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Velopharyngeal insufficiency after maxillary advancement
lOO Correction of Cleft Lip Nasal Deformity. S. J. Stenstrom. Plast Reconstr Surg 5 9 : 6 7 5 - 6 7 9 (May), 1977.
A refinement of an older tecl~nique for correction of the cleft lip nose is presented. Essentially, the technique is a wide mobilization of the affected lateral crus of the alar cartilage as well as the entire skin of the nose on the affected side up to the nasal bone. The alar crus, which has been displaced laterally and caudally, is then allowed to rotate medially and superiorly, being held in place by lifting sutures of nonabsorbable material. The technique is clearly presented with diagramatic illustrations accompanied by excellent clinical photos, depicting pre- and postoperative results. The goals of the operation are to produce a widening of the affected nostril, a lengthening of the columella on the cleft side and a more symmetrical appearing alar portion of the nose.--A. B. Sokol Uses of the Nasolabial Flap in the Correction of Cleft Lip Nasal Deformities. M, "1".Edgerton and J. L. Marsh, Plast Reconstr Surg 6 0 : 5 6 - 6 7 (July). 1977.
Frequently after correction of cleft lip and nasal deformities, there persists a hanging, fiat alar rim with a depressed nasal tip and airway obstruction. The corrective attempts presented in the literature are reviewed by the article and their deficiencies and assets categorized. A technique incorporating the nasolabial flap is reported. The advantages of this surgical technique are as follows: release of alar base from hypoplastic maxilla, reorientation of alar footplate, enlargement of nostril circumference, augmentation of vestibular lining, and creation of nasal sill. This technique can be used to c o r r e c t the a f o r e m e n t i o n e d components of the cleft lip nasal deformity. The authors report on the use of nasolabial flaps in 14 nasal reconstructions. The operative use of this flap is broken down into three specific surgical techniques, each with its own goals. Clear, diagrammatic illustrations and clinical photos are used to enhance the value of this article. The article actually deals with the entire spectrum of nasal reconstruction and discusses in detail the following nasal deformities: alar deformities, septal deformities, external nose deformities, columellar deformities, and nasal sill deformities. The article reviews the available techniques for the correction of each of those conditions and applies the nasolabial flap in various surgical modifications to enhance their repair. The article is supported by 127 operations for secondary correction of cleft nasal deformities among 65 patients. A. B. Sokol A Checklist for Evaluating Palatal Closure, J. F. Bensen. Plast Reconstr Surg 60:45-48 (July), 1977.
The article is written by a speech therapist, primarily for the evaluation of a cleft palate child by the plastic surgeon. The article provides an answer to four questions constantly raised in postoperative visits of the reconstructed palate children. T h e s e q u e s t i o n s are: will f u r t h e r p a l a t a l procedures be necessary; are further palatal procedures and speech therapy necessary; will speech therapy alone produce near-normal speech; and finally, in which cases are neither speech therapy nor surgery indicated? The questions can be answered by a 5-min test that can be applied to each patient by the surgeon or speech therapist. The checklist
ABSTRACTS
uses normal running conversations, counting, plosives, and fricatives, as well as direct observation of the palate. Each specific test is analyzed and related to the above listed questions.--A. B. Sokol Correction of Poor Speech Due to a Low Pharyngeal Flap Attachment by a V-Y Advancement Procedure. B. H/rshow/tz and D. Bar-David. Cleft Palate J 14:167-175 (April). 1977.
The two main causes of hypernasality following pharyngeal flap surgery for velopharyngeal incompetence are either an inadequate sphincter or a low tethering effect of the pharyngeal flap. The paper deals with the correction of the latter cause. Etiologic factors are donor site scarring with inferior traction on the base of the flap and differential growth between the scarred flap and the nasopharynx. The operation selected for correction of this deformity consists of a V flap made in the posterior pharyngeal wall, the base of which includes the scarred superior pharyngeal flap. The flap is advanced superiorly and the donor site is closed sequentially into a Y formation. The objective of this procedure is twofold: primarily, a superior displacement of the tethered pharyngeal flap obviating the restriction of palatal elevation; secondly, a forward projection of the posterior pharyngeal wall due to the "bunching up" or plication of the base of the flap. Four cases are reported, all of whom have shown excellent result in subjective measurements and evaluation of postoperative speech. The authors, however, report on no objective measurements of improvement due to the short follow-up of maximum 2 yr. The article is accompanied by excellent clinical photos and clear diagrammatic illustrations of the operation. A . B . Sokol Cur Pulmonale Secondary to Cleft Palate Repair. /14, C. Robson, J. A. Stankiewicz, and J. S. Mendelsohn. Plast Reconstr
Surg 59:754-757 (May), 1977.
A case of cor pnlmonale occurring in a 4-yr-old female following the repair of her cleft palate by palatoplasty and pharyngeal flap is reported. The child had a complete nasopharyngeal obstruction as well as a small mandible (micrognathia). A review of the literature of almost 3500 cases of pharyngeal flap operations, suggests that there were only 11 patients having some degree of respiratory obstruction and in only one was a diagnosis of cor pulmonale made. The basic mechanisms involved in cor pulmonale, primarily alveolar hypoventilation and an anatomic reduction of the pulmonary vascular, are given. Theories leading to this condition are discussed in light of the present case. The paper details one additional complication of cleft palate surgery that should be known by the clinician dealing with the supp o r t i v e or actual surgical c a r e of t h e cleft p a l a t e patient.--A. B. Sokol Velopharyngeal Insufficiency After Maxillary Advancement. M. A. Witzer and I. R. Munro. Cleft Palate J 14:176-180 (April), 1977.
The case of a 16-yr-old boy who had undergone repair of cleft lip and palate in infancy, and was operated upon for class Ill malocclusion. A L e Fort I surgical procedure was done for maxillary advancement, with an excellent esthetic result. Preoperatively, the patient had minor articulation er-
ABSTRACTS
rors with normal nasality. The velopharyngeal valving mechanism on lateral cephalometric analysis revealed that the soft palate had touch closure. Postoperatively, there was marked hypernasality with no contact of the soft palate on lateral cephalometric analysis. The patient went on to require a palatopharyngoplasty for repair of his velopharyngeal incompetence. The article points out the need to be aware of the problem of postoperative velopharyngeal insufficiency with significant maxillary advancement.
A. B. Sokol Prevalence of Cleft Uvula A m o n g 2 , 7 3 2 Danes. G. Lindermann, B. Riis, and I. Sewerin. Cleft Palate J 14:226-229
(July), 1977.
Because of the assumption that the cleft uvula is a microform of cleft palate, many articles have appeared in recent years associating this phenomenon with either underlying submucous cleft palate or a higher prevalence of cleft palate in relatives. The article reviews the literature and finds the prevalence of cleft palate among the siblings of patients with cleft uvula was 15.7 %, 10.5 % among their parents, and 4.1% among other relatives. In addition, cleft uvula is associated with a higher degree of otologic diseases. The incidence of cleft uvula appears to vary among races studied: blacks, 0.5 %; whites, 1%-2%; Asiatics, 4%- 16%; American Indians 10%-18%. The present article studied 1217 male and 1515 female patients, a total of 2732 who applied to the Department of Oral Diagnosis of the Royal Dental College in Copenhagen during 1973 and 1974. Cleft uvula was observed in a total of 31 cases (1.13%), and no variation of the age group studied from less than one year to over seventy was seen when each decade was analyzed. Cleft uvula was observed in 20 males (1.64%) and 11 females (0.73%), which is a statistically significant difference. The uvula was bifurcated in one-quarter of its length in the majority of cases (27 of 31). Complete bifurcation was seen in only one case. The findings, incidence, and sex variations agree with the review of the literature that supported this paper.--A. B. Sokol Results of the Wilkie Operation to Stop Drooling in Cerebral Palsy. L Kap/an. Plast Reconstr Surg 59:646-648 (May). 1977.
The Wilkie operation, consisting of a relocation of the parotid duct orifice into the pharynx combined with the bilateral excision of the submaxillary glands, is reported in 20 cases. All 20 of these cases had preoperative persistent drooling, unresponsive to conservative measures such as head posture and the use of belladonna-like drugs. The age range of the patients were 5 21 yr, and there were 14 males and 6 females. The results of all the operations were considered excellent, with 4 ducts (9%) revealing postoperative stenosis and fistula formation. A discussion of the various other treatment methods present in the literature is given, all of which appear to be inferior to the reported operation.--A. B. Sokol The Surgical Treatment of Drooling. T. F. Wilkie and G. S. Brody. Plast Reconstr Surg 5 9 : 7 9 1 - 7 9 8 (June), 1977.
The treatment of drooling by combined submandibu!ar gland excision and parotid duct relocation is reviewed in 123 patients over a 10-yr period. The results on these patients have been good to excellent in 86% of the cases. Complica-
101
tions include cyst formation, fistula formation, oral hygiene, and parotitis, and are reviewed in detail. A discussion of alternatives to surgery, as well as informed consents should surgery be decided upon, is clearly given. The surgical procedure for the posterior transposition of the parotid duct is illustrated diagrammatically in a clear fashion supported by clincial intraoperative photos. In addition, the submandibular gland removal is described with techniques that have been found to be helpful to the authors. The article details the findings of the postoperative course and suggestions which could make this period easier for both patient and parent.--A. B. Sokol Pathogenesis and Treatment of Plunging Ranulas. W. LE W. Roediger and S. Kay. Surg Gyneeol Obstet 144: 862-864, 1977
Oral ranulas that have a cervical extension are termed plunging ranulas. The lining of a ranula is fibrous tissue without epithelium that could indicate a tissue response to an extravasation. The source of the extravasation seems to be the sublingual gland. The exact cause for extravasation is not known, but salivary gland duct anomalies and obstruction in salivary ducts have been indicated as prerequisites for extravasation. The authors report three patients, one of whom was a 14-yr-old girl, who were treated by excision of the sublingual gland. Dissection of the cervical ramifications is not considered necessary, and these disappear once the source o f the extravasating saliva has been removed.
--George Holcomb Burkitt's Lymphoma of the Jaw in a Canadian Child. J. /4. Joncas and E. Rioux. Can Med Assoc J 117:367-368 (August).
1977.
Burkitt's lymphoma of the jaw in childhood is seen almost exclusively in Africa. Tumors histologically compatible with the diagnosis in North America are usually found in older children and in adults and occur most often in the abdomen. A Canadian white child aged 5 yr is reported with a tumor of the jaw histologically identical to Burkitt's lymphoma. Antibodies to Epstein-Barr virus nuclear antigen but not to early antigen or to viral capsid antigen were found in the patient's serum during the first mo in hospital (the second mo the tumor was evident). These antibodies disappeared following treatment with cyclophospharnide. The disease has been in complete remission for 7 yr.--Colin C. Ferguson
THORAX latrogenic Injury to the Phrenic Nerve in Infants and Young Children. A. J. Mearns. Br J Surg 64:558-560 (August). 1977
Five cases of iatrogenic phrenic nerve injury in infants are presented. Damage to the phrenic nerve was sustained at the thoracic inlet and in the area of the left atrial appendage. The use of positive pressure ventilation in resuscitation may mask the elevation of the diaphragm and paradoxical movement, which is the cause of the respiratory dysfunction. X-rays should be taken with the child breathing spontaneously. Paradoxic movement of the left hemidiaphragm is a positive indication for plication. Volvulus of the stomach may be a sign of eventration a n d not the primary pathology.--Lewis Spitz
A refinement of an older tecl~nique for correction of the cleft lip nose is presented. Essentially, the technique is a wide mobilization of the affected lateral crus of the alar cartilage as well as the entire skin of the nose on the affected side up to the nasal bone. The alar crus, which has been displaced laterally and caudally, is then allowed to rotate medially and superiorly, being held in place by lifting sutures of nonabsorbable material. The technique is clearly presented with diagramatic illustrations accompanied by excellent clinical photos, depicting pre- and postoperative results. The goals of the operation are to produce a widening of the affected nostril, a lengthening of the columella on the cleft side and a more symmetrical appearing alar portion of the nose.--A. B. Sokol Uses of the Nasolabial Flap in the Correction of Cleft Lip Nasal Deformities. M, "1".Edgerton and J. L. Marsh, Plast Reconstr Surg 6 0 : 5 6 - 6 7 (July). 1977.
Frequently after correction of cleft lip and nasal deformities, there persists a hanging, fiat alar rim with a depressed nasal tip and airway obstruction. The corrective attempts presented in the literature are reviewed by the article and their deficiencies and assets categorized. A technique incorporating the nasolabial flap is reported. The advantages of this surgical technique are as follows: release of alar base from hypoplastic maxilla, reorientation of alar footplate, enlargement of nostril circumference, augmentation of vestibular lining, and creation of nasal sill. This technique can be used to c o r r e c t the a f o r e m e n t i o n e d components of the cleft lip nasal deformity. The authors report on the use of nasolabial flaps in 14 nasal reconstructions. The operative use of this flap is broken down into three specific surgical techniques, each with its own goals. Clear, diagrammatic illustrations and clinical photos are used to enhance the value of this article. The article actually deals with the entire spectrum of nasal reconstruction and discusses in detail the following nasal deformities: alar deformities, septal deformities, external nose deformities, columellar deformities, and nasal sill deformities. The article reviews the available techniques for the correction of each of those conditions and applies the nasolabial flap in various surgical modifications to enhance their repair. The article is supported by 127 operations for secondary correction of cleft nasal deformities among 65 patients. A. B. Sokol A Checklist for Evaluating Palatal Closure, J. F. Bensen. Plast Reconstr Surg 60:45-48 (July), 1977.
The article is written by a speech therapist, primarily for the evaluation of a cleft palate child by the plastic surgeon. The article provides an answer to four questions constantly raised in postoperative visits of the reconstructed palate children. T h e s e q u e s t i o n s are: will f u r t h e r p a l a t a l procedures be necessary; are further palatal procedures and speech therapy necessary; will speech therapy alone produce near-normal speech; and finally, in which cases are neither speech therapy nor surgery indicated? The questions can be answered by a 5-min test that can be applied to each patient by the surgeon or speech therapist. The checklist
ABSTRACTS
uses normal running conversations, counting, plosives, and fricatives, as well as direct observation of the palate. Each specific test is analyzed and related to the above listed questions.--A. B. Sokol Correction of Poor Speech Due to a Low Pharyngeal Flap Attachment by a V-Y Advancement Procedure. B. H/rshow/tz and D. Bar-David. Cleft Palate J 14:167-175 (April). 1977.
The two main causes of hypernasality following pharyngeal flap surgery for velopharyngeal incompetence are either an inadequate sphincter or a low tethering effect of the pharyngeal flap. The paper deals with the correction of the latter cause. Etiologic factors are donor site scarring with inferior traction on the base of the flap and differential growth between the scarred flap and the nasopharynx. The operation selected for correction of this deformity consists of a V flap made in the posterior pharyngeal wall, the base of which includes the scarred superior pharyngeal flap. The flap is advanced superiorly and the donor site is closed sequentially into a Y formation. The objective of this procedure is twofold: primarily, a superior displacement of the tethered pharyngeal flap obviating the restriction of palatal elevation; secondly, a forward projection of the posterior pharyngeal wall due to the "bunching up" or plication of the base of the flap. Four cases are reported, all of whom have shown excellent result in subjective measurements and evaluation of postoperative speech. The authors, however, report on no objective measurements of improvement due to the short follow-up of maximum 2 yr. The article is accompanied by excellent clinical photos and clear diagrammatic illustrations of the operation. A . B . Sokol Cur Pulmonale Secondary to Cleft Palate Repair. /14, C. Robson, J. A. Stankiewicz, and J. S. Mendelsohn. Plast Reconstr
Surg 59:754-757 (May), 1977.
A case of cor pnlmonale occurring in a 4-yr-old female following the repair of her cleft palate by palatoplasty and pharyngeal flap is reported. The child had a complete nasopharyngeal obstruction as well as a small mandible (micrognathia). A review of the literature of almost 3500 cases of pharyngeal flap operations, suggests that there were only 11 patients having some degree of respiratory obstruction and in only one was a diagnosis of cor pulmonale made. The basic mechanisms involved in cor pulmonale, primarily alveolar hypoventilation and an anatomic reduction of the pulmonary vascular, are given. Theories leading to this condition are discussed in light of the present case. The paper details one additional complication of cleft palate surgery that should be known by the clinician dealing with the supp o r t i v e or actual surgical c a r e of t h e cleft p a l a t e patient.--A. B. Sokol Velopharyngeal Insufficiency After Maxillary Advancement. M. A. Witzer and I. R. Munro. Cleft Palate J 14:176-180 (April), 1977.
The case of a 16-yr-old boy who had undergone repair of cleft lip and palate in infancy, and was operated upon for class Ill malocclusion. A L e Fort I surgical procedure was done for maxillary advancement, with an excellent esthetic result. Preoperatively, the patient had minor articulation er-
ABSTRACTS
rors with normal nasality. The velopharyngeal valving mechanism on lateral cephalometric analysis revealed that the soft palate had touch closure. Postoperatively, there was marked hypernasality with no contact of the soft palate on lateral cephalometric analysis. The patient went on to require a palatopharyngoplasty for repair of his velopharyngeal incompetence. The article points out the need to be aware of the problem of postoperative velopharyngeal insufficiency with significant maxillary advancement.
A. B. Sokol Prevalence of Cleft Uvula A m o n g 2 , 7 3 2 Danes. G. Lindermann, B. Riis, and I. Sewerin. Cleft Palate J 14:226-229
(July), 1977.
Because of the assumption that the cleft uvula is a microform of cleft palate, many articles have appeared in recent years associating this phenomenon with either underlying submucous cleft palate or a higher prevalence of cleft palate in relatives. The article reviews the literature and finds the prevalence of cleft palate among the siblings of patients with cleft uvula was 15.7 %, 10.5 % among their parents, and 4.1% among other relatives. In addition, cleft uvula is associated with a higher degree of otologic diseases. The incidence of cleft uvula appears to vary among races studied: blacks, 0.5 %; whites, 1%-2%; Asiatics, 4%- 16%; American Indians 10%-18%. The present article studied 1217 male and 1515 female patients, a total of 2732 who applied to the Department of Oral Diagnosis of the Royal Dental College in Copenhagen during 1973 and 1974. Cleft uvula was observed in a total of 31 cases (1.13%), and no variation of the age group studied from less than one year to over seventy was seen when each decade was analyzed. Cleft uvula was observed in 20 males (1.64%) and 11 females (0.73%), which is a statistically significant difference. The uvula was bifurcated in one-quarter of its length in the majority of cases (27 of 31). Complete bifurcation was seen in only one case. The findings, incidence, and sex variations agree with the review of the literature that supported this paper.--A. B. Sokol Results of the Wilkie Operation to Stop Drooling in Cerebral Palsy. L Kap/an. Plast Reconstr Surg 59:646-648 (May). 1977.
The Wilkie operation, consisting of a relocation of the parotid duct orifice into the pharynx combined with the bilateral excision of the submaxillary glands, is reported in 20 cases. All 20 of these cases had preoperative persistent drooling, unresponsive to conservative measures such as head posture and the use of belladonna-like drugs. The age range of the patients were 5 21 yr, and there were 14 males and 6 females. The results of all the operations were considered excellent, with 4 ducts (9%) revealing postoperative stenosis and fistula formation. A discussion of the various other treatment methods present in the literature is given, all of which appear to be inferior to the reported operation.--A. B. Sokol The Surgical Treatment of Drooling. T. F. Wilkie and G. S. Brody. Plast Reconstr Surg 5 9 : 7 9 1 - 7 9 8 (June), 1977.
The treatment of drooling by combined submandibu!ar gland excision and parotid duct relocation is reviewed in 123 patients over a 10-yr period. The results on these patients have been good to excellent in 86% of the cases. Complica-
101
tions include cyst formation, fistula formation, oral hygiene, and parotitis, and are reviewed in detail. A discussion of alternatives to surgery, as well as informed consents should surgery be decided upon, is clearly given. The surgical procedure for the posterior transposition of the parotid duct is illustrated diagrammatically in a clear fashion supported by clincial intraoperative photos. In addition, the submandibular gland removal is described with techniques that have been found to be helpful to the authors. The article details the findings of the postoperative course and suggestions which could make this period easier for both patient and parent.--A. B. Sokol Pathogenesis and Treatment of Plunging Ranulas. W. LE W. Roediger and S. Kay. Surg Gyneeol Obstet 144: 862-864, 1977
Oral ranulas that have a cervical extension are termed plunging ranulas. The lining of a ranula is fibrous tissue without epithelium that could indicate a tissue response to an extravasation. The source of the extravasation seems to be the sublingual gland. The exact cause for extravasation is not known, but salivary gland duct anomalies and obstruction in salivary ducts have been indicated as prerequisites for extravasation. The authors report three patients, one of whom was a 14-yr-old girl, who were treated by excision of the sublingual gland. Dissection of the cervical ramifications is not considered necessary, and these disappear once the source o f the extravasating saliva has been removed.
--George Holcomb Burkitt's Lymphoma of the Jaw in a Canadian Child. J. /4. Joncas and E. Rioux. Can Med Assoc J 117:367-368 (August).
1977.
Burkitt's lymphoma of the jaw in childhood is seen almost exclusively in Africa. Tumors histologically compatible with the diagnosis in North America are usually found in older children and in adults and occur most often in the abdomen. A Canadian white child aged 5 yr is reported with a tumor of the jaw histologically identical to Burkitt's lymphoma. Antibodies to Epstein-Barr virus nuclear antigen but not to early antigen or to viral capsid antigen were found in the patient's serum during the first mo in hospital (the second mo the tumor was evident). These antibodies disappeared following treatment with cyclophospharnide. The disease has been in complete remission for 7 yr.--Colin C. Ferguson
THORAX latrogenic Injury to the Phrenic Nerve in Infants and Young Children. A. J. Mearns. Br J Surg 64:558-560 (August). 1977
Five cases of iatrogenic phrenic nerve injury in infants are presented. Damage to the phrenic nerve was sustained at the thoracic inlet and in the area of the left atrial appendage. The use of positive pressure ventilation in resuscitation may mask the elevation of the diaphragm and paradoxical movement, which is the cause of the respiratory dysfunction. X-rays should be taken with the child breathing spontaneously. Paradoxic movement of the left hemidiaphragm is a positive indication for plication. Volvulus of the stomach may be a sign of eventration a n d not the primary pathology.--Lewis Spitz