Rutger. M. Schols

Treatment of cleft lip alveolus and/or palate includes surgical repair to treat communication-related outcomes such as velopharyngeal insufficiency and otological dysfunction. Robot-assisted surgery has recently evolved into a promising adjunct to conventional surgery, particularly for complex procedures such as transoral (reconstructive) surgery. This structured literature review aims to investigate whether robot-assisted transoral cleft palate repair enhances communication (i.e., speech and otological) outcomes compared to conventional manual cleft palate surgery. A literature search was performed using PubMed, Embase, the Cochrane Library and Google Scholar. Primary outcomes were the change in cleft speech characteristics and otological disease after robot-assisted cleft palate surgery versus manual cleft palate surgery. The available evidence on communication-related outcomes remains sparse. Six relevant articles were included. In only one study, transoral robotic cleft surgery (TORCS) significantly reduced otitis media with effusion (OME), need for ventilation tubes and hearing threshold within 2 years post-surgery. No postoperative speech or velopharyngeal outcomes were reported. In conclusion, transoral robotic cleft surgery (TORCS) appears safe and feasible for repair of a cleft palate. It provides superior intraoral view and improved surgeon ergonomics. Current drawbacks are the costs and the available tools, the extended surgical duration and the lack of haptic feedback, which limit the current clinical applicability of TORCS. Based on limited clinical evidence, TORCS may support faster recovery of Eustachian tube function and hearing, but no conclusions on speech outcomes can yet be drawn.

Objective: This retrospective study aimed to evaluate the different conservative (ie, speech therapy) and surgical treatment approaches of velopharyngeal insufficiency (VPI) associated speech pathology in patients with submucous cleft palate (SMCP), performed within a single tertiary cleft care centre. Patients, Participants: Thirty-three patients treated for SMCP between January 1999 and December 2023, registered in a database of the Maastricht University Medical Centre and MosaKids Children’s Hospital and a database of the Dutch Association for Cleft Palate and Craniofacial Anomalies (NVSCA), were included. Main Outcome Measures: The decrease in VPI-associated speech pathology after treatment was retrospectively scored using the Cleft Audit Protocol for Speech-Augmented (CAPS-A) in the Dutch language, based on the Dutch Cleft Speech Evaluation Test (DCSET). Results: A significant reduction of the sum scores of the CAPS-A Dutch was seen in surgery combined with speech therapy (95% CI: 1.46–4.19) and speech therapy after surgery (95% CI: 0.85–3.48). Speech therapy only lowered the sum scores, but did not show a significant effect (95% CI: −1.30 to 1.30). Both surgical and conservative treatment resulted in a reduction of VPI-associated speech pathology, but only surgery significantly reduced hypernasality ( P =0.005) and improved speech intelligibility ( P =0.005). Conclusion: This study confirms the need for a multimodal treatment approach for VPI in SMCP by combining surgical cleft palate repair with pre- and post-operative specialised cleft speech therapy for optimal speech outcomes.

Objective: To evaluate speech outcomes in children with cleft palate following single-stage closure of the soft and hard palate. Design: A retrospective cohort study. Setting: Tertiary cleft care center at Maastricht University Medical Center+ (MUMC+), the Netherlands. Patients, Participants: A total of 47 children with cleft palate or cleft lip and palate who underwent single-stage palatal closure between 2011 and 2018. Children with syndromes associated with significant cognitive or developmental impairment precluding valid speech assessment were excluded. Interventions: Primary palatal repair using two-flap palatoplasty, Furlow double-opposing Z-plasty, or von Langenbeck technique. Main Outcome Measure(s): Speech was assessed using the Dutch Cleft Speech Evaluation Test (DCSET) and the Dutch version of the Cleft Audit Protocol for Speech – Augmented (CAPS-A). Secondary outcomes included prevalence of otitis media with effusion (OME) and tympanostomy tube placement. Results: Speech intelligibility improved significantly at the final assessment (median score 2 to 1; P <0.001). No significant changes were found in voice, hypernasality, hyponasality, nasal emission, nasal turbulence, or grimace. CAPS-A analysis showed resolution of palatalisation errors, but increased dentalisation/interdentalisation, likely reflecting temporary compensatory articulation. OME was present in 90.7% of children, and 97.6% required at least one tympanostomy tube. Conclusion: Single-stage palatal closure leads to improved speech intelligibility with stable outcomes across other speech parameters. High prevalence of middle ear disease underscores the need for multidisciplinary follow-up.

Background: The field of speech and language pathology (SLP) expanded to a wide range of specialities, leading to a global trend to decrease the time spent on specific courses on children with cleft palate, with or without cleft lip (CP±L) in SLP education programmes. The lack of CP±L courses has resulted in a global shortage of well‐trained SLPs to deliver high‐quality services to this population. Therefore, alternative training formats are needed. Aim: This study aimed to assess the training needs of Flemish speech and language pathologists (SLPs) working with children with CP±L by examining: (1) their current employment situation, experience and perceived competence regarding CP±L; (2) their preferences for the content, sources and organisation of continuing education on CP±L and (3) potential incentives and barriers to attend continuing education on CP±L. Methods and Procedures: A self‐constructed online survey in Qualtrics ^XM , based on existing literature, was utilised. The study employed a descriptive, quantitative approach, supplemented with open‐ended questions to enrich and deepen the quantitative data. Outcomes and Results: The 158 respondents had a mean work experience of 10 years, a median of 7 years and a mode (most frequently occurring value) of 5 years. Of these 158 respondents, 132 (83.5%) were young SLPs with professional experience ranging from 0 to 15 years. Of these, 53.8% (85/158) had previously treated one or more children with CP±L, of whom 71 (83.5%) had a caseload of 0–3 children within the last 5 years. The mean caseload for the 85 SLPs with experience was 4.74 cases, with a median of one child and a mode of one. Of the 85 respondents with experience, 9.4% (8/85) felt highly competent in treating feeding problems, while 58.8% (50/85) felt highly capable in treating speech and language problems. However, 60% (95/158) of the SLPs would refer children with CP±L, especially when having feeding problems or severe speech and language problems, such as compensatory articulation disorders (CADs) or submucosal cleft, as they feel a lack of competence. Two‐thirds (63.6%, 96/151) of the respondents who answered this question expressed a desire for continuing education in the assessment and treatment of children with CP±L. Conclusions and Implications: Although many Flemish SLPs perceived themselves as highly competent in treating speech and language problems in children with CP±L, they reported a lack of competence in treating complex or severe cases. They expressed a strong demand for specific, highly practical continuing education on CP±L, taught by experts in the field and with personal guidance. Based on the existing literature, our experience with CP±L and the results of this survey, we developed a continuing education programme on CP±L as an alternative educational format, tailored to the needs of Flemish community SLPs. WHAT THIS PAPER ADDS: What is already known on the subject Treating children with CP±L is complex and requires high‐quality care from specialised SLPs with sufficient clinical experience. However, there is a global trend to reduce dedicated coursework on CP±L in SLP training programmes. Instead, the subject is often briefly covered in general courses or offered as an elective. As a result, there is a shortage of well‐trained SLPs, creating an urgent need for alternative training formats. What this paper adds to the existing knowledge This study reveals that Flemish Community SLPs feel insufficiently trained to assess and treat children with CP±L who exhibit complex or severe problems, such as feeding problems, compensatory articulation disorders (CAD), velopharyngeal insufficiency or submucosal cleft palate. They have a strong need for theoretical knowledge and practical continuing education, preferably provided by experts in CP±L. They want a 1‐day or multi‐day training course that utilises extensive video footage, personal coaching, opportunities to observe experts and even an internship. Additionally, they want an online platform to collect and disseminate all knowledge and expertise. What are the potential or actual clinical implications of this work? Given the global decline in specific CP±L courses in SLP programmes, SLPs feel inadequately prepared to assess and treat these children correctly. This increases the risk that no results will be achieved or that undesirable results will occur. To prevent this, alternative training formats are needed. Based on this needs analysis, a training programme was developed for community SLPs, tailored to their needs to enable them to provide high‐quality speech therapy services.

Objective: This explorative study aimed to investigate the potential association between preoperative ultrasound-guided suprazygomatic maxillary nerve block (SMNB) and reduced perioperative opioid consumption in pediatric patients undergoing primary cleft palate repair. The authors hypothesized that SMNB would decrease the need for opioid analgesics for perioperative pain management. Design: A retrospective cohort study. The control group underwent primary cleft palate repair without SMNB, while the intervention group received bilateral SMNB preoperatively. Setting: This study was conducted at the Department of Plastic Surgery, Maastricht University Medical Centre MosaKids Children’s Hospital, a tertiary care institution. Patients, Participants: Twenty pediatric patients (below 2 y) were included. Ten received SMNB, and 10 historical controls were selected from an existing database. Interventions: The SMNB group received bilateral ultrasound-guided 0.15 mL/kg of 0.25% bupivacaine with adrenaline (1:200,000) under general anesthesia. The control group did not receive a regional nerve block. Main Outcome Measure(s): The primary outcome was perioperative opioid consumption (tramadol and morphine). Secondary outcomes included additional analgesic use (paracetamol, NSAIDs) and length of hospital stay. Results: Morphine consumption was significantly lower in the SMNB group (median 0.00 mg versus 0.75 mg, P =0.02), while tramadol use showed no significant difference ( P =0.23). Secondary outcomes, including additional analgesic use and hospital stay, were not significantly different. Conclusion: Preoperative ultrasound-guided SMNB may be associated with reduced perioperative opioid consumption in pediatric primary cleft palate surgery. Larger, preferably randomized trials are needed to confirm its role in multimodal analgesia protocols.

Background: Osteoarthritis of the hand and wrist is common and can have a significant impact on quality of life. Since the carpus consists of multiple bony structures, osteoarthritis can exist in many forms. Arthroplasty using implants has become the standard treatment for many larger joints. In carpal arthroplasty, many implants exist. To determine the most suitable implant in each individual patient, knowledge of the possibilities is important. This article aims to provide an overview of the more commonly used implants in carpal arthroplasty. Methods: This narrative review describes all types of carpal implants, namely, total wrist implants, first carpometacarpal implants, the Amandys® implant, the Pyrocardan® disc, pyrocarbon capitate resurfacing implants, the adaptive proximal scaphoid implant, and total carpal replacement. A literature search was conducted separately for each implant. All studies investigating implant performance were included. Results: Naturally, each implant showed different results. Implant arthroplasty is most often compared to either arthrodesis or resection arthroplasties. For joint replacing implants like total wrist implants or first carpometacarpal implants, the use of joint replacing implants seems to be beneficial in certain populations. Joint resurfacing implants show similar functional results to the comparable non-implant options. However, research on these implants is less prevalent. Regarding all implants, complication rates seemed either similar to or in favor of non-implant options. Almost no studies found a lower complication rate for implant usage. Conclusions: Carpal implants are a valid option in carpal osteoarthritis. Implants seem to perform comparably to non-implant options. Careful patient selection is required, especially since implants may carry a higher risk of complications.

The expansion of (minimally invasive) surgical techniques has led to the development of advanced tools, including high-definition visual systems and fluorescence-guided surgery (FGS), enhancing surgeons' performance and patient safety. FGS employs near-infrared light and fluorophores like indocyanine green (ICG) for intraoperative imaging to improve anatomical navigation and decision-making. Recently, an increasing number of fluorescence imaging systems have shown capability in visualizing methylene blue (MB), which has an excitation peak at 700 nm, and its potential role in perfusion assessment. A recent study has highlighted MB's advantage over ICG due to its shorter washout time, enabling repeated intraoperative perfusion assessments using a dose of 0.5 mg/kg in a porcine model. This characteristic may be particularly beneficial in plastic and reconstructive surgery involving free (chimeric) flaps, pedicled skin flaps, pedicled intestinal transplants, and mastectomy skin flaps, where perfusion assessment can be critical at multiple stages. Therefore, we highlight some examples of flap reconstructions in this technical note. Important to know, MB is considered safe within the therapeutic doses (<2 mg/kg). However, it is contraindicated in certain patients, including those who are pregnant, have renal insufficiency, are on specific serotonin medications and some rare deficiencies. As dual-wavelength fluorescence imaging systems compatible with both ICG and MB advance, there is growing interest in the potential of MB for (multiple) flap perfusion assessment(s) in plastic and reconstructive surgery, building on promising research in bowel perfusion.