R.W. Pigott

A computer-aided method of measuring nasal symmetry in the cleft lip nose

Objective assessment of the results of cleft lip and nose surgery is necessary to quantify differences between alternative surgical techniques. A previously described method of measuring facial asymmetry has been modified to allow a comparison of differently treated cleft noses (radical nasal correction versus no nasal correction). Standardised, inferior view photographs of 10-year-olds were obtained from patient records. These were projected, traced, digitised and analysed using a BBC microcomputer. A method of excluding the ill-defined nasal baseline by obtaining a mirror-image of the upper nasal perimeter is described. The method has a high degree of inter and intra observer reproducibility.

Tongue flap repair of cleft palate fistulae

In a series of 20 patients with palatal fistulae that were judged beyond closure with local tissue alone, the fistulae were successfully closed with tongue flaps in 17 patients (85%), 6 of whom required an additional minor procedure. The social stigma of fluid leaking from the nose was corrected in all patients and, in the older age group, several patients no longer had to wear obturators. Speech was improved in 9 patients due to a reduction in hypernasality and in 8 patients, articulation was noticeably improved. The anteriorly-based tongue flap has proved to be a reliable way of closing the difficult fistula where symptoms are sufficient to justify the attempt. The procedure was used successfully in all three children under 2 1/2 years on whom it was used.

Early postoperative complications in primary cleft lip and palate surgery - how soon may we discharge patients from hospital?

A retrospective review of the early complications of primary cleft lip and palate surgery in one Plastic Surgery Unit was conducted and the results are presented. Out of 164 primary procedures performed there was an overall complication rate of 26.2%. The life-threatening complications were all related to the respiratory system and all but one of these occurred within 2 days of operation.

A comparison of computer versus panel assessment of two groups of patients with cleft lip and palate

A computer-based system of assessing asymmetry was used to compare standardised photographs of primarily corrected cleft noses, uncorrected cleft noses and control (normal) noses. A significant difference was found between control and cleft groups for both upper nasal perimeter (p < 0.001) and nostril outline (p = 0.001), and between uncorrected and corrected noses for upper nasal perimeter (p = 0.03) but not for nostril outline (p = 0.99). Comparing the results achieved by panel assessment (Cussons et al., 1992) with this of the same patients revealed some discordance related to the influence of extraneous factors on panel decisions. Panel assessment is needed in the evaluation of overall appearance, whilst the computer method is able to assess the results of different techniques, and from different centres, on specific features where symmetry is a major objective of surgical technique.

The results of 100 operations for velopharyngeal incompetence—selected on the findings of endoscopic and radiological examination

Of one hundred patients with velopharyngeal incompetence subjected to a pharyngoplasty selected on the results of endoscopic and radiological examination 97% were cured of unacceptable nasal escape and 93% of unacceptable nasal resonance on the criteria described. It was considered that this provided a vindication of the system of treatment. Critical examination of the morbidity revealed an unacceptably high proportion of hyponasality. This appeared to be due to ignoring the criteria for selection for pharyngoplasty and opting for the more radical operation resulting in over-treatment in some cases. With the numbers available in the smaller treatment groups it was not possible to state that there was no significant difference in the results between the different pharyngoplasties in the groups for which they were selected. It is expected that there will be a larger proportion of patients receiving less radical treatment without detriment to the success rate, but with a lower morbidity. Assuming that it is accepted that as much accurate information as possible prior to operation is needed for the correct selection of operation, simultaneous endoscopic and radiological examination provide a time- and cost-efficient system the benefit of which becomes overwhelming for revision of the failed pharyngoplasty.

Quantitative Measurement of Symmetry From Photographs Following Surgery for Unilateral Cleft Lip and Palate

A computer-based program is presented to be used with digitized frontal and basal photographs. SymNose enables the user to quantify asymmetry of the front view of the lip and nose and of the nose from the base view, using the area of mismatch of one side reflected over the other. There is a facility to transfer results to a spreadsheet. The program is simple and quick to use and runs on Apple Macintosh OSX 10.4 or later, power and Intel-based systems. The outline of a feature can be drawn using the mouse or digitizing pad. The program, together with Help files, is available from the authors.

Lip posture and mouth width in children with unilateral cleft lip

The aim of this study was to measure on photographs the protrusion of the upper and lower lips and demonstrate their relationships to each other, to measure the width of the mouth, and to compare these findings within complete and incomplete cleft groups and with normal controls at the ages of 5 and 10 years. It was found that the lower lip was more protrusive and the mouth width was narrower in 5-year-old children with complete clefts prior to maxillary collapse than in the control children. It is concluded that there is a lack of tissue in the cleft lip leading to less distensibility and increased lip pressure and that this may be one of the factors causing maxillary retrusion.

The technique of recording nasal pharyngoscopy

Nasal pharyngoscopy is a relatively simple and most informative technique requiring a small amount of very portable equipment. Recording the observations objectively is of considerable clinical and research value, but will require a two-man team, one of whom must be thoroughly versed in audio-visual communication techniques and apparatus. The equipment is more expensive and although it can be transported is probably best used at a routine site.

Medial Langenbeck: experience of a modified Von Langenbeck repair of the cleft palate. A preliminary report

Early experience of a modified Von Langenbeck repair of cleft palate is reported. In each case the traditional method of repair has been adopted, but with the relieving incision placed medial to the greater palatine artery. Out of a total of 40 patients over a 2-year period 8 were noted to have a fistula, of which 4 closed spontaneously, leaving 4 (10%) potentially requiring further surgery. The modified oral layer closure was conceived with muscle repair directed at restoring normal anatomy and concentrating on construction of a median dorsal convexity.

The feasibility of nasal pharyngoscopy using the 70° Storz-Hopkins nasopharyngoscope

Abstract In a sample of 100 patients of all ages with velopharyngeal incompetence the overall success rate in passing the Storz-Hopkins 70° nasopharyngoscope was 83%. The seventeen failures occurred in children under 10. In a group of 110 children between 3 and 11 years old, success rates for pre-school children were less than 50%, but for primary school children the success rate rises to 75% in the eighth year and failures over the age of 10 are exceptional. The possibility that unilateral cleft patients and neurological patients would have a worse prognosis for age could not be confirmed statistically in this sample. From a practical point of view endoscopy with this endoscope should be reserved for children of school age (over 5), unless the child seems particularly self-possessed, in order to have a reasonable chance of success and to avoid prejudicing the child against subsequent and perhaps more essential examination.