KEY WORDS
Cleft lip and palate - cleft management - cleft survey - Egypt - multidisciplinary
cleft clinic
INTRODUCTION
Cleft lip and/or palate (CLP) is the most common congenital anomaly in the head-and-neck
region.[[1]] The complex care of cleft patients requires a team work of different specialties
including nursing services, plastic surgery, speech pathology, orthodontics, audiology,
paediatrics, anaesthesiology, dentistry, otolaryngology, psychology and genetics.[[2]] Evaluation of treatment results of cleft patients must consider the effects on
growth, the function, the appearance and the psychological outcome.[[3]]
There is currently a large variation between different institutes and centres worldwide
in the protocol of cleft management. The timing of surgery and the surgical techniques
used for cleft repair are quite different.[[3]] For instance, in a survey including the European cleft centres (2001), 194 different
surgical protocols were reported to be used for primary repair of unilateral complete
cleft lip.[[4]] However, little is known about the practice of cleft care in many African and Middle
Eastern countries including Egypt. To our knowledge, there is no previous survey undertaken
in Egypt to explore and assess the current management of cleft lip and palate.
The purpose of this survey is to investigate the current cleft practice in Egypt.
This includes the management protocols, the timing of surgery, the different surgical
techniques and sutures used in cleft lip and palate repair. Furthermore, the caseload
and the presence of multidisciplinary approach were investigated.
MATERIALS AND METHODS
In March 2016, 100 questionnaires were distributed to the surgeons attending the winter
annual meeting of the Egyptian Society of Plastic and Reconstructive Surgeons. They
represent university hospitals, the major ministry of health hospitals and military
hospitals.
The questionnaire was concerned with data regarding the management protocol (surgical
timing, surgical techniques and sutures) used, the caseload of patients per year and
the clinical specialties involved in cleft treatment.
RESULTS
Seventy-two questionnaires were returned: 62 from colleagues working in university
hospitals, 7 from colleagues working in major hospitals affiliated to the ministry
of health and the other 3 responses from colleagues working in a major military hospital.
Out of the 72 responding surgeons, 67 were plastic surgeons, 3 were maxillofacial
surgeons and 2 were paediatric surgeons.
Surgical timing
Unilateral cleft lip is repaired by the majority (75%) of participants by the age
of 3 months, while 12.5% perform the repair earlier in the 1st and 2nd months of life and another 12.5% perform it after 3 and up to 6 months (>3–6 m).
Likewise, the majority of surgeons (77.8%) repair bilateral cleft lip at the age of
3 months although 5.6% do it in the first 2 months of life and the remaining 16.7%
do it after 3–6 months. In bilateral cleft lip, 50% of surgeons repair both sides
in one stage and the other 50% perform the repair in two stages.
Regarding cleft palate, 50% of surgeons do the repair at approximately 9 months of
age and the other 50% repair it at the age of 12 months. The majority (83.3%) of surgeons
repair the soft and hard palate in the same procedure while 16.7% of them repair it
in two stages: 11.1% perform the soft palate first and 5.6% perform the hard palate
first. The second stage of repair is performed after 6–12 months.
Surgical techniques
The most common technique of unilateral cleft lip repair is the rotation-advancement
technique of Millard or its modifications, used by 75% of participants, while 19.4%
use Tennison technique and the remaining 5.6% use other techniques including the straight
line one. As regards bilateral cleft lip repair, 68% of surgeons use Millard technique
while 32% prefer Mulliken technique. Most of the participants (80.5%) stick to one
technique while 19.4% of them use more than one technique according to the given situation.
Lip adhesion procedure is rarely practiced, being routinely performed by only 12.5%
of surgeons, while 36.1% of participants have done it sometimes and the majority (51.4%)
have not done it at all.
Two-thirds of participants (66.7%) perform primary nasal correction at time of cleft
lip repair; the majority of them (56.3%) use closed alar dissection and fixation technique,
33.3% use bolstered sutures and 10.4% use open rhinoplasty technique.
The most popular techniques used to repair cleft palate are the two-flap push-back
technique, performed by 45.8% of the participants, and the Bardach technique, used
by 29.2%, followed by the Furlow's double opposing Z-plasty technique, performed by
15.3%, and the von Langenbeck technique, used by 9.7% of the participants. Half of
the responding surgeons use only one technique for repair of all cleft palate patients,
whereas 19.4% use two different techniques and 30.6% use more than two techniques
for cleft palate repair.
Regarding alveolar bone graft, only 18.1% of the responding surgeons perform it as
a routine procedure in all alveolar cleft patients, 70.8% of participants have used
it sometimes, while 11.1% have never used it. Alveolar bone graft is usually performed
between the ages of 7 and 9 years. Primary gingivoperiosteoplasty at time of cleft
lip repair is practiced by 58.3% of participants while 41.7 of them have never performed
it.
Suture materials
Polypropylene suture is used by 67% of participant surgeons to repair the skin in
cleft lip patients while 16.5% of them prefer polyglactin 910 sutures and the other
16.5% prefer polyglactin 910 rapide. Regarding the size, 6/0 sutures are used for
lip skin by 61.1% of surgeons, 5/0 sutures are used by 29.2% and the remaining 9.7%
use 4/0 sutures. Muscle repair is performed using polyglactin 910 by 67% of the participant
surgeons while the other 33% use polydioxanone sutures. As regards the suture size,
72.2% of the participants use 4/0 sutures while 27.8% prefer 5/0 sutures. In cleft
palate repair, 68.1% of surgeons use polyglactin 910 while 25% prefer polydioxanone
and only 6.9% use silk sutures. Most surgeons (87.5%) use 4/0 sutures for the palate, but a small percentage (12.5%)
prefer 5/0 sutures.
Post-repair palatal fistula rate
The majority (45.8%) of the participant surgeons reported a fistula rate ranging from
10% to 20% of cases, while 37.5% reported a rate less than 10%. Higher fistula rates
up to 30% were reported by 8.3% of participants and another 8.3% of them reported
a fistula rate up to 40%.
Velopharyngeal incompetence
Most of the participant surgeons (87.5%) refer patients with velopharyngeal incompetence
(VPI) to speech pathologists and they stated that speech assessment is the principal
and only tool used to evaluate the velopharyngeal function is their centres. Methods
used for the management of VPI are summarised in [Table 1].
Table 1
Methods used to correct velopharyngeal incompetence
|
Surgical procedure for VPI
|
Percentage of participants using it
|
|
VPI: Velopharyngeal incompetence
|
|
Superiorly-based pharyngeal flap
|
25
|
|
Pharyngoplasty
|
25
|
|
Palatal re-repair with radical muscle dissection
|
20
|
|
Palatal re-repair without muscle dissection
|
10
|
|
Furlow's palatal lengthening
|
10
|
|
Buccinator flap
|
10
|
Cleft teams and multidisciplinary management
More than half of the participant surgeons do not have organised cooperation with
other specialties involved in the management of cleft, while 33% of them have scheduled
multidisciplinary meetings with other cleft-oriented medical specialties, namely speech
pathology, orthodontics, paediatrics, audiology, otolaryngology and dentistry. The
presence of a specialised cleft clinic with a team consisting of at least two medical
specialties beside the cleft surgeons was reported by only 11.1% of participants.
Caseload per year
Out of 20 centres contributed in the questionnaire, we could only collect the data
regarding caseload per year for 12 centres because some participants did not answer
that part of the questionnaire. The caseload per centre per year ranged from 29 to
384 cases [[Table 2]]. The total number of patients operated in all cleft centres across the country
was 921 primary surgeries per year with total of 1634 per year including primary and
secondary cases.
Table 2
The average caseload of various cleft problems per centre per year
|
Surgical Procedures
|
Centre 1
|
Centre 2
|
Centre 3
|
Centre 4
|
Centre 5
|
Centre 6
|
Centre 7
|
Centre 8
|
Centre 9
|
Centre 10
|
Centre 11
|
Centre 12
|
Total
|
|
VPI: Velopharyngeal incompetence
|
|
Primary cases
|
48
|
120
|
24
|
48
|
24
|
24
|
150
|
75
|
12
|
240
|
144
|
12
|
921
|
|
Secondary lip
|
24
|
24
|
12
|
24
|
36
|
24
|
20
|
15
|
|
60
|
10
|
4
|
253
|
|
Palate fistula
|
12
|
12
|
0
|
12
|
12
|
24
|
|
20
|
12
|
12
|
10
|
2
|
128
|
|
VPI
|
4
|
12
|
0
|
6
|
6
|
12
|
10
|
20
|
12
|
12
|
10
|
2
|
106
|
|
Rhinoplasty
|
1
|
36
|
10
|
4
|
24
|
12
|
|
9
|
|
36
|
|
5
|
137
|
|
Alveolar bone graft
|
3
|
0
|
0
|
0
|
6
|
12
|
|
6
|
12
|
12
|
6
|
4
|
61
|
|
Orthodontics
|
9
|
0
|
0
|
0
|
0
|
0
|
|
1
|
|
12
|
6
|
|
28
|
|
Total
|
101
|
204
|
46
|
94
|
108
|
108
|
180
|
146
|
48
|
384
|
186
|
29
|
1634
|
DISCUSSION
This survey tried to find the different adopted protocols for the management of cleft
lip and palate patients in Egypt. The survey included surgeons representing various
healthcare providers in Egypt. The majority of participants were affiliated to the
university hospitals in Egypt. These university hospitals carry out a major portion
of the healthcare burden, especially in higher specialised disciplines as plastic
surgery which is rarely available in the hospitals of the ministry of health. Thus,
the results of the survey can be considered to be representative of the actual current
situation of cleft care in the country.
In the current study, all participant surgeons perform the repair of cleft lip under
the age of 6 months. The Millard technique is the method of choice in both unilateral
and bilateral cleft lip. This is consistent with the findings of Sitzman et al. concluding that Millard technique and its modifications represent the preferred
method by 84% of surgeons in the United States and Canada for unilateral cleft lip
repair.[[5]] In the repair of bilateral cleft lip, our results are similar to what was reported
by Tan et al. in their survey of surgical management of bilateral cleft lip in North America who
have found that Millard technique is the most common method (38%), followed by Mulliken
(26%) and Manchester (12%).[[6]] Regarding to staging of the bilateral cleft repair, our report showed that half
of the participant surgeons perform one-stage repair of bilateral cleft lip, and this
was similar to the findings of the Eurocleft project published in 2001.[[4]]
Lip adhesion is not a common procedure in Egypt: only 12.5% of surgeons are practicing
it. It has been reported that 4% of surgeons in the United States and Canada routinely
perform lip adhesion in patients with unilateral complete cleft lip and 11% of them
use preliminary bilateral lip adhesion before formal repair of bilateral complete
cleft lip.[[5]
[6]]
The majority of Egyptian surgeons (66.7%) perform primary nasal correction with cleft
lip repair as opposed to 52% of the American and Canadian surgeons.[[5]
[6]]
In our study, we found that all surgeons perform palate repair between the ages of
9 and 12 months. This is slightly different from the cleft palate repair survey conducted
in the United States by Katzel et al. which showed that 85% of surgeons perform palate surgery when the patient is between
6 and 12 months of age.[[7]] In our study, the most frequent technique used by the participants to repair cleft
palate is the two-flap push-back technique, followed by the Bardach technique. This
is different from the above-mentioned American report, which reported the use of two-flap
technique with intravelar veloplasty as the most common method (45%) followed by Furlow's
double opposing Z-plasty (42%).[[7]] The same report showed that 96% of American surgeons perform a one-stage palate
repair, whereas our study shows a bit lower percentage 83.3%. Alveolar bone grafting
is not a frequently performed procedure in our country: only 18.1% of surgeons perform
it routinely for all alveolar cleft patients, while primary gingivoperiosteoplasty
at the time of cleft lip repair is found to be popular procedure done by 58.3% of
the participants. The few number of surgeons performing alveolar bone grafting is
indication the lack of long-term patients’ follow-up.
Evaluation of VPI in Egypt is mainly dependent on speech assessment alone, as nasoendoscopy
and fluoroscopy are not available in all centres. In contrast, a survey on the members
of the craniofacial society of Great Britain and Ireland in 2015 revealed that videofluoroscopy
and nasendoscopy were the most frequently used methods of assessing and diagnosing
VPI in cleft patients.[[8]] The current survey showed that the most commonly used techniques to correct VPI
in Egypt are superiorly based pharyngeal flap followed by palatal re-repair, pharyngoplasty
and Furlow's palatal lengthening, while palatal re-repair was the most frequently
utilised technique in Great Britain and Ireland, followed by Hynes pharyngoplasty
and Furlow's technique.[[8]]
Cleft patients need specialised multidisciplinary management from birth till maturity.[[3]] Multidisciplinary management is widely recognised as the preferred form of care
of cleft lip and palate.[[9]
[10]] The royal college of surgeons of England recommended that cleft patients should
have access to a comprehensive service including the full range of the concerned specialties.[[11]] However, the current survey indicates the paucity of multidisciplinary cleft teams
for delivery of care for cleft lip and palate patients in Egypt.
We found a wide variation in the caseloads per centre, but these differences can be
explained by the particular region in which the centre is situated and the population
density around each centre. Furthermore, the number of cleft surgeons and the availability
of facilities for cleft surgery in each given centre are critical determinants of
the number of patients served. Some centres have a limited number of cleft cases per
surgeon per year.
However, these numbers are mostly subjective estimates and not the exact caseload.
In most hospitals, there is no accurate registration system for the patients, and
even in the few centres that have such system, it is usually recently introduced and
enabled only for the recent admissions, but obtaining old data of patients’ admission
is still a difficult job.
There has been increasing evidence from multicentre studies that decentralised cleft
care may be associated with inferior outcomes, especially by low-volume operators.[[12]] This, in turn, results in greater suffering for patients and increases the healthcare
cost due to additional surgeries and hospital admissions.[[4]] Many reports support the move toward fewer, high-volume operators which could be
achieved by a higher degree of intra speciality referrals and it has been stated as
an aim of the British Association of Plastic Surgeons in 1994 that cleft surgery should
not be carried out by the occasional operator and that cleft teams should be centred
in larger units so that expertise can be concentrated from treating significant numbers
of patients.[[10]
[13]] However, our survey showed that the management of cleft patients in Egypt is provided
by large numbers of local hospitals and the majority of surgeons work in isolation.
Not surprisingly, we found that different surgeons in the same hospital often practice
different techniques.
In this study, all the responding surgeons use absorbable sutures to repair the muscles
of the lip: two-thirds of them use polyglactin 910 and the other one-third uses polydioxanone.
For the palatal muscle repair, 93.1% of participants use absorbable sutures while
6.9% of them use non-absorbable sutures. A little can be found in literature about
the effects of the suture material or size on the outcome of the repair results. However,
Sommerlad has stated that there is no difference between different types of sutures
used to repair palatal muscles and he stated ‘I have always used nylon because it
is monofilament, non-reactive and reliable and as long as they are cut short enough,
I have not had problems with them and if I did not use nylon or Polypropylene, I would
use Polydioxanone’ (personal communication, January 2017).
Post-repair palatal fistula is the most common early complication after palatal surgery
with a variable incidence reported by different studies. Cohen et al. stated that the incidence of oronasal fistulae varies from 4% to 35%.[[14]] A more recent study reported a fistula rate as high as 68%.[[15]] Our results are very similar to Cohen et al. as we found the fistula rate ranging from <10% up to 40%.
There are 15 university hospitals in Egypt which carries the major burden of care
for free medical service and much fewer hospitals affiliated to the Ministry of Health
and Army. This survey included at least 20 centres, which means that there was well
representation of the major governmental hospitals in Egypt. However, the total number
of the primary cases in the current survey was 921. In Egypt, the birth rate is approximately
30 births per 1000 population.[[16]] It is expected to have >3000 new cleft cases per year (considering the total population
is around 90,000,000 and the incidence of cleft is 1/750 live birth). This means that
big portion of cleft cases is treated in private sector in Egypt. Furthermore, only
24 cases of orthodontics were reported to be done, which is very few in relation the
surgeries performed. This could indicate that significant number of cleft cases is
not completing their orthodontic treatment or the orthodontic care of cleft patients
is mainly centred in the private sector.
Action is needed to be taken to improve the outcome in cleft surgery. Multidisciplinary
care should be encouraged by increasing the cooperation between different specialties,
giving more attention for subspeciality in cleft surgery and encouraging subspeciality
fellowship training. Development of a national cleft society can support these efforts
through organising instructional courses and training workshops for the young doctors
in different subspecialties of the cleft team.
CONCLUSION
This study gives important information about the current national status of the management
of cleft lip and palate in Egypt. The results show wide variation in many aspects
of cleft management. Even within the same hospital, there are often interpersonal
variations in the protocols and surgical techniques used. We recommend the establishment
of multidisciplinary cleft team and clinic in every major heath facility involved
in the management of cleft lip and palate patients. This team should include at least
a speech pathologist, an orthodontist, an audiologist and paediatrician, beside the
cleft surgeon. It is also recommended that regional cleft centres should be established
in Egypt for a more effective and comprehensive care of cleft lip and palate patients.
Financial support and sponsorship
Nil.
