Quality Assurance Standards for Outreach Cleft Lip and Cleft Palate Repair Programs in Low-Resource Settings.

BACKGROUND: Comprehensive cleft care is a multidisciplinary team endeavor. While untreated craniofacial conditions have multiple undue repercussions, cleft care in outreach settings can be fraught with significant perioperative morbidity risks. AIM: Propose updated quality assurance standards addressing logistic and operational considerations essential for the delivery of safe and effective cleft lip and /or palate (CL/P) care in low and middle-income countries (LMICs) settings. METHODS: Based on American Cleft Palate-Craniofacial Association (ACPA) quality standards, published literature, published protocols by Global Smile Foundation (GSF), and the senior author's three-decade experience, updated standards for outreach cleft care were synthesized. RESULTS: Ten axes for safe, effective, and sustainable cleft lip and palate care delivery in underserved settings were generated: 1) site assessment, 2) establishment of community partnerships, 3) team composition and credentialing, 4) team training and mission preparation, 5) implementation of quality assurance guidelines, operative safety checklists, and emergency response protocols, 6) immediate and long-term postoperative care, 7) medical record keeping, 8) outcomes evaluation, 9) education, and 10) capacity building and sustainability. Subsequent analysis further characterized essential components of each of those ten axes to delineate experience derived and evidence-based recommendations. DISCUSSION: Quality assurance guidelines are essential for the safe delivery of comprehensive cleft care to patients with CL/P in any setting. Properly designed surgical outreach programs relying on honest community partnerships can be effectively used as vehicles for local capacity building and the establishment of sustainable cleft care ecosystems.

Feeding Performance and Outcomes in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis.

To describe perioperative feeding performance in infants with Robin sequence (RS) who underwent mandibular distraction osteogenesis (MDO).A retrospective study of infants that underwent MDO from May 2010 to December 2019.Tertiary pediatric hospital.A total of 40 patients underwent MDO and 20 met inclusion criteria. Of the included infants, 6 had an associated syndrome and 80% were male.Time to full oral feeds, rate of G-tube placement, and change in weight percentile following MDO.Average oral intake prior to MDO was 22.1% of individual goal feeds. Among the 15 (75%) children that did not require G-tube placement, mean time to full oral feeds after MDO was 11 days ± 5.7 days, with 80% of infants reaching full oral feeds within 2 weeks after extubation. The proportion of G-tube placement in patients with a syndrome was higher than in isolated RS (-0.6; 95% CI: -1.0, -0.2). Mean percentages of weight-for-age percentile decreased during the first 3 months after the procedure. This was followed by a mean upturn in weight starting after the third month after MDO with a recovery to preoperative mean weight-for-age percentiles by 6 months after surgery.This study suggests that infants with RS may achieve full oral feeds despite poor feeding performance before MDO. Infants with syndromic RS are more likely to require G-tube. These findings may be used to inform G-tube discussion and offer a timeline to work toward goal oral feeds for infants with RS after MDO.

Impact of Hospital Characteristics on Mandibular Distraction Osteogenesis Outcomes Among Patients With Pierre Robin Sequence Utilizing a National Inpatient Database.

OBJECTIVES: This study collected national inpatient data to investigate the impact of hospital specialty and size on patient outcomes following mandibular distraction osteogenesis (MDO). DESIGN: Kids' Inpatient Database was used to identify patients less than 12 months of age with Pierre Robin sequence (PRS) who underwent MDO in one of the following years: 2006, 2009, and 2012. SETTING: Inpatient database from the United States. PARTICIPANTS: Two hundred seventy-six patients with PRS underwent MDO with 134 (48.6%) identified as nonsyndromic and 142 (51.4%) as syndromic. INTERVENTIONS: Mandibular distraction osteogenesis. MAIN OUTCOME MEASURES: Length of hospital stay, adjunct airway and nutritional interventions and disposition. RESULTS: The average length of stay was 24 and 30 days for patients with nonsyndromic and syndromic PRS, respectively (P = .066). Patients with a syndromic as compared to nonsyndromic diagnosis had a higher incidence of gastrostomy tube placement (21.8 vs 12.7%, P = .045). Univariate analysis showed that a lower proportion of patients at children's hospitals as compared to non-children's hospitals necessitated 1 or more airway or nutrition-related intervention (19/148 [12.8%] vs 31/127 [24.4%]; P = .012) and had a lower incidence of a nonroutine discharge (transfer or patient death; 7.4% vs 40.0% nonroutine; P < .001). Multivariable analysis additionally revealed that patients at children's hospitals were less likely to discharge nonroutine (OR = 0.07, 95% CI: 0.02-0.32). CONCLUSIONS: Results from this national cohort demonstrated that at children-specific hospitals patients with PRS were less likely to require additional airway and nutritional procedures and more likely to discharge to home.

A unique case of penetrating neck and cervical spine trauma resulting in vertebral artery transection and internal carotid artery laceration.

OBJECTIVES: Describe the presentation and treatment of a patient who suffered a penetrating cervical trauma resulting in occlusion of the vertebral and internal carotid arteries. METHODS: The electronic medical record was used to collect information pertaining to the patient's clinical history. RESULTS: A 20-year-old male suffered a unique penetrating neck injury resulting in simultaneous injuries to the internal carotid and vertebral arteries as demonstrated by pre-operative angiography. Combined endovascular and open surgical approaches were utilized to successfully manage the vascular injuries prior to foreign body extraction. CONCLUSION: Complex penetrating cervical trauma is best managed with a multidisciplinary and multimodality approach. In appropriately selected patients, pre-operative angiography is a critical diagnostic modality that can prevent life-threatening hemorrhage following foreign body extraction.

Treatment of oropharyngeal dysphagia secondary to idiopathic cricopharyngeal bar: Surgical cricopharyngeal muscle myotomy versus dilation.

OBJECTIVE: To compare swallowing outcomes following cricopharyngeal (CP) dilation versus surgical myotomy in patients with dysphagia secondary to idiopathic CP bar. METHODS: All patients had an idiopathic CP bar without a history of Zenker's diverticulum, head and neck cancer, or systemic neurologic disease treated between 2000 and 2013. The Functional Outcome Swallowing Scale (FOSS) was utilized to assess dysphagia symptoms. RESULTS: Twenty-three patients underwent 46 dilations and 20 patients had a myotomy. Nineteen of 23 (83%) patients in the dilation group and all patients in the myotomy group reported improved swallow function. The median difference in pre- versus post-intervention FOSS scores was not statistically significant (p=0.07) between the dilation and myotomy groups with mean reductions of 1.3 and 1.8, respectively. Seventeen of 23 (74%) dilation patients had persistent or recurrent dysphagia with 13 (57%) requiring repeat dilation and 4 (17%) undergoing CP myotomy. The median time to first reintervention in the dilation group was 13.6months. Nineteen of 20 (95%) surgical myotomy patients did not experience recurrent dysphagia. CONCLUSION: Both endoscopic CP dilation and myotomy led to similar initial improvement in swallow function for patients with primary idiopathic CP bar; however, dilation is more likely to provide temporary benefit.

A Unique Case of Bilateral Recurrent Sphenoid Sinus Cerebrospinal Fluid Leaks: Primary Acquired Leak Within the Lateral Sphenoid Sinus Recess, Followed by a Leak via Sternberg's Canal.

OBJECTIVES: This case presents a previously undescribed clinical scenario of spontaneous cerebrospinal fluid (CSF) leaks secondary to a lateral sphenoid sinus recess skull base dehiscence and contralateral Sternberg's canal. This case report aims to characterize the presentation and successful management of these lesions. METHODS: The electronic medical record was used to collect information pertaining to the patient's clinical history. RESULTS: The patient was a middle-aged, obese female with persistent clear rhinorrhea as her only presenting symptom. Neuroradiologic studies localized the defect to the lateral sphenoid sinus recess. CSF opening pressures were within normal limits, but radiographic findings were consistent with elevated intracranial pressure. After an endoscopic transnasal transsphenoidal approach failed to resolve the CSF leak, a transpterygoid approach facilitated CSF leak resolution. The patient then did well for the following 2 years, but later developed a CSF leak through a contralateral Sternberg's canal. An endoscopic suprapterygoid procedure and ventriculoperitoneal shunt placement led to CSF leak resolution. CONCLUSION: This case demonstrates one of the only published examples of a sphenoid sinus CSF leak secondary to Sternberg's canal as it was originally described in the literature. Wide endoscopic surgical exposure and intracranial pressure management ultimately led to CSF leak resolution.

Update on using buccal myomucosal flaps for patients with cleft palate and velopharyngeal insufficiency: primary and secondary interventions.

PURPOSE OF REVIEW: This review aims to examine the indications and anatomical circumstances for when to optimally incorporate buccal myomucosal flaps (BMFs) into palatal surgical reconstruction. RECENT FINDINGS: Studies examining outcomes following primary cleft palate repair with incorporation of BMF have demonstrated excellent speech outcomes and low rates of fistula. Furthermore, some reports cite an association of buccal flap use with reduced midface hypoplasia and the need for later orthognathic surgery. When used for secondary speech surgery, BMFs have been shown to lead to speech improvements across multiple outcome measures. Advantages of BMF techniques over conventionally described pharyngeal flap and pharyngoplasty procedures include significant lengthening of the velum, favorable repositioning of the levator muscular sling, and lower rates of obstructive sleep apnea. SUMMARY: Although the published data demonstrate excellent outcomes with use of BMFs for primary and secondary palatal surgery, there are limited data to conclude superiority over the traditional, more extensively investigated surgical techniques. The authors of this review agree with the evidence that BMF techniques can be useful in primary palatoplasty for congenitally wide clefts, secondary speech surgery for large velopharyngeal gaps, and/or in individuals with a predisposition for airway obstruction from traditional approaches.

Publishing Trends in International Humanitarian Cleft Lip and Palate Care: A Systematic Review.

Background: Humanitarian outreach delivers essential cleft lip and palate (CLP) care in low- and middle-income countries. Objective: To review the literature regarding humanitarian CLP care and determine if a shift toward more sustainable care delivery is observed. Methods: A systematic review was performed on articles describing CLP repair in humanitarian settings from 1985 to 2020. Publications were categorized into trip reports, outcomes, teaching, and public health. Articles were stratified into three 12-year intervals (T1-T3) for analysis. Results: A total of 246 publications were included. Average annual publications increased 15.4-fold from T1 to T3 (p < 0.001). Among publications focused on delivering CLP-related care, descriptive trip report articles trended downward (58% in T1 vs. 42% in T3), whereas outcome-focused publications trended upward (42% in T1 vs. 58% T3). Public health research represented the greatest percentage of publications in T3 (50%). There were 22 teaching-related publications in T3 and only one in prior years. Conclusion: Research trends demonstrate a shift away from focusing solely on the number of surgical cases completed and toward more sustainable models of care delivery that address barriers to receiving longitudinal care.

Longitudinal Anatomic Analysis of Primary Cleft Lip Rhinoplasty Outcomes.

Background: The unilateral cleft lip deformity is associated with nasal deformities with secondary functional and aesthetic challenges. Objectives: Compare the change in nasal symmetry before and incrementally after primary endonasal cleft rhinoplasty concurrent with lip repair. Methods: This is a retrospective chart review of infants undergoing unilateral cleft lip repair. Data collection included demographics, surgical history, and pre- and postoperative alar and nostril photographs analyzed with Image J. Statistical analysis was done using linear and multivariable mixed effect models. Results: Twenty-two patients with a near even gender distribution (46% female) and primarily left-sided cleft lips underwent unilateral lip repair at a mean age of 3.9 months (median 3.0, range 2-12). Mean pre- and postoperative alar symmetry ratios were 0.099 (standard error [SE] 0.0019) and -0.0012 (SE 0.0179), with zero representing perfect symmetry and negative values indicating overcorrection. These values at 1, 2-4, 5-7, 8-12, 13-24, and 25+ months were 0.026, 0.050, 0.046, 0.052, 0.049, and 0.052 (SE range: 0.0015-0.0096), respectively, demonstrating stability of the alar symmetry 4 months postrepair. Conclusions: In this study, patients who underwent an overcorrective primary cleft rhinoplasty concurrent with lip repair had an initial regression of symmetry within the first 4 months postoperatively, followed by observed stabilization.

Masseteric-to-facial nerve transfer for treatment of pediatric facial paralysis: An initial report.

OBJECTIVES: The indications and outcomes of masseteric-to-facial nerve transfer in pediatric patients with short-term facial paralysis is incompletely understood as compared to its use in adult patients. This report aims to retrospectively quantify outcomes with both clinician-based measurements and objective facial analysis software. METHODS: Retrospective case series at a single institution. The Sunnybrook Facial Grading System was used for clinician-based measurements and Emotrics software for objective measurements. RESULTS: Four pediatric patients underwent masseteric-to-facial nerve transfers from 2016 to 2018. The mean patient age at the time of surgery was 4.5 years (range = 2-7) and the mean time from paralysis onset to surgical intervention was 12.9 months (range = 10.0-16.2). The mean follow-up was 18.3 months (range = 14.5-23.6). With regards to the Sunnybrook resting nasolabial fold symmetry, 3 of the 4 patients improved from 2 (absent nasolabial fold) to 1 (less pronounced nasolabial fold). Per the Emotrics analysis, the pre- and post-operative mean absolute differences for commissure excursion between the normal functioning and paralyzed sides were 11.8 mm and 6.7 mm, respectively (p = 0.04). CONCLUSION: The masseteric-to-facial nerve transfer technique leads to an objective improvement in dynamic smile function in select pediatric patients.

Metanalysis of alloplastic materials versus autologous fat for injection augmentation pharyngoplasty treatment of velopharyngeal insufficiency.

BACKGROUND: Velopharyngeal insufficiency (VPI) can cause resonance, speech and feeding problems. While reconstructive palatoplasty and surgical pharyngoplasty techniques are the mainstay of treatment for severe VPI, injection augmentation pharyngoplasty offers a minimally invasive approach in patients with mild-to-moderate VPI. METHODS: We conducted a systematic review of the literature available on PubMed and Embase from 1990 to 2019 including studies that addressed VPI, incompetence, or dysfunction managed with injection augmentation. Patient demographics, etiology of VPI, injection material, volume of injection, number of injections, complications and both subjective and objective outcomes were recorded. RESULTS: Twenty-nine studies met our inclusion criteria encompassing 587 patients, ages 3-75 years (mean = 16) who underwent injection pharyngoplasty. Injection materials included glutaraldehyde cross-linked (GAX) collagen (n = 5), calcium hydroxyapatite (n = 36), dextranomer and hyaluronic acid (n = 72) and autologous fat (n = 471). Follow-up averaged 15.4 months (range = 2-60 months). Functional improvements in nasality were recorded in a large proportion of patients (0.79, 95% CI 0.75 to 0.82). However, a greater proportion of patients in the synthetic materials group demonstrated either reduced or resolved hypernasality compared with those receiving autologous fat injections (χ2 = 7.035, n = 91/103 vs. 255/338, p = 0.008). Complete velopharyngeal gap closure post-injection was achieved at a higher frequency with injection of synthetic materials compared with autologous fat (χ2 = 11.270, n = 61/69 vs. 58/91 p = 0.001).r CONCLUSION: Injection pharyngoplasty offers a minimally invasive alternative intervention for treatment of VPI secondary to small velopharyngeal gaps. Patients treated with synthetic materials experienced a greater improvement in velopharyngeal closure and a corresponding improvement in resonance balance.

Cleft Lip and Palate in Newborns Diagnosed With Neonatal Abstinence Syndrome.

OBJECTIVE: Cleft lip and/or cleft palate (CLP) is the most common major congenital malformation of the head and neck. Previous studies suggested an association between fetal opioid exposure and CLP. This study seeks to evaluate the associations between CLP and neonatal abstinence syndrome (NAS) in the United States. STUDY DESIGN: Population-based inpatient registry analysis. SETTING: Academic medical center. SUBJECTS AND METHODS: Kids' Inpatient Database (2016) was used to identify weighted in-hospital births with diagnoses of CLP or NAS. Demographic information was obtained. RESULTS: Among 3.8 million weighted in-hospital births, prevalence rates of CLP in the NAS and non-NAS populations were 3.13 and 1.35 per 1000, respectively. The odds ratios for patients with NAS developing CLP, isolated cleft palate, isolated cleft lip, and cleft lip and palate when compared with the reference population were 2.33 (95% CI, 1.87-2.91; P < .001), 4.97 (95% CI, 3.84-6.43; P < .001), 1.01 (P = .98), and 0.80 (P = .46). Independent predictors of CLP within the NAS population included median household income for patients' zip code, race, hospital region, payment method, and maternal use of tobacco or other drugs of addiction. The binary logistic regression model accounting for possible confounding variables produced an odds ratio of 1.74 (95% CI, 1.36-2.23; P < .001) for the association between NAS and CLP. CONCLUSION: Our study found an association between NAS and CLP, specifically isolated cleft palate, suggesting that prenatal exposure to opioids may be an environmental risk factor in the development of CLP.

Cleft Palate in Newborns Diagnosed With Prematurity.

OBJECTIVE: Cleft lip and/or palate (CLP) is the most common major congenital malformation of the head and neck. Although numerous genetic features, syndromes, nutritional deficiencies, and maternal exposures have been implicated in the etiology of CLP, the impact of prematurity on the pathogenesis remains incompletely understood. This study seeks to evaluate the associations between prematurity and the development of CLP in the United States. STUDY DESIGN: Cross-sectional. SETTING: Academic medical center. METHODS: The Kids' Inpatient Database (2016) was used to identify weighted in-hospital births with diagnoses of prematurity or CLP. Demographic information was obtained. Odds ratios were used to determine associations between prematurity and CLP. RESULTS: Among patients included in our data set, 8.653% (n = 326,147) were preterm; 0.136% (n = 5115) had CLP; and 0.021% (n = 808) were preterm and had CLP. Preterm infants had 1.90 times the odds (95% CI, 1.74-2.07) of developing CLP when compared with the nonpreterm population. The binary logistic regression model accounting for possible confounding variables produced an odds ratio of 1.83 (95% CI, 1.66-2.01) for the association between prematurity and CLP. CONCLUSION: Infants who are born preterm are more likely to have CLP than full-term infants. The current results will allow for improved risk stratification, maternal counseling, and interventions in the case of prematurity. LEVEL OF EVIDENCE: 4.

Neonatal tooth infection resulting in subperiosteal orbital abscess: A case report.

Neonatal orbital infections are quite rare, and are most often attributed to ethmoid sinusitis. This report describes a case of subperiosteal orbital abscess in a neonate secondary to an infected neonatal tooth. Although there have been two cases reported in the literature describing odontogenic infection resulting in orbital abscess in neonates, these cases were due to infected tooth buds rather than an infected neonatal tooth. We discuss workup and surgical management of this patient, including tooth extraction and intraoral approach to the orbit for abscess drainage.

Outcomes Assessment of Multi-Level Sleep Surgery in Syndromic Versus Non-Syndromic Children.

OBJECTIVES: Analyze the differences in length of stay, cost, disposition, and demographics between syndromic and non-syndromic children undergoing multi-level sleep surgery. METHODS: Children with sleep disordered breathing or obstructive sleep apnea that had undergone sleep surgeries were isolated from the 1997 to 2012 editions of the Kids' Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Children were then classified as syndromic or non-syndromic and stratified by level of sleep surgery (tonsillectomy & adenoidectomy, tonsillectomy & adenoidectomy plus other site surgery, other site surgery). Length of stay and cost were reported with Kruskal-Wallis one-way analysis of variance, disposition with binomial logistic regression, and demographics with chi-square. RESULTS: Syndromic children compared to non-syndromic children were more likely to have surgery beyond just tonsillectomy & adenoidectomy and also had a longer length of stay, higher total cost and non-routine disposition (all P < .001). Syndromic children undergoing tonsillectomy and adenoidectomy plus other site surgery had a longer length of stay compared to syndromic children undergoing tonsillectomy & adenoidectomy (6.00 days vs 3.63 days, P < .001). However, no similar statistically significant difference in length of stay was found in non-syndromic children (2.01 days vs 2.87 days, P > .05). CONCLUSION: The potential risks/benefits need to be weighed carefully before undertaking sleep surgery in syndromic children. They experience a longer length of stay, higher cost, and non-routine disposition when compared to non-syndromic children. This is especially true when considering the transition from tonsillectomy & adenoidectomy to tonsillectomy & adenoidectomy plus other site surgery, as syndromic children experience a longer length of stay and non-syndromic children do not.

Publishing trends in velopharyngeal insufficiency.

OBJECTIVE: This study seeks to describe publishing trends for VPI over a 33-year span with regard to treating specialty, methods of assessment, related diagnoses, and methods of treatment for each specialty. METHODS: A PubMed search was performed on "velopharyngeal insufficiency" using medical subject headings terms from 1985 to 2017. Publisher specialty, method(s) of VPI assessment, associated diagnosis/diagnoses, and method(s) of VPI treatment per specialty and combined across specialties were analyzed. Respective publications were totaled in 11-year intervals and two-way analysis of variance was used to compare change over time within specialties and across specialties. RESULTS: 763 publications were included for analysis. The total number of publications on VPI increased from a total of 6 in 1985 to a peak of 67 in 2015. The specialties that showed the largest increase in relative frequency of publication were Otolaryngology (p < 0.001), Plastic Surgery (p < 0.001), and Multidisciplinary (p < 0.001). Publications on endoscopic (p < 0.001) evaluation of VPI have significantly increased over time relative to magnetic resonance imaging and lateral cephalometry. Across all specialties, publications that feature pharyngoplasty (p < 0.001), palatoplasty (p < 0.001), and pharyngeal flap (p < 0.001) as methods of VPI treatment have significantly increased over time. CONCLUSION: There is a trend towards endoscopy for diagnostics and a multidisciplinary approach when managing patients with VPI. The specialty that showed the largest increase in the relative frequency of publication was Otolaryngology. Surgical methods of treatment continue to be described at increasing frequency relative to more conservative treatments.

Short-Term Risk Factor Profile of Pediatric Choanal Atresia Repair Using ACS-NSQIP National Database.

OBJECTIVES: The goal of this study is to describe the 30-day postoperative sequelae of pediatric choanal atresia repair and identify predictive factors for adverse events. STUDY DESIGN: The American College of Surgeons' National Surgery Quality Improvement Program-Pediatric (NSQIP-P) database was searched between January 2012 and December 2015 to identify pediatric patients status post choanal atresia repair. Postoperative outcomes included surgical site complications, readmissions, and total length of stay. RESULTS: A total of 178 children underwent choanal atresia repair. The overall complication rate was 6.2%, while the 30-day readmission rate was 15%. Patients with CHARGE had a longer mean duration of hospitalization (26.91 days vs 8.05 days, P = .013). Additionally, patients ≤10 days of age had longer duration of hospitalization (17.84 days vs 9.24 days, P ≤ .001) and higher readmission rates (33.30% vs 10.1%, P = .001). Among the nonsyndromic cohort, ventilator dependence was a predictor of postoperative complications (odds ratio [OR] = 16.08, P < .001), higher readmission rates (OR = 5.46, P = .002), and a longer hospital stay (OR = 18.69, P < .001). CONCLUSION: Analysis of the 2012-2015 NSQIP-P data set reveals that patients with a diagnosis of CHARGE and those ≤10 days of age have a longer duration of hospitalization. Increased risk of postoperative complications and longer duration of hospitalization were both influenced by chronic steroid use and ventilator dependence.

Association of Pediatric Patient Demographic Factors and Scar Anatomic Features With Scar Outcomes After Surgical Repair of Cleft Lip.

IMPORTANCE: Scar outcomes following cleft lip repair are an important component of pediatric patient and family satisfaction and indicate the need for future surgical interventions. OBJECTIVE: To assess the association of pediatric patient demographic factors and scar anatomic features with scar outcomes following cleft lip surgical repair. DESIGN, SETTING, AND PARTICIPANTS: A case-control study was conducted involving 58 pediatric patients who underwent surgical repair of a cleft lip from October 31, 2008, to August 4, 2016, at a tertiary care pediatric specialty hospital. Data on patient demographic factors, cleft type, and the surgical technique used were collected and analyzed from June 11, 2009, to November 21, 2017. Scar outcomes were subjectively rated by 3 physicians at 6-month and 12-month postoperative intervals. MAIN OUTCOMES AND MEASURES: Overall scar outcomes at 6-month and 12-month postoperative intervals were based on rating of scar appearance, color, width, height, and alignment by using a subjective, 5-point scar-assessment scale in which 1 indicated the poorest aesthetic appearance and 5, the ideal aesthetic appearance. RESULTS: A total of 58 pediatric patients who underwent cleft lip repair were evaluated; mean (SD) age at time of repair, 4.8 (3.0) months. Of these, 44 (76%) were male and 14 (24%) were female, 37 (64%) were white, 11 (19%) were black, 7 (12%) were Hispanic, 2 (3%) were Asian, and 1 (2%) was of another race/ethnicity. Scores on the Cohen κ interrater test indicated either a substantial or almost perfect strength of agreement among the physicians grading the scar outcomes. At 12 months, patients with black skin type had worse overall scar outcomes than patients with white skin type (odds ratio [OR], -0.31; 95% CI, -1.15 to -0.14; P = .03). A depressed scar height (OR, -0.54; 95% CI, -1.32 to -0.49; P < .001), and hypopigmented scar color (OR, -0.45; 95% CI, -1.34 to -0.32; P = .002) were associated with worse scar outcomes at 12 months following surgery. The overall median lip scar outcome significantly improved between the 6-month and 12-month follow-up assessments (scar-assessment scale score, 3.3; interquartile range [IQR], 2.7-4.0 vs 4.0; IQR, 3.3-4.3; P < .001). No association was observed between the anatomic type and severity of the cleft lip and scar outcomes (unilateral vs bilateral cleft, complete vs incomplete or microform cleft, and lip height ratio of the unilateral noncleft to cleft lip). CONCLUSIONS AND RELEVANCE: This study's findings suggest that, compared with white pediatric patients, black pediatric patients exhibited worse overall scar outcomes. A depressed scar and a hypopigmented scar also were associated with overall worse scar appearance after surgical repair. Cleft lip scar outcomes were not significantly associated with the type and severity of the cleft lip.

Subglottic Stenosis.

The subglottis is a narrow region of the pediatric airway that is exquisitely susceptible to the development of airway stenosis. The incidence of acquired subglottic stenosis in the setting of prolonged intubation has significantly decreased because of improved endotracheal tube management protocols. Advances in otolaryngology interventions, such as balloon dilation and endoscopic cricoid split techniques, may allow the avoidance of tracheostomy in patients with mild to moderate subglottic stenosis. However, patients with severe subglottic stenosis are often tracheostomy dependent. Open surgical techniques to treat severe disease, such as laryngotracheal reconstruction and cricotracheal resection, offer high rates of tracheostomy decannulation.