Otologic and audiologic outcomes with the Furlow and von Langenbeck with intravelar veloplasty palatoplasties in unilateral cleft lip and palate.

OBJECTIVE: Cleft palate increases the risk of chronic middle ear disease and hearing loss. The goal of this report was to determine which of two palate surgeries and which timing of palate surgery were associated with better otologic and audiologic outcomes in children with unilateral cleft lip and palate at 5 to 6 years of age. DESIGN: Subjects were randomly assigned to the von Langenbeck with intravelar veloplasty or Furlow palate repair, to palate surgery at 9 to 12 months or 15 to 18 months of age, and to the Spina or Millard lip repair. SETTING: Centralized, tertiary care craniofacial treatment center. PATIENTS: A total of 673 infants with unilateral cleft lip and palate. INTERVENTIONS: Palate and lip were repaired using established techniques. Serial otoscopic and audiometric evaluations were performed. MAIN OUTCOME MEASURES: Hearing and otoscopic findings at 5 to 6 years old. RESULTS: There were 370 children available for analysis. Hearing and need for tympanostomy tube placement did not differ by palatoplasty, age at palatoplasty, cheiloplasty, or surgeon. Risk of developing cholesteatoma or perforation was higher with Millard cheiloplasty (odds ratio  =  5.1, 95% confidence interval  =  1.44 to 18.11, p  =  .012). Type and age at palatoplasty were not significantly associated with either the rate of developing these sequelae or the rate of achieving bilaterally normal hearing and ear examinations. CONCLUSIONS: Type of palatoplasty did not influence otologic and audiologic outcomes in 5- to 6-year-olds with unilateral cleft lip and palate. The potential influence of lip repair on otologic outcomes warrants further investigation.

Prospective clinical trial comparing outcome measures between Furlow and von Langenbeck Palatoplasties for UCLP.

The goal of this prospective randomized clinical trial was to compare 2 cohorts of standardized cleft patients with regard to functional speech outcome and the presence or absence of palatal fistulae. The 2 cohorts are randomized to undergo either a conventional von Langenbeck repair with intravelar velarplasty or the double-opposing Z-plasty Furlow procedure. A prospective 2 × 2 × 2 factorial clinical trial was used in which each subject was randomly assigned to 1 of 8 different groups: 1 of 2 different lip repairs (Spina vs. Millard), 1 of 2 different palatal repair (von Langenbeck vs. Furlow), and 1 of 2 different ages at time of palatal surgery (9-12 months vs. 15-18 months). All surgeries were performed by the same 4 surgeons. A cul-de-sac test of hypernasality and a mirror test of nasal air emission were selected as primary outcome measures for velopharyngeal function. Both a surgeon and speech pathologist examined patients for the presence of palatal fistulae. In this study, the Furlow double-opposing Z-palatoplasty resulted in significantly better velopharyngeal function for speech than the von Langenbeck procedure as determined by the perceptual cul-de-sac test of hypernasality. Fistula occurrence was significantly higher for the Furlow procedure than for the von Langenbeck. Fistulas were more likely to occur in patients with wider clefts and when relaxing incisions were not used.

Longitudinal study of growth of children with unilateral cleft-lip palate from birth to two years of age.

OBJECTIVE: To study the growth of children with complete unilateral cleft lip and palate (UCLP) from birth to 2 years of age and to construct specific UCLP growth curves. DESIGN: Physical growth was a secondary outcome measure of a National Institutes of Health-sponsored longitudinal, prospective clinical trial involving the University of Florida (United States) and the University of São Paulo (Brazil). PATIENTS: Six hundred twenty-seven children with UCLP, nonsyndromic, both genders. METHODS: Length, weight, and head circumference were prospectively measured for a group of children enrolled in a clinical trial. Median growth curves for the three parameters (length, weight, head circumference) were performed and compared with the median for the National Center for Health Statistics (NCHS) curves. The median values for length, weight, and head circumference at birth and 6, 12, 18, and 24 months of age were plotted against NCHS median values and statistically compared at birth and 24 months. SETTING: Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Bauru, Brazil (HRAC-USP). RESULTS: At birth, children of both genders with UCLP presented with smaller body dimensions in relation to NCHS median values, but the results suggest a catch-up growth for length, weight, and head circumference for girls and for weight (to some degree) and head circumference for boys. CONCLUSIONS: Weight was the most compromised parameter for both genders, followed by length and then head circumference. There was no evidence of short stature. This study established growth curves for children with UCLP.

Nasopharyngeal intubation in Robin sequence: technique and management.

OBJECTIVE: To provide a detailed description of the nasopharyngeal intubation (NPI) technique and photographs, which should be helpful for those who may need to perform it for treating the airway obstruction in Robin sequence. DESIGN: To describe and illustrate the NPI technique and the necessary considerations for its application. SETTING: Hospital de Reabilitação de Anomalias Craniofacial of University of São Paulo, Brazil. RESULT: The NPI procedure involves the use of a whitish, Portex, number 3.0 or 3.5, silicone tube, introduced 8 cm deep into the infant's nostril and fixed with Micropore tape. The tube is to be removed at least twice a day for proper hygiene (with running water, detergent, and swabs) and should be changed every 7 days. This procedure is taught to the children's parents or caretakers by the nurse during hospitalization. CONCLUSION: The technique is so simple that it can be performed by the parents themselves, allowing continuation of the treatment at home.

Longitudinal study of the growth of infants with isolated Robin sequence considered being severe cases.

AIM: To study the growth of infants with isolated Robin sequence (IRS) considered being severe cases during the first 6 months of life. METHODS: Twenty infants with IRS, considered being severe cases were followed in a pure prospective longitudinal study. Feeding facilitating techniques were applied to all infants after airway disobstruction and a hypercaloric diet was offered. Weight and length were measured at birth and at 2-month intervals until 6 months of age. RESULTS: The infants with severe IRS under study showed impaired weight and length growth from birth to 6 months of age when the values were compared to the NCHS2000 reference. CONCLUSIONS: Malnutrition persisted in infants with severe IRS during the first 6 months of life despite the use of special diet and techniques developed for clinical recovery of this anomaly.

[Robin sequence: a single treatment protocol]. / Seqüência de Robin -- protocolo único de tratamento.

OBJECTIVE: To present a single protocol that might cover both the respiratory and feeding difficulties of neonates and infants with Robin sequence. SOURCES OF DATA: The article was prepared on the basis of the most recent publications available in bibliographic databases and in books that discuss the treatment of Robin sequence, especially the studies conducted at the Hospital for Rehabilitation of Craniofacial Anomalies of Universidade de São Paulo (HRAC/USP). SUMMARY OF THE FINDINGS: We present the morphological and genetic aspects of Robin sequence and concepts about nasopharyngoscopy and its clinical implications; we discuss the treatment of respiratory and feeding difficulties, and we present a single protocol for the treatment of all Robin sequence cases regardless of their severity and complexity. CONCLUSIONS: Robin sequence is not only an anatomic obstructive disorder to be treated with surgical procedures, but knowledge about children s growth and development must be applied by a multidisciplinary team, since this permits the maintenance of airway permeability and of the ability to feed orally, often without the need of surgical procedures and their risks, especially when applied to neonates and small infants.

Seqüência de Robin: protocolo único de tratamento / Robin sequence: a single treatment protocol

OBJETIVO: Apresentar protocolo único que possa atender tanto às dificuldades respiratórias como às dificuldades alimentares dos neonatos e lactentes com seqüência de Robin. FONTE DE DADOS: O artigo foi desenvolvido tomando como base as publicações mais recentes disponíveis em bancos de dados bibliográficos e livros que discutem o tratamento da seqüência de Robin, em especial os estudos realizados no Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de São Paulo (HRAC/USP). SíNTESE DE DADOS: O artigo apresenta os aspectos morfológicos e genéticos da seqüência de Robin e conceitos sobre nasofaringoscopia e suas implicações clínicas, discute o tratamento das dificuldades respiratórias e alimentares e apresenta um protocolo único para atender a todos os casos de seqüência de Robin, independentemente de sua gravidade e complexidade. CONCLUSÕES: A seqüência de Robin não é somente uma patologia obstrutiva anatômica para ser resolvida com procedimentos cirúrgicos, mas os conhecimentos sobre crescimento e desenvolvimento devem ser aplicados por uma equipe multidisciplinar, porque possibilitam a rápida recuperação da permeabilidade das vias aéreas e da capacidade de alimentação oral, evitando-se, muitas vezes, os procedimentos cirúrgicos e seus riscos, principalmente quando realizados em neonatos e lactentes pequenos.