Andrew Hodges

Incidence of Cleft Lip and Palate in Uganda

Objective The purpose of the study was to estimate the need for resources for cleft repairs in Uganda by determining the overall incidence of -facial clefts and the ratio of isolated cleft lip to isolated cleft palate to cleft lip and palate. Design A 1-year prospective study was implemented in seven hospitals and health centers with maternity units in and around Kampala. All live babies were examined for cleft lip and/or palate at birth. The birth of a baby with a cleft was communicated to the research coordinator by maternity staff, and the babies were assessed within 24 hours of delivery. Maternity data (live births) for each center were collected monthly to determine the denominator. Results Over the course of 1 year (February 1, 2008 to January 31, 2009), 26,186 babies were delivered. Nineteen babies had a cleft lip and/or palate, giving an incidence of 0.73 in 1000; 12 of the 19 babies (63.2%) had a cleft lip and palate, six (31.2%) had an isolated cleft lip, and only one (5.3%) had an isolated cleft palate. The ratio of boys to girls was 1.1:1. Conclusions The incidence of clefts in this study was 0.73 in 1000. With an estimated 1100 babies born with a cleft per year, this would result in the need for 1800 cleft repairs for babies in Uganda (695 babies needing two repairs each). These data will be helpful to advocate for and plan the necessary resources to effectively treat this condition.

Normative Nasalance Data in Ugandan English-Speaking Children

Aims: The aim of this study was to obtain normative nasalance values for typically developing Ugandan English-speaking children as a reference point for clinical practice and further research. Methods: Sixty-nine typically developing Ugandan children (35 males and 34 females, 2.7–13.5 years of age) participated in the study. Nasalance scores were obtained with the Nasometer while children repeated 4 sustained sounds, 14 repeated syllables, 15 sentences (12 oral, 3 nasal) and 2 texts (‘Rainbow Passage’ and ‘Zoo Passage’). Data were analyzed for gender and age dependence. Results: No significant effects of age or gender on nasalance values were obtained; hence, normative values for the overall group were reported. The average nasalance scores for Ugandan English-speaking children were 17 and 64% for the oral and nasal sentences and 33 and 14% for the oronasal and oral text, respectively. Conclusion: The normative values are important as a reference point to assess the impact of several surgical procedures and several surgical timing strategies on speech in Uganda.

Wound infection in a rural hospital: the benefit of a wound management protocol.

INTRODUCTION A discrepancy was noticed between the infection rates on two wards receiving post-operative patients. Those patients on the surgical ward in a small study were found to have an overall infection rate of 13% for all cases whereas on the maternity ward, infection rates following lower segment Caesarean sections (LSCS) were in excess of 50% with sometimes all patients on the ward having a wound infection. Wound infections cause a prolonged hospital stay which increases the cost to the patient and places pressure on scarce hospital beds. Therefore a protocol was designed to standardize the management of surgical wounds. Several factors were analysed and changed: (A) All wounds were graded and given antibiotics as required by the protocol:

Impact of tongue reduction on overall speech intelligibility, articulation and oromyofunctional behavior in 4 children with Beckwith-Wiedemann syndrome.

Objective: The purpose of this study was to determine the impact of partial glossectomy (using the keyhole technique) on speech intelligibility, articulation, resonance and oromyofunctional behavior. Patients and Methods: A partial glossectomy was performed in 4 children with Beckwith- Wiedemann syndrome between the ages of 0.5 and 3.1 years. An ENT assessment, a phonetic inventory, a phonemic and phonological analysis and a consensus perceptual evaluation of speech intelligibility, resonance and oromyofunctional behavior were performed. Results: It was not possible in this study to separate the effects of the surgery from the typical developmental progress of speech sound mastery. Improved speech intelligibility, a more complete phonetic inventory, an increase in phonological skills, normal resonance and increased motor-oriented oral behavior were found in the postsurgical condition. The presence of phonetic distortions, lip incompetence and interdental tongue position were still present in the postsurgical condition. Conclusion: Speech therapy should be focused on correct phonetic placement and a motor-oriented approach to increase lip competence, and on functional tongue exercises and tongue lifting during the production of alveolars. Detailed analyses in a larger number of subjects with and without Beckwith-Wiedemann syndrome may help further illustrate the long-term impact of partial glossectomy.

Global Variation in Cleft Palate Repairs: An Analysis of 352,191 Primary Cleft Repairs in Low- to Higher-Middle-Income Countries

Objectives Resources for repair of cleft lip and palate may be lacking in low- and middle-income countries. The Smile Train is a registered charity that supports cleft repair in resource-poor settings. In the global health care challenge, it has been suggested that many babies born with cleft palates are not repaired. This study aims to determine whether any variation exists in the proportion of cleft lip and cleft palate repairs undertaken in low- and middle-income countries. Methods Data were obtained from the Smile Train database of 352,191 consecutive cleft operations performed between 2008 and 2011 in low- to higher-middle-income countries. The ratio of cleft lip to palate repair was analyzed as a function of geographic region and by country income (gross national income). Results A significant correlation exists between both the income of a country and its geographical region to the ratio of lip and palate repair procedures undertaken. Higher-income countries had a higher ratio of cleft palate repairs. Countries in sub-Saharan Africa have the lowest proportion of cleft palate repairs. Conclusion This study emphasizes that many babies born with cleft palates in resource-poor regions do not have their palates repaired. This finding may be explained by an increased neonatal mortality in cleft palate babies. Furthermore, fewer isolated palatal clefts may present to an appropriate health care facility or there may be a reluctance to treat cleft palate due to concerns regarding higher perioperative risks or the lack of available surgical and anesthetic expertise.

Parental satisfaction in Ugandan children with cleft lip and palate following synchronous lip and palatal repair.

UNLABELLED The purpose of the present case control study was to assess parental satisfaction with speech and facial appearance in Ugandan children with complete unilateral or bilateral cleft lip and palate (CLP), who underwent a synchronous lip and palatal closure. The results are compared with an age- and gender-matched control group. The experimental group consisted of the parents or guardians of 44 Ugandan patients (21 males, 23 females) with complete unilateral or bilateral CLP (mean age: 3;1 years). The control group included the foster mothers of 44 orphan children matched by age and gender (mean age: 3;7 years). A survey based on the Cleft Evaluation Profile was used to assess the perceived satisfaction for individual features related to cleft care. Overall high levels of satisfaction were observed in the experimental group for all features (range: 56-100%). No significant differences could be established regarding age, gender, age of lip and palatal closure, cleft type or maternal vs. paternal judgments. In participants who were dissatisfied with the appearance of the lip, the time period between the cleft closure and the survey was significantly larger compared with satisfied participants. Furthermore, significantly lower levels of satisfaction were observed in the cleft group for speech and the appearance of the teeth and the nose compared with the control group. Satisfaction with speech and facial appearance in Ugandan children with cleft lip and/or palate is important since normal esthetics and speech predominantly determine the childrens social acceptance in the Ugandan society. LEARNING OUTCOMES As a result of reading this manuscript, the reader will be able to explain the attitudes of parents toward the surgical repair of their childrens cleft lip and palate. As a result of reading this manuscript, the reader will be able to identify differences in parental attitudes toward synchronous lip and palate repair.

Excision of a 1.9 kg goitre under local anaesthetic

A 30-year-old woman with a large goitre underwent thyroidectomy under local anaesthetic field block. A 1.9 kg goitre was resected. She was given light sedation but was able to communicate throughout the whole procedure which was performed comfortably under the local anaesthesia. She made an uneventful recovery with no complications. Local anaesthetic was chosen as the safest procedure in a remote rural Ugandan hospital which lacked close post-operative monitoring. Other benefits of using local anaesthesia are discussed.

Challenges in global microsurgery: A six year review of outcomes at an East African hospital

BACKGROUND Free tissue transfer is an invaluable resource for reconstruction of complex defects. There is very little evidence as to the feasibility and outcomes of microsurgery performed in East Africa. This study will analyse outcomes of 114 consecutive free flaps, performed over 6 years at a single plastic surgery unit in Uganda. It aims to demonstrate that despite its challenges, successful microsurgical practice can be set up in East Africa. METHODS AND PATIENTS The notes of 100 consecutive patients who underwent 114 free flaps between 01/06/2009 and 01/07/2015 at CoRSU Hospital, Uganda were analysed. RESULTS One hundred and fourteen free flaps were performed on 100 patients. The types of free flaps used included free fibula (n = 41), ALT (n = 30), gracillis (n = 8), radial forearm (n = 7), latissimus dorsi (n = 9) and rectus (n = 7) amongst others (n = 12). The most common indications for surgery were head and neck cancer (n = 50), trauma (n = 19), osteomyelitis (n = 18), burns (n = 13), head and neck infection (n = 6). Over the six year period there was an overall 76% survival of the flaps. However in the last two years of the series there was a flap survival rate of over 93% (n = 50). There were 40 non-microsurgical complications including wound infection (n = 10) and graft loss (n = 8). CONCLUSION This is one of the first studies to report on the outcomes of free flaps performed at an East African centre. There is a steep but surmountable learning curve to improve microsurgery delivery in East Africa. This study identifies challenges in patient demographics, surgical experience and resources that have been overcome to improve outcomes.

Impact of early synchronous lip and palatal repair on speech.

Aims: The purpose of this study was to describe articulation and resonance characteristics of Ugandan English-speaking children with cleft lip and palate (CLP) after synchronous lip and palatal closure (Sommerlad technique) prior to the age of 6 months in comparison with an age- and gender-matched control group. Methods: Eleven Ugandan patients with CLP (mean age 4;9 years), repaired during a synchronous lip and (soft and hard) palatal closure at a mean age of 3.4 months, were included as well as a control group (n = 22) consisting of 2 Ugandan age- and gender-matched noncleft children for each patient (mean age 4;10 years). Objective and perceptual speech assessment techniques were applied. Results: Consonant inventories were significantly smaller in the CLP group. Moreover, phonetic disorders and phonological processes occurred in 91 and 100% of the CLP group, respectively. Perceptual consensus evaluation revealed absence of hyponasality and cul-de-sac resonance in all patients. Hypernasality and nasal emission/turbulence occurred in 18 and 27% of the patients, respectively. No significant group differences were observed regarding the mean nasalance values of oral speech samples. Conclusion: Various deviations from normal speech development seem to occur in patients with CLP following synchronous lip and palatal closure before 6 months of age.

Speech characteristics in a Ugandan child with a rare paramedian craniofacial cleft: A case report

The purpose of this study is to describe the speech characteristics in an English-speaking Ugandan boy of 4.5 years who has a rare paramedian craniofacial cleft (unilateral lip, alveolar, palatal, nasal and maxillary cleft, and associated hypertelorism). Closure of the lip together with the closure of the hard and soft palate (one-stage palatal closure) was performed at the age of 5 months. Objective as well as subjective speech assessment techniques were used. The speech samples were perceptually judged for articulation, intelligibility and nasality. The Nasometer was used for the objective measurement of the nasalance values. The most striking communication problems in this child with the rare craniofacial cleft are an incomplete phonetic inventory, a severely impaired speech intelligibility with the presence of very severe hypernasality, mild nasal emission, phonetic disorders (omission of several consonants, decreased intraoral pressure in explosives, insufficient frication of fricatives and the use of a middorsum palatal stop) and phonological disorders (deletion of initial and final consonants and consonant clusters). The increased objective nasalance values are in agreement with the presence of the audible nasality disorders. The results revealed that several phonetic and phonological articulation disorders together with a decreased speech intelligibility and resonance disorders are present in the child with a rare craniofacial cleft. To what extent a secondary surgery for velopharyngeal insufficiency, combined with speech therapy, will improve speech intelligibility, articulation and resonance characteristics is a subject for further research. The results of such analyses may ultimately serve as a starting point for specific surgical and logopedic treatment that addresses the specific needs of children with rare facial clefts.