ANNALS OF IBADAN POSTGRADUATE MEDICINE
I.I. Onah, C.O. Amanari, I. Onwuagha and C.A. Jac-Okereke
Background: Despite an increase in the number of palatoplasty procedures at the National Orthopaedic Hospital Enugu (NOHE) sequel to a partnership with Smile Train, no reports on subsequent outcomes have been published. We investigated the speech outcomes and rates of fistula formation, the relationship between introduction of solids and incidence of post-operative oronasal fistulae and the benefits of post-operative honey licks.
Objective: To determine the outcome of palatal repairs performed at our center in relation to the timing and nature of post-operative feeds.
Method: This was a cohort study of patients who had palatoplasty over a five-year period and were subsequently followed up for a maximum period of 9 years. The patient’s present condition, timing of first feeds, onset of solid feeds, honey licks, frequency of wound dehiscence, fistula formation, and speech outcomes were assessed. The evaluation for a fistula was made from two weeks after the surgery by a senior resident in plastic surgery. Analysis was done using SPSS version 21.0 and p value set at <0.05.
Results: A total of 115 surgeries: 90 primary cleft palate repairs, 6 combined cleft lip and palate surgeries and 19 secondary cleft palate repairs were done. Male to female ratio was 1:1.3. Age range of patients was 6 weeks to 36 years. Timing of introduction of solid meals significantly affected incidence of repair breakdown; and 58% had normal to near-normal speech.
Conclusions: Licking honey was associated with fewer wound breakdowns. Early return to solid feeds is associated with a higher incidence of wound breakdown following palate repair.
Keywords: Palatoplasty; Outcomes; Fistula; Speech
Dr. I.I. Onah
National Orthopaedic Hospital,
Cleft lip and palate is the most common major craniofacial anomaly that presents to the plastic surgeon.1 Cleft surgery has been on the increase at the National Orthopaedic Hospital Enugu (NOHE) since onset of partnership with the Smile Train charity in 2006. Data shows an increase in palate repairs but no reports on outcomes of palate repair from NOHE since the inception of this partnership. Increasing volume is expected to translate to better results as the surgeon’s experience is an important variable in palate surgery among fit patients. Speech and fistula formation are the most important indicators of success in palate repair. We investigated these outcomes in a nine-year period, as well as the relationship between timing of postoperative introduction of solids and development of oronasal fistulae. We also assessed the potential benefit of post-operative honey licks in reducing wound complication rates following repair.
MATERIALS AND METHODS
This was a cohort study of patients who had palatoplasty over a five-year period and were subsequently followed up for a maximum period of 9 years. Assessors conducted telephone interviews with patients and care-givers. The assessors were not the surgeons who performed the repairs. The patients’ present condition, timing of first feeds, onset of solid feeds, post-operative honey licks, wound dehiscence and spontaneous closure, fistula formation, need for revision surgery, and speech outcomes were assessed. Analysis was done using SPSS version 21.0 and p value set at <0.05
Selection of participants
All cleft palate surgeries done at NOHE are routinely uploaded to the SmileTrain Express database. Records from November 2008 to November 2013 were used to retrieve patient data. These included isolated palatal clefts, and cleft lip with cleft palate. Interviews of patients/parents between January 2014 and October 2018 were also used to provide data. Speech quality was assessed by two methods: The parent/care-giver’s ability to understand the patient’s speech, and (for adults) the interviewer’s assessment. There were three interviewers. One was trained in cleft speech language pathology while the other two were residents in training. Children less than a year at the time of assessment were not assessed.
Intravenous antibiotics were routinely administered before induction of general anaesthesia and continued for up to five days post operatively.
The patient is laid supine on the operating table and anaesthetised with a cuffed armoured tube placed securely in the midline. Continuous monitoring with non-invasive multiparameter monitors is routine. A sandbag is placed between the shoulders and the patient prepped. A self-retaining mouth gag is inserted and the head of the table turned down in extension until the entire cleft palate is clearly visualised. Oxygen saturation is rechecked and the oral and nasal cavities are cleaned with povidone iodine lotion or ointment paying particular attention to the shelves, cleft and tonsillar regions. A throat pack is inserted. Intra operative infiltration with adrenaline solution is routine.
After a seven minute pause the cleft margins are pared on the oral side. Moistened gauze is cut, insinuated and pushed posteriorly and laterally to aid elevation of the shelves, separation of the oral and nasal layers as well as haemostasis. They are removed by the time of closure of the layers. Where the hard palate is involved the nasal layer is separated from the palatine bone. With good visualisation the nasal layer of the soft palate close to the bone is held taut with tissue forceps and the nasal layer teased out with a cleft palate dissector. Every attempt is made to avoid buttonholing. The rest of the surgery proceeds depending on the selected technique. Intra-velar veloplasty, von Langenbeck’s and Furlow’s repairs, in that order of frequency, were the surgical techniques used. The throat pack is removed before extubation which is done when the patient has regained the swallowing reflex and shows spontaneous movement. The patient is turned to the side and routinely given supplemental oxygen briefly before transfer out of the theatre.
The feeding protocol was clear fluids (sugared water) upon recovery from anaesthesia on the day of surgery, and semi-solid diet based on pap for 3 weeks thereafter.
Honey was encouraged from the second day. The instruction on commencement of feeds and duration of liquid diet varied between the units. One unit allowed oral intake of clear liquids within 24 hours of the repair and routinely prescribed honey licks post operatively. A majority (72%) of the surgeries was done by the surgeon in this unit. Other units allowed oral intake of clear liquids after 48 hours and did not recommend honey licks.