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Effect of Cleft Width on Incidence Rates of Palatal Fistula and Velopharyngeal Insufficiency
Nance Yuan, B.A., Keith E. Follmar, MD, Courtney Pendleton, B.S., Amir H. Dorafshar, M.B.Ch.B., Richard J. Redett, M.D.
Johns Hopkins/ University of Maryland
2012-02-02
Presenter: Nance Yuan
Affidavit:
The presenter Nance Yuan completed the majority of the work including data collection, analysis, and the writing of the abstract.
Director Name: Richard J. Redett, MD
Author Category: Student
Presentation Category: Clinical
Abstract Category: Craniomaxillofacial
How does this presentation meet the established conference educational objectives?
Through this presentation of our institution's outcomes over a 7-year period, participants will gain greater understanding of the factors contributing to palatal fistula and velopharyngeal insufficiency (VPI), two major complications after cleft palate repair (Objective 1). Participants will learn about our surgical management approaches for wide clefts, which we believe have been helpful for maintaining low fistula rates(Objective 2). We will focus on the impact of initial cleft width on outcomes, which has not been previously addressed in the literature (Objective 3).
How will your presentation be used by practicing physicians in the audience?
Greater knowledge of pre-operative factors that contribute to rates of palatal fistula and VPI after cleft palatoplasty will help physicians practice better counseling and patient-specific management. Physicians will be able to evaluate our outcomes with their own and learn about specific surgical techniques we have used in the repair of wide clefts.
Background: Rates of palatal fistula and velopharyngeal insufficiency (VPI) after cleft palatoplasty vary. The impact of initial cleft width on outcomes has not been evaluated.
Methods: We conducted a retrospective review on patients who underwent primary cleft palatoplasty by a single surgeon between 2004 and 2011. Primary outcomes were palatal fistula and VPI (defined by recommendation for secondary surgery). Intentionally unrepaired anterior fistulas were excluded.
Results: 177 patients (84 male and 93 female) were identified. Median age at repair was 10 months with mean follow-up time of 3.6 years (range 0.5-7.7 years). Pre-operative cleft width was ≤10 mm for 72 patients (41%), 11-14 mm for 54 patients (30%), and ≥15 mm for 51 patients (29%). Palatal fistula was observed in 8 patients (4.5%). Fistulae for only 2 (1.1%) patients were clinically significant (requiring surgical repair). Palatal fistula was not associated with cleft width but was associated with Veau IV classification (p=0.005 by two-tailed Fisher exact test). VPI occurred in 8 patients (4.5%) and was associated with increasing cleft width (p=0.01). Use of vomer flaps, osteotomies, and acellular dermal matrix (Alloderm) increased significantly with repair of wider clefts.
Conclusion: Palatal fistula rates can be low, even in patients with very wide clefts. Use of techniques such as vomer flaps, osteotomies, and acellular dermal matrix likely contributes to our low fistula rates. However, techniques for repair of very wide clefts can shorten the palate without recreating physiologic motor function, leading to the higher VPI rates observed in patients with wider clefts.
