Sanjay Naran

The Pittsburgh Fistula Classification System: A Standardized Scheme for the Description of Palatal Fistulas

Objective: Vague terminology is a problem in cleft palate research. No classification scheme for palatal fistulas has been proposed to date. Although a well-healed velum is a significant outcome of palatoplasty, it is nearly impossible to compare fistula-related palatoplasty results in the literature or in medical records without a standardized vocabulary. We endeavor to devise a palatal fistula classification system that may have clinical and research applicability. Design: PubMed was searched for definitions and classifications of palatal fistula as well as incidence and recurrence rates of this outcome. Next, a 25-year retrospective review of our Cleft Centers records was performed, and fistulas were identified (n = 641 charts reviewed). The fistula descriptions yielded by this chart review were evaluated in the context of anatomical descriptions in the literature, and a clinician-friendly classification scheme was designed. Results: A literature review failed to reveal a standardized fistula classification system. An anatomically based numerical fistula classification system was devised: type I, bifid uvula; type II, soft palate; type III, junction of the soft and hard palate; type IV, hard palate; type V, junction of the primary and secondary palates (for Veau IV clefts); type VI, lingual alveolar; and type VII, labial alveolar. Conclusions: We propose a standardized numerical classification system for palatal fistulas. Its clinical adoption may prospectively clarify ambiguities in the literature and facilitate future cleft palate research and clinical practice.

A Successful Algorithm for Limiting Postoperative Fistulae following Palatal Procedures in the Patient with Orofacial Clefting

Background: Palatal procedures include (1) primary palatoplasty, (2) oronasal fistulas repair, and (3) secondary palatoplasty for velopharyngeal insufficiency. Any time a palatal procedure is performed, postoperative fistulas remain potential consequences. Presented here is a successful algorithm for performing palatal procedures and decreasing the rate of postoperative fistulas in a large, single-surgeon, consecutive series. Methods: A retrospective review of all consecutive palatal procedures performed between 2002 and 2006 including (1) primary palatoplasty, (2) oronasal fistulas repair, and (3) secondary palatoplasty for velopharyngeal insufficiency was performed. Cleft Veau type, surgical technique, and outcomes are reviewed. The algorithm included (1) relaxing incisions, (2) complete intravelar veloplasty, (3) total release of the tensor tendon, (4) dissection of the neurovascular bundle with optional osteotomy of the foramen, and (5) incorporation of acellular dermal matrix to achieve complete nasal lining reconstruction. Results: Two hundred sixty-eight palatal procedures were performed: (1) 132 primary Furlow palatoplasties yielding one symptomatic post–Furlow palatoplasty fistula (0.76 percent) (acellular dermal matrix was used in 39.4 percent of primary palatoplasties); (2) 55 oronasal fistula repairs yielding two symptomatic postoperative fistulas (3.6 percent) (acellular dermal matrix was used in 90.9 percent of fistula repairs); and (3) 81 secondary palatoplasties for velopharyngeal insufficiency resulting in no postoperative fistulas. Acellular dermal matrix was used in 14.8 percent of secondary palatoplasties for velopharyngeal insufficiency. No recommendations for speech surgery followed palatoplasty. Conclusions: Using the proposed algorithm in this single-surgeon consecutive series of 268 cases, the authors achieved the lowest reported incidence of postoperative fistulas in all forms of palatal procedures, including the lowest incidence (0.76 percent) of symptomatic palatal fistulas following primary Furlow palatoplasty.

Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients.

Background: Pediatric craniofacial fractures are anatomically distinct from their adult counterparts and must be managed with respect for future growth and development. These injuries must be approached as entities fundamentally different from adult craniofacial fractures. Here, the authors aim to provide context for practitioners managing pediatric facial fractures by augmenting presently available demographic, diagnostic, and treatment data. Methods: This is a retrospective review of demographics, diagnosis, and treatment of patients under 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with facial fractures. Patients were included regardless of treating specialty, treatment modality, or inpatient status. Results: A total of 772 consecutive patients met inclusion criteria. A significant majority (p < 0.001) of patients (68.9 percent) were male; older children were significantly more likely to sustain a facial fracture (p < 0.001). Fracture pattern, level of care, and cause of injury varied by age; 55.6 percent of patients had severe associated injuries. Male subjects, older patients, and patients of lower socioeconomic status were significantly more likely to sustain facial fractures secondary to violence (p ⩽ 0.001). Conclusions: Pediatric facial fractures may be associated with severe concomitant injuries. Injury patterns are significantly correlated with socioeconomic metrics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Inhibition of HGF/MET as therapy for malignancy

Background: Inhibition of inappropriate tyrosine kinase activity by neoplasms is an attractive strategy for the treatment of malignancy. Objective: We aimed to produce a concise review of the potential role of hepatocyte growth factor (HGF)/Mesenchymal-epithelial transition factor (MET) tyrosine kinase pathway inhibition in the treatment of cancer. Methods: The current literature, abstracts and internet resources related to HGF/MET structure, function and inhibition are summarized. The potential of inhibiting this pathway as a therapy for cancer and remaining hurdles prior to routine clinical use of MET inhibition are discussed. Results/conclusions: Current knowledge suggests that the inhibition of the HGF/MET pathway has significant potential for the treatment of cancer. A number of MET inhibitor molecules are nearing completion of their development for clinical use.

215 mandible fractures in 120 children: Demographics, treatment, outcomes, and early growth data

Background: Optimal management of pediatric mandible fractures demands that the practitioner balance reduction and fixation with preservation of growth potential and function. The ideal synthesis of these goals has not yet been defined. The authors catalogue their experience with pediatric mandible fractures at a major pediatric teaching hospital with reference to demographics, injury type, treatment, and outcomes to inform future management of these injuries. Methods: Demographics, management, and outcomes of pediatric mandible fractures presenting over 10 years at a pediatric trauma center were assessed. Cephalometric analysis was conducted. Relationships among demographics, fracture type, management, outcomes, and growth were explored. Results: Two hundred fifteen mandible fractures in 120 patients younger than 18 years were analyzed (average follow-up, 19.5 months). The condylar head and neck were fractured most frequently. Operative management was significantly more likely for children older than 12 years (p < 0.05). Operative management and multiple fractures were significantly associated with a higher rate of adverse outcomes (p < 0.05), but no adverse outcomes were considered to significantly affect mandibular function by patient or surgeon. No significant growth differences existed on cephalometric analysis between our cohort and age- and sex-matched controls (p > 0.05). Conclusions: This study reports the demographics, treatment, and early follow-up of a sizable cohort of pediatric mandible fractures. Management principles for these injuries are outlined. Although definitive recommendations must be withheld until longer follow-up is available, the data presented here show that the treatment protocols used at the authors’ center have yielded largely uncompromised mandibular function and growth thus far.

Outcomes in pediatric facial fractures: early follow-up in 177 children and classification scheme.

A comprehensive study of adverse outcomes after pediatric facial fractures has not been published. This study aimed to determine the incidence and classify adverse outcomes after facial fractures in children while reporting our early results. A retrospective chart review was performed on facial fracture patients identified in the Craniofacial Trauma Database of the Childrens Hospital of Pittsburgh and seen in follow-up from 2003 to 2007. An Adverse Outcome Classification Scheme was developed: type 1, outcomes resulting from the fracture; type 2, outcomes resulting from fracture treatment; and type 3, outcomes resulting from the interaction between the fracture, its treatment, and subsequent growth and development. Fisher exact or &khgr;2 analyses were completed. A total of 177 pediatric facial fracture patients were identified with 13.3 months of average follow-up. Mean age was 9.8 years (range, 0.4-18.7 y). Of these patients, 41.8% underwent surgery and 57 patients (32.2%) had adverse outcomes (type 1, 14.1%; type 2, 11.3%; and type 3, 15.8%); 26.3% of these had multiple adverse outcomes. Isolated fractures resulted in fewer adverse outcomes and fewer multiple adverse outcomes compared with combined fractures (26.6% versus 45.3%, P = 0.015; 4% versus 18.9%, P = 0.002). Patients treated operatively exhibited more types 1, 2, and 3 and multiple adverse outcomes compared to those treated conservatively (P < 0.01). In our pediatric cohort, 32.2% of patients had an adverse outcome. With longer follow-up and growth and development studies, we will likely see an increase in the incidence of type 3 adverse outcomes. We recommend, whenever possible, conservative treatment of pediatric facial fractures.

Postoperative hyponatremia following calvarial vault remodeling in craniosynostosis.

Background:  The incidence, severity, and risk factors for the development of hyponatremia in patients undergoing craniosynostosis surgery are not well known.

Safety of preoperative erythropoietin in surgical calvarial remodeling: an 8-year retrospective review and analysis.

Background: Calvarial remodeling is typically associated with significant blood loss. Although preoperative erythropoiesis-stimulating agents have proven to significantly decrease the need for blood transfusions, recent data in adults have raised concerns that elevating hemoglobin levels greater than 12.5 g/dl may increase the risk of thrombotic events. This study was designed to assess the risks of erythropoietin in the pediatric population. Methods: Records were retrospectively reviewed from 2000 to 2008 at three major metropolitan childrens hospitals of all children undergoing calvarial remodeling after receiving preoperative erythropoietin. Demographic and perioperative outcome data were reviewed, including transfusion reactions, pressure ulcer secondary to prolonged positioning, pneumonia, infection, deep vein thrombosis, cerebrovascular accident, pulmonary embolism, sagittal sinus thrombosis, pure red cell aplasia, and myocardial infarction. Results: A total of 369 patients met the inclusion criteria (mean age, 0.86 ± 1.1 years). On average, three preoperative doses of erythropoietin were administered (600 U/kg). Iron was also supplemented. No complications associated with dosing were noted, there were no thrombotic events identified, and no other major complications were seen (i.e., death or blindness). Thirty-one patients (8.40 percent) experienced one or more postoperative complications. There was no significant correlation between hemoglobin levels greater than 12.5 g/dl and the occurrence of any noted complication. Conclusions: With zero thrombotic postoperative complications, the authors estimate the risk of a thrombotic event in the pediatric population to be less than 0.81 percent (95 percent confidence). These data suggest that preoperative administration of erythropoietin in children undergoing calvarial remodeling does not appear to increase the incidence of thrombotic events or other significant complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Speech Outcomes After Clinically Indicated Posterior Pharyngeal Flap Takedown.

BackgroundVelopharyngeal insufficiency affects as many as one in three patients after cleft palate repair. Correction using a posterior pharyngeal flap (PPF) has been shown to improve clinical speech symptomatology; however, PPFs can be complicated by hyponasality and obstructive sleep apnea. The goal of this study was to assess if speech outcomes revert after clinically indicated PPF takedown. MethodsThe cleft-craniofacial database of the Childrens Hospital of Pittsburgh at the University of Pittsburgh Medical Center was retrospectively queried to identify patients with a diagnosis of velopharyngeal insufficiency treated with PPF who ultimately required takedown. Using the Pittsburgh Weighted Speech Score (PWSS), preoperative scores were compared to those after PPF takedown. Outcomes after 2 different methods of PPF takedown (PPF takedown alone or PPF takedown with conversion to Furlow palatoplasty) were stratified and cross-compared. ResultsA total of 64 patients underwent takedown of their PPF. Of these, 18 patients underwent PPF takedown alone, and 46 patients underwent PPF takedown with conversion to Furlow Palatoplasty. Patients averaged 12.43 (range, 3.0–22.0)(SD: 3.93) years of age at the time of PPF takedown, and 58% were men. Demographics between groups were not statistically different. The mean duration of follow-up after surgery was 38.09 (range, 1–104) (SD, 27.81) months. For patients undergoing PPF takedown alone, the mean preoperative and postoperative PWSS was 3.83 (range, 0.0–23.0) (SD, 6.13) and 4.11 (range, 0.0–23.0) (SD, 5.31), respectively (P = 0.89). The mean change in PWSS was 0.28 (range, −9.0 to 7.0) (SD, 4.3). For patients undergoing takedown of PPF with conversion to Furlow palatoplasty, the mean preoperative and postoperative PWSS was 6.37 (range, 0–26) (SD, 6.70) and 3.11 (range, 0.0–27.0) (SD, 4.14), respectively (P < 0.01). The mean change in PWSS was −3.26 (range, −23.0 to 4.0) (SD, 4.3). For all patients, the mean preoperative PWSS was 5.66 (range, 0.0–26) (SD, 6.60) and 3.39 (range, 0.0–27) (SD, 4.48), respectively (P < 0.05). The mean change in PWSS was −2.26 (range, −23.0 to 7) (SD, 5.7). There was no statistically significant regression in PWSS for either surgical intervention. Two patients in the PPF takedown alone cohort demonstrated deterioration in PWSS that warranted delayed conversion to Furlow palatoplasty. Approximately 90% of patients, who undergo clinically indicated PPF takedown alone, without conversion to Furlow Palatoplasty, will show no clinically significant reduction in speech. ConclusionsAlthough there is concern that PPF takedown may degrade speech, this study finds that surgical takedown of PPF, when clinically indicated, does not result in a clinically significant regression of speech.

Novel animal model of calvarial defect: part IV. Reconstruction of a calvarial wound complicated by durectomy.

Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been shown to be an effective therapy in the acute calvarial defect wound and in calvarial defects complicated by chronic scar and radiation. The authors assessed the effectiveness of rhBMP-2–mediated bone regeneration in calvarial defects complicated by durectomy. Methods: Sixteen adult New Zealand White rabbits underwent subtotal calvariectomy and dural removal, followed by dural repair and reconstruction in one of four groups: empty (n = 3), vehicle (buffer solution on an absorbable collagen sponge, n = 2), autologous graft (n = 3), or rhBMP-2 repair (rhBMP-2/absorbable collagen sponge, n = 8). Animals underwent computed tomographic imaging at 0, 2, 4, and 6 weeks postoperatively, followed by euthanasia and histologic analysis. Percent healing was determined by three-dimensional analysis. A 4 × 3 mixed model analysis of variance was performed on healing versus treatment group/postoperative time. Results: The rhBMP-2/absorbable collagen sponge and autograft repair groups had 51.4 and 37.3 percent healing, respectively, at 6 weeks; empty and vehicle control groups had 7.8 and 17.9 percent healing, respectively, at 6 weeks. Compared with immediate favorable reconstruction (96.8 percent healing), rhBMP-2 in this setting was significantly less effective (p = 0.001). Bone in the rhBMP-2/absorbable collagen sponge group was compact and cellular but appeared only over the intact sagittal sinus and irregularly within the absorbable collagen sponge. Conclusions: Although promising in the acute calvarial wound and other complex defects, rhBMP-2 therapy is less effective in reconstruction following dural compromise. Future studies using additional growth factors and cell therapy may improve results in this especially difficult scenario.