Diversity of microglial transcriptional responses during opioid exposure and neuropathic pain.

ABSTRACT: Microglia take on an altered morphology during chronic opioid treatment. This morphological change is broadly used to identify the activated microglial state associated with opioid side effects, including tolerance and opioid-induced hyperalgesia (OIH). Microglia display similar morphological responses in the spinal cord after peripheral nerve injury (PNI). Consistent with this observation, functional studies have suggested that microglia activated by opioids or PNI engage common molecular mechanisms to induce hypersensitivity. In this article, we conducted deep RNA sequencing (RNA-seq) and morphological analysis of spinal cord microglia in male mice to comprehensively interrogate transcriptional states and mechanistic commonality between multiple models of OIH and PNI. After PNI, we identify an early proliferative transcriptional event across models that precedes the upregulation of histological markers of microglial activation. However, we found no proliferative transcriptional response associated with opioid-induced microglial activation, consistent with histological data, indicating that the number of microglia remains stable during morphine treatment, whereas their morphological response differs from PNI models. Collectively, these results establish the diversity of pain-associated microglial transcriptomic responses and point towards the targeting of distinct insult-specific microglial responses to treat OIH, PNI, or other central nervous system pathologies.

Computer Vision-Radiomics & Pathognomics.

The role of computer vision in extracting radiographic (radiomics) and histopathologic (pathognomics) features is an extension of molecular biomarkers that have been foundational to our understanding across the spectrum of head and neck disorders. Especially within head and neck cancers, machine learning and deep learning applications have yielded advances in the characterization of tumor features, nodal features, and various outcomes. This review aims to overview the landscape of radiomic and pathognomic applications, informing future work to address gaps. Novel methodologies will be needed to potentially engineer ways of integrating multidimensional data inputs to examine disease features to guide prognosis comprehensively and ultimately clinical management.

An Ear Mystery: Conductive Hearing Loss with Normal Acoustic Reflexes and VEMPs.

The cause of sudden conductive loss in the absences of other vestibulo-audiologic abnormalities can be isolated to specific subsites of the ossicular chain using audiometric testing. In the absence of such abnormalities, a rare etiology may be the cause after an inciting trauma. Laryngoscope, 134:4344-4346, 2024.

Identifying Opportunities to Deliver High-Quality Cancer Care Across a Health System: A Clinical Responsibility.

OBJECTIVE: We examined process-related quality metrics for oral squamous cell carcinoma (OSCC) depending on treating facility type across a health system and region. STUDY DESIGN: Retrospective in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines. SETTING: Single health system and region. METHODS: Patients with OSCC diagnosed between 2012 and 2018 were identified from tumor registries of 6 hospitals (1 academic and 5 community) within a single health system. Patients were categorized into 3 care groups: (1) solely at the academic center, (2) solely at community facilities, and (3) combined care at academic and community facilities. Primary outcome measures were process-related quality metrics: positive surgical margin rate, lymph node yield (LNY), adjuvant treatment initiation ≤6 weeks, National Comprehensive Cancer Network (NCCN)-guideline adherence. RESULTS: A total of 499 patients were included: 307 (61.5%) patients in the academic-only group, 101 (20.2%) in the community-only group, and 91 (18.2%) in the combined group. Surgery at community hospitals was associated with increased odds of positive surgical margins (11.9% vs 2.5%, odds ratio [OR]: 47.73, 95% confidence interval [CI]: 11.2-275.86, P < .001) and lower odds of LNY ≥ 18 (52.8% vs 85.9%, OR: 0.15, 95% CI: 0.07-0.33, P < .001) relative to the academic center. Compared with the academic-only group, odds of adjuvant treatment initiation ≤6 weeks were lower for the combined group (OR: 0.30, 95% CI: 0.13-0.64, P = .002) and odds of NCCN guideline-adherent treatment were lower in the community only group (OR: 0.35, 95% CI: 0.18-0.70, P = .003). CONCLUSION: Quality of oral cancer care across the health system and region is comparable to or better-than national standards, indicating good baseline quality of care. Differences by facility type and fragmentation of care present an opportunity for bringing best in-class cancer care across an entire region.

Circulating tumor HPV DNA assessments after surgery for human papilloma virus-associated oropharynx carcinoma.

PURPOSE: To understand the utility of circulating tumor human papillomavirus DNA (ctHPVDNA) blood testing for HPV-associated oropharynx squamous cell carcinoma (HPV + OPSCC) after definitive surgery. MATERIALS AND METHODS: Prospective cohort study of HPV(+)OPSCC patients with ctHPVDNA test data to assess its accuracy in detecting biopsy-confirmed disease at various post-treatment time points. Eligible patients had p16(+)/HPV(+) OPSCC and ctHPVDNA testing performed at any time pre-operatively and/or postoperatively. In cases of recurrence, patients were excluded from analysis if ctHPVDNA testing was not performed within 6 months of biopsy. RESULTS: 196 all-treatment-type patients had at least one PT ctHPVDNA test. The initial post-treatment (PT) ctHPVDNA sensitivity, specificity, PPV, and NPV were 69.2 % (9/13), 96.7 % (177/183), 60.0 % (9/15), and 97.8 % (177/181). 61 surgery alone (SA) patients underwent 128 PT tests. The initial PT SA ctHPVDNA sensitivity, specificity, PPV, and NPV were 100 % (2/2), 96.0 % (48/50), 50 % (2/4), and 100 % (48/48). 35 of 61 (57.4 %) SA patients had NCCN-based histopathologic indications for adjuvant (chemo)radiation but declined. 3 of 35 (8.57 %) had a positive PT ctHPVDNA test of which 1 of 3 (33 %) had biopsy-proven recurrence. Prospectively, ten patients had a PreT positive ctHPVDNA, underwent SA, refused adjuvant treatment, had an undetectable ctHPVDNA within 2 weeks of SA, and remained free of disease (mean 10.3 months). CONCLUSION: The high specificity and NPV of ctHPVDNA after SA suggest ctHPVDNA may have a role in determining the omission of PT adjuvant (chemo)radiation in select patients.

Trends in Private Equity Acquisitions of US Otolaryngology Practices.

With the increasing consolidation of physician practices, private equity (PE) firms have been playing a growing role in healthcare delivery and recently began entering the otolaryngology-head and neck surgery space. To date, no studies have examined the extent of PE investment in otolaryngology. We assessed trends and geographic distribution of US otolaryngology practices acquired by PE using Pitchbook (Seattle, WA), a comprehensive market database. From 2015 to 2021, 23 otolaryngology practices were acquired by PE. The number of PE acquisitions increased over time: 1 practice was acquired in 2015 versus 4 practices in 2019 versus 8 practices in 2021. Nearly half (43.5%, n = 10) of acquired practices were in the South Atlantic region. The median number of otolaryngologists at these practices was 5 (interquartile range: 3-7). As PE investment in otolaryngology continues to grow, further research is needed to assess its impact on clinical decision-making, healthcare costs, physician job satisfaction, clinical efficiency, and patient outcomes.

Long-term laryngological sequelae and patient-reported outcomes after COVID-19 infection.

PURPOSE: We examine prevalence, characteristics, quality of life (QOL) assessments, and long-term effects of interventions for laryngeal dysfunction after recovery from COVID-19 infection. MATERIALS AND METHODS: 653 patients presenting to Yale's COVID clinic from April 2020 to August 2021 were identified retrospectively. Patients with PCR-positive COVID-19 who underwent evaluation by fellowship-trained laryngologists were included. Patient demographics, comorbidities, intubation/tracheostomy, strobolaryngoscopy, voice metrics, and management data were collected. Patient-reported QOL indices were Dyspnea Index (DI), Cough Severity Index (CSI), Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), and Reflux Symptom Index (RSI). RESULTS: 57 patients met inclusion criteria: 37 (64.9 %) were hospitalized for COVID-19 infection and 24 (42.1 %) required intubation. Mean duration between COVID-19 diagnosis and presentation to laryngology was significantly shorter for patients who were intubated compared to non-intubated (175 ± 98 days versus 256 ± 150 days, respectively, p = 0.025). Dysphonia was diagnosed in 40 (70.2 %) patients, dysphagia in 14 (25.0 %) patients, COVID-related laryngeal hypersensitivity in 13 (22.8 %), and laryngotracheal stenosis (LTS) in 10 (17.5 %) patients. Of the 17 patients who underwent voice therapy, 11 (64.7 %) reported improvement in their symptoms and 2 (11.8 %) patients reported resolution. VHI scores decreased for patients who reported symptom improvement. 7 (70 %) patients with LTS required >1 procedural intervention before symptom improvement. Improvement across QOL indices was seen in patients with LTS. CONCLUSIONS: Laryngeal dysfunction commonly presents and is persistent for months after recovery from COVID-19 in non-hospitalized and non-intubated patients. Voice therapy and procedural interventions have the potential to address post-COVID laryngeal dysfunction.

Novel Machine Learning Model to Predict Interval of Oral Cancer Recurrence for Surveillance Stratification.

OBJECTIVE(S): We aimed to develop a machine learning (ML) model to accurately predict the timing of oral squamous cell carcinoma (OSCC) recurrence across four 1-year intervals. METHODS: Patients with surgically treated OSCC between 2012-2018 were retrospectively identified from the Yale-New Haven Health system tumor registry. Patients with known recurrence or minimum follow-up of 24 months from surgery were included. Patients were classified into one of five levels: four 1-year intervals and one level for no recurrence (within 4 years of surgery). Three sets of data inputs (comprehensive, feature selection, nomogram) were combined with 4 ML architectures (logistic regression, decision tree (DT), support vector machine (SVM), artificial neural network classifiers) yielding 12 models in total. Models were primarily evaluated using mean absolute error (MAE), lower values indicating better prediction of 1-year interval recurrence. Secondary outcomes included accuracy, weighted precision, and weighted recall. RESULTS: 389 patients met inclusion criteria: 102 (26.2%) recurred within 48 months of surgery. Median follow-up time was 25 months (IQR: 15-37.5) for patients with recurrence and 44 months (IQR: 32-57) for patients without recurrence. MAE of 0.654% and 80.8% accuracy were achieved on a 15-variable feature selection input by 2 ML models: DT and SVM classifiers. CONCLUSIONS: To our knowledge, this is the first study to leverage multiclass ML models to predict time to OSCC recurrence. We developed a model using feature selection data input that reliably predicted recurrence within 1-year intervals. Precise modeling of recurrence timing has the potential to personalize surveillance protocols in the future to enhance early detection and reduce extraneous healthcare costs. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1652-1659, 2023.

Trends in Residency Applicant Volume in Otolaryngology-Head and Neck Surgery and Peer Specialties.

OBJECTIVE: To evaluate the 2020 to 2021 Otolaryngology residency application cycle in the context of recent trends. STUDY DESIGN: Retrospective data analysis. SETTING: Disruptions caused by the COVID-19 pandemic may significantly alter trends among residency applicants, especially in highly competitive and/or smaller specialties. METHODS: Applicant and residency statistics from Electronic Residency Application Service (ERAS) and National Residency Matching Program (NRMP) were extracted from the 2016 to 2021 and 2011 to 2021, respectively. Trends in Otolaryngology-Head and Neck Surgery (OHNS) were compared to peer specialties (PS) including Dermatology, Neurological Surgery, Orthopedic Surgery, and Integrated Pathway for Plastic and Reconstructive Surgery (PRS). The ratio of the number of applicants per positions (APP) was used to reflect the degree of competition. RESULTS: Between 2011 and 2021, the number of OHNS programs and positions expanded less than those of PS and General Surgery. The increase in the APP ratio was significantly greater for OHNS compared to those Dermatology, Orthopedic Surgery, General Surgery and all PGY1 residency positions for both US MD and all applicants (P < .01 for each). OHNS expansion of US MD (P = .046), but not all applicants (P = .169), outgrew that of Neurosurgery. CONCLUSION: The 2020 to 2021 cycle affected by the COVID-19 pandemic saw a continuation of the recent trend in the expanding OHNS applicant pool. OHNS remains one of the specialties with the highest APP ratio and has observed a significant growth compared to PS since 2018. Understanding and anticipating trends in residency application cycles is critical for designing processes to optimize the best fit between applicants and programs.

Integration of Reinforcement Learning in a Virtual Robotic Surgical Simulation.

Background. The revolutions in AI hold tremendous capacity to augment human achievements in surgery, but robust integration of deep learning algorithms with high-fidelity surgical simulation remains a challenge. We present a novel application of reinforcement learning (RL) for automating surgical maneuvers in a graphical simulation.Methods. In the Unity3D game engine, the Machine Learning-Agents package was integrated with the NVIDIA FleX particle simulator for developing autonomously behaving RL-trained scissors. Proximal Policy Optimization (PPO) was used to reward movements and desired behavior such as movement along desired trajectory and optimized cutting maneuvers along the deformable tissue-like object. Constant and proportional reward functions were tested, and TensorFlow analytics was used to informed hyperparameter tuning and evaluate performance.Results. RL-trained scissors reliably manipulated the rendered tissue that was simulated with soft-tissue properties. A desirable trajectory of the autonomously behaving scissors was achieved along 1 axis. Proportional rewards performed better compared to constant rewards. Cumulative reward and PPO metrics did not consistently improve across RL-trained scissors in the setting for movement across 2 axes (horizontal and depth).Conclusion. Game engines hold promising potential for the design and implementation of RL-based solutions to simulated surgical subtasks. Task completion was sufficiently achieved in one-dimensional movement in simulations with and without tissue-rendering. Further work is needed to optimize network architecture and parameter tuning for increasing complexity.

Characterization of Trapezial Pommel in Relation to Radiographic and Wear Patterns in Carpometacarpal Osteoarthritis.

BACKGROUND: Trapezial pommel, or ulnar osteophyte positioned at the vertex of the saddle-shaped facet, is a consistent structural appearance in osteoarthritis (OA) of the first carpometacarpal. This study investigates its relation to radiographic measures (modified Eaton staging and thumb OA [ThOA] index) and wear patterns (trapezial surface morphology and cartilaginous eburnation). METHODS: In all, 137 whole trapezia were explanted from 116 patients and evaluated for Eaton staging, morphology (saddle, cirque, or dish), and eburnation (degree of cartilaginous effacement) of the articular surface of the trapezium. In total, 131 Robert's views and 126 stress views were reviewed by 2 blinded senior surgeons for ThOA index and pommel size. Statistical analyses included Spearman correlation and linear regression. RESULTS: Standardized pommel size achieved good intrarater reliability (correlation coefficient: 0.80-0.98) and moderate interrater reliability (correlation coefficient: 0.60-0.67). The ThOA index and pommel size were significantly correlated across Robert's (rs = 0.51) and stress views (rs = 0.64). The ThOA index better distinguished between stages compared with pommel size. All the radiographic measures inversely correlated with preserved cartilage and varied across morphologies. Pommel size differed significantly between dish and saddle, and the ThOA index was significantly different between all morphologies when using stress views. CONCLUSIONS: We reliably quantified the pommel feature and demonstrated significant correlations with other radiographic and topologic measures of arthritic disease. If future studies can demonstrate that the pommel is a pathogenic process in ThOA and its correction can curb disease progression, the identification of the pommel feature may help guide targeted intervention.

Characterization of Laryngotracheal Fractures and Repairs: A TQIP Study.

OBJECTIVES: Laryngotracheal trauma is poorly studied and associated with serious morbidity and mortality. This study reports features associated with laryngotracheal fractures, and factors associated with laryngeal fracture repair. STUDY DESIGN: Retrospective database study SETTING: American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP®) METHODS: ACS-TQIP® 2014-2015 participant user data files were queried for laryngotracheal fractures using the International Classification of Diseases (ICD) 9th edition encodings. Demographic, diagnostic and procedure characteristics were analyzed with univariate chi-squared analysis and multivariate logistic regression. RESULTS: We extracted 635 cases of laryngotracheal injury, with a median Injury Severity Score of 16 (IQR: 10 - 25). Most were caused unintentionally (65.7%), followed by assault (28.8%). Blunt trauma (79.5%) was more common than penetrating trauma (20.0%). These trends were upheld in the subgroup of repaired fractures, which made up 12.6% (80/635) of cases. The median length of hospital stay was 6 days (IQR: 3 - 13) in all fractures and 10 days (IQR: 6 - 14) in the subgroup of repaired fractures, while the median length of ICU stay was 4 days (IQR: 2 - 9) in all fractures and 4.5 (IQR: 6 - 14.3) in the subgroup of repaired fractures. Cut/pierce injuries (OR: 4.7, P < 0.001) and ISS (OR: 0.97, pP = 0.026) significantly affected rate of laryngeal fracture repair. CONCLUSION: Laryngotracheal fractures are uncommon but serious injuries. Our results show that penetrating causes of injuries have the shortest time to repair, and that a higher ISS score is negatively associated with repair.

Correlations of Radiographic and Endoscopic Observations in Subglottic Stenosis.

OBJECTIVE(S): Subglottic stenosis (SGS) represents a constellation of diverse pathologic processes that ultimately lead to narrowing of the subglottic region and can produce significant morbidity. Existing endoscopic and radiographic assessments may not be consistent in practice. METHODS: Severity of stenosis was evaluated and reported using the Cotton-Myer classification system from 33 endoscopic procedures from 32 unique subjects. Radiographic imaging within the preceding 3 month period was subsequently reviewed and narrowing was measured by a blinded radiologist. Degree of stenosis was reported as a percentage in 30 out of 33 endoscopic evaluations and subsequently compared to radiographically determined percentage of stenosis. Statistical analyzes were conducted to evaluate concordance between endoscopic and radiographic assessments. RESULTS: About 45.5% (15/33) of the evaluations were in agreement using Cotton-Myer scoring, while 27.3% (9/33) were discrepant by 1 grade and 27.3% (9/33) by 2 grades. Correlation of degree of stenosis as a percentage using Spearman (coefficient: 0.233, P-value: .214) and Pearson (coefficient: 0.138, P-value: .466) methods demonstrated very weak relationships. Radiographic scoring did not predict endoscopic classification to a significant degree using mixed effects regression. CONCLUSIONS: Radiographic and endoscopic grading of subglottic stenosis may not be reliably concordant in practice.

Safety considerations for esophageal dilation by anesthetic type: A systematic review.

OBJECTIVES: Esophageal dilation (ED) may be performed in the office under local anesthesia or in a procedure/operating room under general anesthesia or intravenous (IV) sedation. However, indications for type of anesthesia during these procedures have not been established. The purpose of this review is to assess outcomes of esophageal dilation performed using different types of anesthesia to assess the safety of office-based techniques. METHODS: We conducted a systematic review and meta-analysis comparing the outcomes of anesthesia techniques for ED in adults. Exclusion criteria included reviews, small case series, use of stents, diagnoses with high morbidity, and rare diseases. A comprehensive literature search of the PubMed, CINAHL, and EMBASE databases was performed for articles relating to esophageal dilation. RESULTS: 876 papers were identified of which 164 full text studies were assessed and 25 were included in the analysis using the PRISMA guidelines. Data regarding demographics, dilation technique, and adverse events were extracted. The DerSimonian-Laird random-effect models with inverse-variance weighting were fit to estimate the combined effects. There were no statistically significant differences among mortality, perforation, or bleeding based on anesthetic. CONCLUSIONS: With office-based procedures gaining popularity in laryngology, there is a need to profile their safety. Office-based ED appears to have equivalent safety to general and IV sedation, although further research is necessary to define indications favoring office-based techniques.

Anesthesia screen use may impact operating room communication practices in otolaryngology.

OBJECTIVES: Failures in communication are a leading contributor to medical error. There is increasing attention on cultivating robust communication practices in the Operating Room (OR) to mitigate against patient injury and optimize efficient patient care. Few studies have evaluated how surgical equipment may introduce barriers to team dynamics. DESIGN: We conducted a pilot observational study to examine the relationship between anesthesia screen drapes (which are used inconsistently) and the frequency of verbal exchanges between surgical and anesthesia members. 25 procedures spanning various procedures in Otolaryngology were covertly observed, 12 of which employed a screen. Verbal exchanges were recorded across three stages of the surgery: pre-procedure (before the draping), procedure (drapes placed throughout) and post-procedure (after the removal of the draping). Speaker and content of the exchange was noted as well as various features about the procedure. RESULTS: Decreases in rates of exchanges were most pronounced during the procedure stage, although they did not reach significance on T-testing (p = 0.0719). After controlling for attending, table orientation and number of professionals, regression analysis did reveal a statistically significant decrease in rates of verbal exchanges during the procedure in the presence of the anesthesia screen (7.17 (± 6.33) versus 2.23 (± 1.00), p = 0.0318). Differences were also significant among surgeon-initiated and patient-care-related exchanges (p = 0.0168 and p = 0.0432, respectively). Decreases in anesthesiologist-initiated and non-clinical exchanges did not reach significance (p = 0.1530 and p = 0.5120, respectively). CONCLUSION: This pilot study suggests that anesthesia screens may negatively impact communication practices in the OR.

Characterizing Epidemiology and Associated-Factors of Adolescent Sports-Related Traumas Using Trauma Quality Improvement Program.

ABSTRACT: Sports-related injuries contribute to a considerable proportion of pediatric and adolescent craniofacial trauma, which can have severe and longstanding consequences on physical and mental health. The growing popularity of sports within this at-risk group warrants further characterization of such injuries in order to enhance management and prevention strategies. In this study, the authors summarized key trends in 1452 sports-related injuries among individuals aged 16 to 19 using the American College of Surgeon's Trauma Quality Improvement Program database from 2014 to 2016. The authors observed a preponderance of injuries associated with skateboarding, snowboarding, and skiing, with significantly higher percentages of traumatic brain injuries among skateboarding-related traumas. Notably, we observed that traumatic brain injurie rates were slightly higher among subjects who wore helmets. Intensive care unit durations and hospital stays appeared to vary by sport and craniofacial fracture. Altogether, this study contributes to the adolescent sports-related injuries and craniofacial trauma literature.

Review of probiotic use in otolaryngology.

OBJECTIVE: Probiotics have garnered considerable attention as an intervention for various conditions common to otolaryngology. The purpose of this review is to evaluate the current literature to offer recommendations about the safety and efficacy of probiotic management in otolaryngologic conditions. STUDY DESIGN: Narrative review. METHODS: PubMed and Google Scholar were queried using pertinent keywords to retrieve relevant studies with particular focus in the recent 5 years. All abstracts were assessed and studies, reviews and meta-analyses achieving evaluation of probiotic therapies or characterization of microbiome changes were included for further review. Studies were categorized by condition or anatomic region across various subspecialties. Key data parameters were extracted and evaluated across studies and treatment types. RESULTS: Strong evidence exists for the use probiotic agents to improve symptoms for allergic rhinitis, chronic rhinosinusitis and certain dental conditions. Despite promising results, further investigation is needed to evaluate and optimize probiotic delivery for mitigating otitis media, oropharyngeal inflammation and upper respiratory tract infections. Preclinical studies suggest that probiotics may potentially offer benefit for voice prosthesis maintenance, wound healing and mitigation of oral dysplasia. CONCLUSION: Probiotic therapies may offer clinical benefit in a variety of contexts within the field of otolaryngology, especially for short-term relief of certain inflammatory conditions of the oral cavity, auditory and nasal cavities. Further investigation is warranted for evaluation of long-term outcomes and pathogenic deterrence.

The Effect of Surgical Timing on 30-Day Outcomes in Cleft Palate Repair.

BACKGROUND: The optimal age for cleft palate repair continues to be debated, with little discussion of surgical risk related to operative timing. This study of 3088 cleft palate patients analyzed the impact of surgical timing on perioperative and 30-day postoperative outcomes. METHODS: Primary cleft palate repairs were identified in the National Surgical Quality Improvement Program database from 2012 to 2015. Data were combed for total postoperative complications, rates of readmission and reoperation, operating room time, and length of stay. Bivariate analyses were performed comparing 3-month periods from months 6 to 18, and months 0 to 5, 18 to 23, 24 to 29, and 30 to 59. RESULTS: Despite a higher proportion of isolated soft palate closure, children operated on before 6 months had a higher complication rate than children at other ages (7.1 percent versus 3.2 percent; OR, 2.4; p = 0.04), and higher rates of both readmission (3.6 percent versus 1.4 percent; OR, 3.6; p = 0.02) and reoperation (2.4 percent versus 0.5 percent; OR, 4.7; p = 0.04). There were no differences in short-term outcomes for any other age group younger than 5 years, and no differences in hospital length of stay among any age groups. CONCLUSIONS: The authors' findings suggest a relative contraindication to operation before 6 months. As there were no differences between any other age groups, long-term speech optimization should continue to be the primary consideration for operative planning. These findings improve the current rationale for palatoplasty timing, and can aid surgeons and parents in the surgical decision-making process. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.