Ananth S. Murthy

The GILLS Score: Part I. Patient Selection for Tongue-Lip Adhesion in Robin Sequence

Background: The compromised airway in Robin sequence demands prompt operative intervention. Tongue-lip adhesion is one alternative; however, the outcome of this technique is variable. The purpose of this study was to identify variables that preoperatively predict the success of adhesion in Robin sequence patients with life-threatening respiratory distress. Methods: This is a retrospective review of infants with severe (Laberge grade II or III) Robin sequence managed by tongue-lip adhesion. Variables analyzed included diagnosis (syndromic versus nonsyndromic), age at operation, preoperative and postoperative airway management, duration of intubation, length of intensive care and hospital stay, serial weight, and postoperative complications. Results: Fifty-three infants had tongue-lip adhesion for airway compromise: 47 (89 percent) were successfully managed and treatment failed in six. Preoperative intubation, days of intubation, intensive care unit days and hospitalization, and reintubation were more common in syndromic infants (p < 0.05). Those infants who had adhesion within 14 days of birth required shorter duration of postoperative ventilator support and intensive care unit/hospital stay (p < 0.05) than those who had a later procedure. Significant variables were gastroesophageal reflux (p = 0.002), intubation preoperatively (p = 0.002), late operation (older than 2 weeks) (p = 0.001), low birth weight (<2500 g) (p = 0.01), and syndromic diagnosis (p < 0.001). The acronym GILLS summarizes these predictive findings; one point was assigned for each variable present. Adhesion was successful in 100 percent of infants with a GILLS score of 2 or less (n = 39) but failed in 43 percent (six of 14 infants) with a score of 3 or more. Conclusion: The GILLS score may improve patient selection and predict outcome of tongue-lip adhesion in infants with Robin sequence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II. Figure. No caption available.

Symptomatic plate removal in maxillofacial trauma: a review of 76 cases.

This study reviewed the fate of titanium plates used to correct maxillofacial trauma in 76 patients to define risk factors for plate removal. Medical records of 76 consecutive patients at a single institution, over a 10-year period, were retrospectively reviewed. Variables included age, sex, trauma type, diagnosis, fracture type, fracture diagnosis, plate location, surgical approach, and reasons for plate removal. Fracture diagnosis was described as panfacial (42%), blowout (3%), midface (28%), zygoma (26%), mandible angle (6%), ramus (7%), and symphysis (9%). All plate removals according to fracture diagnosis were in the mandible angle (30%) and symphysis (20%). When plate location was reviewed, 68% of the plates were placed in the upper and midface and 32% were placed in the mandible. Specifically, plates were placed in the frontozygomatic suture (18%), zygomaticomaxillary suture (19%), infraorbital rim (14%) and mandible symphysis (15%), mandible angle (9%), piriform (6%), nasal (5%), mandible ramus (4%) and body (4%), zygoma (2%), and frontal (2%). Of 163 plates that were placed, 6 plates (3.7%) were removed. Three (12%) of the symphysis plates and 3 (20%) of the angle plates were removed. Among all variables, only fracture diagnosis (P = 0.01) and plate location (P = 0.01) were statistically significant in plate removal. Five plates were removed for abscess/infection; 1 plate was removed for osteomyelitis. Further review revealed that 4 out of 6 plates removed involved synchronous mandible fractures. Most infections after maxillofacial trauma occur in the mandible, and often these infections are the main reason for plate removal. More vigilance is needed in the treatment of mandible angle and symphyseal fractures, especially if there are synchronous fractures, to prevent infection, plate removal and subsequent malunion.

Speech outcome after palatal repair in nonsyndromic versus syndromic Robin sequence.

Background: The authors’ purpose was to document speech outcome after cleft palate repair in patients with syndromic versus nonsyndromic Robin sequence. They also report the results of secondary correction of velopharyngeal insufficiency using a superiorly based pharyngeal flap or double-opposing Z-palatoplasty. Methods: Charts of patients with Robin sequence and cleft palate between 1980 and 2007 were reviewed. Data collected included date of birth, sex, syndrome/association, cleft palatal type (Veau class I or II), age at palatoplasty, incidence of palatal fistula, postoperative speech assessment, videofluoroscopic results, need for secondary operation for velopharyngeal insufficiency, and type of secondary operation (pharyngeal flap or double-opposing Z-palatoplasty). Results: The authors identified 140 patients with Robin sequence who had palatal closure. Postoperative speech evaluation was available for 96 patients (69 percent). A syndrome or association was identified in 42 patients (30 percent). Primary palatoplasty was successful in 74 patients (77 percent); speech was characterized as competent and competent to borderline competent. The authors found a significantly higher incidence of velopharyngeal insufficiency following palatal repair for syndromic (38 percent) than nonsyndromic Robin sequence (16 percent). (p = 0.039). In patients with velopharyngeal insufficiency, competent or borderline competent speech was determined after double-opposing Z-palatoplasty (two of five patients) or pharyngeal flap (eight of 10 patients). Conclusions: The rate of velopharyngeal insufficiency in syndromic Robin sequence is significantly greater than in nonsyndromic Robin sequence. The authors prefer pharyngeal flap for velopharyngeal insufficiency in patients with Robin sequence, whether syndromic or nonsyndromic, without retrognathism or signs/symptoms of obstructive sleep apnea. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Secondary alveolar bone grafting: An outcome analysis

OBJECTIVE To review the outcome of secondary alveolar bone grafting in unilateral and bilateral cleft lip and palate. DESIGN A surgeons experience, by retrospective chart review, of 70 consecutive patients at a tertiary care centre. OUTCOME MEASURE Periapical radiographs were taken at least six months after secondary alveolar bone grafting. The Enemark grading system was used to stratify graft-take. RESULTS In unilateral clefts, 33% were level 1, 36% were level 2, 20% were level 3 and 11% were level 4. In bilateral clefts, 29% were level 1, 50% were level 2, 14% were level 3 and 7% were level 4. There was no statistically significant difference between the level of take and the type of cleft. Complications encountered were infection (n=3), fistula (n=3), pain (n=4) and bone graft exposure that led to failure (n=2). Two patients required reoperation for bone grafting. CONCLUSIONS The iliac crest is a good donor site with excellent results and minimal morbidity.

Effects of FGF-2 and OP-1 in vitro on donor source cartilage for auricular reconstruction tissue engineering §

OBJECTIVE Microtia is a congenital partial or total loss of the external ear with current treatment approaches involving autologous construction from costal cartilage. Alternatively, tissue engineering provides possible use of normal or microtia auricular chondrocytes harvested from patients. This study investigated effects in vitro of basic fibroblast growth factor (FGF-2) and osteogenic protein 1 (OP-1) on human pediatric normal and microtia auricular chondrocytes and their potential proliferation and differentiation for cellular expansion. A working hypothesis was that FGF-2 promotes proliferation and OP-1 maintains an auricular phenotype of these cells. METHODS Two patients, one undergoing otoplasty and one an ear construction, yielded normal and microtia auricular chondrocytes, respectively. The two donor sets of isolated chondrocytes were equally divided into four experimental cell groups. These were controls without added growth factors and cells supplemented with FGF-2, OP-1 or FGF-2/OP-1 combined. Cells were cultured 3, 5, 7, and 10 days (3 replicates/time point), counted and assayed by RT-qPCR to determine elastin and types II and III collagen gene expression. RESULTS Compared to control counterparts, normal and microtia chondrocytes with OP-1 alone were similar in numbers and varied in elastin and types II and III collagen expression over all culture times. Compared to respective controls and chondrocyte groups with OP-1 alone, normal and microtia cell groups with FGF-2 had statistically significant (p<0.05) enhanced proliferation and statistically significant (p<0.05) decreased elastin and types II and III collagen expression over 10 days of culture. CONCLUSIONS FGF-2 effects on normal and microtia chondrocytes support its use for increasing cell numbers while OP-1 maintains a chondrocyte phenotype, otherwise marked by increasing type III collagen expression and cellular dedifferentiation to fibroblasts in culture.

2.5D constructs for characterizing phase separated polymer blend surface morphology in tissue engineering scaffolds

Previously, we used 2D films to identify an annealed PCL-PDLLA phase-separated blend morphology which provided nanoscale surface texture and patterning that stimulated osteoblast differentiation. In order to translate these 2D surface nanopatterning effects to the walls of 3D salt-leached scaffolds, the blend phase morphology of scaffold walls must be characterized. For salt-leached scaffolds, NaCl is used as a porogen, which may affect phase separation in PCL-PDLLA blends. However, it is not possible to characterize the surface blend morphology of 3D scaffold walls using standard approaches such as AFM or optical microscopy, since scaffolds are too rough for AFM and do not transmit light for optical microscopy. We introduce a 2.5D approach that mimics the processing conditions of 3D salt-leached scaffolds, but has a geometry amenable to surface characterization by AFM and optical microscopy. For the 2.5D approach, PCL-PDLLA blend films were covered with NaCl crystals prior to annealing. The presence of NaCl significantly influenced blend morphology in PCL-PDLLA 2.5D constructs causing increased surface roughness, higher percent PCL area on the surface and a smaller PCL domain size. During cell culture on 2.5D constructs, osteoblast (MC3T3-E1) and dermal endothelial cell (MDEC) adhesion were enhanced on PCL-PDLLA blends that were annealed with NaCl while chondrogenic cell (ATDC5) adhesion was diminished. This work introduces a 2.5D approach that mimicked 3D salt-leached scaffold processing, but enabled characterization of scaffold surface properties by AFM and light microscopy, to demonstrate that the presence of NaCl during annealing strongly influenced polymer blend surface morphology and cell adhesion.

Congenital fenestration of the palate: A case of embryologic syzygy.

Congenital fenestration of the secondary palate is the rarest type of facial cleft. Of the 26 putative cases in the literature, only 5 had confirmation of the cleft during the neonatal period. This report documents such a cleft in an infant and presents the likely pathogenesis.

Propranolol Therapy for Problematic Infantile Hemangioma.

BackgroundInfantile hemangioma (IH) is a common, benign tumor occurring in up to 10% of white infants. Propranolol has emerged as a front-line therapy for IH. The retrospective study examined the response of propranolol therapy on hemangioma size. MethodsTwenty-seven children (4 to 20 weeks old) with IH were enrolled into the study of oral propranolol solution 2 mg/kg per day divided 3 times daily for 10 months. Response was assessed by size measurements at pretreatment and posttreatment. Scoring was stratified into no response, plateau, and regression groups. Secondary outcomes measured were drug compliance and complications. ResultsTwenty-seven consecutive patients with IH were treated with propranolol, of whom 67% completed a 6-month therapy. No correlation was demonstrated between tumor size and age at therapy initiation or patient (P = 0.7 and P = 0.7, respectively). A large number of infants responded to therapy (85.2%). Response was first observed sooner in the regression group compared to plateau responders (15.15 ± 8.06 and 20.5 ± 18.42 days, respectively). A significant difference in median pretreatment and posttreatment tumor size was noted (4.50 vs 1.55 cm2, P = 0.02). Attrition was secondary to drug-induced side effects, no response, and dosing noncompliance. ConclusionsPropranolol is a safe and effective first-line therapy for problematic IHs. Therapy should show significant response by 2 weeks. If no response is observed by 3 weeks, then other treatment should be sought.