Adverse airway events (AAEs) are rare but devastating complications following palatoplasty. The purpose of this study is to evaluate patient risk factors for their effect on these complications. We hypothesize that prolonged operative time and the presence of multiple medical comorbidities are risk factors for AAEs.
Design
Retrospective cohort study.
Setting
Participant hospitals in the Pediatric American College of Surgeons National Surgical Quality Improvement Program year 2016–2019.
Patients
Cases of palatoplasty in children under 3 years of age.
Outcomes
Adverse airway events including postoperative reintubation or any requirement of postoperative mechanical ventilation.
Results
A total of 6668 patients met inclusion criteria. The median operative time was 126 min (IQR 82). AAEs were identified in 107 (1.6%) patients. The incidence of risk factors was found to increase with age and AAEs were more prevalent in younger and older patients. Although patients in the older age groups had significantly higher burden of comorbidities, differences in age were not independently associated with AAEs. Following multivariable logistic regressions, operative times greater than 2 h, ASA class ≥3, >3 medical comorbidities, and black race were found to be significant independent risk factors.
Conclusions
In this large, retrospective database study in palatoplasty, increased operative time, ASA classification ≥3, multiple comorbidities, and black race were independently associated with AAEs.
CanfieldMAHoneinMAYuskivN, et al.National estimates and race/ethnic-specific variation of selected birth defects in the United States, 1999–2001. Birth Defects Res A Clin Mol Teratol. 2006;76(11):747‐756. doi:https://doi.org/10.1002/bdra.20294.
2.
IPDTOC Working Group. Prevalence at birth of cleft lip with or without cleft palate: data from the International Perinatal Database of Typical Oral Clefts (IPDTOC). Cleft Palate Craniofac J. 2011;48(1):66‐81. doi:https://doi.org/10.1597/09-217.
3.
ReesJMuskettTEnderbyPStackhouseJ. Implications of untreated cleft palate in the developing world: adaptation of an outcome measure. Folia Phoniatr Logop. 2016;68(1):1‐9. doi:https://doi.org/10.1159/000440836.
4.
ShkoukaniMALawrenceLALiebertzDJSviderPF. Cleft palate: a clinical review. Birth Defects Res C Embryo Today. 2014;102(4):333‐342. doi:https://doi.org/10.1002/bdrc.21083.
TimbangMRGharbBBRampazzoAPapayFZinsJDoumitG. A systematic review comparing furlow double-opposing Z-plasty and straight-line intravelar veloplasty methods of cleft palate repair. Plast Reconstr Surg. 2014;134(5):1014‐1022. doi:https://doi.org/10.1097/prs.0000000000000637.
7.
KaraMCalisMKaraIKulak KayikciMEGunaydinROOzgurF. Comparison of speech outcomes using type 2b intravelar veloplasty or furlow double-opposing Z plasty for soft palate repair of patients with unilateral cleft lip and palate. J Craniomaxillofac Surg. 2021;49(3):215‐222. doi:https://doi.org/10.1016/j.jcms.2021.01.003.
8.
MahboubiHTruongAPhamNS. Prevalence, demographics, and complications of cleft palate surgery. Int J Pediatr Otorhinolaryngol. 2015;79(6):803‐807. doi:https://doi.org/10.1016/j.ijporl.2015.02.032.
9.
Rossell-PerryP. Flap necrosis after palatoplasty in patients with cleft palate. Biomed Res Int. 2015;2015:516375. doi:https://doi.org/10.1155/2015/516375.
10.
DeshpandeGSCampbellAJagtapR, et al.Early complications after cleft palate repair: a multivariate statistical analysis of 709 patients. J Craniofac Surg. 2014;25(5):1614‐1618. doi:https://doi.org/10.1097/scs.0000000000001113.
11.
HosseinabadHHDerakhshandehFMostaajeranF, et al.Incidence of velopharyngeal insufficiency and oronasal fistulae after cleft palate repair: a retrospective study of children referred to isfahan cleft care team between 2005 and 2009. Int J Pediatr Otorhinolaryngol. 2015;79(10):1722‐1726. doi:https://doi.org/10.1016/j.ijporl.2015.07.035.
FollmarKEYuanNPendletonCSDorafsharAHKolkCVRedettRJIII. Velopharyngeal insufficiency rates after delayed cleft palate repair: lessons learned from internationally adopted patients. Ann Plast Surg. 2015;75(3):302‐305. doi:https://doi.org/10.1097/sap.0000000000000082
14.
ChouairiFMetsEJGabrickKSAlperovichM. Veau III and veau IV cleft palate: do peri-operative complications differ?J Craniofac Surg. 2019;30(8):2372‐2374. doi:https://doi.org/10.1097/scs.0000000000005918.
15.
MetsEJChouairiFTorabiSJAlperovichM. Predictors of adverse events following cleft palate repair. J Craniofac Surg. 2019;30(5):1414‐1418. doi:https://doi.org/10.1097/scs.0000000000005542.
16.
NybergJPetersonPLohmanderA. Speech outcomes at age 5 and 10 years in unilateral cleft lip and palate after one-stage palatal repair with minimal incision technique – a longitudinal perspective. Int J Pediatr Otorhinolaryngol. 2014;78(10):1662‐1670. doi:https://doi.org/10.1016/j.ijporl.2014.07.016.
LiaoYFColeTJMarsM. Hard palate repair timing and facial growth in unilateral cleft lip and palate: a longitudinal study. Cleft Palate Craniofac J. 2006;43(5):547‐556. doi:https://doi.org/10.1597/05-119.
19.
FriedeH. Maxillary growth controversies after two-stage palatal repair with delayed hard palate closure in unilateral cleft lip and palate patients: perspectives from literature and personal experience. Cleft Palate Craniofac J. 2007;44(2):129‐136. doi:https://doi.org/10.1597/06-037.1.
20.
LighCAFoxJPSwansonJYuJWTaylorJA. Not all clefts are created equal: patterns of hospital-based care use among children with cleft lip and palate within 4 years of initial surgery. Plast Reconstr Surg. 2016;137(6):990e‐998e. doi:https://doi.org/10.1097/prs.0000000000002146.
21.
BloughJTPurnellCAChowIGosainAK. Wound complications, additional ventilation requirement, prolonged stay, and readmission in primary palatoplasty: a risk factor analysis of 3616 patients. Plast Reconstr Surg. 2019;144(5):1150‐1157. doi:https://doi.org/10.1097/prs.0000000000006163.
22.
JacksonOBastaMSonnadSStrickerPLarossaDFiadjoeJ. Perioperative risk factors for adverse airway events in patients undergoing cleft palate repair. Cleft Palate Craniofac J. 2013;50(3):330‐336. doi:https://doi.org/10.1597/12-134.
23.
MelhemAMRamlyEPAl AbyadOS, et al.Enhanced recovery after cleft lip repair: protocol development and implementation in outreach settings. Cleft Palate Craniofac J. 2022:10556656221078744. doi:https://doi.org/10.1177/10556656221078744.
24.
MoffittJKCepedaAJrEkeoduruRATeichgraeberJFNguyenPDGreivesMR. Enhanced recovery after surgery protocol for primary cleft palate repair: improving transition of care. J Craniofac Surg. 2021;32(1):e72‐e76. doi:https://doi.org/10.1097/scs.0000000000006985
25.
HushSEChenJTBradyCM, et al.Implementation of a modified enhanced recovery protocol in cleft palate repairs. J Craniofac Surg. 2019;30(7):2154‐2158. doi:https://doi.org/10.1097/scs.0000000000005718.
26.
PeckCJGowdaAUShultzBN, et al.The effect of surgical timing on 30-day outcomes in cleft palate repair. Plast Reconstr Surg. 2021;147(1):131‐137. doi:https://doi.org/10.1097/prs.0000000000007458.
BaratiBHashemiSMGoljanian TabriziA. Otological findings ten years after myringotomy with tympanostomy tube insertion. Iran J Otorhinolaryngol. 2012;24(69):181‐186.
30.
JunghaenelSKellerTMischkowskiR, et al.Massive macroglossia after palatoplasty: case report and review of the literature. Eur J Pediatr. 2012;171(3):433‐437. doi:https://doi.org/10.1007/s00431-011-1567-6.
31.
ChanMTChanMSMuiKSHoBP. Massive lingual swelling following palatoplasty. An unusual cause of upper airway obstruction. Anaesthesia. 1995;50(1):30‐34. doi:https://doi.org/10.1111/j.1365-2044.1995.tb04509.x.
32.
SherifRDSanati-MehrizyPTaubPJ. Lingual pressure during dingman-assisted cleft palate repair: an investigatory case series. Cleft Palate Craniofac J. 2018;55(2):312‐315. doi:https://doi.org/10.1177/1055665617739313.
KoruyucuMKasimoğluYSeymenF, et al.Rethinking isolated cleft lip and palate as a syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018;125(4):307‐312. doi:https://doi.org/10.1016/j.oooo.2018.01.007.
35.
LeeJTKingstonHG.Airway obstruction due to massive lingual oedema following cleft palate surgery. Can Anaesth Soc J. 1985;32(3Pt 1):265‐267. doi:https://doi.org/10.1007/bf03015140
36.
ZimmermannJStubbsDJRichardsAJ, et al.Stickler syndrome: airway complications in a case series of 502 patients. Anesth Analg. 2021;132(1):202‐209. doi:https://doi.org/10.1213/ane.0000000000004582.
37.
SchoenbrunnerARDalle OreCLLanceSMcIntyreJJonesMGosmanA.Effect of surgeon volume and craniofacial fellowship training on cleft palate complication rates. Ann Plast Surg. 2017;78(5Suppl 4):S229‐s232. doi:https://doi.org/10.1097/sap.0000000000001046
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
