Faculty Bibliography

Background & Purpose: We have produced a freely available, web-based, multimedia surgical simulator in partnership with Smile Train which demonstrates the cardinal procedures in primary cleft surgery. This tool is intended to help surgeons in developing countries care for their local cleft populations. Limitations of Internet access and local technology may hinder use in the developing world. We report on the international utilization of the world's first internet-based cleft simulator. Methods & Description: The Smile Train Virtual Surgery Simulator contains an internal tracking system which records the unique Internet Protocol (IP) addresses all users. Using these IP addresses, each country accessing the Simulator was identified over a one year period. All users accessing the Simulator for less than 5 minutes were eliminated. The countries were analyzed based upon economic factors such as Gross Domestic Product (GDP) and per capita income (PCI) as well as health metrics such as health expenditures and underweight children. Results: There were 849 novel users of the Simulator from 78 countries were recorded over the one-year study period. Those countries represent 6.28 billion persons or 88.5% of the global population. Of the countries utilizing the simulator 54 were classified as developing economies, representing 5.3 billion people. The developing countries average GDP was $467.4 +/- 147 billion and PCI was $8,281 +/- 815. The poorest developing countries accessing the Simulator in terms of PCI were Congo ($400), Ethiopia ($1,200), and Nepal ($1,300). In terms of percent population living below the poverty line, the poorest countries accessing the simulator were Haiti (80%) Congo (71%) and Nigeria (70%). In developing countries, the health expenditures as a percentage of GDP averaged 6.1%. The nations with the lowest healthcare expenditures as a percentage of GDP were Myanmar 2%, Pakistan 2.2%, and Indonesia 2.6%. Penetration into advanced economies was also extensive including 24 countries representing 979 million people and an aggregate GDP of $40.98 Trillion. In the United States the simulator was used in 40 states from both academic and community Internet service providers. Surprisingly, the simulator was used in 21 countries with active armed conflicts and 28 where the US State Department advises against travel including Ukraine, Egypt, Yemen, Iraq and Nigeria. Conclusions: The presented internet-based surgical simulator is accessible globally and has quickly gained use in 78 countries representing 88% of the global population including 5.3 billion of the worlds developing population. Over 2/3rds of the countries accessing the simulator are developing nations and include regions experiencing severe poverty. Projects directed towards international education of cleft care in the developing world should strongly consider the use of web-based digital technology as a means to immediately access and educate caregivers, particularly in countries with significant economic and political constraints. Disclosure: Receipt of Intellectual Property Rights/Patent Holder-Aaron Oilker holds the intellectual property rights for the biodigital surgery simulator

INTRODUCTION: Protocols for the treatment of Robin sequence (RS) consider the presence of laryngomalacia as a contraindication to mandibular distraction osteogenesis (MDO). The authors report their institutional experience of MDO applied to infants with RS and associated laryngomalacia. METHODS: An 8-year (2005-2013) retrospective review of all infants with RS and laryngomalacia who underwent MDO at a tertiary care children's hospital was performed. Patients were excluded if they possessed an airway anomaly other than laryngomalacia. Laryngomalacia was identified on laryngoscopy before MDO. Laser supraglottoplasty was performed at the discretion of the otolaryngologist. Recorded variables included preoperative and postoperative AHI, syndromic diagnosis or genetic anomalies, cardiac, central nervous system (CNS), and gastrointestinal (GI) abnormalities. The primary outcomes measured were avoidance or decannulation of tracheostomy and decrease in postoperative AHI. RESULTS: Eleven infants met inclusion criteria. Mean follow-up was 28 months. 18.2% of patients had a syndromic diagnosis, 36.4% cardiac, 9.1% CNS, and 72.7% GI abnormalities. Mean preoperative AHI was 46.1 +/- 31.8 and mean postoperative AHI was 4.1 +/- 3.0 (P = 0.002). All patients without a tracheostomy before intervention avoided tracheostomy after MDO. One patient had a tracheostomy before MDO and was subsequently decannulated. One patient died 1 year after MDO due to complex congenital heart disease. CONCLUSIONS: Infants with RS and laryngomalacia can be successfully treated with MDO to relieve upper airway obstruction. Close cooperation with a pediatric otolaryngologist and treatment of laryngomalacia can significantly enhance tracheostomy avoidance in infants with Robin sequence.

BACKGROUND: Prior studies report a high incidence of airway complications in patients with Robin sequence following palatoplasty. The authors' institution uses polysomnography to assess risk of airway compromise before palatoplasty in Robin sequence. This study compares airway complications in Robin sequence to cleft palate only using this screening airway protocol and identifies risk factors for airway complications after palatoplasty. METHODS: A 12-year retrospective review of patients with Robin sequence undergoing palatoplasty was performed. Robin sequence patients were divided into nonoperative management and mandibular distraction osteogenesis subgroups. Preoperative variables including comorbidities were recorded. The primary outcome was postoperative airway complication, defined as reintubation, emergency room visit, or hospital admission within 3 months of palatoplasty. RESULTS: One hundred thirteen patients met inclusion criteria: polysomnography, 34.5 percent; Robin sequence, 65.5 percent; and Robin sequence treated with mandibular distraction osteogenesis, 30.1 percent. Screening polysomnography was used to indicate patients for palatoplasty or other airway interventions. The total airway complication rate was 7.1 percent; this was similar in Robin sequence (5.8 percent) and cleft palate only (7.7 percent). In isolated Robin sequence, the reintubation rate was 0 percent. Lower airway anomalies were associated with airway complications (p = 0.03). Significant variables for reintubation were cardiac (p = 0.046), gastrointestinal (p = 0.04), and lower airway anomalies (p = 0.025) and syndromic diagnosis (p = 0.05). CONCLUSION: Screening polysomnography can control airway complications following palatoplasty in Robin sequence patients to a rate that is comparable to that of patients with cleft palate only.

Mandibular distraction has revolutionized the treatment of Robin sequence associated with severe airway obstruction. The distraction technique remains the only intervention that directly corrects mandibular hypoplasia and the retropositioned tongue, providing efficient relief of airway stenosis. Multiple studies have demonstrated the efficacy of distraction in avoiding tracheostomy and decreasing the severity airway obstruction in this patient population. The benefit to avoiding tracheostomy and relieving airway obstruction is superior to that of tongue-lip adhesion. It is, therefore, not surprising that mandibular distraction has become the first-line intervention at many centers for the surgical treatment of Robin sequence. The complication profile associated with mandibular distraction appears low; the most common complication is infection, which can be treated by antibiotics alone. The severity of airway obstruction can be quantified by polysomnogram: This tool has become one of the most widely used objective metrics in the Robin sequence population. Therefore indications for surgery, timing of palatoplasty and long-term assessment of airway function should be performed in conjunction with sleep study analysis. The effects of mandibular lengthening on feeding difficulty in Robin sequence patient remains a topic of controversy. Studies have demonstrated conflicting results: This can be an area of future study. Agreed-upon indications for surgery and definitive protocols of care have yet to be formulized; future research should focus on achieving these goals. Such studies would require agreed-upon terminology for Robin sequence, an increase in comparative and prospective analysis, and the use of quantifiable metrics of clinical results.

Cleft lip and palate (CLP) affects the dentoalveolar and nasolabial facial regions. Internal and external nasal dysmorphology may persist in individuals born with CLP despite surgical interventions. 7-18 year old individuals born with unilateral and bilateral CLP (n = 50) were retrospectively assessed using cone beam computed tomography. Anterior, middle, and posterior nasal airway volumes were measured on each facial side. Septal deviation was measured at the anterior and posterior nasal spine, and the midpoint between these two locations. Data were evaluated using principal components analysis (PCA), multivariate analysis of variance (MANOVA), and post-hoc ANOVA tests. PCA results show partial separation in high dimensional space along PC1 (48.5% variance) based on age groups and partial separation along PC2 (29.8% variance) based on CLP type and septal deviation patterns. MANOVA results indicate that age (P = 0.007) and CLP type (P