Minority and Public Insurance Status: Is There a Delay to Alveolar Bone Grafting Surgery?

OBJECTIVE: This study sought to determine the timing of alveolar bone grafting (ABG) surgery among children with cleft lip with or without cleft palate (CL±P) with regard to race and insurance status. DESIGN: A retrospective chart review of consecutive patients receiving ABG surgery was conducted. A multivariate regression model was constructed using predetermined clinical and demographic variables. SETTING: A large, urban cleft referral center. PATIENTS, PARTICIPANTS: Nonsyndromic patients with CL±P were eligible for study inclusion. INTERVENTIONS: ABG surgery using autogenous bone harvested from the anterior iliac crest. MAIN OUTCOME MEASURE: The primary outcome of interest was age at ABG surgery. RESULTS: A total of 233 patients underwent ABG surgery at 8.1 ± 2.3 years of age. African American and Hispanic patients received delayed ABG surgery compared with Caucasian patients by approximately 1 year (P < .05). There was no difference in ABG surgery timing by insurance status (P > .05). CONCLUSIONS: The timing of ABG surgery varied by race but not by insurance status. Greater resources may be needed to ensure timely delivery of cleft care to African American and Hispanic children.

A 35-year experience with syndromic cleft palate repair: operative outcomes and long-term speech function.

BACKGROUND: Associated comorbidities can put syndromic patients with cleft palate at risk for poor speech outcomes. Reported rates of velopharyngeal insufficiency (VPI) vary from 8% to 64%, and need for secondary VPI surgery from 23% to 64%, with few studies providing long-term follow-up. The purpose of this study was to describe our institutional long-term experience with syndromic patients undergoing cleft palatoplasty. METHODS: A retrospective review was conducted of all patients with syndromic diagnoses undergoing primary Furlow palatoplasty from 1975 to 2011. Outcomes included postoperative oronasal fistula (ONF) and need for secondary VPI surgery. Speech scores for verbal patients 5 years or older were collected via the Pittsburgh scale for speech assessment. Aggregate scores categorized the velopharyngeal mechanism as competent, borderline, or incompetent. Outcomes were analyzed by patient and operative factors. RESULTS: One hundred thirty-two patients were included with average age at repair of 20.7 months. Cleft type was 9% submucosal, 16% Veau class I, 50% class II, 12% class III, and 13% class IV. Forty-five syndromes were recorded, most commonly Stickler syndrome (n = 32) and 22q11.2 deletion syndrome [22q11.2DS (n = 19)]. Forty-four patients also had associated Pierre Robin sequence (PRS). The overall ONF rate was 4.5% and was highest in Veau class IV clefts (P = 0.048). Seventy-six patients were included in speech analysis, with an average age at last assessment of 10.4 years. Overall, 60.5% of patients had a competent velopharyngeal mechanism, 23.7% borderline, and 15.8% incompetent mechanism. Fifty percent of 22q11.2DS patients had borderline speech and none had competent speech, compared to 73.3% with Stickler syndrome (P = 0.01) and 71.4% of patients with associated PRS (P = 0.02). Secondary VPI surgery was performed in 11.4% of patients overall. Patients with PRS (13.6%) and with Stickler syndrome (15.6%) had secondary VPI surgery, compared to 31.6% of patients with 22q11.2DS (P = 0.01). CONCLUSIONS: This study demonstrates low rates of postoperative ONF after modified Furlow palatoplasty in syndromic patients. Speech outcomes were comparable to nonsyndromic patients at our institution, but patients with 22q11.2DS consistently had borderline-incompetent speech and a 3-fold higher incidence of secondary VPI surgery.

Incidence of positive screening for obstructive sleep apnea in patients with isolated cleft lip and/or palate.

OBJECTIVE: To determine the incidence of obstructive sleep apnea (OSA) in children with isolated cleft lip and/or palate (CL/P). METHODS: The present prospective study was performed at a pediatric tertiary care centre. Consecutive patients evaluated at the cleft clinic from January 2011 to August 2013 were identified. Patients' families prospectively completed the Pediatric Sleep Questionnaire (PSQ), a validated tool used to predict moderate to severe OSA. Patients with CL/P and an underlying syndrome or other craniofacial diagnosis were excluded. A positive OSA screen was recorded if the ratio of positive to total responses was >0.33. Risk factors associated with a positive screen were identified using the Student's t or ANOVA test. RESULTS: A total of 867 patients completed the PSQ, 489 of whom with isolated CL/P met inclusion criteria. The mean age was 8.4 years. The overall incidence of positive screening was 14.7%. The most commonly reported symptoms among positive screeners were 'fidgets with hands or feet' (73.6%), 'interrupts others' (69.4%) and 'mouth breather during the day' (69.4%). The most sensitive items were 'stops breathing during the night' and 'trouble breathing during sleep', with positive predictive values of 0.78 and 0.67, respectively. Sex, body mass index, ancestry and cleft type were not significantly associated with increased risk for positive screening. CONCLUSION: One in seven children with isolated CL/P screened positively for OSA according to the PSQ. This finding highlights the potential importance of routine screening in this at-risk group.

OBJECTIF: Déterminer l'incidence d'apnée obstructive du sommeil (AOS) chez les enfants ayant une fente labiale ou palatine isolée (F/LP). MÉTHODOLOGIE: La présente étude prospective a été effectuée dans un centre de soins tertiaires. Des patients consécutifs évalués à la clinique de fente labiale ou palatine entre janvier 2011 et août 2013 ont été repérés. Les familles des patients ont rempli prospectivement un questionnaire sur le sommeil pédiatrique (PSQ), un outil validé utilisé pour prédire l'AOS modérée à grave. Les patients ayant une F/LP et un syndrome sous-jacent ou un autre diagnostic crâniofacial étaient exclus. Le dépistage d'AOS était positif si le ratio entre la réponse positive et les réponses totales était supérieur à 0,33. Les facteurs de risque de dépistage positif ont été déterminés à l'aide du test t de Student ou du test ANOVA. RÉSULTATS: Au total, 867 patients ont rempli le PSQ, dont 489 avaient une F/LP qui respectait les critères d'inclusion. Ils avaient un âge moyen de 8,4 ans. L'incidence globale de dépistage positif s'élevait à 14,7 %. Les symptômes les plus déclarés chez les personnes dépistées comme positives étaient « agite les mains ou les pieds ¼ (73,6 %), « interrompt ¼ (69,4 %) et « respire par la bouche pendant la journée ¼ (69,4 %). Les faits les plus inquiétants étaient « arrête de respirer pendant la nuit et « a de la difficulté à respirer pendant qu'il dort ¼, dont les valeurs prédictives positives étaient respectivement de 0,78 et de 0,67. Le sexe, l'indice de masse corporelle, l'ascendance et le type de fente ne s'associaient pas de manière significative à un risque accru de dépistage positif. CONCLUSION: Un enfant sur sept ayant une F/LP isolée était positif à l'AOS selon le PSQ. Cette observation fait ressortir l'importance potentielle du dépistage systématique dans ce groupe à haut risque.