September 2019 HSC Section 1 Congenital and Pediatric Problems

Dao & Goudy

Fig. 10. Oxford/three-flap: both flaps raised.

speech and feedings, minimal impact on facial growth, and improved eustachian tube function. Oronasal fistulas typically occur in up to 10% of cases and are usually located at the junction of the hard and soft palate. They may result in hyper- nasality, nasal emission, and nasal regurgitation. The factors that influence fistula formation all have an impact on the principles of wound closure and include forming robust tissue flaps, maintain- ing a tension-free closure, and creating a multilay- ered closure. Velopharyngeal insufficiency (VPI) may occur in up to one-fourth of patients and man- ifests as hypernasal speech, increased nasal reso- nance, nasal regurgitation, and nasal emission during phonation. 17 Because several surgical and nonsurgical treatment options exist for VPI 18 a multispecialty team composed of a speech- language pathologist, otolaryngologist, and pros- thodontist could assist in choosing the most appropriate option. Of the surgical options listed previously, the Children’s Hospital of Philadelphia modification of double-opposing Z-palatoplasty Fig. 12. Oxford/three-flap: use of AlloDerm (LifeCell Corporation, Bridgewater, NJ) between the nasal and oral layers.

Postprocedural Care Primary goals in the postoperative period include preventing wound complications, providing ad- equate pain relief, and ensuring the patient is taking in satisfactory nutrition. Every child should stay as an inpatient for at least 1 night to monitor for airway obstruction and ability to tolerate oral intake. Arm restraints that prevent the child from putting their hands and fingers in their mouths should be used for 2 weeks. Bottle-feeding and straws should also be avoided. Antibiotics are prescribed for 1 week, and pain control is achieved with acetaminophen and ibuprofen. A follow-up appointment is scheduled in 3 weeks, and the family is told to call with any additional questions or concerns. Outcomes/Potential Complications and Management A successful cleft palate repair includes complete closure of the oral and nasal layers without fistula formation, velopharyngeal competence with

Fig. 11. Oxford/three-flap: sewing the flaps together starting posteriorly.

Fig. 13. Oxford/three-flap: oral flaps sewn to the anterior mucosa.

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