Publications by authors named "Matthew D Ford"

24 Publications

  • Page 1 of 1

The Association Between Age at Palatoplasty and Speech and Language Outcomes in Children With Cleft Palate: An Observational Chart Review Study.

Cleft Palate Craniofac J 2020 02 24;57(2):148-160. Epub 2019 Oct 24.

Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, PA, USA.

Objective: To determine whether timing of palatoplasty (early, standard, or late) is associated with speech and language outcomes in children with cleft palate.

Design: Retrospective case series.

Setting: Tertiary care children's hospital.

Participants: Records from 733 children born between 2005 and 2015 and treated at the Cleft Craniofacial Clinic of a tertiary children's hospital were retrospectively reviewed. Exclusion criteria were cleft repair at an outside hospital, intact secondary palate, absence of postpalatoplasty speech evaluation, syndromes, staged palatoplasty, and introduction to clinic after 12 months of age. Data from 232 children with cleft palate ± cleft lip were analyzed.

Interventions: Palatoplasty.

Main Outcome Measures: Speech/language delays and disorders at 20 months and 5 years of age based on formal hospital or community-based testing or screening evaluation in the Cleft Craniofacial Clinic; additional speech surgery.

Results: Median age at palatoplasty was 12.6 months (range: 8.8-21.9 months). Age at palatoplasty was classified as early (<11 months, n = 28), standard (11-13 months, n = 158), or late (>13 months, n = 46). Late palatoplasty was associated with increased odds of speech/language delays and speech therapy at 20 months, and language delays at 5 years, compared with standard or early palatoplasty ( < .05 for all comparisons). However, speech sound production disorders, velopharyngeal incompetence, tube replacement, and hearing loss were not significantly associated with age at palatoplasty.

Conclusions: Late palatoplasty may be associated with short- and long-term delays in speech/language development. Future studies with standardized surgical technique/timing and outcome measures are required to more definitively describe the impact of age at palatoplasty on speech/language development.
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http://dx.doi.org/10.1177/1055665619882566DOI Listing
February 2020

Airway anomalies in patients with craniosynostosis.

Laryngoscope 2019 Nov 19;129(11):2594-2602. Epub 2018 Nov 19.

Department of Otolaryngology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A.

Objectives: 1) Characterize the spectrum of airway anomalies in patients with craniosynostosis, and 2) identify clinical characteristics of these patients that may be associated with the development of airway anomalies.

Methods: This study is a retrospective case series assessing the type and frequency of airway anomalies in all patients with craniosynostosis seen at a tertiary-care children's hospital between 2000 and 2016. Cohort analyses were then performed to identify differences in airway anomalies dependent on syndromic associations, multisutural fusion, and location of suture fusion. Clinical characteristics examined included demographics and additional neurologic and craniofacial abnormalities.

Results: Four hundred and ninety-six patients with craniosynostosis (83.5% white, 64.5% male; 33.9% sagittal, 28.8% metopic, 11.5% coronal, 1.2% lambdoid, and 24.6% multisutural) were included. Notable airway anomalies included the following: 13.3% adenotonsillar hypertrophy, 8.9% laryngomalacia, 7.3% tracheomalacia, 7.1% subglottic stenosis, 4.0% bronchomalacia, 3.8% laryngeal cleft, and 1.2% vocal fold paresis. Multisutural craniosynostosis patients (n = 122) were more likely to have obstructive sleep apnea (P = 0.005), adenotonsillar hypertrophy (P = 0.014), tracheomalacia (P = 0.011), subglottic stenosis (P < 0.001), and epiglottic/base of tongue collapse (P = 0.003) and require tracheostomy (P = 0.001) and mechanical ventilation (P = 0.017) compared with single suture craniosynostosis. Syndromic craniosynostosis patients (n = 33) were more likely to have obstructive sleep apnea (P < 0.001), laryngomalacia (P = 0.047), and subglottic stenosis (P = 0.009) compared with nonsyndromic patients.

Conclusion: Airway anomalies are prevalent in patients with craniosynostosis; patients with multisutural or syndromic types have an increased risk of developing certain abnormalities. There should be a lower threshold for referral for airway evaluation in these populations.

Level Of Evidence: 4. Laryngoscope, 129:2594-2602, 2019.
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http://dx.doi.org/10.1002/lary.27589DOI Listing
November 2019

The Impact of Timing of Tympanostomy Tube Placement on Sequelae in Children With Cleft Palate.

Cleft Palate Craniofac J 2019 07 11;56(6):720-728. Epub 2018 Nov 11.

1 Department of Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.

Objective: To describe the impact of timing of tympanostomy tube insertion on the number of tubes received and complications in children with routine tube placement.

Design: Retrospective case series.

Setting: Tertiary care children's hospital.

Participants: Records from a consecutive sample of 401 children with cleft palate were reviewed. Sixty-five patients with isolated cleft palate and 82 patients with cleft lip and palate had follow-up until 5 years of age and were included.

Interventions: Tympanostomy tubes.

Main Outcome Measure(s): Number of tubes received and tube-related complications. The hypothesis was formulated prior to data collection.

Results: Males comprised 55.8% of included patients, and tubes were placed in 98.6% of patients at a median age of 6.5 months. Effusion was documented at first tube placement for 96.5% of patients. Most (67.4%) patients required replacement of tubes, and 10.6% required long-term tubes. Complications included otorrhea (71.0%), myringosclerosis (35.2%), granulation (22.8%), perforation (17.9%), retained tubes (5.5%), and cholesteatoma (1.4%). Cleft lip and palate ( < .001) and otorrhea ( = .023) were associated with tube placement before palatoplasty. Patients with tube placement before palatoplasty ( = .033), genetic disorders ( = .007), failed newborn hearing screen ( = .012), otorrhea ( < .001), and granulation ( < .001) received more tubes.

Conclusions: Nearly universal effusion in patients with cleft palate supports the need for routine tube placement. The potential for otorrhea and requiring more tubes should be weighed against the risks associated with prolonged effusion when considering tube placement before palatoplasty.
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http://dx.doi.org/10.1177/1055665618809228DOI Listing
July 2019

Laryngomalacia in Patients With Craniosynostosis.

Ann Otol Rhinol Laryngol 2018 Aug 20;127(8):543-550. Epub 2018 Jun 20.

1 Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Objective: To characterize differences in the clinical presentation and treatment outcomes of laryngomalacia in patients with and without craniosynostosis.

Methods: A retrospective cohort study was performed comparing all patients with concomitant laryngomalacia and craniosynostosis seen at a tertiary care children's hospital between 2000 and 2016 with a control group of patients with isolated laryngomalacia. Thirty-two patients with craniosynostosis (59% male) and 68 control patients (56% male) were included. There were no significant differences in age of diagnosis or incidence of prematurity. Symptom presentation, disease severity, swallowing function, comorbidities, treatment modalities, and outcomes were examined using logistic regression.

Results: Patients with craniosynostosis had increased odds of presenting with stertor (odds ratio [OR] = 3.41, P = .022), increased work of breathing (OR = 18.8, P = .007), obstructive sleep apnea (OR = 8.48, P = .003), dysphagia (OR = 3.40, P = .008), and aspiration (OR = 40.2, P < .001) and decreased odds of presenting with stridor (OR = 0.0804, P < .001) compared with controls. Patients with craniosynostosis had increased odds of severe laryngomalacia (OR = 5.00, P = .031) and other airway anomalies such as tracheomalacia (OR = 5.73, P = .004), bronchomalacia (OR = 15.5, P = .013), and subglottic stenosis (OR = 2.75, P = .028). Treatment of patients with craniosynostosis was more likely to include tracheostomy (OR = 24.8, P < .001) and gastrostomy tube (OR = 88.4, P < .001). There were no significant differences in rates of supraglottoplasty.

Conclusion: Clinical presentations, comorbidities, and treatments of laryngomalacia are significantly different in the context of craniosynostosis.
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http://dx.doi.org/10.1177/0003489418779413DOI Listing
August 2018

Diagnosing Tongue Base Obstruction in Pierre Robin Sequence Infants: Sleep vs Awake Endoscopy.

Cleft Palate Craniofac J 2018 05 15;55(5):692-696. Epub 2018 Feb 15.

4 Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.

Objective: To investigate whether awake endoscopy can diagnose base-of-tongue obstruction as reliably as sleep endoscopy in infants with Pierre Robin sequence (PRS).

Design: The study was retrospective with the clinicians blinded to patient identity. Endoscopy findings were assessed and measured by the performing pediatric otolaryngologist.

Setting: Tertiary care children's hospital.

Patients: All infants with PRS managed between January 2005 and July 2015 were included. There were 141 patients, of which 35 underwent both awake endoscopy (AE) and drug-induced sleep endoscopy (DISE).

Interventions: Bedside AE and DISE in the operating room.

Main Outcome Measures: Presence of moderate or severe base-of-tongue collapse was assessed. Sensitivity, specificity, and positive likelihood ratio of AE findings as well as intertest differences between AE and DISE were calculated.

Results: AE had 50.0% sensitivity (95% confidence interval [CI] 27.2%-72.8%) and 86.7% specificity (95% CI 59.5%-98.3%) for detecting base-of-tongue obstruction compared to DISE; false negative rate was 50.0% (n = 10). Positive likelihood ratio was 3.75 (CI 0.96-14.65). Compared to AE, DISE demonstrated significantly more cases of base-of-tongue obstruction ( P = .039).

Conclusions: Bedside AE has low sensitivity for detecting base-of-tongue collapse in infants with PRS. Because of the substantial false negative rate, AE may not be a reliable diagnostic modality for ruling out base-of-tongue obstruction in this susceptible population. DISE may be indicated in high-risk patients to avoid underdiagnosing upper airway obstruction.
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http://dx.doi.org/10.1177/1055665618756706DOI Listing
May 2018

Should Children With Cleft Palate Receive Early Long-Term Tympanostomy Tubes: One Institution's Experience.

Cleft Palate Craniofac J 2018 03 14;55(3):389-395. Epub 2017 Dec 14.

1 Department of Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.

Objectives: To determine whether children with cleft palate might benefit from early long-term tympanostomy tubes with the hypothesis that receiving multiple tubes is associated with shorter duration of first tubes.

Design: Retrospective cohort study.

Setting: Tertiary care children's hospital.

Participants: Records from 401 consecutive children with cleft palate ± cleft lip, born April 2005 to April 2010, were reviewed. After exclusion of children with cleft repair at an outside hospital, no follow-up after 5 years of age, intact secondary palate, no tubes, or tube replacement at palatoplasty, 105 children remained.

Main Outcome Measure: Number of tubes.

Results: Armstrong grommet tubes were placed at a median age of 6.7 months (range 2.3-19.6 months). Tubes were replaced in 55.3% of patients, with 34.0% receiving ≥3 sets. Duration of first tubes was significantly longer for children with 1 set of tubes compared with those with multiple sets (median 26 vs 19 months, P = .004). Otorrhea, but not perforation, was associated with longer duration of first tubes (median 27 vs 20.5 months, P = .028). Cleft type did not impact the proportion of patients with multiple tubes. Median age at last tube placement for children with multiple tubes was 5.0 years (range 1.9-8.7 years).

Conclusion: Short duration of first tubes is associated with receiving multiple tubes. Because most patients require repeat tubes and many require tubes until school age, there is a significant need for controlled, prospective trials of early long-term tube placement in this population.
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http://dx.doi.org/10.1177/1055665617736775DOI Listing
March 2018

The Impact of Tympanostomy Tubes on Speech and Language Development in Children with Cleft Palate.

Otolaryngol Head Neck Surg 2017 09 2;157(3):504-514. Epub 2017 May 2.

1 Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA.

Objective Describe the impact of hearing loss, tympanostomy tube placement before palatoplasty, and number of tubes received on speech outcomes in children with cleft palate. Study Design Case series with chart review. Setting Tertiary care children's hospital. Subjects and Methods Records from 737 children born between April 2005 and April 2015 who underwent palatoplasty at a tertiary children's hospital were reviewed. Exclusion criteria were cleft repair at an outside hospital, intact secondary palate, absence of postpalatoplasty speech evaluation, sensorineural or mixed hearing loss, no tubes, first tubes after palatoplasty, or first clinic after 12 months of age. Data from 152 patients with isolated cleft palate and 166 patients with cleft lip and palate were analyzed using Wilcoxon rank-sum, χ, and Fisher exact test and logistic regression. Results Most patients (242, 76.1%) received tubes before palatoplasty. Hearing loss after tubes, but not before, was associated with speech/language delays at 24 months ( P = .005) and language delays ( P = .048) and speech sound production disorders (SSPDs, P = .040) at 5 years. Receiving tubes before palatoplasty was associated with failed newborn hearing screen ( P = .001) and younger age at first posttubes type B tympanogram with normal canal volume ( P = .015). Hearing loss after tubes ( P = .021), language delays ( P = .025), SSPDs ( P = .003), and velopharyngeal insufficiency ( P = .032) at 5 years and speech surgery ( P = .022) were associated with more tubes. Conclusion Continued middle ear disease, reflected by hearing loss and multiple tubes, may impair speech and language development. Inserting tubes before palatoplasty did not mitigate these impairments better than later tube placement.
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http://dx.doi.org/10.1177/0194599817703926DOI Listing
September 2017

Characteristics of sleep apnea in infants with Pierre-Robin sequence: Is there improvement with advancing age?

Int J Pediatr Otorhinolaryngol 2015 Dec 25;79(12):2059-67. Epub 2015 Sep 25.

Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA 15224, United States. Electronic address:

Objectives: To investigate changes in obstructive sleep apnea (OSA) and central sleep apnea (CSA) in infants with Pierre-Robin sequence (PRS) with advancing age and after mandibular distraction osteogenesis (MDO).

Methods: Charts from 141 infants with PRS that presented to our tertiary-care children's hospital between 2005 and 2015 were retrospectively reviewed. Forty-five patients received a polysomnogram (PSG) prior to surgical intervention. Linear regression was utilized to compare age at pre-operative PSG with apnea-hypopnea index (AHI), obstructive apnea-hypopnea index (OAHI), and central apnea index (CAI). We then analyzed a subset of 9 patients who underwent MDO with pre- and post-operative PSGs. Wilcoxon signed-rank test was utilized to examine differences in pre- and post-operative OSA and CSA scores.

Results: Forty-five patients received pre-operative PSGs. Of these, 80.0% demonstrated severe sleep apnea (AHI≥10), 68.9% demonstrated severe obstructive sleep apnea (OAHI≥10), and 55.6% demonstrated central sleep apnea (CAI≥1). There was no significant pattern of decrease in AHI, OAHI, and CAI with increased age up to 1 year. Among the 9 patients who underwent MDO with pre- and post-operative PSGs, significant reductions in AHI, OAHI, CAI, and percentage of total sleep time with arterial oxygen saturation (SaO2) <90% and significant increases in SaO2 nadir were identified after MDO.

Conclusions: Contrary to previously examined literature in non-PRS patients, we did not find a decreased severity of central or obstructive sleep apnea with advancing age. Infants with PRS who underwent MDO demonstrated significant decreases in both obstructive and central apnea indices.
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http://dx.doi.org/10.1016/j.ijporl.2015.09.014DOI Listing
December 2015

Speech Outcomes After Clinically Indicated Posterior Pharyngeal Flap Takedown.

Ann Plast Surg 2016 Oct;77(4):420-4

From the Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA.

Background: Velopharyngeal insufficiency affects as many as one in three patients after cleft palate repair. Correction using a posterior pharyngeal flap (PPF) has been shown to improve clinical speech symptomatology; however, PPFs can be complicated by hyponasality and obstructive sleep apnea. The goal of this study was to assess if speech outcomes revert after clinically indicated PPF takedown.

Methods: The cleft-craniofacial database of the Children's Hospital of Pittsburgh at the University of Pittsburgh Medical Center was retrospectively queried to identify patients with a diagnosis of velopharyngeal insufficiency treated with PPF who ultimately required takedown. Using the Pittsburgh Weighted Speech Score (PWSS), preoperative scores were compared to those after PPF takedown. Outcomes after 2 different methods of PPF takedown (PPF takedown alone or PPF takedown with conversion to Furlow palatoplasty) were stratified and cross-compared.

Results: A total of 64 patients underwent takedown of their PPF. Of these, 18 patients underwent PPF takedown alone, and 46 patients underwent PPF takedown with conversion to Furlow Palatoplasty. Patients averaged 12.43 (range, 3.0-22.0)(SD: 3.93) years of age at the time of PPF takedown, and 58% were men. Demographics between groups were not statistically different. The mean duration of follow-up after surgery was 38.09 (range, 1-104) (SD, 27.81) months. For patients undergoing PPF takedown alone, the mean preoperative and postoperative PWSS was 3.83 (range, 0.0-23.0) (SD, 6.13) and 4.11 (range, 0.0-23.0) (SD, 5.31), respectively (P = 0.89). The mean change in PWSS was 0.28 (range, -9.0 to 7.0) (SD, 4.3). For patients undergoing takedown of PPF with conversion to Furlow palatoplasty, the mean preoperative and postoperative PWSS was 6.37 (range, 0-26) (SD, 6.70) and 3.11 (range, 0.0-27.0) (SD, 4.14), respectively (P < 0.01). The mean change in PWSS was -3.26 (range, -23.0 to 4.0) (SD, 4.3). For all patients, the mean preoperative PWSS was 5.66 (range, 0.0-26) (SD, 6.60) and 3.39 (range, 0.0-27) (SD, 4.48), respectively (P < 0.05). The mean change in PWSS was -2.26 (range, -23.0 to 7) (SD, 5.7). There was no statistically significant regression in PWSS for either surgical intervention. Two patients in the PPF takedown alone cohort demonstrated deterioration in PWSS that warranted delayed conversion to Furlow palatoplasty. Approximately 90% of patients, who undergo clinically indicated PPF takedown alone, without conversion to Furlow Palatoplasty, will show no clinically significant reduction in speech.

Conclusions: Although there is concern that PPF takedown may degrade speech, this study finds that surgical takedown of PPF, when clinically indicated, does not result in a clinically significant regression of speech.
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http://dx.doi.org/10.1097/SAP.0000000000000632DOI Listing
October 2016

Ear Infection in Isolated Cleft Lip: Etiological Implications.

Cleft Palate Craniofac J 2017 03 8;54(2):189-192. Epub 2015 Jul 8.

Background And Hypothesis: Chronic ear infections are a common occurrence in children with orofacial clefts involving the secondary palate. Less is known about the middle ear status of individuals with isolated clefts of the lip, although several studies have reported elevated rates of ear infection in this group. The purpose of this retrospective study was to test the hypothesis that chronic ear infections occur more frequently in isolated cleft lip cases (n = 94) compared with controls (n = 183).

Methods: A questionnaire was used to obtain information on history of chronic ear infection. The association between ear infection status (present/absent) and cleft lip status (cleft lip case/control) was tested using both chi-square and logistic regression.

Results And Conclusions: The reported occurrence of chronic ear infection was significantly greater in cleft lip cases (31%) compared with unaffected controls (11%). After adjusting for age and sex, having a cleft lip increased the odds of being positive for ear infection by a factor greater than 3 (odds ratio = 3.698; 95% confidence interval = 1.91 to 7.14). Within cleft lip cases, there was no difference in the occurrence of ear infection by defect laterality or by the type of clefting present in the family history. Although velopharyngeal insufficiency was present in 18.4% of our cleft lip sample, there was no statistical association between ear infection and abnormal speech patterns. These results may have potential implications both for the clinical management of isolated cleft lip cases and for understanding the etiology of orofacial clefting.
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http://dx.doi.org/10.1597/15-010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4706498PMC
March 2017

Improving speech outcomes after failed palate repair: evaluating the safety and efficacy of conversion Furlow palatoplasty.

J Craniofac Surg 2014 Mar;25(2):343-7

From the *Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and †Departments of Oral Biology and Surgery/Plastic Surgery, Georgia Health Sciences University, Augusta, Georgia.

Background: Velopharyngeal insufficiency occurs in a nontrivial number of cases following cleft palate repair. We hypothesize that a conversion Furlow palatoplasty allows for long-term correction of VPI resulting from a failed primary palate repair, obviating the need for pharyngoplasty and its attendant comorbidities.

Methods: A retrospective review of patients undergoing a conversion Furlow palatoplasty between 2003 and 2010 was performed. Patients were grouped according to the type of preceding palatal repair. Velopharyngeal insufficiency was assessed using Pittsburgh Weighted Speech Scale (PWSS). Scores were recorded and compared preoperatively and postoperatively at 3 sequential visits.

Results: Sixty-two patients met inclusion criteria and were grouped by preceding repair (straight-line repair (n = 37), straight-line repair with subsequent oronasal fistula (n = 14), or pharyngeal flap (n = 11). Median PWSS scores at individual visits were as follows: preoperative = 11, first postoperative = 3 (mean, 114.0 ± 6.7 days), second postoperative = 1 (mean, 529.0 ± 29.1 days), and most recent postoperative = 3 (mean, 1368.6 ± 76.9 days). There was a significant difference between preoperative and postoperative PWSS scores in the entire cohort (P < 0.001) with overall improvement, and post hoc analysis showed improvement between each postoperative visit (P < 0.05) with the exception of the second to the most recent visit. There were no differences between postoperative PWSS scores in the operative subgroupings (P > 0.05). Eight patients failed to improve and showed no differences in PWSS scores over time (P > 0.05). Patients with a PWSS score of 7 or greater (n = 8) at the first postoperative visit (0-6 months) displayed improvement at the most recent visit (P< 0.05).

Conclusions: Conversion Furlow palatoplasty is an effective means for salvaging speech. Future studies should elucidate which factors predict the success of this technique following failed palate repair.
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http://dx.doi.org/10.1097/SCS.0000000000000375DOI Listing
March 2014

Intraoperative high-dose epinephrine infiltration in cleft palate repair.

J Craniofac Surg 2014 Jan;25(1):140-2

From the Departments of *Plastic Surgery, and†Anesthesia, University of Pittsburgh, Pittsburgh, Pennsylvania.

Objective: Local infiltration of epinephrine before surgical procedures is a well-accepted technique to promote vasoconstriction. Typically, the dose of epinephrine is limited by the co-administration of local anesthetic as well as the risk for arrhythmogenesis and hemodynamic changes. In addition, some controversy exists regarding the acceptable dose of epinephrine given to children. This retrospective review examines the use and safety of "high-dose" epinephrine in palatoplasty at our cleft-craniofacial center.

Design: A retrospective review of epinephrine use in primary palatoplasty at a tertiary children's hospital from 2003 to 2007 was performed. Operative and anesthetic records were reviewed for hypertension (systolic blood pressure, >120 or diastolic blood pressure, >70) and tachycardia (>190 beats per min) as defined by the American Heart Association guidelines, as well as dysrhythmias, intraoperative complications, and postoperative complications.

Results: A total of 102 patients who underwent consecutive primary palatoplasties performed by a single surgeon were identified. After the induction of anesthesia and before incision, the patients received an initial epinephrine infiltration (without local anesthetic) up to a maximum 10 μg/kg. The average total dose of epinephrine administered during palatoplasty was 12.8 μg/kg (range, 3.2-75.0 μg/kg). Doses up to a maximum of 10 μg/kg were administered as needed at 30-minute intervals. No instances of clinically unstable tachycardia or hypertension occurred. A total of 21.6% of the patients (22/102) experienced an instance of hypertension, and only 13.7% of these (14/102) were related to epinephrine administration. One (1%) postoperative fistula was identified.

Conclusions: Locally infiltrated high-dose epinephrine during palatoplasty can be safely used as a means of vasoconstriction. Doses reaching a maximum of 10 μg/kg, administered as needed at 30-minute intervals, do not seem to be a significant risk for hemodynamic instability, intraoperative complications, or postoperative complications.
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http://dx.doi.org/10.1097/SCS.0000000000000376DOI Listing
January 2014

Exploring high frequency temporal fluctuations in the terminal aneurysm of the basilar bifurcation.

J Biomech Eng 2012 Sep;134(9):091003

Department of Mechanical and Materials Engineering, Queen's University, Kingston, Ontario K7L 3N6, Canada.

Cerebral aneurysms are a common cause of death and disability. Of all the cardiovascular diseases, aneurysms are perhaps the most strongly linked with the local fluid mechanic environment. Aside from early in vivo clinical work that hinted at the possibility of high-frequency intra-aneurysmal velocity oscillations, flow in cerebral aneurysms is most often assumed to be laminar. This work investigates, through the use of numerical simulations, the potential for disturbed flow to exist in the terminal aneurysm of the basilar bifurcation. The nature of the disturbed flow is explored using a series of four idealized basilar tip models, and the results supported by four patient specific terminal basilar tip aneurysms. All four idealized models demonstrated instability in the inflow jet through high frequency fluctuations in the velocity and the pressure at approximately 120 Hz. The instability arises through a breakdown of the inflow jet, which begins to oscillate upon entering the aneurysm. The wall shear stress undergoes similar high-frequency oscillations in both magnitude and direction. The neck and dome regions of the aneurysm present 180 deg changes in the direction of the wall shear stress, due to the formation of small recirculation zones near the shear layer of the jet (at the frequency of the inflow jet oscillation) and the oscillation of the impingement zone on the dome of the aneurysm, respectively. Similar results were observed in the patient-specific models, which showed high frequency fluctuations at approximately 112 Hz in two of the four models and oscillations in the magnitude and direction of the wall shear stress. These results demonstrate that there is potential for disturbed laminar unsteady flow in the terminal aneurysm of the basilar bifurcation. The instabilities appear similar to the first instability mode of a free round jet.
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http://dx.doi.org/10.1115/1.4007279DOI Listing
September 2012

Hemodynamics of the mouse abdominal aortic aneurysm.

J Biomech Eng 2011 Dec;133(12):121008

Department of Mechanical and Materials Engineering, Queen's University, Kingston, ON, K7L 3N6, Canada.

The abdominal aortic aneurysm (AAA) is a significant cause of death and disability in the Western world and is the subject of many clinical and pathological studies. One of the most commonly used surrogates of the human AAA is the angiotensin II (Ang II) induced model used in mice. Despite the widespread use of this model, there is a lack of knowledge concerning its hemodynamics; this study was motivated by the desire to understand the fluid dynamic environment of the mouse AAA. Numerical simulations were performed using three subject-specific mouse models in flow conditions typical of the mouse. The numerical results from one model showed a shed vortex that correlated with measurements observed in vivo by Doppler ultrasound. The other models had smaller aneurysmal volumes and did not show vortex shedding, although a recirculation zone was formed in the aneurysm, in which a vortex could be observed, that elongated and remained attached to the wall throughout the systolic portion of the cardiac cycle. To link the hemodynamics with aneurysm progression, the remodeling that occurred between week one and week two of the Ang II infusion was quantified and compared with the hemodynamic wall parameters. The strongest correlation was found between the remodeled distance and the oscillatory shear index, which had a correlation coefficient greater than 0.7 for all three models. These results demonstrate that the hemodynamics of the mouse AAA are driven by a strong shear layer, which causes the formation of a recirculation zone in the aneurysm cavity during the systolic portion of the cardiac waveform. The recirculation zone results in areas of quiescent flow, which are correlated with the locations of the aneurysm remodeling.
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http://dx.doi.org/10.1115/1.4005477DOI Listing
December 2011

The Murine Angiotensin II-Induced Abdominal Aortic Aneurysm Model: Rupture Risk and Inflammatory Progression Patterns.

Front Pharmacol 2010 14;1. Epub 2010 Jul 14.

Department of Physiology, Queen's University Kingston, ON, Canada.

An abdominal aortic aneurysm (AAA) is an enlargement of the greatest artery in the body defined as an increase in diameter of 1.5-fold. AAAs are common in the elderly population and thousands die each year from their complications. The most commonly used mouse model to study the pathogenesis of AAA is the angiotensin II (Ang II) infusion method delivered via osmotic mini-pump for 28 days. Here, we studied the site-specificity and onset of aortic rupture, characterized three-dimensional (3D) images and flow patterns in developing AAAs by ultrasound imaging, and examined macrophage infiltration in the Ang II model using 65 apolipoprotein E-deficient mice. Aortic rupture occurred in 16 mice (25%) and was nearly as prevalent at the aortic arch (44%) as it was in the suprarenal region (56%) and was most common within the first 7 days after Ang II infusion (12 of 16; 75%). Longitudinal ultrasound screening was found to correlate nicely with histological analysis and AAA volume renderings showed a significant relationship with AAA severity index. Aortic dissection preceded altered flow patterns and macrophage infiltration was a prominent characteristic of developing AAAs. Targeting the inflammatory component of AAA disease with novel therapeutics will hopefully lead to new strategies to attenuate aneurysm growth and aortic rupture.
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http://dx.doi.org/10.3389/fphar.2010.00009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3112241PMC
July 2011

Is flow in the common carotid artery fully developed?

Physiol Meas 2008 Nov 14;29(11):1335-49. Epub 2008 Oct 14.

Biomedical Simulation Laboratory, University of Toronto, Toronto, ON, Canada.

The assumption of fully developed or axisymmetric velocity profiles in the common carotid artery (CCA) underlies the straightforward estimation of CCA blood flow rates or wall shear stresses (WSS) from limited velocity data, such as spectral peak velocities acquired using Doppler ultrasound. Using an automated velocity profile classifier developed for this study, we characterized the shape of the CCA velocity profile from cine phase contrast magnetic resonance images acquired as part of an Atherosclerosis Risk in Communities (ARIC) ancillary study, here focusing on 45 participants imaged twice as part of a repeatability protocol. When averaged over the cardiac cycle, roughly 60% of the velocity profiles were classified as skewed, with over half of these exhibiting the crescent shape characteristic of strong Dean-type flow in a curved tube. During early diastole, roughly 80% of the velocity profiles were skewed. In most cases the degree and orientation of skewing were reproduced in the repeat scan, indicating the persistence of these flow features. Fully developed flow thus appears to be the exception rather than the rule in the nominally straight CCA. Implications of this for flow rate and WSS estimation, and perhaps the development and progression of carotid atherosclerosis, warrant further investigation.
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http://dx.doi.org/10.1088/0967-3334/29/11/008DOI Listing
November 2008

A qualitative description of receiving a diagnosis of clefting in the prenatal or postnatal period.

J Genet Couns 2008 Aug 15;17(4):336-50. Epub 2008 May 15.

Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA 15219, USA.

This study investigated the experience of receiving a diagnosis of clefting in the prenatal or postnatal period. Open-ended interviews were conducted with 20 parents of children with cleft lip with or without cleft palate. Interviews were transcribed and analyzed using a qualitative descriptive approach with an emphasis on thematic analysis. Common themes emerged from participants' responses regarding the delivery of the diagnosis, preparation for the birth of their child, advantages and disadvantages of prenatal diagnosis, use of the Internet, views on abortion and genetic testing, among other issues. All participants in the prenatal group indicated they were satisfied they learned of the cleft before the birth of their child. Some participants in the postnatal group would rather have received the diagnosis prenatally, while others were content with learning of the diagnosis in the delivery room. Greater awareness of the parental experience of the timing of receiving a cleft diagnosis may assist health care professionals in providing care for these families.
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http://dx.doi.org/10.1007/s10897-008-9152-5DOI Listing
August 2008

PIV-measured versus CFD-predicted flow dynamics in anatomically realistic cerebral aneurysm models.

J Biomech Eng 2008 Apr;130(2):021015

Imaging Research Laboratories, Robarts Research Institute, London, Canada N6A 5K8.

Computational fluid dynamics (CFD) modeling of nominally patient-specific cerebral aneurysms is increasingly being used as a research tool to further understand the development, prognosis, and treatment of brain aneurysms. We have previously developed virtual angiography to indirectly validate CFD-predicted gross flow dynamics against the routinely acquired digital subtraction angiograms. Toward a more direct validation, here we compare detailed, CFD-predicted velocity fields against those measured using particle imaging velocimetry (PIV). Two anatomically realistic flow-through phantoms, one a giant internal carotid artery (ICA) aneurysm and the other a basilar artery (BA) tip aneurysm, were constructed of a clear silicone elastomer. The phantoms were placed within a computer-controlled flow loop, programed with representative flow rate waveforms. PIV images were collected on several anterior-posterior (AP) and lateral (LAT) planes. CFD simulations were then carried out using a well-validated, in-house solver, based on micro-CT reconstructions of the geometries of the flow-through phantoms and inlet/outlet boundary conditions derived from flow rates measured during the PIV experiments. PIV and CFD results from the central AP plane of the ICA aneurysm showed a large stable vortex throughout the cardiac cycle. Complex vortex dynamics, captured by PIV and CFD, persisted throughout the cardiac cycle on the central LAT plane. Velocity vector fields showed good overall agreement. For the BA, aneurysm agreement was more compelling, with both PIV and CFD similarly resolving the dynamics of counter-rotating vortices on both AP and LAT planes. Despite the imposition of periodic flow boundary conditions for the CFD simulations, cycle-to-cycle fluctuations were evident in the BA aneurysm simulations, which agreed well, in terms of both amplitudes and spatial distributions, with cycle-to-cycle fluctuations measured by PIV in the same geometry. The overall good agreement between PIV and CFD suggests that CFD can reliably predict the details of the intra-aneurysmal flow dynamics observed in anatomically realistic in vitro models. Nevertheless, given the various modeling assumptions, this does not prove that they are mimicking the actual in vivo hemodynamics, and so validations against in vivo data are encouraged whenever possible.
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http://dx.doi.org/10.1115/1.2900724DOI Listing
April 2008

On the effect of parent-aneurysm angle on flow patterns in basilar tip aneurysms: towards a surrogate geometric marker of intra-aneurismal hemodynamics.

J Biomech 2008 ;41(2):241-8

Imaging Research Laboratories, Robarts Research Institute, London, Canada.

As a part of previous computational fluid dynamic (CFD) validation studies, particle image velocimetry (PIV) of two anatomically realistic basilar artery tip aneurysm models revealed two distinct types of flow (one of which has yet to be reported in the literature), characterized by the location and strength of the intra-aneurismal vortex. We hypothesized that these distinct "hemodynamic phenotypes" could be anticipated by a simple geometric parameter: the angle of the aneurysm bulb relative to the parent artery. An idealized basilar tip aneurysm model was constructed to allow independent control of this angle, and CFD simulations were carried out for angles ranging from 2 degrees to 30 degrees , these extremes corresponding to the angles measured from the two anatomically realistic models. The gross hemodynamics predicted by the idealized model for 2 degrees and 30 degrees were consistent with those seen in the corresponding anatomically realistic models. For the idealized model, the flow type switched at an angle between 8 degrees and 12 degrees . Sensitivity studies suggested that, near these angles, the hemodynamic phenotype was sensitive to inflow momentum. Outside this range, however, the parent-bulb angle appeared to be a robust predictor of hemodynamic phenotype. Our findings suggest that blood flow dynamics in basilar artery tip aneurysms fall into one of the two broad phenotypes, each subject to distinct hemodynamic forces. That the general features of these flow types may be anticipated by a relatively simple-to-measure geometric parameter could help ease the introduction of hemodynamic information into routine clinical decision-making.
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http://dx.doi.org/10.1016/j.jbiomech.2007.09.032DOI Listing
April 2008

Delayed closure of the hard palate leads to speech problems and deleterious maxillary growth.

Plast Reconstr Surg 2007 Apr;119(4):1302-1310

Pittsburgh, Pa.; and Los Angeles, Calif. From the Divisions of Plastic and Reconstructive Surgery of the University of Pittsburgh and the University of California, Los Angeles.

Background: Hard palate cleft closure has been associated with maxillary hypoplasia. The Schweckendiek procedure offers delayed hard palate closure to avoid early subperiosteal dissection and palatal scarring. This study sought to compare single-stage versus delayed hard palate closure for speech outcome and maxillary growth.

Methods: A retrospective outcome study was performed of unilateral cleft lip and palate patients with either delayed hard palate repair with a pinned-retained speech prosthesis (Schweckendiek repair) (group 1, delayed hard palate repair, 1978 to 1983) or single-stage cleft palate repair (group 2, single-stage repair, 1983 to 1988). Patients with complete records to maturity at the University of Pittsburgh Cleft Palate Craniofacial Center (n = 82, two equal groups of 41 patients) were studied. Comparative data were collected from multidisciplinary evaluations, perceptual speech scores, speech tests, and cephalometric analysis.

Results: Single-stage cleft palate repair had a lower fistulization rate (11 percent) compared with delayed hard palate repair (58 percent). It also had better speech outcomes compared with delayed hard palate repair: mean speech score, 3.1 versus 7.8; final speech score, 0.9 versus 2.9; velopharyngeal incompetency, 21 percent versus 66 percent; failed video fluoroscopy or nasoendoscopy, 18 percent versus 52 percent; and need for secondary speech procedure, 20 percent versus 63 percent. Single-stage repair showed less maxillary growth disturbance, with class III malocclusion, 31 percent versus 66 percent; cephalometric SNA, 78.2 versus 74.8; need for Le Fort I advancement, 24 percent versus 42 percent; and amount of maxillary advancement required, 6 mm versus 9 mm.

Conclusion: The delayed cleft palate repair led to worse speech outcomes; thus, the authors' center abandoned this technique in favor of single-stage repair. In addition, their data showed that the delayed cleft palate repair led to deleterious maxillary growth.
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http://dx.doi.org/10.1097/01.prs.0000258518.81309.70DOI Listing
April 2007

Diagnosis and treatment of velopharyngeal insufficiency: clinical utility of speech evaluation and videofluoroscopy.

Ann Plast Surg 2006 May;56(5):511-7; discussion 517

Division of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.

Introduction: The workup of velopharyngeal insufficiency (VPI) includes speech pathology evaluation and examination of velopharyngeal anatomy and physiology. This study sought to determine whether perceptual speech symptoms were predictive of velopharyngeal closure.

Patients And Methods: A retrospective chart review of patients with VPI following primary palatoplasty was performed. All patients underwent perceptual speech evaluation using the Pittsburgh Weighted Speech Scale (PWSS) and examination of velopharyngeal anatomy by videofluoroscopy. PWSS scores were correlated to velopharyngeal closure.

Results: All patients exhibited clinical VPI (PWSS = 5-27). No patient demonstrated complete velopharyngeal closure on videofluoroscopy. Velopharyngeal closure on the lateral view showed a statistically significant, moderate correlation with both the PWSS total score (rs = -0.424; P = 0.03) and the phonation subscore (rs = -0.405; P = 0.04).

Conclusions: Although certain aspects of speech are related to velopharyngeal anatomy, speech and videofluoroscopic studies each provide unique information in the workup of VPI. Selection of surgical approach often depends on anatomic factors, and improvement in speech postoperatively indicates successful treatment.
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http://dx.doi.org/10.1097/01.sap.0000210628.18395.deDOI Listing
May 2006

Virtual angiography for visualization and validation of computational models of aneurysm hemodynamics.

IEEE Trans Med Imaging 2005 Dec;24(12):1586-92

Imaging Research Laboratories, Robarts Research Institute and the Department of Medical Biophysics, The Universty of Western Ontario, 100 Perth Drive, P.O. Box 5015, London, ON N6A 5K8, Canada.

It has recently become possible to simulate aneurysmal blood flow dynamics in a patient-specific manner via the coupling of three-dimensional (3-D) X-ray angiography and cmputational fluid dynamics (CFD). Before such image-based CFD models can be used in a predictive capacity, however, it must be shown that they indeed reproduce the in vivo hemodynamic environment. Motivated by the fact that there are currently no techniques for adequately measuring complex blood velocity fields in vivo, in this paper we describe how cine X-ray angiograms may be simulated for the purpose of indirectly validating patient-sperific CFD models. Mimicking the radiological procedure, a virtual angiogram is constructed by first simulating the time-varying injection of contrast agent into a precomputed, patient-specific CFD model. A time-series of images is then constructed by simulating the attenuation of X-rays through the computed 3-D contrast-agent flow dynamics. Virtual angiographic images and residence time maps, here derived from an image-based CFD model of a giant aneurysm, are shown to be in excellent agreement wiith the corresponding clinical images and residence time maps, but only when the interaction between the quasisteady contrast agent injection and the pulsatile flow are properly accounted for. These virtual angiographic techniques pave the way for validating image-based CFD models against routinely available clinical data, and provide a means of visualizing complex, 3-D blood flow dynamics in a clinically relevant manner. They also clearly show how the contrast agent injection perturbs the noraml blood flow patterns, further highlighting the potential utility of image-based CFD as a window into the true aneurysmal hemodynamics.
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http://dx.doi.org/10.1109/TMI.2005.859204DOI Listing
December 2005

Characterization of volumetric flow rate waveforms in the normal internal carotid and vertebral arteries.

Physiol Meas 2005 Aug 29;26(4):477-88. Epub 2005 Apr 29.

Imaging Research Labs, Robarts Research Institute and Department of Medical Biophysics, University of Western Ontario, London, Ontario, Canada.

Knowledge of normal cerebrovascular volumetric flow rate (VFR) dynamics is of interest for establishing baselines, and for providing input data to cerebrovascular model studies. Retrospectively gated phase contrast magnetic resonance imaging was used to measure time-resolved VFR waveforms from the two internal carotid arteries (ICA) and two vertebral arteries (VA) of 17 young, normal volunteers (16M:1F) at rest in a supine posture. After normalizing each waveform to its respective cycle-averaged VFR, the timing and amplitude of feature points from the individual waveforms were averaged together to produce archetypal ICA and VA waveform shapes. Despite significant inter-individual differences in cycle-averaged VFR within the ICA compared to VA (275+/-52 versus 91+/-18 mL min-1), the respective waveform shapes were qualitatively similar overall. The VA waveform shape did, however, exhibit significantly higher amplitudes (e.g., peak:average VFR of 1.78+/-0.30 versus 1.66+/-0.16; p<0.05) and significantly higher variability both between and within subjects. A significant correlation was observed between peak and cycle-averaged VFR, suggesting that the representative waveform shapes presented here-when scaled by an individual's cycle-averaged VFR-may be used to characterize normal ICA and VA flow rate dynamics. This capability may be of particular utility for studies where cerebrovascular flow dynamics are required, but only average flow rates are available.
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http://dx.doi.org/10.1088/0967-3334/26/4/013DOI Listing
August 2005

The effects of Le Fort I osteotomies on velopharyngeal and speech functions in cleft patients.

J Oral Maxillofac Surg 2004 Mar;62(3):308-14

Department of Oral and Maxillofacial Surgery, Cleft Palate Craniofacial Center, School of Dental Medicine, University of Pittsburgh, PA 15216, USA.

Purpose: Orthognathic surgery alters or even worsens symptoms of velopharyngeal insufficiency in cleft patients. The goal of this study was to evaluate how advancing the maxilla would affect the speech and articulation disorders of these patients.

Patients And Methods: This was a retrospective study in which we compiled and evaluated the speech scores of 54 cleft lip and palate patients who underwent maxillary advancement between 1981 and 2001. Although 34 individuals underwent an isolated Le Fort I advancement, 20 patients had a combined Le Fort I advancement/mandibular setback operation. The following variables were recorded from both preoperative and postoperative speech evaluations: presence of a pharyngeal flap at the time of surgery, oronasal fistulas, nasality, 7 different articulation errors, velopharyngeal function assessment, and overall speech score. Preoperative and postoperative changes in the data were analyzed using the McNemar test and paired t test.

Results: A decrease in competent velopharyngeal function mechanisms was noted postoperatively (42% to 18%), increased borderline incompetence (9% to 22%), and complete velopharyngeal insufficiency (13% to 20%). Speech scores deteriorated significantly (P <.05), whereas articulation defects insignificantly (P =.146) improved after surgery (84% to 73%), with those related to the anterior dentition (P =.064) showing the greatest change (64% to 47%). The frequency of hyponasality decreased after surgery. The number of cases of mild to moderate hypernasality increased.

Conclusion: This study confirms previous findings that patients with clefts of the lip and palate or palate alone are predisposed to velopharyngeal function alteration after maxillary advancement, particularly with borderline function preoperatively. However, the results show that surgical correction of skeletal relationships and occlusion may translate into improvements in certain aspects of speech disorders.
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http://dx.doi.org/10.1016/j.joms.2003.08.014DOI Listing
March 2004