RESUMO
INTRODUCTION: Velopharyngeal insufficiency (VPI), a stigmatizing hallmark of palatal dysfunction, occurs in a wide spectrum of pediatric craniofacial conditions. The mainstays for surgical correction include palate repair and/or pharyngeal surgery. However, primary pharyngoplasty has a failure rate of 15% to 20%. Although revision pharyngoplasty may be necessary in those with persistent VPI, little is known regarding the indications for and outcomes after such procedures. The purpose of this study is to describe the authors' experience with indications for and outcomes after revision pharyngoplasty. METHODS: A single-center retrospective review was performed of all patients undergoing revision pharyngoplasty between 2002 and 2019. Demographic data and Pittsburgh Weighted Speech Scores, diagnoses, comorbidities, and complications were tabulated. Two-tailed Student t test was used, and a P value of 0.05 or less was considered statistically significant. RESULTS: Thirty-two patients (65.6% male) met inclusion criteria for this study. The most common diagnoses included cleft palate (68.8%), submucous cleft palate (SMCP, 18.8%), and congenital VPI (6.3%, likely occult SMCP). Most patients (84.4%) underwent palatoplasty before their initial pharyngoplasty. The primary indication for initial pharyngoplasty was VPI (mean age 7.1 ± 4.6 years). The most common indication for revision pharyngoplasty (mean age 11.2 ± 5.1 years) included persistent VPI (n = 22), followed by obstructive sleep apnea (OSA) (n = 11). Persistent VPI (n = 8) and OSA (n = 6) were the most common complications after secondary pharyngoplasty. Thirteen patients (40.6%) within the revision pharyngoplasty cohort required additional surgical intervention: 4 underwent tertiary pharyngoplasty, 4 underwent takedown for OSA (n = 3) or persistent VPI (n = 1), 3 underwent takedown and conversion Furlow for persistent VPI (n = 2), OSA (n = 2) and/or flap dehiscence (n = 1), and 2 underwent palatal lengthening with buccal myomucosal flaps for persistent VPI. Of the 4 patients who required a tertiary pharyngoplasty, the mean age at repair was 6.6 ± 1.1 years and their speech scores improved from 13.5 to 2.3 after tertiary pharyngoplasty (P = 0.11). The overall speech score after completion of all procedures improved significantly from 19 to 3.3. CONCLUSION: Patients who fail primary pharyngoplasty represent a challenging population. Of patients who underwent secondary pharyngoplasty, nearly half required a tertiary procedure to achieve acceptable speech scores or resolve complications.
Assuntos
Fissura Palatina , Apneia Obstrutiva do Sono , Insuficiência Velofaríngea , Adolescente , Criança , Pré-Escolar , Fissura Palatina/cirurgia , Feminino , Humanos , Masculino , Faringe/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Insuficiência Velofaríngea/etiologia , Insuficiência Velofaríngea/cirurgiaRESUMO
BACKGROUND: The COVID-19 pandemic had multiple effects on the provision of health care, including the suspension of elective and nonessential surgeries. The objective of this study was to determine the early effect of the COVID-19 pandemic on the surgical care of patients with cleft lip and/or palate at a high-volume cleft center. METHODS: A retrospective comparative cohort study of patients with cleft lip and/or palate undergoing lip adhesion, cleft lip and nose repair, and palatoplasty before and during the pandemic was conducted. There were 50 patients in the prepandemic cohort and 53 in the pandemic cohort. RESULTS: Mean age at lip adhesion was 3.1 ± 1.1 months prepandemic (n = 8) and 3.5 ± 2.5 months in the pandemic cohort (n = 8) (P = 0.75). One lip adhesion was delayed by 1.6 months. Mean age at cleft lip and nose repair was 6.6 ± 1.9 months prepandemic (n = 23) and 8.0 ± 2.1 months in the pandemic cohort (n = 23) (P = 0.03). Six pandemic cleft lip and nose repairs were delayed; the mean delay was 2.6 ± 1.8 months. The mean age at palatoplasty was 13.9 ± 2.2 months prepandemic (n = 26) and 14.1 ± 2.9 months in the pandemic cohort (n = 26) (P = 0.79). Seven pandemic palatoplasties were delayed; the mean delay was 3.3 ± 1.4 months. CONCLUSIONS: The COVID-19 pandemic caused delays at each stage of repair for cleft lip and/or palate-related procedures; however, only cleft lip and nose repair were significantly affected. This study emphasizes the importance of remaining vigilant regarding the care of this vulnerable population during this challenging time.
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BACKGROUND: Age is a frequent consideration for surgical timing in pediatric craniofacial surgery for optimal psychosocial development. However, systematic evaluations of the effects of age in children under active treatment have not been thoroughly evaluated. METHODS: Ninety-nine patients (age, 8 to 17 years; 46.5 percent male) from the University of California, Los Angeles, Craniofacial Clinic were prospectively evaluated using the Pediatric Patient-Reported Outcomes Measurement Information System to assess anger, anxiety, depression, and quality of peer relationships. Patients were stratified into three age groups by years: group A, 8 to 10 years, n = 30; group B, 11 to 13 years, n = 41; and group C, 14 to 17 years, n = 28. Analyses of variance and logistic regression analyses were performed. RESULTS: Significant differences in anxiety (F2,96 = 5.1; p = 0.008), depression (F2,96 = 9.7; p < 0.001), peer relationships (F2,96 = 3.5; p = 0.03), and anger (F2,96 = 4.9; p = 0.009) were found among the age groups. Group A demonstrated the highest anxiety, highest depression, and lowest peer relationship scores overall. Although there were no differences in anger between groups A and C, group B had the lowest anger scores. Children with poor scores of higher severity, defined as greater than 1 SD worse than the national mean, were compared. Group A contributed the highest percentages of more severely affected children in all categories. A logistic regression analysis demonstrated that group A was a statistically significant predictor for scores of higher severity in both anxiety (OR, 3.8; 95 percent CI, 1.3 to 11.5; p = 0.02) and peer relationships (OR, 3.4; 95 percent CI, 1.3 to 9.3; p = 0.02). CONCLUSIONS: Children between 8 and 10 years of age with craniofacial anomalies constitute a high-risk subset for psychosocial dysfunction. The authors' work suggests that tight surveillance with family and school awareness may be necessary for this age group. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
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Adaptação Psicológica , Anormalidades Craniofaciais/psicologia , Depressão/epidemiologia , Psicometria/métodos , Qualidade de Vida , Adolescente , Fatores Etários , Criança , Anormalidades Craniofaciais/complicações , Depressão/diagnóstico , Depressão/etiologia , Feminino , Humanos , Los Angeles/epidemiologia , Masculino , Estudos Prospectivos , Índice de Gravidade de DoençaRESUMO
The need for surgical care in Haiti remains vast despite the enormous relief efforts after the earthquake in 2010. As the poorest country in the Western hemisphere, Haiti lacks the necessary infrastructure to provide surgical care to its inhabitants. In light of this, a multidisciplinary approach led by Partners In Health and Dartmouth-Hitchcock Medical Center is improving the access to surgical care and offering treatment of a broad spectrum of pathology. This article discusses how postearthquake Haiti partnerships involving academic institutions can alleviate the surgical burden of disease and, in the process, serve as a profound educational experience for the academic community. The lessons learned from Haiti prove applicable in other resource-constrained settings and invaluable for the next generation of surgeons.