Bilateral Buccal Flap Revision Palatoplasty to Correct Velopharyngeal Dysfunction: Perceptual Speech, Acoustic, and Aerodynamic Outcomes.

BACKGROUND: The purpose of this study was to analyze perceptual, acoustic, and aerodynamic changes in speech and velopharyngeal function after bilateral buccal flap revision palatoplasty (BBFRP) in patients with repaired cleft palate. METHODS: Ten consecutive patients ages 4 to 18 years with velopharyngeal dysfunction treated with BBFRP by a single surgeon were evaluated. Using a visual analog scale, nine blinded speech-language pathologists independently rated hypernasality, hyponasality, audible nasal emission, and speech acceptability. Measurements of the acoustic speech signal were used to quantify changes in hypernasality and nasal emission. The pressure flow technique was used to determine changes in velopharyngeal gap size. RESULTS: Complete records were available for eight patients. After surgery, hypernasality decreased ( P < 0.001) and speech acceptability increased ( P < 0.001) significantly. Audible nasal emission was significantly reduced ( P < 0.001). Postoperative acoustic measures showed a reduction of nasal emission and nasalization. Velopharyngeal gap size significantly decreased after BBFRP ( P < 0.001), correlating with lower visual analog scale ratings of hypernasality ( P = 0.015). Hyponasality did not change significantly after surgery ( P = 0.964). No patient developed sleep-disordered breathing. CONCLUSION: BBFRP resulted in a measurable improvement in hypernasal speech, audible nasal emission, and speech acceptability without significant changes in hyponasality or risk of obstructive sleep apnea. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Long-Term Patient-Reported Outcomes in Internationally Adopted Children with Cleft Lip and Palate.

OBJECTIVE: To compare patient-reported outcomes (PROs) in internationally adopted patients with cleft lip and palate to those in non-adopted peers. DESIGN: Cross-sectional study. SETTING: Multidisciplinary cleft team at tertiary care hospital. PATIENTS: Patients aged ≥ 8 with cleft lip and palate attending routine cleft team evaluations September 2021 - September 2022. MAIN OUTCOME MEASURE: CLEFT-Q PRO scores. RESULTS: Sixty-four internationally adopted patients and 113 non-adopted patients with a mean age of 13 years were included. Compared to non-adopted peers, adopted patients demonstrated worse satisfaction with face appearance (mean 59 vs. 66, p = .044), speech function (mean 69 vs. 78, p = .005), and speech distress (mean 80 vs. 84, p = .032). No significant differences were observed on the nose, nostrils, teeth, lips, lip scar, jaws, psychological function, or social function scales (p > .05). Objective clinical evaluation corroborated these findings, with adopted patients demonstrating worse Pittsburgh Weighted Speech scores (mean 3.0 vs 1.9, p = .027) and greater incidence of articulation errors (64% vs 46%, p = .021). No significant differences were observed in rates of mood, anxiety, or behavior concerns identified on psychosocial assessment (p = .764). Among adopted patients, undergoing palatoplasty prior to adoption was associated with worse satisfaction with speech, appearance, school, and social function (p < .05). CONCLUSIONS: Patient-reported outcomes among internationally adopted adolescents and young adults with cleft lip and palate show slightly lower satisfaction with facial appearance and speech but otherwise demonstrate similar results to non-adopted peers on most appearance and psychosocial measures. PRO data correlated well with objective speech assessment and did not portend worse psychosocial function.

Radiographic Evidence of Dental Complications Following Mandibular Distraction Osteogenesis: Inverted-L versus Oblique Osteotomy.

INTRODUCTION: Patients with micrognathia undergoing mandibular distraction osteogenesis (MDO) for functional and aesthetic improvement are at significant risk for dental complications. This study investigates association of two osteotomy patterns-oblique and inverted-L-with risk to developing dentition. METHODS: Our senior orthodontist performed a retrospective review of dental radiographs of patients undergoing MDO with confirmed oblique or inverted-L osteotomies between 2012 and 2022. Images were assessed for evidence of missing, damaged, or displaced teeth, and proportion of affected hemimandibles by injury type and median number of affected teeth per hemimandible were compared between groups using appropriate statistical methodology. RESULTS: Analysis included 44 patients (23 oblique, 21 inverted-L) and 85 hemimandibles (45 and 40). Mean age at surgery was 3.1±4.6 years, and mean time to imaging was 4.9±4.1 years; there was no difference between groups (p=0.23, p=0.34, respectively). Oblique osteotomy was associated with greater odds of missing teeth (OR 13.3, p<0.001), damaged teeth (OR 3.2, p=0.02), and any dental injury (OR 39.9, p<0.001) compared to inverted-L, as well as greater number of missing teeth (ß=0.6, p<0.01), damaged teeth (ß=0.3, p=0.02), and total number of affected teeth (ß=0.9, p<0.001). There was no difference in incidence (p=0.5) or number (p=0.4) of displaced teeth between groups. CONCLUSION: Inverted-L osteotomies were associated with fewer dental complications as compared to oblique osteotomy at all ages studied. While longer-term follow up and prospective data are needed prior to making definitive recommendations, this data is helpful to surgeons as they plan MDO.

Genomic profiling informs diagnoses and treatment in vascular anomalies.

Vascular anomalies are malformations or tumors of the blood or lymphatic vasculature and can be life-threatening. Although molecularly targeted therapies can be life-saving, identification of the molecular etiology is often impeded by lack of accessibility to affected tissue samples, mosaicism or insufficient sequencing depth. In a cohort of 356 participants with vascular anomalies, including 104 with primary complex lymphatic anomalies (pCLAs), DNA from CD31+ cells isolated from lymphatic fluid or cell-free DNA from lymphatic fluid or plasma underwent ultra-deep sequencing thereby uncovering pathogenic somatic variants down to a variant allele fraction of 0.15%. A molecular diagnosis, including previously undescribed genetic causes, was obtained in 41% of participants with pCLAs and 72% of participants with other vascular malformations, leading to a new medical therapy for 63% (43/69) of participants and resulting in improvement in 63% (35/55) of participants on therapy. Taken together, these data support the development of liquid biopsy-based diagnostic techniques to identify previously undescribed genotype-phenotype associations and guide medical therapy in individuals with vascular anomalies.

Pediatric Maxillary Giant Cell Tumors: Surgical Management by Transoral and Endoscopic Transnasal Enucleation and Curettage.

Giant cell tumors are uncommonly found within the craniofacial skeleton, and of those within the head and neck, are exceedingly rare in the maxilla. Here the authors present 2 cases of large, maxillary giant cell tumors: one presenting with mass-effect symptoms and another presenting from incidental findings on routine orthodontic care. Both patients were treated surgically with transoral and endoscopic transnasal excision and demonstrated favorable surgical results. One patient demonstrated no recurrence after 9 years and the other patient was disease free after 4 years. The authors end by discussing the role of emerging biologic agents, such as denosumab, for treating giant cell tumors of the jaws.

Craniosynostosis in a patient with Fanconi-Bickel syndrome: a case report.

OBJECTIVES: Craniosynostosis may be a rare but severe complication of Fanconi-Bickel syndrome (FBS). Both conditions can be associated with feeding intolerance in young children. Prompt recognition and correction of increased intracranial pressure may lead to improved dietary tolerance in FBS patients and decrease morbidity. CASE PRESENTATION: We present the case of a child with genetically confirmed FBS, severe feeding intolerance and evidence of metabolic bone disease. At two years of age, a diagnosis of multi-sutural craniosynostosis with increased intracranial pressure was made. The patient underwent cranial vault expansion using distraction osteogenesis, after which his feeding intolerance completely resolved. CONCLUSIONS: This case highlights the importance of monitoring for secondary craniosynostosis in patients with FBS and frequent emesis. Objective markers of bone health may help identify children at highest risk, though the actual mechanism of development is likely multifactorial. Increased awareness of this potential association should prompt more routine screening and improve outcomes.

Case Report: Safety and Efficacy of Denosumab in Four Children With Noonan Syndrome With Multiple Giant Cell Lesions of the Jaw.

Noonan syndrome is a genetic disorder caused by mutations in the RAS/MAPK pathway. Multiple giant cell lesions are a rare sequelae of disruptions in this pathway, termed Noonan-like multiple giant cell lesions (NL/MGCLs). Medical management of these tumors rather than surgical intervention is preferential as the lesions are benign but locally destructive and recurring. This case series describes four male pediatric patients with Noonan syndrome and multiple giant cell lesions of the jaw treated with denosumab, a monoclonal antibody to receptor activator of nuclear factor kappa B ligand (RANKL), which has been approved for the treatment of malignant giant cell tumors in adults but not evaluated for safety or efficacy in children. All four pediatric patients responded clinically and radiographically to the treatment. Adverse events occurred in a predictable pattern and included hypocalcemia and joint pain during the initiation of treatment and symptomatic hypercalcemia after the cessation of treatment. Growth was not significantly impaired in these skeletally immature patients. This case series demonstrates how a weight-adjusted denosumab dose can effectively treat NL/MGCLs and provides laboratory data for consideration of the timing of monitoring for known side effects.

Elucidating the Proton Transport Pathways in Liquid Imidazole with First-Principles Molecular Dynamics.

Imidazole is a promising anhydrous proton conductor with a high conductivity comparable to that of water at a similar temperature relative to its melting point. Previous theoretical studies of the mechanism of proton transport in imidazole have relied either on empirical models or on ab initio trajectories that have been too short to draw significant conclusions. Here, we present the results of multiple time-step ab initio molecular dynamics simulations of an excess proton in liquid imidazole reaching 1 ns in total simulation time. We find that the proton transport is dominated by structural diffusion, with the diffusion constant of the proton defect being ∼8 times higher than that of self-diffusion of the imidazole molecules. By using correlation function analysis, we decompose the mechanism for proton transport into a series of first-order processes and show that the proton transport mechanism occurs over three distinct time and length scales. Although the mechanism at intermediate times is dominated by hopping along pseudo-one-dimensional chains, at longer times the overall rate of diffusion is limited by the re-formation of these chains. These results provide a more complete picture of the traditional idealized Grotthuss structural diffusion mechanism.

Resolving Heterogeneous Dynamics of Excess Protons in Aqueous Solution with Rate Theory.

Rate theories have found great utility across the chemical sciences by providing a physically transparent way to analyze dynamical processes. Here we demonstrate the benefits of using transition state theory and Marcus theory to study the rate of proton transfer in HCl solutions. By using long ab initio molecular dynamics simulations, we show that good agreement is obtained between these two different formulations of rate theory and how they can be used to study the pathways and lifetime of proton transfer in aqueous solution. Since both rate theory formulations utilize identical sets of molecular data, this provides a self-consistent theoretical picture of the rates of aqueous phase proton transfer. Specifically, we isolate and quantify the rates of proton transfer, ion-pair dissociation, and solvent exchange in concentrated HCl solutions. Our analysis predicts a concentration dependence to both proton transfer and ion-pairing. Moreover, our estimate of the lifetime for the Zundel species is 0.8 and 1.3 ps for 2 M and 8 M HCl, respectively. We demonstrate that concentration effects can indeed be quantified through the combination of state-of-the-art simulation and theory and provides a picture of the important correlations between the cation (hydronium) and the counterion in acid solutions.

Optical spectra in the condensed phase: Capturing anharmonic and vibronic features using dynamic and static approaches.

Simulating optical spectra in the condensed phase remains a challenge for theory due to the need to capture spectral signatures arising from anharmonicity and dynamical effects, such as vibronic progressions and asymmetry. As such, numerous simulation methods have been developed that invoke different approximations and vary in their ability to capture different physical regimes. Here, we use several models of chromophores in the condensed phase and ab initio molecular dynamics simulations to rigorously assess the applicability of methods to simulate optical absorption spectra. Specifically, we focus on the ensemble scheme, which can address anharmonic potential energy surfaces but relies on the applicability of extreme nuclear-electronic time scale separation; the Franck-Condon method, which includes dynamical effects but generally only at the harmonic level; and the recently introduced ensemble zero-temperature Franck-Condon approach, which straddles these limits. We also devote particular attention to the performance of methods derived from a cumulant expansion of the energy gap fluctuations and test the ability to approximate the requisite time correlation functions using classical dynamics with quantum correction factors. These results provide insights as to when these methods are applicable and able to capture the features of condensed phase spectra qualitatively and, in some cases, quantitatively across a range of regimes.

Tracking Aqueous Proton Transfer by Two-Dimensional Infrared Spectroscopy and ab Initio Molecular Dynamics Simulations.

Proton transfer in water is ubiquitous and a critical elementary event that, via proton hopping between water molecules, enables protons to diffuse much faster than other ions. The problem of the anomalous nature of proton transport in water was first identified by Grotthuss over 200 years ago. In spite of a vast amount of modern research effort, there are still many unanswered questions about proton transport in water. An experimental determination of the proton hopping time has remained elusive due to its ultrafast nature and the lack of direct experimental observables. Here, we use two-dimensional infrared spectroscopy to extract the chemical exchange rates between hydronium and water in acid solutions using a vibrational probe, methyl thiocyanate. Ab initio molecular dynamics (AIMD) simulations demonstrate that the chemical exchange is dominated by proton hopping. The observed experimental and simulated acid concentration dependence then allow us to extrapolate the measured single step proton hopping time to the dilute limit, which, within error, gives the same value as inferred from measurements of the proton mobility and NMR line width analysis. In addition to obtaining the proton hopping time in the dilute limit from direct measurements and AIMD simulations, the results indicate that proton hopping in dilute acid solutions is induced by the concerted multi-water molecule hydrogen bond rearrangement that occurs in pure water. This proposition on the dynamics that drive proton hopping is confirmed by a combination of experimental results from the literature.

Unraveling electronic absorption spectra using nuclear quantum effects: Photoactive yellow protein and green fluorescent protein chromophores in water.

Many physical phenomena must be accounted for to accurately model solution-phase optical spectral line shapes, from the sampling of chromophore-solvent configurations to the electronic-vibrational transitions leading to vibronic fine structure. Here we thoroughly explore the role of nuclear quantum effects, direct and indirect solvent effects, and vibronic effects in the computation of the optical spectrum of the aqueously solvated anionic chromophores of green fluorescent protein and photoactive yellow protein. By analyzing the chromophore and solvent configurations, the distributions of vertical excitation energies, the absorption spectra computed within the ensemble approach, and the absorption spectra computed within the ensemble plus zero-temperature Franck-Condon approach, we show how solvent, nuclear quantum effects, and vibronic transitions alter the optical absorption spectra. We find that including nuclear quantum effects in the sampling of chromophore-solvent configurations using ab initio path integral molecular dynamics simulations leads to improved spectral shapes through three mechanisms. The three mechanisms that lead to line shape broadening and a better description of the high-energy tail are softening of heavy atom bonds in the chromophore that couple to the optically bright state, widening the distribution of vertical excitation energies from more diverse solvation environments, and redistributing spectral weight from the 0-0 vibronic transition to higher energy vibronic transitions when computing the Franck-Condon spectrum in a frozen solvent pocket. The absorption spectra computed using the combined ensemble plus zero-temperature Franck-Condon approach yield significant improvements in spectral shape and width compared to the spectra computed with the ensemble approach. Using the combined approach with configurations sampled from path integral molecular dynamics trajectories presents a significant step forward in accurately modeling the absorption spectra of aqueously solvated chromophores.

Decoding the spectroscopic features and time scales of aqueous proton defects.

Acid solutions exhibit a variety of complex structural and dynamical features arising from the presence of multiple interacting reactive proton defects and counterions. However, disentangling the transient structural motifs of proton defects in the water hydrogen bond network and the mechanisms for their interconversion remains a formidable challenge. Here, we use simulations treating the quantum nature of both the electrons and nuclei to show how the experimentally observed spectroscopic features and relaxation time scales can be elucidated using a physically transparent coordinate that encodes the overall asymmetry of the solvation environment of the proton defect. We demonstrate that this coordinate can be used both to discriminate the extremities of the features observed in the linear vibrational spectrum and to explain the molecular motions that give rise to the interconversion time scales observed in recent nonlinear experiments. This analysis provides a unified condensed-phase picture of the proton structure and dynamics that, at its extrema, encompasses proton sharing and spectroscopic features resembling the limiting Eigen [H3O(H2O)3]+ and Zundel [H(H2O)2]+ gas-phase structures, while also describing the rich variety of interconverting environments in the liquid phase.

Nephroblastomatosis or Wilms tumor in a fourth patient with a somatic PIK3CA mutation.

Wilms tumor and nephroblastomatosis are associated with syndromic conditions including hemihyperplasia. Hemihyperplasia is genetically heterogeneous and may be the result of genomic abnormalities seen in Beckwith-Wiedemann syndrome, mosaic chromosome or genomic abnormalities, or somatic point mutations. Somatic missense mutations affecting the PI3K-AKT-MTOR pathway result in segmental overgrowth and are present in numerous benign and malignant tumors. Here, we report a fourth patient with asymmetric overgrowth due to a somatic PIK3CA mutation who had nephroblastomatosis or Wilms tumor. Similar to two of three reported patients with a somatic PIK3CA mutation and renal tumors, he shared a PIK3CA mutation affecting codon 1047, presented at birth with asymmetric overgrowth, and had fibroadipose overgrowth. Codon 1047 is most commonly affected by somatic mutations in PIK3CA-related overgrowth spectrum (PROS). While the fibroadipose overgrowth phenotype appears to be common in individuals with PIK3CA mutations at codon 1047, individuals with a clinical diagnosis of Klippel-Trenaunay syndrome or isolated lymphatic malformation also had mutations affecting this amino acid. Screening for Wilms tumor in individuals with PROS-related hemihyperplasia may be considered and, until the natural history is fully elucidated in larger cohort studies, may follow guidelines for Beckwith-Wiedemann syndrome, or isolated hemihyperplasia. It is not known if the specific PIK3CA mutation, the mosaic distribution, or the clinical presentation affect the Wilms tumor or nephroblastomatosis risk in individuals with PROS. © 2016 Wiley Periodicals, Inc.

Facial dysmorphology and odontogenic tumor development associated with inborn errors of metabolism: a case report.

PURPOSE: Inborn errors of metabolism (IEMs) are genetic disorders that alter normal physiologic functioning. Deficiency of 3-methylcrotonyl-coenzyme A carboxylase is one such IEM that can lead to major episodes of metabolic dysfunction. Certain IEMs are associated with characteristic congenital dysmorphic facial features. This can be problematic, because these dysmorphisms can mask underlying tumor growth. Literature is lacking on a causal relation between IEM and odontogenic tumor development. MATERIALS AND METHODS: This case was explained in detail and a review of the literature was undertaken. PubMed was used to search for articles involving surgical management of odontogenic myxoma (OM) and associations between odontogenic tumors and IEM. RESULTS: It was determined that the development of odontogenic tumors, specifically OM, is associated with IEMs. These tumors can easily be overlooked as a common dysmorphic feature of an IEM. CONCLUSION: IEMs lead to major metabolic disturbances and, thus, can alter the cellular microenvironment. Hypothetically, these alterations can lead to the development of odontogenic tumors. With the diagnosis of IEM becoming more common owing to improved newborn screening, careful attention should be given to these patients because of the possibility that dysmorphologic facial features could be masking underlying tumor growth.

Topical amphotericin B in combination with standard therapy for severe necrotizing skin and soft-tissue mucormycosis in an infant with bilineal leukemia: case report and review.

During chemotherapy for bilineal leukemia, a 6-month-old infant presented with a necrotizing skin and soft-tissue infection of the chest wall due to Rhizopus sp. Successful outcome was achieved by systemically administered liposomal amphotericin B and local wound control with the novel administration of topical deoxycholate amphotericin B and surgical resection.

A study of speech, language, hearing, and dentition in children with cleft lip only.

OBJECTIVE: To examine the prevalence of speech, language, hearing, and dental problems in children with an initial diagnosis of isolated cleft lip only (CL), for which evidence-based practice can be developed. DESIGN: Retrospective chart review of 95 patients with cleft lip (age range, 2.8 to 3.7 years; mean, 3.1 years). RESULTS: Speech and language impairment was documented in 13% and 18% of the patients, respectively. Thirty-three percent of the children presented with middle ear effusion. Thirteen percent had abnormal hearing. With one exception, the type and degree of hearing loss was a mild conductive loss most often attributed to the presence of effusion. Dental and/or occlusal anomalies were documented in 62% of the patients. A supernumerary tooth was the most frequently occurring dental anomaly and crossbite the most frequently occurring occlusal anomaly. Two children had a submucous cleft palate. Resonance was abnormal in 5% of the children. CONCLUSION: Children with an initial diagnosis of CL need to be monitored by the interdisciplinary team for speech, language, ear disease, hearing, and dentition beginning in infancy and followed until all management needs are met.