Protocols for Reporting Speech Outcomes following Palatoplasty or Velopharyngeal Surgery: A Literature Review.

BACKGROUND: To determine best practices, surgeons who perform cleft palate surgery or surgery for velopharyngeal insufficiency need to be able to compare their outcomes in normalizing the velopharyngeal valve. METHODS: We conducted a comprehensive review of articles that reported speech/resonance outcomes following palatoplasty or surgery for velopharyngeal insufficiency. We analyzed protocols that were used and how the results were reported. We found 170 articles, published between 1990 and 2014, that met our inclusion criteria. RESULTS: Most studies (66%) had a sample size of <50 subjects, were retrospective (67%), were not blinded (83%), and did not report the use of reliability (68%). Most studies included 1 evaluator (27%) or 2 evaluators (30%). Only 80% of the articles specified that at least one speech pathologist was an evaluator. Most articles (56%) did not specify the speech samples used, and 65% used an informal test or did not specify the type of test used. Most studies used a perceptual rating scale for articulation (75%) and resonance (83%). Only 39% of the studies included an evaluation of velopharyngeal function. Finally, objective measures were used in only 28% of the studies (9% used aerodynamic measures and 19% used nasometry). CONCLUSIONS: Because these articles showed significant variability in how speech/resonance is evaluated and how the outcomes are reported, it is virtually impossible to compare results to determine best surgical procedures. Suggestions are given to standardize outcome measures to improve comparability of data.

Current practice in assessing and reporting speech outcomes of cleft palate and velopharyngeal surgery: a survey of cleft palate/craniofacial professionals.

OBJECTIVE: To determine methods by which professionals serving cleft palate/craniofacial teams are evaluating velopharyngeal function and to ascertain what they consider as a successful speech outcome of surgery. DESIGN: A 12-question survey was developed for professionals involved in management of velopharyngeal dysfunction. PARTICIPANTS: The survey was distributed through E-mail lists for the American Cleft Palate-Craniofacial Association and Division 5 of the American Speech-Language-Hearing Association. Only speech-language pathologists and surgeons were asked to complete the survey. A total of 126 questionnaires were completed online. RESULTS: Standard speech evaluations include perceptual evaluation (99.2%), intraoral examination (96.8%), nasopharyngoscopy (59.3%), nasometry (28.9%), videofluoroscopy (19.2%), and aerodynamic measures (4.3%). Significant variation existed in the types and levels of perceptual rating scales. Pharyngeal flap (52.9%) is the most commonly performed procedure for velopharyngeal insufficiency, followed by sphincter pharyngoplasty (27.5%). Criteria for surgical success included normal speech (50.8%), acceptable speech (27.9%), and "improved" speech (8%). However, most respondents felt that success should be defined as normal speech (71.2%). Most respondents believed that surgical success should be determined by the team speech-language pathologist (81.5%); although, some felt success should be determined by the patient/family (17.7%). CONCLUSION: This survey shows considerable variability in the methods for evaluating and reporting speech outcomes following surgery. There is inconsistency in what is considered a successful surgical outcome, making comparison studies impossible. Most respondents thought that success should be defined as normal speech, but this is not happening in current practice.

Pediatric tracheal reconstruction using cadaveric homograft.

OBJECTIVE: To examine the indications, risks, and surgical outcomes after tracheal reconstruction using cadaveric homograft in children. DESIGN: Retrospective medical record review. SETTING: Tertiary referral center. PATIENTS: Ten children (4 boys and 6 girls). INTERVENTION: Tracheal reconstruction using cadaveric homograft. MAIN OUTCOME MEASURES: Cause of stenosis, number and type of procedures before homograft reconstruction, severity of preoperative stenosis, surgical approach, homograft length, duration of stenting, number and type of procedures after reconstruction, and rates of decannulation and survival. RESULTS: Ten children (mean [SD] age, 8.4 [5.5] years) underwent 14 tracheal reconstructions using cadaveric homograft. Patients had an average of 7.0 (range, 1-16) procedures before homograft reconstruction, including an average of 2.8 (range, 0-6) major open airway reconstructions. Mean (SD) pretracheoplasty Myer-Cotton grade of stenosis was 3.80 (0.42) (range, 3-4), and all patients were tracheotomy dependent. A cervical approach was used in 12 reconstructions (86%), and 2 (14%) required median sternotomy. Mean (SD) homograft length was 3.9 (1.7) cm (range, 2-8 cm), which was approximately 0.60 times the length of the total recipient trachea. Mean (SD) duration of stenting for all homografts was 0.67 (0.46) years (range, 0.24-1.98 years). The survival rate was 90% after a mean follow-up of 5.47 (1.52) years (range, 3.32-7.55 years). Surviving patients required an average of 7.38 (5.52) procedures (range, 1-19) after homograft transplant, including an average of 1 major open airway reconstruction (range, 0-4). The mean (SD) grade of stenosis after the final homograft placement was 1.89 (1.27) (range, 1-4). Although the operation-specific decannulation rate was only 7% (1 of 14), the overall decannulation rate eventually reached 60%. Statistical bootstrapping methods and a multivariate regression model determined that increasing patient age (odds ratio, 1.21; 95% confidence interval, 1.07-1.36), increasing number of prior procedures (1.26; 1.02-1.57), and increasing homograft length (2.42; 1.60-3.40 [P < .001]) were associated with an increased risk of no decannulation after tracheal homograft reconstruction. CONCLUSIONS: Tracheal reconstruction using cadaveric homograft is an option in children who have undergone multiple airway surgical procedures and present with long-segment stenoses that cannot be bridged using conventional methods. These patients must receive close postoperative follow-up. Subsequent procedures are almost always required before decannulation, and eventual decannulation rates are only 60%. Decannulation rates are lower in older patients who have previously undergone many procedures and require a long tracheal homograft.

Comprehensive airway management of neonatal head and neck teratomas.

OBJECTIVES: To determine the success of initial airway management and to characterize late airway-related complications in patients with airway obstruction due to congenital head and neck teratomas. STUDY DESIGN: Case series with chart review. SETTING: Tertiary airway referral institution. SUBJECTS AND METHODS: Review of consecutive patients with congenital head and neck teratomas from 1988 to 2010. Variables examined include initial airway stabilization at time of birth and perinatal airway management. Outcomes include short- and long-term complications. RESULTS: Fourteen cases were reviewed. In 12 patients, initial airway management was accomplished on placental support with either intubation or tracheotomy. Two vaginal births required subsequent uncomplicated oral intubation within 24 hours. Nine patients required tracheotomy (3 within the delivery suite, 2 during mass excision on day of life 6 and 24, and the remaining 4 occurred at days 29, 32, 92, and 100). Five deaths occurred, 4 within several days of birth due to complications related to the cervical teratomas and 1 on day of life 32 due to an airway-related complication. Follow-up for surviving patients ranged from 1 month to 18 years. Long-term airway complications ranged from vocal cord paralysis to stenosis requiring laryngotracheoplasty. CONCLUSION: This study demonstrates that a multidisciplinary team and a standardized approach in the operating suite have led to successful initial airway stabilization. Furthermore, this study demonstrates the need for continued airway management after delivery. Reassessment of the airway after delivery and an airway management planning meeting with the multidisciplinary team may help decrease morbidity and mortality.

Long-term treatment outcome of presurgical nasoalveolar molding in patients with unilateral cleft lip and palate.

PURPOSE: The purpose of this study was to evaluate the long-term effectiveness of presurgical nasoalveolar molding (PNAM) in patients with unilateral cleft lip and palate (UCLP). METHODS: Twenty-five patients with UCLP treated by either PNAM or non-PNAM therapy between 1998 and 2003 were recruited in the study. During the clinical examination and data analysis, the evaluators were blinded to which patients received PNAM. The patients were reviewed clinically, and their facial morphology was captured with a three-dimensional scanner. Their dental arch configuration and occlusion were recorded by plaster dental models. After the patient evaluations and measurements were completed, the patient list was unblinded. There were 20 patients in the PNAM group and 5 patients in the non-PNAM group. Fisher exact tests and Wilcoxon rank sum tests were used to compare the outcomes. RESULTS: Clinically, the improvement in the PNAM group was most evident in nasal and lip anatomy. However, there were no statistically significant differences between the 2 groups on each of the measurements on three-dimensional facial images and dental models. CONCLUSIONS: Our study suggests a trend toward a long-term clinical improvement in nasal and lip anatomy of UCLP patients treated with PNAM. However, these improved results were not confirmed by three-dimensional stereophotography. There was no statistically significant difference in the long-term three-dimensional anthropometric measurements and dental model analysis between the PNAM group and the non-PNAM group.

Electrochromatographic retention studies on a flavin-binding RNA aptamer sorbent.

Aptamers are oligonucleotides that are isolated and amplified on the basis of their recognition of a target molecule. In this study, an RNA aptamer isolated and amplified on the basis of its affinity for flavin mononucleotide (FMN) was covalently bound to the inner walls of fused-silica capillaries. This aptamer recognizes the flavin moiety of both FMN and flavin adenine dinucleotide (FAD). When an attempt was made to evaluate these capillaries according to existing theory, the theory proved to be insufficient. We describe a new method to evaluate capillaries for use in open-tubular capillary electrochromatography (OTCEC) of charged analytes, which combines OTCEC and flow-counterbalanced capillary electrophoresis. This method enabled us to extract k' and evaluate k(CEC) values for these capillaries, and the dependence of these values on Mg(2+) concentration was explored. The k' values for these capillaries ranged from 0.0951 to 0.2530 and from 0.0255 to 0.1118 for FMN and FAD, respectively.

Aptamers as analytical reagents.

Many important analytical methods are based on molecular recognition. Aptamers are oligonucleotides that exhibit molecular recognition; they are capable of specifically binding a target molecule, and have exhibited affinity for several classes of molecules. The use of aptamers as tools in analytical chemistry is on the rise due to the development of the "systematic evolution of ligands by exponential enrichment" (SELEX) procedure. This technique allows high-affinity aptamers to be isolated and amplified when starting from a large pool of oligonucleotide sequences. These molecules have been used in flow cytometry, biosensors, affinity probe electrophoresis, capillary electrochromatography, and affinity chromatography. In this paper, we will discuss applications of aptamers which have led to the development of aptamers as chromatographic stationary phases and applications of these stationary phases; and look towards future work which may benefit from the use of aptamers as stationary phases.