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

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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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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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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Cleft Palate

10.2310/ot.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

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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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Endoscope-Assisted Multilayered Repair in Oronasal Fistula

Ear Nose & Throat Journal ◽

10.1177/0145561321997607 ◽

2021 ◽

pp. 014556132199760

Author(s):

Boo-Young Kim ◽

Bommi Florence Seo

Keyword(s):

Cleft Palate ◽

Success Rate ◽

Inferior Turbinate ◽

Composite Graft ◽

Challenging Problem ◽

Fistula Closure ◽

Fistula Surgery ◽

Oronasal Fistula ◽

Cleft Palate Repair ◽

Palate Repair

Oronasal fistula following cleft palate repair is a considerable complication with a recurrence rate of 33% to 37% and remains a challenging problem for surgeons. Furthermore, many patients have undergone several operations and experienced scar problems and other forms of morbidity. Therefore, we report a multilayered technique for oronasal fistula closure using an endoscopic nasal inferior turbinate composite graft with a palatal advance flap. This will increase the success rate after closure of small-sized oronasal fistula surgery without complications or recurrence (IRB: 2020-1671-0001).

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Reinforcing the Modified Double-Opposing Z-Plasty Approach Using the Pedicled Buccal Fat Flap as an Interpositional Layer for Cleft Palate Repair

The Cleft Palate-Craniofacial Journal ◽

10.1177/10556656211064769 ◽

2021 ◽

pp. 105566562110647

Author(s):

Rafael Denadai ◽

Pang-Yun Chou ◽

Lun-Jou Lo

Keyword(s):

Cleft Palate ◽

Middle Layer ◽

Fistula Formation ◽

Growth Disturbance ◽

Full Coverage ◽

Oronasal Fistula ◽

Cleft Palate Repair ◽

Single Intervention ◽

Palate Repair ◽

Relaxing Incisions

Pedicled buccal fat flaps have been adopted in primary Furlow double-opposing Z-plasty palatoplasty to reduce oronasal fistula formation or to attenuate maxillary growth disturbance. We combined both goals in a single intervention. This study describes a series of 33 modified Furlow small double-opposing Z-plasty palatoplasties reinforced with a middle layer of pedicled buccal fat flaps between the oral and nasal layers for full coverage of the dissected palatal surfaces, with rapid mucosalization of lateral relaxing incisions and no dehiscence or fistula formation.

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On the Frequency of Oronasal Fistulation After Primary Cleft Palate Repair

The Cleft Palate-Craniofacial Journal ◽

10.1177/1055665619856243 ◽

2019 ◽

Vol 56 (10) ◽

pp. 1302-1313

Author(s):

Ana Tache ◽

Maurice Y. Mommaerts

Keyword(s):

Systematic Review ◽

Cleft Palate ◽

Soft Palate ◽

Hard Palate ◽

Cleft Lip ◽

Oronasal Fistula ◽

Type Iv ◽

Cleft Palate Repair ◽

Palate Repair ◽

Fistula Rate

Objective: The aims of the study were to assess the postoperative oronasal fistula rate after 1-stage and 2-stage cleft palate repair and identify risk factors associated with its development. Design: Systematic review. Setting: Various primary cleft and craniofacial centers in the world. Patients, Participants: Syndromic and nonsyndromic cleft lip, alveolus, and palate patients who had undergone primary cleft palate surgery. Intervention: Assessment of oronasal fistula frequency and correlation with staging, timing, and technique of repair, gender, and Veau type. The results obtained in this systematic review were compared with those in previous reports. Outcome: The main outcome is represented by the occurrence of the oronasal fistula after 1-stage versus 2-stage palatoplasty. Results: The mean fistula percentage was 9.94%. In the Veau I, II, III, and IV groups, the respective fistula rates were 2%, 7.3%, 8.3%, and 12.5%. Oronasal fistula locations based on the Pittsburgh Fistula Classification System were soft palate (type II), 16.2%; soft palate–hard palate junction (type III), 29.3%; and hard palate (type IV), 37.3%. There were no statistically significant differences between 1-stage and 2-stage palatoplasty, syndromic and nonsyndromic, or male and female patients. Primary palatoplasty timing was not a significant predictor. Conclusion: Some disparities arose when comparing studies, mainly regarding location and types of clefting prone to oronasal fistulation. Interestingly, the fistula rate does not differ between 1- and 2-stage closure, and timing of the repair does not play a role.

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Comparison of Codeine Phosphate and Morphine Sulphate in Infants Undergoing Cleft Palate Repair

The Cleft Palate-Craniofacial Journal ◽

10.1597/06-206.1 ◽

2007 ◽

Vol 44 (5) ◽

pp. 528-531 ◽

Cited By ~ 7

Author(s):

S. Fenlon ◽

N. Somerville

Keyword(s):

Cleft Palate ◽

Analgesic Effect ◽

Outcome Measure ◽

Codeine Phosphate ◽

Double Blind ◽

Pain Scores ◽

Significant Difference ◽

Cleft Palate Repair ◽

Palate Repair ◽

Clinically Significant

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.

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Five-Fold Variation Among Surgeons and Hospitals in the Use of Secondary Palate Surgery

The Cleft Palate-Craniofacial Journal ◽

10.1177/1055665618799906 ◽

2018 ◽

Vol 56 (5) ◽

pp. 586-594 ◽

Cited By ~ 8

Author(s):

Thomas J. Sitzman ◽

Adam C. Carle ◽

Pamela C. Heaton ◽

Michael A. Helmrath ◽

Maria T. Britto

Keyword(s):

Cleft Palate ◽

Cleft Lip ◽

Cleft Lip And Palate ◽

Primary Repair ◽

Multivariable Analysis ◽

Secondary Surgery ◽

Secondary Palate ◽

Primary Palate ◽

Cleft Palate Repair ◽

Palate Repair

Objective: To identify child-, surgeon- and hospital-specific factors at the time of primary cleft palate repair that are associated with the use of secondary palate surgery. Design: Retrospective cohort study. Setting: Forty-nine pediatric hospitals. Participants: Children who underwent cleft palate repair between 1998 and 2015. Main Outcome Measure: Time from primary cleft palate repair to secondary palate surgery. Results: By 5 years after the primary palate repair, 27.5% of children had undergone secondary palate surgery. In multivariable analysis, cleft type and age at primary palate repair were both associated with secondary surgery ( P < .01). Children with unilateral cleft lip and palate had a 1.69-fold increased hazard of secondary surgery (95% confidence interval [CI]: 1.54-1.85) compared to children with cleft palate alone. Primary palate repair before 9 months had a 3.99-fold increased hazard of secondary surgery (95% CI: 3.39-4.07) compared to repair at 16 to 24 months of age. After adjusting for cleft type, age at repair, and procedure volume, there remained substantial variation in secondary surgery use among surgeons and hospitals ( P < .01). For children with isolated cleft palate, the predicted proportion of children undergoing secondary surgery within 5 years of primary repair ranged from 8.5% to 46.0% across surgeons and 9.1% to 49.4% across hospitals. Conclusions: There are substantial differences among surgeons and hospitals in the rates of secondary palate surgery. Further work is needed to identify causes for this variation among providers and develop interventions to reduce the need for secondary surgery.

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Reliability of Oronasal Fistula Classification

The Cleft Palate-Craniofacial Journal ◽

10.1597/16-186 ◽

2018 ◽

Vol 55 (6) ◽

pp. 871-875 ◽

Cited By ~ 3

Author(s):

Thomas J. Sitzman ◽

Alexander C. Allori ◽

Damir B. Matic ◽

Stephen P. Beals ◽

David M. Fisher ◽

...

Keyword(s):

Cleft Palate ◽

Classification System ◽

Surgical Quality ◽

General Classification ◽

Oronasal Fistula ◽

Secondary Palate ◽

Cleft Palate Repair ◽

Individual Surgeon ◽

Palate Repair

Objective: Oronasal fistula is an important complication of cleft palate repair that is frequently used to evaluate surgical quality, yet reliability of fistula classification has never been examined. The objective of this study was to determine the reliability of oronasal fistula classification both within individual surgeons and between multiple surgeons. Design: Using intraoral photographs of children with repaired cleft palate, surgeons rated the location of palatal fistulae using the Pittsburgh Fistula Classification System. Intrarater and interrater reliability scores were calculated for each region of the palate. Participants: Eight cleft surgeons rated photographs obtained from 29 children. Results: Within individual surgeons reliability for each region of the Pittsburgh classification ranged from moderate to almost perfect (κ = .60-.96). By contrast, reliability between surgeons was lower, ranging from fair to substantial (κ = .23-.70). Between-surgeon reliability was lowest for the junction of the soft and hard palates (κ = .23). Within-surgeon and between-surgeon reliability were almost perfect for the more general classification of fistula in the secondary palate (κ = .95 and κ = .83, respectively). Conclusions: This is the first reliability study of fistula classification. We show that the Pittsburgh Fistula Classification System is reliable when used by an individual surgeon, but less reliable when used among multiple surgeons. Comparisons of fistula occurrence among surgeons may be subject to less bias if they use the more general classification of “presence or absence of fistula of the secondary palate” rather than the Pittsburgh Fistula Classification System.

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