Partnership improves the treatment of patients with cleft palate

The work of the Physiology Laboratory at the Bauru Center has gained visibility and importance in the last decade thanks to collaboration with the University of North Carolina

By Karina Toledo, in Raleigh

Agência FAPESP – With the help of techniques that enable measurement of the quality of speech, breathing and sleep, a group of researchers at the Hospital for Rehabilitation of Craniofacial Anomalies at the University of São Paulo (HRAC/USP) in Bauru, have contributed to improving the treatment of patients with cleft palate – a malformation in the area of the lip and palate, commonly known as harelip.

“The results of our studies have contributed to the team’s search for alternatives to a surgical technique that we have found to cause breathing problems, as well as the opening of a Sleep Studies Unit in the hospital,” reports Inge Elly Kiemle Trindade, coordinator of the Physiology Laboratory at the HRAC/USP.

According to Trindade, the work of the physiology team at the Center – as the HRAC is called – gained visibility and importance starting in the mid-1990s, when it began a partnership with the University of North Carolina (UNC). Some of the findings of the collaboration effort that is still in place today were presented this Tuesday (11/12/13) in the U.S. city of Raleigh during FAPESP Week North Carolina.

“The first two pieces of equipment used in the laboratory were donated by Donald Warren, Director of the UNC Craniofacial Center at that time. The nasometer measures the degree of nasality in speech production and the rhinometer allows measurement of the degree of closure of the velopharyngeal sphincter, which separates the nasal cavity from the oral cavity,” explained Trindade.

The tools helped researchers study the physiological repercussions of a surgical technique known as pharyngeal flap, designed to prevent air from escaping through the nose during speech, which is what causes the “twangy” or hypernasal sound that characterizes patients with cleft palate.

“We showed that the technique was effective in eliminating speech problems, but at the same time, it caused significant breathing problems. We began to suspect that the airway obstruction might explain the higher than average incidence of sleep apnea in these patients,” Trindade explained.

Based on the results of these studies, alternative and less obstructive methods were used, such as prolongation of the palate (roof of the mouth). In addition, the sleep apnea problem among patients received greater attention with the opening of the Sleep Studies Unit.

As the years passed, and with funding from entities like FAPESP, CNPq and CAPES, the laboratory received new equipment, including the acoustic rhinometry system that allows measurement of the nasal airways, purchased through a Regular Line of Research Award.

The equipment was used by Andressa Sharllene Carneiro da Silva to evaluate speech problems in patients with cleft palates during her master’s degree studies carried out with a grant from FAPESP. In order to do this, the team at UNC modified the standard technique.

The purchase of a polysomnography machine, which is used to measure sleep quality, contributed to the work of doutoral candidate Leticia Dominguez Campos, who also received a grant from FAPESP. The study showed that the pharyngeal flap was not in fact the most significant obstructive factor among middle-aged patients who develop sleep apnea, middle age being the phase in which there is a higher incidence of the disorder.

“We are now studying the morphology of the airways to find out if there is excessive narrowing of the pharynx due to the cleft that could be causing the sleep disturbance. This would apply to the elderly as well as to children and young adults,” said Trindade.

The work is being done with the help of a software that enables use of digital tomography images to perform 3-D reconstruction of the airways. It also includes the partnership with Brazilian Luiz André Freire Pimenta, who currently serves as Dental Director of the UNC Craniofacial Center, located in the city of Chapel Hill.

“Today there are several different types of software that can do a volumetric (3D) reconstruction of the airways. In the joint project we are starting, we will compare the results of the method used at the Bauru Center with the system adopted by the UNC Craniofacial Center to see which performs better,” said Pimenta, in attendance on the second day of FAPESP Week North Carolina.

According to him, the equipment for 3-D analysis has allowed the establishment of a new classification for cases involving cleft palate, as well as facilitated communication among specialists. “It has created new ways to evaluate patients. We can send images anywhere in the world in a matter of seconds so we no longer need to have the patient in the hospital for an initial evaluation. With the proposed new classification, which will be submitted for publication soon, physicians and dentists will be able to communicate more easily and plan treatment,” said Pimenta, former professor at the University of Campinas (Unicamp).

In his presentation, Pimenta –– former professor at the University of Campinas (Unicamp) –– highlighted FAPESP’s contribution to his academic career. “I was working as a professor in Brazil between 1992 and 2006 when I received an invitation to come to North Carolina. During this period, FAPESP has financed 13 of my research projects, which have resulted in 18 master’s theses, 11 doctoral dissertations and 54 published articles,” he explained.

International projects

The visibility achieved by the physiology team at the Center – due in part to its collaboration with North Carolina – has also earned it an invitation to take part in three large international projects, two of which are financed by the U.S. National Institutes of Health (NIH).

One of these projects entitled, “Timing of primary surgery for isolated cleft palate (TOPS)” is designed to study the best time for surgically correcting children with isolated cleft palate (at 6 months or at 12 months) in terms of the outcome for speech, hearing and craniofacial growth. In addition to the Center, the study is also taking place at institutions in six European countries: Denmark, Norway, Finland, Sweden, England and Ireland.

Regarded as a leading center for the treatment of craniofacial anomalies, the Bauru Center today cares for more than 60,000 patients from all over Brazil. Treatment includes oral and cosmetic surgery in addition to dental, speech therapy and psychological monitoring and follow-up. It begins during the early years and, if the patient wishes, continues into adulthood.

Cleft palate is a malformation that occurs during pregnancy and affects one out of every 650 live births. Some risk factors are known, such as exposure to radiation or certain medications taken during pregnancy, and family history, but science is still studying possible genetic mutations behind the problem.