On randomised trials of surgical timings for cleft palate repair

Background: In this article we review randomised controlled trials (RCTs) comparing palatal surgery at different ages to examine their design features and quantify their conclusions. Method: A literature search of RCTs comparing surgical timings for cleft palate and/or lip repair from 1 January 2004 to 31 December 2013 was undertaken. This supplements an earlier systematic review of 62 RCTs in cleft lip and palate from 1 January 2004 to 31 December 2013 in English using the Cochrane Central Register of Controlled Trials, MEDLINE® and EMBASE with key words ‘cleft lip’ or ‘cleft palate’. Results: Four RCTs were identified, each comparing palate surgery at different lower (six, nine and 12 months) and upper (12, 18 and 36 months) ages with velopharyngeal competence (VPC) also at different ages (three, four, more than four or five years). These surgical and assessment age differences prevent a synthesis using meta-analysis techniques. Nevertheless, three RCTs indicate that VP function is more impaired with later surgery. Two ask questions about the type of surgery; one suggests that VPC is greater with Furlow palatoplasty than von Langenbeck surgery and the other that one technique appears to have better VPC at six months and the other at 12 months. Conclusion: The role of the timing of palatal surgery with respect to VPC remains unclear. We propose an international strategy that is designed to establish the optimal age for palatal surgery in infants requiring palate and/or lip repair.

Evaluation of Eustachian tube function in patients of cleft palate and effects of palatoplasty on these findings

<p class="abstract"><strong>Background:</strong> Isolated cleft palate and cleft palate and cleft lip patients have poor Eustachian tube function which results in hearing impairment that too in the speech formative years. Aim of study was to evaluate tympanometric findings in patient of cleft palate and effect of palatoplasty on both short term and long term postoperatively.</p><p class="abstract"><strong>Methods:</strong> The subjects consisted of patients attending the cleft lip and palate clinic. This was a combined clinic consisting of department of plastic surgery, department of ENT and department of dental surgery held every month at a tertiary care hospital in Delhi. Study consisted of three groups of patients namely preoperative group, postoperative group and pre-postoperative group.</p><p class="abstract"><strong>Results:</strong> No significant difference was observed in tympanometric abnormalities in cases of combined cleft lip and palate as compared to isolated cleft palate. After age of 5 months once changes of OME has set in there was no significant change in middle ear findings irrespective of palatal repair.</p><p class="abstract"><strong>Conclusions:</strong> There is a very high prevalence of otitis media with effusion in these patients. The changes do resolve spontaneously after age of seven, this perhaps is due to combined effect, growth, development and l maturity of Eustachian tube and palatal surgery rather than palatal surgery alone.</p><p> </p>

What do we know about N.V. Sklifosovsky?

Nikolay Sklifosovsky was called the acting surgeon of all wars of the 19th century. At the age of 30, he first got into the Austro-Prussian War, which allowed him to gain invaluable experience, after which he volunteered for the front during all the Russian-Turkish campaigns.Participation in military actions allowed him to rise to the rank of general and made Sklifosovsky the founder of modern military field surgery. It was he who first in the world began to use local anesthesia, using cocaine during palatal surgery; he proposed to disinfect instruments and introduced the rules of asepsis and antiseptics. However, his innovative ideas not only contributed to the rescue of hundreds of wounded, but also caused ridicule from colleagues, who used to say things like, you, Sklifosovsky, are so big, but you are afraid of some small bacteria that cannot be clearly discerned. Scientific and practical interests of N.V. Sklifosovsky were not limited to abdominal interventions alone; he successfully performed operations on female genital organs, joints and was very interested in maxillofacial surgery. On Sklifosovsky’s initiative, dentistry was included in the program of university disciplines as an independent science. Despite his undeniable achievements, in life outside the walls of medical institutions, he remained a very simple and courteous person; he never refused to provide medical care to the poor, and sometimes he himself purchased medicine for such patients. Wanting to calm and cheer up the patient before the operation, he never spared his time talking with patients.

Speech in a consecutive series of children born with cleft lip and palate with and without syndromes and/or additional malformations

Background When evaluating speech in children with cleft palate with or without cleft lip (CP/L), children with known syndromes and/or additional malformations (CP/L+) are usually excluded. The aim of this study was to present speech outcome of a consecutive series of 5-year-olds born with CP/L, and to compare speech results of children with CP/L + and children with CP/L without known syndromes and/or additional malformations (CP/L-). Methods One hundred 5-year-olds (20 with CP/L+; 80 with CP/L-) participated. All children were treated with primary palatal surgery in one stage with the same procedure for muscle reconstruction. Three independent judges performed phonetic transcriptions and rated perceived velopharyngeal competence from audio recordings. Based on phonetic transcriptions, percent consonants correct (PCC) and percent non-oral errors were investigated. Group comparisons were performed. Results In the total group, mean PCC was 88.2 and mean percent non-oral errors 1.5. The group with bilateral cleft lip and palate (BCLP) had poorer results on both measures compared to groups with other cleft types. The average results of PCC and percent non-oral errors in the CP/L + group indicated somewhat poorer speech, but no significant differences were observed. In the CP/L + group, 25 % were judged as having incompetent velopharyngeal competence, compared to 15 % in the CP/L- group. Conclusions The results indicated relatively good speech compared to speech of children with CP/L in previous studies. Speech was poorer in many children with more extensive clefts. No significant differences in speech outcomes were observed between CP/L + and CP/L- groups.

Conversion Furlow Palatoplasty and the Use of Preoperative Video Nasendoscopy

Objective: To assess outcomes after conversion Furlow palatoplasty with and without routine preoperative flexible fiberoptic video nasendoscopy (FFVN). Design: Retrospective cohort study. Setting: Tertiary Children’s Hospital. Patients: Greater than 3 years of age with cleft palate and velopharyngeal insufficiency (VPI) after straight-line palatoplasty requiring secondary surgery performed with a Furlow palatoplasty. Main Outcome Measures: The number of children with and without routine FFVN prior to conversion Furlow palatoplasty for VPI after initial straight-line palatoplasty. Groups were compared for surgical timing, speech outcomes, and need for additional surgery after conversion Furlow palatoplasty. Results: Fifty-eight patients underwent preoperative FFVN versus 29 without. Mean age at FFVN was 73.8 (SD 34) months. Mean age for secondary palatal surgery by conversion Furlow palatoplasty was 81.5 (SD 34.8) months with FFVN versus 73.4 (SD 34.0) months without FFVN. There was a significant difference ( P < .001) for VPI diagnosis and time to surgery between the groups. Preoperative hypernasality ratings were similar between groups. Postoperatively 65.5% of FFVN and non-FFVN patients corrected to normal resonance. Only 6.9% of all patients rated moderate-severe hypernasality after surgery compared to 42.5% preoperatively. Of total, 5.7% of patients had unchanged hypernasality and only 1 patient rated worse. Seven patients ultimately required additional surgery in attempt to normalize their resonance. Conclusions: Routine preoperative FFVN does not offer any advantage for improved outcomes in children undergoing conversion Furlow palatoplasty after straight-line repair. Routine preoperative FFVN was associated with increased time to surgery after diagnosis of VPI compared to those without FFVN.

The Palatal Fistula Closure Using Buccal Fat Graft After Palatoplasty for Cleft Palate: Two Case Reports

Fistula recurrence is high after secondary follow-up operation to close the fistula after primary palatal surgery. Therefore, preventing fistula recurrence is important. Here, we describe the technique of closing palatal fistula after palatal surgery with a buccal fat graft in 2 cases. We elevate the mucosal flap around the palatal fistula, suture the nasal mucosa, transplant the buccal fat between the nasal and oral mucosa for the palatal fistula after palatal surgery, and suture the oral mucosa. Palatal fistula did not recur after surgery. This method is simple and useful for suturable fistula and does not require a local flap.