Jeffrey A. Goldstein

Timing of palatal surgery and speech outcome.

Objective: To examine the impact of age and lexical status at the time of primary palatal surgery on speech outcome of preschoolers with cleft palate. Participants: Forty children (33 to 42 months) with nonsyndromic cleft palate participated in the study. Twenty children (Group 1) were less lexically advanced and younger (mean age  =  11 months) and 20 children (Group 2) were more lexically advanced and older (mean age  =  15 months) when palatal surgery was performed. Main Outcome Measures: Samples of the childrens spontaneous speech were compared on 11 speech production measures (e.g., size of consonant inventory, total consonants correct, % correct for manner of articulation categories, compensatory articulation usage, etc.). Next, listeners rated a 30-second sample of each childs connected speech for articulation proficiency and hypernasality, separately, using direct magnitude estimation (DME). Results: Group differences were noted for 4 of the 11 speech production measures. Children in Group 1 exhibited larger consonant inventories (and true consonant inventories) and more accurate production of nasals and liquids compared to children in Group 2. On the DME task, significant group differences were found for ratings of articulation proficiency and hypernasality. Children in Group 1 exhibited better articulation and less hypernasality than children in Group 2. Conclusions: The findings suggested that children who were less lexically advanced and younger at the time of palatal surgery exhibited better articulation and resonance outcomes at 3 years of age.

Early experience with biodegradable fixation for congenital pediatric craniofacial surgery

We describe early experience using a polymeric bioresorbable bone fixation system in a consecutive series of eight pediatric patients for the correction of craniofacial malformations. Indications for surgical treatment included craniosynostosis (7) and enceph-alocele (1). All patients underwent bifrontal craniotomies with cranial vault or orbital reconstruction or both. Segments were then stabilized using bioresorbable fixation systems. Patients were evaluated pre-and postoperatively clinically and with radiographs and photographs. Mean follow-up was 4.5 months, with a minimum follow-up of 3 months. In seven of eight patients, there was no incidence of infection, extrusion, exposure, erythema, instability of the advanced segments, relapse, hematoma, seroma formation, or adverse inflammatory reaction. One patient experienced difficulty with respect to system imperfections (i.e., drill holes after tapping were too large for screws). This study demonstrated the efficacy of bioresorbable plates and screws for the growing pediatric craniofacial patient; excellent short-term results were achieved. Prospective studies and longer longitudinal follow-up of larger numbers of patients are desirable to confirm these findings.

Bioresorbable Fixation for Congenital Pediatric Craniofacial Surgery: A 2-Year Follow-Up

We describe our experience with the use of a polymeric biodegradable system for the correction of congenital pediatric craniofacial malformations. These fixation methods present several advantages over conventional metallic fixation systems. Our series consists of 51 patients that underwent craniofacial surgery, 46 for craniosysostosis, and 5 for encephalocele. The mean age of the patients was 3 years (median age 9 months). Patients with coronal or metopic craniosynostosis underwent a bifrontal craniotomy and anterior cranial vault and orbital reconstruction. Three patients with late sagittal synostosis underwent cranial vault reconstruction in two stages. Encephalocele defects were repaired with osteotomies, and/or onlay bone graft. Lactosorb (Lorenz Biomet, Warsaw, Ind.) plates (cut from a prefabricated mesh) and screws were employed using established fixation techniques. Cranial bone was the source of all bone graft when required. Pre- and postoperative clinical, radiographic and photographic examinations were performed on all patients. At 2 years follow-up, no evidence of infection, erythema, extrusion, instability of the bony fragments or relapse has been noted. The plates themselves were universally impalpable by the one year follow-up examination. The results in this series support the use of resorbable fixation systems in the correction of congenital craniofacial deformities.

Favorable prognosis for children with Pfeiffer syndrome types 2 and 3: Implications for classification

Pfeiffer syndrome (PS) is an autosomal dominant condition comprising bilateral coronal craniosynostosis, midface hypoplasia with a beaked nasal tip, and broad and medially deviated thumbs and great toes. It is a clinically variable disorder and has been divided into three subtypes [Cohen, 1993: Am J Med Genet 45:300-307]. Type 1 represents the less severe cases, while types 2 and 3 are the more severe cases. These latter types tend to have a higher risk for neurodevelopmental problems and a reduced life expectancy. Here we review the clinical course of seven children with PS type 3. All of these children had severe manifestations of PS; however, development was essentially normal in three, mild delay was noted in two, and moderate delay in one. Favorable outcomes in children with types 2 and 3 PS were also documented by Moore et al. [1995: Cleft Pal-Craniofac J 32:62-70]. These cases illustrate that while children with PS types 2 and 3 have an increased risk for neurodevelopmental difficulties, a favorable outcome can be achieved in some cases with aggressive medical and surgical management. Finally, although such management should be the rule for PS types 2 and 3, it needs to be remembered that normal outcome is not the rule. The prognosis for favorable neurodevelopmental outcome and/or life expectancy remains guarded in most cases.

The impact of early palatal obturation on consonant development in babies with unrepaired cleft palate

OBJECTIVE The purpose of this investigation was to determine whether palatal obturators enhance consonant development during babbling for babies with unrepaired cleft palate. PARTICIPANTS Fourteen babies with cleft palate who had worn anterior palatal obturators prior to palatal surgery were matched to 14 unobturated babies according to cleft type, sex, and age at time of presurgical evaluation. MAIN OUTCOME MEASURES Spontaneous vocalizations of the obturated and unobturated groups were compared to determine whether differences were evident in size of consonant inventory as well as place and manner of consonant production. RESULTS Paired t tests revealed no significant differences between the groups in size of consonant inventory or place and manner of consonant production. There was a trend for babies in the obturated group to produce more glottal consonants. CONCLUSIONS In general, the findings of this study suggested that palatal obturators do not appear to facilitate production of anterior palatal consonants during babbling.

A preventable complication of LactoSorb craniomaxillofacial fixation.

The use of resorbable craniomaxillofacial fixation has recently garnered support, especially in the pediatric population. Its advantages are well summated in other articles within this journal. The aim of this article is to present a unique but preventable complication of the LactoSorb resorbable craniomaxillofacial fixation system (Lorenz/Biomet, Inc., Warsaw, IN): retention of the hex head of a LactoSorb screw. This article addresses the complication and its future avoidance.

Infantile hemangioma of the accessory parotid gland.

Parotid gland tumors, especially those of the accessory parotid gland, are rare in infancy. Although infantile hemangiomas have been frequently reported as a cause of parotid gland tumors, their association with the accessory parotid gland has not been reported. This article describes the presentation of a hemangioma of the accessory parotid gland in an infant. Review of the literature and treatment methods are discussed.

Intracranial migration of metallic fixation devices into the sagittal sinus

Abstract Metallic rigid fixation has enjoyed a broad spectrum of application in craniofacial surgery. However, this technology has been associated with several concerns: infection, extrusion, immunologic reaction, growth restriction, and intracranial passive migration of hardware. While intracranial migration has been observed in many cases of pediatric craniofacial surgery, no observed sequalae have been reported. This case report presents a patient that demonstrated intracranial migration of metallic fixation hardware, rigid fixation plates and screws were observed to have translocated into the sagittal sinus. A brief review of intracranial migration literature accompanies the case report.