Cleft Palate

1,707 views
1,667 views

Published on

1 Comment
2 Likes
Statistics
Notes
  • Interventi di chirurgia ortognatica: http://www.giuseppespinelli.it/chirurgia-estetica-maxillo-facciale/chirurgia-ortognatica.html
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total views
1,707
On SlideShare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
93
Comments
1
Likes
2
Embeds 0
No embeds

No notes for slide

Cleft Palate

  1. 1. The Cleft Palate
  2. 2. Case Study <ul><li>Full term infant, NSVD </li></ul><ul><li>Respiratory Distress at birth </li></ul><ul><li>Numerous O2 desaturations </li></ul><ul><li>Unable to feed </li></ul>
  3. 3. Case Study <ul><li>Cleft palate </li></ul>
  4. 4. Incidence <ul><li>Cleft lip </li></ul><ul><li>1/1000 live births </li></ul><ul><li>Cleft palate </li></ul><ul><li>1/2000 live births </li></ul>
  5. 5. Classification - Veau <ul><li>Clefts of soft palate only </li></ul><ul><li>Clefts of soft and hard palate reaching anteriorly to incisive foramen </li></ul><ul><li>Complete unilateral alveolar clefts - generally involve the lip as well </li></ul><ul><li>Bilateral alveolar clefts - associated with bilateral clefts of the lip </li></ul>
  6. 6. Classification <ul><li>A - Incomplete cleft of the secondary palate </li></ul><ul><li>B - Complete cleft of the secondary palate </li></ul><ul><li>C- Incomplete cleft of the primary and secondary palates </li></ul><ul><li>D - Unilateral complete cleft of the primary and secondary palates </li></ul><ul><li>E - Bilateral complete cleft of the primary and secondary palates </li></ul>
  7. 7. Case Study <ul><li>Micrognathia </li></ul>
  8. 8. Case Study <ul><li>Glossoptosis </li></ul><ul><li>Increase in frequency of O2 desaturations that improve when neonate is placed in prone position </li></ul>
  9. 9. Timeline of Care <ul><li>Neonatal to one month of age </li></ul><ul><li>Refer to cleft palate team </li></ul><ul><li>Medical diagnosis </li></ul><ul><li>Genetic counseling </li></ul><ul><li>Address psychosocial issues </li></ul><ul><li>Airway management </li></ul><ul><li>Provide feeding instructions </li></ul><ul><li>Monitor growth </li></ul><ul><li>Hearing screening </li></ul>
  10. 10. The NICU team consults ENT…
  11. 11. What might your flexible fiberoptic laryngoscopy show?
  12. 12. Doctor, what is in your differential diagnosis? <ul><li>Environmental </li></ul><ul><li>Alcohol </li></ul><ul><li>Tobacco smoke </li></ul><ul><li>Phenytoin </li></ul><ul><li>Retinoic acid </li></ul><ul><li>Folate Deficiency </li></ul>
  13. 13. Doctor, what is in your differential diagnosis? Syndromes <ul><li>van der Woude syndrome - Autosomal dominant disorder is on chromosome </li></ul>
  14. 14. Syndromes <ul><li>Robin Sequence </li></ul><ul><li>Micrognathia </li></ul><ul><li>Glossoptosis </li></ul><ul><li>Cleft palate </li></ul><ul><li>Associated abnormalities - 52% to 83% </li></ul>
  15. 15. Syndromes <ul><li>Velocardiofacial syndrome </li></ul><ul><li>Overlaps with DiGeorge syndrome and conotruncal anomaly face syndrome </li></ul><ul><li>CATCH 22: cardiac anomalies (usually conotruncal), a bnormal facies, t hymic disorders, c left palate, and h ypocalcemia caused a deletion of chromosome 22 at the q11.2 region. </li></ul>
  16. 16. Syndromes <ul><li>Stickler syndrome </li></ul><ul><li>Most common syndrome found in children with Robin Sequence - 14% to 34% of cases </li></ul><ul><li>Sensorineural hearing loss </li></ul><ul><li>Myopia - Risk of retinal detachment and early cataracts </li></ul><ul><li>Hypermobilityof joints </li></ul><ul><li>Stiffness and premature osteoarthritis </li></ul>
  17. 17. Airway management <ul><li>Prone positioning, which allows the tongue to fall away from the posterior pharyngeal wall. </li></ul><ul><li>Gavage feeding may be needed in such cases </li></ul><ul><li>Glossopexy or lip-tongue adhesion in infants </li></ul><ul><li>Tracheotomy </li></ul><ul><li>Mandibular distraction osteogenesis </li></ul>
  18. 18. Seibert’s Technique Lip Adhesion <ul><li>Medially and laterally based rectangular flaps from the margin of the cleft </li></ul><ul><li>Tension-bearing suture through the membranous septum. </li></ul><ul><li>Unilateral lip adhesion: A, landmarks and incisions; B, flaps elevated and undermined; C, placement of 3-0 nylon retention suture; D, final suturing. </li></ul>
  19. 19. Airway Management <ul><li>One hundred seven patients with Pierre Robin Sequence </li></ul><ul><li>74 (69.2%) - positioning alone </li></ul><ul><li>29 - tongue lip adhesion </li></ul><ul><ul><li>Airway obstruction relieved in 20 (83.3%) </li></ul></ul><ul><li>10 - Tracheostomy </li></ul><ul><ul><li>Including six (20.7%) who initially underwent a TLA </li></ul></ul>
  20. 20. Timeline One to Four months <ul><li>Monitor feeding and growth </li></ul><ul><li>Monitor ears and hearing </li></ul><ul><li>Repair cleft lip with possible PE tube placement </li></ul>
  21. 21. Incidence of Eustachian Tube Dysfunction <ul><li>Middle ear disease - 22% to 88% </li></ul><ul><li>Conductive hearing loss and chronic suppurative otitis media may result </li></ul><ul><li>Repeated tympanostomy tube placement </li></ul>
  22. 22. Why do cleft kids have eustachian tube dysfunction? <ul><li>Paratubal cartilage abnormalities </li></ul><ul><li>Hypoplasia of the lateral cartilage relative to the medial cartilage </li></ul><ul><li>Abnormal curvature of the eustachian tube lumen </li></ul><ul><li>Cephalometric data - width and angulation of the skull base with respect to the eustachian tube are different </li></ul><ul><li>Abnormal insertions of the tensor and levator veli palatini muscles into the cartilages and skull base </li></ul><ul><li>Palatal muscle dysplasia </li></ul>
  23. 23. How do you manage ear disease? <ul><li>96% of children with cleft palate required tympanostomy tube placement </li></ul><ul><li>50% of these children required repeat tympanostomy tube placement. </li></ul><ul><li>Frequency of otitis media decreases as the child with CP ages </li></ul><ul><li>Audiology and tympanometry as well as exams / clinical history </li></ul><ul><li>First set are frequently placed during cleft lip or cleft palate repair </li></ul>
  24. 24. Latham Appliance
  25. 25. Cleft Lip Repair Rule of 10’s <ul><li>Surgery > 10 weeks old </li></ul><ul><li>Weight > 10 pounds </li></ul><ul><li>Hemoglobin level > 10 g/dL </li></ul>
  26. 26. Cleft Lip Repair Goals <ul><li>Bridge the cleft </li></ul><ul><li>Create a complete muscular sling around the entire circumference of the oral cavity </li></ul><ul><li>Approximate cleft edges </li></ul><ul><li>Maintain Cupid's bow and philtral dimple </li></ul><ul><li>Align vermillion border </li></ul><ul><li>Create an intact nasal floor and sill </li></ul><ul><li>Produce symmetry of the alar base and columella </li></ul><ul><li>Reconstituting the circumferential integrity of the orbicularis oris muscle </li></ul>
  27. 27. Cleft Lip Repair - Types <ul><li>Millard Repair - Rotation advancement technique </li></ul><ul><li>Randall - Graham - Triangular flap interposition </li></ul><ul><li>Rose - Thompson - Straight line repair, Risk of vertical contracture </li></ul>
  28. 28. Millard Repair <ul><li>Downward and lateral rotation of the medial segment of the cleft lip combined with the medial advancement of the lateral cleft segment into the defect </li></ul><ul><li>Bridges the gap </li></ul><ul><li>Maintains the rotation flap in position </li></ul><ul><li>Maintains the amount of vertical height gained by the rotation flap and back cut </li></ul>
  29. 29. Timeline Five to Fifteen Months <ul><li>Monitor feeding, growth, and development </li></ul><ul><li>Repair cleft palate </li></ul><ul><li>Monitor ears and hearing </li></ul><ul><li>Instructions in oral hygiene </li></ul>
  30. 30. Cleft Palate Repair - Timing <ul><li>Dorf and Curtin </li></ul><ul><ul><li>10% occurrence of articulation errors when palatoplasty was completed by 1 year </li></ul></ul><ul><ul><li>86% incidence of articulation errors when repair was complete after 1 year </li></ul></ul><ul><li>Haapanen and Rantala - Significantly fewer children in the groups repaired before 18 months had hypernasal speech, articulation errors, or required secondary surgery to correct speech </li></ul>
  31. 31. Cleft Palate Repair <ul><li>V-Y Pushback </li></ul><ul><li>Two Flap Palatoplasty </li></ul><ul><li>Four Flap Palatoplasty </li></ul><ul><li>Schweckendick’s Primary Veloplasty </li></ul><ul><li>Furlow Palatoplasty </li></ul>
  32. 32. Cleft Palate Repair V-Y Pushback <ul><li>Two uni-pedicled flaps (greater palatine artery) and one or two anteriorly based pedicled flaps </li></ul><ul><li>Posterior flaps rotated in a V-Y advancement technique - increasing the length of the palate </li></ul><ul><li>Nasal mucosa not closed </li></ul><ul><li>Improved speech results compared with bipedicled techniques </li></ul><ul><li>Indicated for incomplete clefts </li></ul>
  33. 33. Cleft Palate Repair Schweckendick’s Primary Veloplasty <ul><li>Incisions made in soft palate </li></ul><ul><li>Muscle bundles released from the posterior hard palate and rotated </li></ul><ul><li>Reconstruction of levator sling </li></ul><ul><li>Closure of mucosal layers separately </li></ul>
  34. 34. Cleft Palate Repair Furlow Palatoplasty <ul><li>Lengthens the soft palate </li></ul><ul><li>Reconstructs the muscle sling. </li></ul><ul><li>Also commonly used to correct velopharyngeal insufficiency in patients with submucous cleft palate </li></ul><ul><li>Speech outcomes are improved compared with other palatoplasty techniques. </li></ul>
  35. 35. Cleft Palate Repair Complications <ul><li>Oronasal fistula - 8.7% to 23% </li></ul><ul><ul><li>Sites of fistulization are typically the anterior hard palate and the junction of the hard and soft palate. </li></ul></ul><ul><li>Velopharyngeal insufficiency </li></ul>
  36. 36. Timeline Two to Five years old <ul><li>Monitor speech and language development </li></ul><ul><li>Manage velopharyngeal insufficiency </li></ul><ul><li>Monitor ears and hearing; ear tubes if indicated </li></ul><ul><li>Assess development and psychosocial needs </li></ul><ul><li>Consider lip/nose revision before school </li></ul>
  37. 37. Timeline Six to Eleven years old <ul><li>Monitor speech and language; manage velopharyngeal insufficiency </li></ul><ul><li>Orthodontic evaluation and treatment </li></ul><ul><li>Alveolar bone graft </li></ul><ul><li>Monitor school and psychosocial needs </li></ul>
  38. 38. Timeline Twelve to Twenty One years old <ul><li>Monitor school and psychosocial needs </li></ul><ul><li>Orthodontics and restorative dentistry </li></ul><ul><li>Genetic counseling </li></ul><ul><li>Rhinoplasty (if needed) </li></ul><ul><li>Orthognathic surgery (if needed) </li></ul>

×