Unilateral complete cleft palate repair: a morpho-functional approach
A scientific essay in Medical Sciences
DOCTORAL THESIS defended in public on 16th of November 2018
In chapter 1, we try to address the question ‘’Why to study patients with cleft lip and palate and their treatment?’’. As a result of a cleft in the palate there is an open communication between the mouth and nose. This defect, therefore, causes difficulties in speech and eating. The etiology of cleft palate is poorly understood. But once a child is diagnosed with a cleft palate, surgical repair is the only viable option to close the communication between the mouth and nose. In this thesis, we have limited our research to complete unilateral cleft lip and palate. The aim of this research project was to understand the cleft palate repair procedures and possibly find better techniques to repair cleft palates primarily and secondarily.
Before starting any research in the field of cleft treatment, we felt it was necessary to get more insight into the number of patients that can be treated at our center. We initiated a study to determine the incidence of cleft lip and palate in the region we set up our hospital. Chapter 2, describes the study we undertook with the local government to investigate the incidence of cleft lip and palate.
In chapter 3 we report the results of a systematic review that we performed to explore previous research into the treatment for primary cleft palate repair, specifically comparing one and two stage palatoplasty techniques with respect to post-operative fistula formation, speech and growth. Due to the lack of high-quality studies we could not find conclusive evidence of a relationship between one- or two- stage palatoplasty and facial growth, speech and fistula formation in patients with unilateral cleft lip and palate.
Chapter 4 describes the results of a parallel blocked randomised controlled clinical trial that was performed to compare one and two stage palatoplasty in children with unilateral complete cleft lip and palate. These patients were previously treated for their cleft lip defects. This comparison was done for post-operative fistula formation and speech. This trial included 100 patients with non-syndromic complete unilateral cleft lip and palate with a repaired cleft lip, divided into two equal groups. Group A included patients who were operated according to a one-stage palatoplasty at age 12 to 13 months while group B patients had a two-stage palatoplasty with soft palatoplasty at age 12 to 13 months and hard palatoplasty at age 24 to 25 months. We found no difference in fistula rates between the two groups. Nasalance was slightly higher in patients in the one-stage palatoplasty group than in the two-stage palatoplasty group, but the difference was not clinically relevant. This study helped our hospital determine the best protocol for treating our patients with cleft palate defects.
A major complication of primary cleft palate repair is the formation of fistulae due to surgical wound dehiscence postoperatively. We performed the study described in chapter 5, to determine if placing an antibiotic pack on the hard palate immediately after surgery, would help reduce the incidence of fistula formation. This study was a parallel blocked randomized controlled trial. The study consisted of two groups of 100 patients each that underwent primary palatoplasty. Group A had an oral pack placed on the hard palate for 5 days postoperatively while group B did not. Occurrence of fistulae between both groups was tested using odds ratios (OR). The findings of this study provide evidence that the rate of fistula formation after primary palatoplasty is significantly reduced if a pack soaked with antibiotic cream is placed on the palate postoperatively for 5 days.
Another major complication after cleft palate repair is a persistent defect in speech. There are many reasons for such defects to occur. One of the most prevalent reasons for such a persistent speech defect is velo-pharyngeal incompetence (VPI). A short soft palate is the cause of VPI. This shortening of the repaired soft palate does not seal the mouth from the nose sufficiently while the patient speaks, thereby causing air to escape through the nose. In chapter 6, we test the efficacy of a modified Furlow’s technique to lengthen the soft palate and reduce VPI. Fifty-five children aged between 12 and 15 years, with postoperative VPI following primary palatoplasty, underwent a modified Furlow Z-plasty. Nasometry was done to determine the change in velopharyngeal function due to the secondary Furlow Z- plasty by comparing the preoperative with the 1-year postoperative nasalance scores. Patients with VPI after primary palatoplasty and treated using a modified Furlow Z-plasty had significantly lower nasalance scores at 1 year postoperative, indicating significantly improved velopharyngeal function.
In chapter 7, we discuss the results of the various studies in the thesis. We also discuss the strengths and limitations of the thesis. Based on the results of our research we also explain how we have adapted our treatment protocols to include the techniques tested here. We recommend future studies, especially to study maxillofacial growth in patients which clefts after primary cleft palate repair. This research project is the first step in finding common protocols for the repair of cleft palate.