Faculty Bibliography

Movement disorder emergencies of the aerodigestive tract are dramatic and often life threatening. With appropriate timely evaluation and intervention, most patients can be effectively managed and major morbidity avoided. This chapter provides a comprehensive review of both the causes and appropriate treatment of breathing disturbances secondary to primary disorders and iatrogenic causes, as well as swallowing emergencies. Additionally, basic physiology, anatomy, and various methods for assessment of the upper aerodigestive tract are reviewed. Specific disorders that are addressed include the following: spasmodic dysphonia, adductor laryngeal breathing dystonia, Shy-Drager abductor weakness, drug-induced tardive dystonia, oromandibulolingual dystonia, multiple system atrophy, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson's disease, Huntington's disease, and palatal myoclonus.
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The identification of ancient worked materials is one of the fundamental goals of lithic use wear analysis and one of the most important parts of understanding how stone tools were used in the past. Given the documented overlaps in wear patterns generated by different materials, it is imperative to understand how individual materials' mechanical properties might influence wear formation. Because isolating physical parameters and measuring their change is necessary for such an endeavor, controlled (rather than replicative) experiments combined with objective measurements of surface topography are necessary to better grasp how surface modifications formed on stone tools. Therefore, we used a tribometer to wear natural flint surfaces against five materials (bone, antler, beech wood, spruce wood, and ivory) under the same force, and speed, over one, three, and five hours. The study aimed to test if there is a correlation between surface modifications and the hardness of the worked material. We measured each raw material's hardness using a nano-indentation test, and we compared the surface texture of the flint bits using a 3D optical profilometer. The interfacial detritus powder was analyzed with a scanning electron microscope to look for abraded flint particles. We demonstrate that, contrary to expectation, softer materials, such as wood, create a smoother surface than hard ones, such as ivory.

In New York City, the population of Chinese Americans has grown faster than that of any other minority racial/ethnic group, and now this community constitutes almost half of all Chinese Americans living in the northeastern United States. Nonetheless, scant research attention has been given to Chinese American ethnic enclaves and little is known about the health status of their residents. This study aims to help address this gap in the literature by: (1) improving our understanding of the spatial settlement of Chinese Americans living in New York City from 2000 to 2016; and (2) assessing associations between a New York City resident's likelihood of living in a Chinese American enclave and their access to health care and perceived health status, two measures of community health. In support of this aim, this study establishes a robust criterion for defining ethnic enclaves at the Census tract level in New York City as the communities of interest in this paper. An ethnic enclave is defined as an area at the Census tract level with high dissimilarity and a spatial cluster of Chinese Americans. The spatial findings were that Chinese Americans in New York City were least segregated from other Asian American residents, somewhat segregated from White residents, and most segregated from Black residents. Also, the population density of Chinese Americans increased since 2000, as reflected by their declining exposure index with other Asian Americans. Results from logistic regression indicated that the probability of living in a Chinese American enclave was negatively associated with positive self-perception of general health and positively associated with delays in receiving health care. For Chinese American residents of New York City, living in an ethnic enclave was also associated with both lower socioeconomic status and poorer community health.

Background/Purpose: Nasoalveolar molding (NAM) in combination with primary gingivoperiosteoplasty (GPP) may obviate the need for a secondary alveolar bone graft. While the long-term facial growth following GPP has been well documented, no study has evaluated the transverse growth of the cleft-maxilla following NAM and GPP. Here we report the effects of NAM and GPP on the maxillary transverse dimension in patients with complete unilateral cleft lip and palate (UCLP). Methods/Description: A retrospective single-institution review of nonsyndromic patients with complete unilateral cleft lip and palate born between 2005 and 2010 was completed. Patients were divided into four groups based on their interventions: 1) NAM-GPP with adequate bone formation 2) NAM-GPP without adequate bone formation (requiring ABG) 3) NAM-no GPP (requiring ABG), and 4) No NAM-no GPP control (patients who received primary surgeries outside of our institution). Cone-beam computed tomographic scans (CBCTs) taken at the early-mixed dentition stage, prior to orthodontic intervention, were used to assess the anterior and posterior maxillary transverse dimensions. The transverse discrepancy at the affected and non-affected sides was measured at the level of the primary canines (anterior dimension) and the permanent first molars (posterior dimension) to the maxillary midline. Wilcoxon signed-rank tests were used to compare the transverse dimension of the affected versus non-affected sides within each group. Mann-Whitney U tests were used to compare each NAM group with the no NAM-no GPP control group.
Result(s): A total of 85 patients were included in this study (mean age = 8.7). Male patients (50.6%) and the left side (64.7%) were most affected. Of the 85 patients, 26 (30.6%) underwent NAM-GPP with adequate bone formation, 22 (25.9%) underwent NAM-GPP but required ABG, 16 (18.8%) underwent NAM without GPP, and 21 (24.7%) underwent no NAM-no GPP. Median values were significantly different in the anterior maxilla between the affected and nonaffected sides across all four groups (p = 0.001). The transverse dimension at the affected side also revealed a significant difference in both the NAM-GPP (with adequate bone formation) and the NAM-GPP (requiring ABG) groups compared to the no NAM-no GPP group (p= 0.022 and p= 0.001, respectively). There was no significant difference between the NAM-no GPP group compared to the control (p = 0.059). Distances to the molars of the affected and nonaffected sides were not statistically significant within or across any of the groups (p > 0.05).
Conclusion(s): In patients with UCLP, the maxillary primary canine transverse dimension on the affected side is significantly reduced in patients undergoing NAM and GPP compared to the control. However, the position of the maxillary first molars appear to be unaffected by NAM and GPP

Background/Purpose: Gingivoperiosteoplasty (GPP) is a procedure performed at the time of primary cleft lip or palate repair in which the alveolus is repaired without the need for bone graft. Although the success of GPP is reported up to 70%, the associated disparities with regards to access or receipt of GPP has not been studied. This study reports on patient access to GPP reconstruction. Methods/Description: The American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS NSQIP Peds) was queried from 2014 to 2019. Patients were selected using the Current Procedural Terminology (CPT) codes (Table 1). Patient race, gender, age at time of surgery, 30 day readmission, comorbidities and complications were recorded. Postoperative complications included surgical site infections (SSI), dehiscence and transfusion. Receipt of GPP was analyzed using binary logistic regression to control for variables that could potentially affect access to/ receipt of GPP. For multivariable analysis, Bonferroni correction was used.
Result(s): 23408 patients with a cleft were included in our analysis. 12590 were White, 1732 were Black/African American, 3914 were Hispanic, 2267 were Asian/other Pacific Islander, and 2905 did not have a reported Race. Amongst this cohort, 709 patients underwent GPP (2.25%). Patients who did not report/of unknown Race were less likely to undergo GPP (p = 0.001), while there was no statistically significant difference amongst access to GPP for Black/African American, Hispanic, or Asian/ other Pacific Islander patients. The average age of all patients was 2411 days. White patients had primary cleft repair at a younger age (p = 0.000) than non-White patients. There was no difference in gender or co-morbidities (cardiac risk factors and congenital/chronic lung disease, respectively) amongst all Races (p = 0.291, p = 0.276, p = 0.547). There was no statistically significant difference in unplanned 30-day readmission and 30-day postoperative complication (p = 0.326, 0.934, respectively). Patients with ASA class 3 or 4 and minor or major cardiac risk factors had a statistically significant higher chance of 30-day readmission (p = 0.000, 0.000, 0.000, 0.001, respectively).
Conclusion(s): Amongst reported Races there was no statistically significant difference with regards to access/receipt of GPP, but patients without a reported Race were less likely to undergo GPP. Undergoing GPP did not appear to increase the likelihood of 30-day readmission or postoperative complication. We did find that White patients received cleft lip/palate repair at a statistically significant younger age and Hispanic patients at a later age, which is similar to previous studies. Although there was no difference in access to GPP amongst Races, further studies to evaluate disparities in outcomes for children undergoing GPP needs to be elucidated

Background/Purpose: Craniofacial microsomia (CFM) is the second most common congenital facial anomaly, yet its genetic etiology remains unknown. Methods/Description: We perform whole-exome or genome sequencing of 146 kindreds with sporadic (n=138) or familial (n=8) CFM.
Result(s): We identify a highly significant burden of loss of function variants in SF3B2 (P=3.8 x 10-10), a component of the U2 small nuclear ribonucleoprotein complex, in probands. We describe twenty individuals from seven kindreds harboring de novo or transmitted haploinsufficient variants in SF3B2. Probands display mandibular hypoplasia, microtia, facial and preauricular tags, epibulbar dermoids, lateral oral clefts in addition to skeletal and cardiac abnormalities. Targeted morpholino knockdown of SF3B2 in Xenopus results in disruption of cranial neural crest precursor formation and subsequent craniofacial cartilage defects, supporting a link between spliceosome mutations and impaired neural crest development in congenital craniofacial disease.
Conclusion(s): The results establish haploinsufficient variants in SF3B2 as the most prevalent genetic cause of CFM, explaining ~3% of sporadic and ~25% of familial cases

Background/Purpose: Traditional palatoplasty techniques rely on repositioning of soft palate muscle and mucosa to restore velopharyngeal closure. In the case of the wide cleft palate (10 mm or greater), we hypothesize that soft palate nasal mucosa closure can result in vertical shortening of the palate. Furthermore, horizontal release of the reconstructed soft palate nasal mucosa from the hard palate will result in significant lengthening of the soft palate, identifying a potential loss of domain of palatal length in patients with a wide cleft palate. This study characterizes this potential loss of vertical length of the nasal soft palate mucosa in patients with a wide cleft. Methods/Description: A retrospective review of all patients who underwent a primary cleft palate repair with a buccal flap prior to 18 months of age by a single plastic surgeon over a 2-year period. Inclusion criteria was defined as patients with cleft palate at least 10 mm in length at the area of the posterior nasal spine. All patients who met inclusion criteria underwent primary cleft palate repair with horizontal transection of the nasal mucosa during palatoplasty. This transection was performed after nasal mucosa repair, but prior to muscular reconstruction. The resulting mucosal defect was measured and reconstructed with a buccal flap. Patient demographics, intra-operative palatal measurements, and post-operative outcomes were analyzed.
Result(s): Twenty-two patients met inclusion criteria. Mean age at surgery was 10.68+/-1.04 months, mean gestational age at birth was 38.14+/-1.75 weeks, and mean weight at surgery was 8.75+/-1.22 kg. Three (13.6%) had a history of Pierre Robin sequence and 5 (22.7%) had an associated syndrome. Notably, 13 (59.1%) had a history of nasoalveolar molding, and 15 (68.2%) had previously had a cleft lip repair. No patients had a Veau I cleft, 7 (31.8%) had a Veau II, 12 (54.5%) had a Veau III, and 3 (13.6%) had a Veau IV cleft. Regarding palate repair techniques employed, 12 (54.5%) had a Bardach, 7 (31.8%) had a Von Langenbeck, 3 (13.6%) had an Oxford, and all had a concomitant radical intravelar veloplasty. All 22 (100%) patients had a right buccal flap during primary palatoplasty. The mean cleft width or horizontal separation of the palate at the posterior nasal spine was 10.6+/-2.82 mm, and the mean lengthening of the palate was measured as 10.5+/-2.23 mm. For complications, there were 2 (9.1%) fistulas, 1 (4.5%) wound dehiscence, 1 (4.5%) 30-day readmission (for RSV bronchiolitis), and no bleeding complications.
Conclusion(s): Patients with a wide cleft palate have a potential loss of vertical length of approximately 1 cm. Considering that patients with a wide palatal cleft are predisposed to developing VPI, these data provide supportive evidence that acute palatal lengthening during palatoplasty should be considered for this patient population. The buccal flap can mitigate the loss of domain in palatal length, and potentially improve palatal excursion

Background/Purpose: After LeFort I advancement surgery, soft tissue changes are unpredictable, especially in patients with orofacial clefts, as scar tissue from primary repair can alter soft tissue responses. Therefore, this study aimed to measure and evaluate soft tissue response following LeFort I advancement in skeletally matured patients with complete cleft lip and palate (CLP). Methods/Description: The cohort of 26 patients with non-syndromic CLP who underwent Le Fort I osteotomy between 2013 and 2019 and met the inclusion criteria. Patients were included if they had lateral cephalograms or CBCT at pre-operative (T1), immediately post-operative (T2), and one-year follow-up (T3). Patients who underwent nose/lip revision surgery before T3 were excluded. Four skeletal and dental hard-tissue (ANS, point A; A-point, upper incisor most labial; U1-most, upper incisor edge; U1-tip) and 5 softtissue (tip of nose or pronasale; Prn, subnasale; Sn, superior labial sulcus; SLS, upper lip anterior or labrale superius; LS, and stomion superius; SIMS) landmarks were digitized and measured. For the outcome analyses, 5 ratios of soft- to hard-tissue changes (Prn/ANS, Sn/A-point, SLS/A-point, LS/U1-most, and SIMS/ U1-tip) were calculated for each group, and associations between hard-and-soft tissue counterparts were assessed using Pearson correlation coefficient (r).
Result(s): Sixteen patients had UCLP, and 10 patients had BCLP. At one-year follow-up (T1-T3), the mean advancement in UCLP and BCLP groups at ANS were 4.4+/-3 and 4.7+/-3.9 mm, from point A were 6.6+/-2.5, 8.8+/- 2.6 mm, respectively. The mean horizontal changes of the corresponding soft tissue anatomy, Prn, were 2.7 +/-1.7, 4.6+/-3.5 mm, from Sn, were 3.9+/-1.9, 6.2+/-2.4. mm, and from SLS were 5.2+/-2.5, 7.4+/-2.8 mm. The mean advancement in at upper incisor most labial were 7.2+/-2.7 and 8.4+/-2.4 mm, and from the upper incisal edge were 7.5+/-2.9 and 8.4+/-2.7. mm. The mean horizontal changes of the soft tissue counterpart, LS, were 5.6+/-2.9, 7.9+/- 3.7 mm, and SIMS were 6.0+/-3.2, 7.3+/- 2.7 mm. All skeletal, dental, and soft tissue advancements from T1-T3 were significant (P< 0.01) except for Sn and LS in both groups and SIMS in UCLP group. For ratio and correlation analyses in UCLP and BCLP groups, Prn/AND were 0.48 (r=0.40) and (r=0.00), Sn/A-point were 0.58 (r=0.79) and 0.70 (r=0.77), SLS/A-point were 0.79 (r=0.82) and 0.85 (r=0.80), LS/U1-most were 0.74 (r=0.92) and 0.96 (r=0.74), and SIMS/U1-tip were 0.78 (r=0.75) and 0.82(r=0.67), respectively. All associations except for Prn/ANS were statistically significant (P< 0.01).
Conclusion(s): This study demonstrated a linear relationship between soft- and hard-tissue changes in the maxillary landmarks following LeFort I advancement in patients with complete cleft lip and palate (UCLP and BCLP)

Background/Purpose: Primary cheiloplasty for infants born with cleft lip and palate has long been preceded and facilitated by oral appliances intended to aid in feeding, narrow the cleft width, or mold the surrounding cartilages. Presurgical infant orthopedic (PSIO) therapy has evolved in both its popularity and focus of treatment since its advent. Nasoalveolar molding (NAM), nasal elevators, the Latham appliance, lip taping, and passive plates are the modern treatment options offered by cleft teams, and each varies in their associated protocols and treatment philosophies. The purpose of this study is to examine trends in the currently available modalities of PSIO care and PSNS for the management of patients with cleft lip and palate. Methods/Description: Methods: An electronic survey comprised of eight questions was distributed to the one hundred and sixty-seven cleft team coordinators listed by the American Cleft Palate Association. The survey reported on team setting, provider availability, PSIO treatment offerings, relative contraindications, and use of postsurgical nasal stenting. Descriptive statistics and analyses were performed using MS Excel (Microsoft, Redmond, WA) and SPSS (IBM, Chicago, IL).
Result(s): One hundred and two survey responses were received from the total one hundred, and sixty-seven sent, resulting in a response rate of 61%. The majority of settings were children's specialty hospitals (66%) or university hospitals (27%). PSIO was offered by 86% of cleft teams, and the majority of those (68%) provided NAM. Nasal elevators and lip taping are offered at 44% and 53% of centers, respectively. Latham and passive plates are both offered at 5.5% of centers. Teams with a dental specialist as the PSIO provider offered NAM significantly more than centers with surgeons as the provider of PSIO. Most centers (45%) had an orthodontist providing treatment. Patients are considered contraindicated for treatment at many centers for reasons such as mild cleft severity (46%), medically-compromised (42%), advanced age at first visit (29%), far commute (35%), and/or financial reasons (16%). The majority of centers use postsurgical nasal stenting (86%), and almost all insert the device immediately in the operating room (88%).
Conclusion(s): NAM is the most popular PSIO technique in North American cleft centers followed by the nasal elevator, suggesting that the nasal molding component of PSIO of critical influence on current treatment practices. With 86% of centers providing PSIO, access to care is improving with an increasing variety of treatment modalities. Postsurgical nasal stenting is also gaining popularity. The use of various PSIO techniques is ubiquitous, but the emphasis on nasal molding may continue to be the driving force for treatment in the future