngeal Function For Speech In Initial Cleft Palate Repair: A Systematic Review Protocol

Systematic Reviews ◽

10.1186/s13643-019-1141-2 ◽

2019 ◽

Vol 8 (1) ◽

Cited By ~ 1

Author(s):

David Sainsbury ◽

◽

Caroline Williams ◽

Catherine de Blacam ◽

Joanne Mullen ◽

...

Keyword(s):

Systematic Review ◽

Cleft Palate ◽

Cleft Lip ◽

Screening Tool ◽

Outcome Measure ◽

Cleft Lip And Palate ◽

Velopharyngeal Insufficiency ◽

Future Studies ◽

Cleft Palate Repair ◽

Palate Repair

Abstract Background This systematic review aims to inform the development of a screening tool which pre-operatively predicts which children are likely to develop velopharyngeal insufficiency, one of the causes of poor speech outcomes, following cleft palate repair. This would be highly beneficial as it would inform pre-operative counselling of parents, allow targeted speech and language therapy, and enable meaningful comparison of outcomes between surgeons, techniques, and institutions. Currently, it is unclear which factors influence speech outcomes. A systematic review investigating the non-interventional factors which potentially influence speech outcomes following cleft palate repair is warranted. This may be illuminating in itself or provide foundations for future studies. Methods A systematic review will be carried out according to Cochrane methodology and reported according to PRISMA guidelines (PLoS Med 6: e1000097, 2009). Systematic review software will be used to facilitate three-stage screening by two independent reviewers experienced in cleft lip and palate. Thereafter, data extraction and GRADE assessment will be performed in duplicate by five independent reviewers experienced in cleft lip and palate. Studies reporting the proportion of patients who were recommended or underwent secondary speech surgery for velopharyngeal insufficiency following primary surgery for cleft palate will be included. The study findings will be tabulated and summarised. The primary outcome measure will be further speech surgery (either recommended or performed). The secondary outcome measure will be perceptual speech assessment for the presence of velopharyngeal insufficiency. A meta-analysis is planned. However, if this is not possible, due to the anticipated marked heterogeneity of study characteristics, pre-operative assessment, and the recorded outcome measures, a narrative synthesis will be undertaken. Discussion This systematic review may provide sufficient data to inform the development of a screening tool to predict the risk of velopharyngeal insufficiency prior to cleft palate repair. However, it is anticipated that these findings will provide the foundation for future studies in this area. Systematic review registration Registered on 19 December 2016 with PROSPERO CRD42017051624

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Is Risk of Secondary Surgery for Oronasal Fistula Following Primary Cleft Palate Repair Associated With Hospital Case Volume and Cost-to-Charge Ratio?

The Cleft Palate-Craniofacial Journal ◽

10.1177/1055665620959528 ◽

2021 ◽

Vol 58 (5) ◽

pp. 603-611

Author(s):

Giap H. Vu ◽

Christopher L. Kalmar ◽

Carrie E. Zimmerman ◽

Laura S. Humphries ◽

Jordan W. Swanson ◽

...

Keyword(s):

Cleft Palate ◽

Outcome Measure ◽

Charge Ratio ◽

Fistula Repair ◽

Case Volume ◽

Secondary Surgery ◽

Hospital Case ◽

Oronasal Fistula ◽

Cleft Palate Repair ◽

Palate Repair

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.

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Greater Palatal Cleft Width Predicts an Increased Risk for Unfavorable Outcomes in Cleft Palate Repair

The Cleft Palate-Craniofacial Journal ◽

10.1177/10556656211029537 ◽

2021 ◽

pp. 105566562110295

Author(s):

Åsa C. Okhiria ◽

Fatemeh Jabbari ◽

Malin M. Hakelius ◽

Monica M. Blom Johansson ◽

Daniel J. Nowinski

Keyword(s):

Cleft Palate ◽

Cleft Lip ◽

Cleft Lip And Palate ◽

University Hospital ◽

Velopharyngeal Insufficiency ◽

Secondary Surgery ◽

Increased Risk ◽

Cleft Palate Repair ◽

The Impact ◽

Nasal Emission

Objective: To investigate the impact of cleft width and cleft type on the need for secondary surgery and velopharyngeal competence from a longitudinal perspective. Design: Retrospective, longitudinal study. Setting: A single multidisciplinary craniofacial team at a university hospital. Patients: Consecutive patients with unilateral or bilateral cleft lip and palate and cleft palate only (n = 313) born from 1984 to 2002, treated with 2-stage palatal surgery, were reviewed. A total of 213 patients were included. Main Outcome Measures: The impact of initial cleft width and cleft type on secondary surgery. Assessment of hypernasality, audible nasal emission, and glottal articulation from routine follow-ups from 3 to 16 years of age. The assessments were compared with reassessments of 10% of the recordings. Results: Cleft width, but not cleft type, predicted the need for secondary surgery, either due to palatal dehiscence or velopharyngeal insufficiency. The distribution of cleft width between the scale steps on a 4-point scale for hypernasality and audible nasal emission differed significantly at 5 years of age but not at any other age. Presence of glottal articulation differed significantly at 3 and 5 years of age. No differences between cleft types were seen at any age for any speech variable. Conclusions: Cleft width emerged as a predictor of the need for secondary surgery as well as more deviance in speech variables related to velopharyngeal competence during the preschool years. Cleft type was not related to the need for secondary surgery nor speech outcome at any age.

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Cleft Palate

10.2310/ps.10026 ◽

2018 ◽

Author(s):

Oksana A Jackson ◽

Alison E Kaye ◽

David W Low

Keyword(s):

Cleft Palate ◽

Normal Function ◽

Speech Development ◽

Velopharyngeal Insufficiency ◽

Surgical Interventions ◽

Feeding Difficulties ◽

Oronasal Fistula ◽

Cleft Palate Repair ◽

Palate Repair ◽

Impaired Speech

A cleft of the palate represents one of the most common congenital anomalies of the craniofacial region. Palatal clefting can occur in combination with a cleft of the lip and alveolus or as an isolated finding and can vary significantly in severity. The intact palate is a structure that separates the oral and nasal cavities, and the function of the palate is to close off the nasal cavity during deglutition and to regulate the flow of air between the nose and mouth during speech production. An unrepaired cleft palate can thus result in nasal regurgitation of food and liquid, early feeding difficulties, and impaired speech development. The goals of surgical repair are to restore palatal integrity by closing the cleft defect and repairing the musculature to allow for normal function during speech. The secondary goal of cleft palate repair is to minimize deleterious effects on growth of the palate and face, which can be impacted by standard surgical interventions. This review describes two of the most commonly performed cleft palate repair techniques in use today, as well as highlighting special anatomic considerations, summarizing perioperative care, and reviewing postoperative complications and their management. This review contains 11 figures, 2 videos, 3 tables and 63 references Key words: cleft, cleft team, Furlow, orofacial, oronasal fistula, palatoplasty, speech, submucous cleft, velopharyngeal insufficiency

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Diagnosis and management of velopharyngeal insufficiency following cleft palate repair

Journal of Cleft Lip Palate and Craniofacial Anomalies ◽

10.4103/2348-2125.126536 ◽

2014 ◽

Vol 1 (1) ◽

pp. 4 ◽

Cited By ~ 2

Author(s):

ArunK Gosain ◽

MichaelS Gart

Keyword(s):

Cleft Palate ◽

Velopharyngeal Insufficiency ◽

Diagnosis And Management ◽

Cleft Palate Repair ◽

Palate Repair

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Treatment of Asymmetric Velopharyngeal Insufficiency with Skewed Pharyngeal Flap

The Cleft Palate-Craniofacial Journal ◽

10.1597/1545-1569_1994_031_0287_toaviw_2.3.co_2 ◽

1994 ◽

Vol 31 (4) ◽

pp. 287-294 ◽

Cited By ~ 8

Author(s):

Ravelo V. Argamaso ◽

Gerald J. Levandowski ◽

Karen J. Golding-Kushner ◽

Robert J. Shprintzen

Keyword(s):

Cleft Palate ◽

Cleft Lip ◽

Tumor Resection ◽

Velocardiofacial Syndrome ◽

Velopharyngeal Insufficiency ◽

Lateral Pharyngeal Wall ◽

Pharyngeal Wall ◽

Wall Movement ◽

Hypernasal Speech

Twenty-two patients, with hypernasal speech and asymmetric velopharyngeal insufficiency (VPI) identified preoperatively by multi-view videofluoroscopy and nasopharyngoscopy, were managed with superiorly based pharyngeal flaps skewed to the side with reduced lateral pharyngeal wall movement. Patient age ranged from 5 to 58 years. The etiology of the VPI included cleft palate with or without cleft lip, neurogenic VPI, velocardiofacial syndrome, tumor resection or latrogenic causes, submucous cleft palate, neurofibromatosis, and hemifacial microsomia. Follow-up, at 1 year and thereafter, showed resolution of VPI in all but two patients. An auxiliary flap to augment the primary flap was added on the side of diminished lateral pharyngeal wall motion which corrected the residual VPI. Three patients developed hyponasality. One was a child whose symptoms improved with time and growth. Two were adults, but the hyponasal resonance was mild and required no further Intervention. The advantage of skewing flaps is that at least one port functions adequately for ease in respiration and for drainage of secretions, thus reducing the risk of nasal obstruction. One open port also allows access for nasoendotracheal intubation should anesthetic be required for future operations.

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Association Between Gout and Injury Risk: A National Retrospective Cohort Study

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17103679 ◽

2020 ◽

Vol 17 (10) ◽

pp. 3679

Author(s):

Shih-Hsiang Ou ◽

Chu-Lin Chou ◽

Chia-Wei Lin ◽

Wu-Chien Chien ◽

Te-Chao Fang ◽

...

Keyword(s):

Retrospective Cohort ◽

Injury Risk ◽

Cox Regression ◽

Drug Intervention ◽

Cox Regression Analysis ◽

Analysis Group ◽

Risk Of Injury ◽

Increased Risk ◽

Insurance Database

The association between gout and injury remains unclear. This study aimed to investigate the injury risk in patients with gout. Using the Longitudinal Health Insurance Database (LHID) from 2000 to 2010 in Taiwan, patients with gout (group CFG) and those without gout (group C) were enrolled for further analysis. The CFG group was separated into two subgroups (with and without medication) to determine whether the risk of injury was reduced with drug intervention. The follow-up period was defined as the time from the initial diagnosis of gout to the date of injury. A total of 257,442 individuals were enrolled in this study, with 85,814 people in group CFG and 171,628 people in group C. Using Cox regression analysis, group CFG showed a significant increase in the risk of injury. Traffic injuries, poisoning, falls, crushing/cutting/piercing injury, and suicides were prominent among these injuries. Furthermore, when urate-lowing drugs were used to treat the CFG group, there were no significant differences in the occurrence of injury. Patients with gout had an increased risk of injury overall, and drug intervention did not lower the risk of injury in these patients.

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