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Objective: To assess risk factors for oronasal fistula, including 2-stage palate repair. Design: Retrospective analysis. Setting: Tertiary children’s hospital. Patients: Patients with non-submucosal cleft palate whose entire cleft repair was completed at the study hospital between 2005 and 2013 with postsurgical follow-up. Interventions: Hierarchical binary logistic regression assessed predictive value of variables for fistula. Variables tested for inclusion were 2 stage repair, Veau classification, sex, age at surgery 1, age at surgery 2, surgeon volume, surgeon, insurance status, socioeconomic status, and syndrome. Variables were added to the model in order of significance and retained if significant at a .05 level. Main Outcome Measure: Postoperative fistula. Results: Of 584 palate repairs, 505 (87%) had follow-up, with an overall fistula rate of 10.1% (n = 51). Among single-stage repairs (n = 211), the fistula rate was 6.7%; it was 12.6% in 2-stage repairs (n = 294, P = .03). In the final model utilizing both single-stage and 2-stage patient data, significant predictors of fistula were 2-stage repair (odds ratio [OR]: 2.5, P = .012), surgeon volume, and surgeon. When examining only single-stage patients, higher surgeon volume was protective against fistula. In the model examining 2-stage patients, surgeon and age at hard palate repair were significant; older age at hard palate closure was protective for fistula, with an OR of 0.82 ( P = .046) for each additional 6 months in age at repair. Conclusions: Two-stage surgery, surgeon, and surgeon volume were significant predictors of fistula occurrence in all children, and older age at hard palate repair was protective in those with 2-stage repair.

Objective: To evaluate the effect of an American Cleft Palate-Craniofacial Association (ACPA)–approved multidisciplinary team on velopharyngeal insufficiency (VPI) diagnosis and treatment. Design: Retrospective cohort setting; tertiary children’s hospital patients; children with cleft palate repair identified through procedure codes. Main Outcome Measures: Velopharyngeal insufficiency diagnosis was assigned based on surgeon or team assessment. Age at diagnosis and surgery was recorded. Difference in age and rate of VPI diagnosis and surgery was analyzed with t test. Multivariate linear and logistic regression adjusted for confounding variables. Results: Nine hundred forty patients were included with 71.5% cared for by an ACPA-approved multidisciplinary team. More (38.8% ) team care patients were found to have a diagnosis of VPI in comparison to 10% in independent care ( P < .001). Team care was associated with an almost 6-fold increase in VPI diagnosis ( P < .001). Team care was associated with a higher proportion of speech surgery (21% vs 10%, P < .001). Among children receiving team care, each visit was associated with 25% increased odds of being diagnosed with VPI ( P < .001) and 20% increased odds of receiving speech surgery ( P < .001). Age at VPI diagnosis and speech surgery were similar between groups ( P = .55 and .29). Discussion: Team care was associated with more accurate detection of VPI, resulting in more VPI speech therapy visits and surgical management. A higher number of team visits were similarly associated. Conclusion: Further studies of the clinical implication of timely and accurate VPI diagnosis, including quality of life assessments, are recommended to provide stronger guidance on team visit and evaluation planning.

Objective: To evaluate the association of 2-stage cleft palate (CP) surgery on velopharyngeal insufficiency (VPI) incidence, speech surgeries, and cleft-related surgical burden. Design: Retrospective cohort with follow-up of 4 to 19 years. Setting: Academic, tertiary children’s hospital. Patients: Patients who underwent CP surgery between 2000 and 2017. Exclusions included submucous CP or age at last contact under 3.9. Interventions: Cleft palate surgery, completed in either a single-stage or 2-stage repair. Main Outcome Measure(s): Rates of VPI diagnosis and speech surgery and total cleft surgeries; t tests, tests of proportion, and linear and logistic regression were performed. Total cleft-related surgeries were examined in a subset (n = 418) of patients with chart reviews. Results: A total of 1047 patients were included; 59.6% had 2-stage CP repair, 40.4% had single-stage repair. Approximately 32% of children with 2-stage CP repair were diagnosed with VPI, as opposed to 22% of single-stage patients ( P < .001). Children with 2-stage CP repair were 1.8 times as likely to be diagnosed with VPI ( P < .001). Speech surgery rates were similar across groups. Patients who had 2-stage repair received an average of 2.3 more cleft-related procedures, when excluding prosthesis management procedures. Conclusion: Our data show an increased risk of VPI diagnosis and increased surgical burden among patients receiving 2-stage CP repair.