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It appears as if the person is trying to hold his breath and talk at the same time. Hearing disorders are prevalent among individuals with orofacial clefts. These disorders are a result of chronic otitis media with effusion due to eustachian tube dysfunction. The tensor veli palatini muscle that normally functions to open the eustachian tube fails to do so causing pressure and fluid build-up in the middle ear with subsequent infections, inflammation, and scarring.
Some form of hearing disorder is present in all infants with unrepaired palatal clefts before the age of 2 years. A multidisciplinary team is essential to manage the many facets affected by orofacial clefting. The reconstructive surgeon works in cooperation with otolaryngologists, dentists and orthodontists, speech pathologists, audiologists, geneticists, psychiatrists, maxillofacial surgeons, social workers, and prosthodontists.
The techniques of cleft palate repair that are practiced today are the result of principles learned through many years of modifications. The challenge of modern palatoplasty is no longer simply successful closure of the cleft palate.
Enabling optimal speech without compromising maxillofacial growth is the goal of the modern craniofacial surgeon. Nonsurgical treatment of the cleft palate is attempted with prosthodontic devices designed to correct velopharyngeal incompetence. Indications for use of prosthodontic devices are rare and largely of historical interest. Candidates who may benefit from prosthodontic devices are those who do not want or are too high risk for surgery, those in whom surgery has failed, or patients who would benefit from better alignment of the maxillary segments prior to definitive surgery.
Additionally, the device may be irritating to the fragile mucosal surface, difficult to clean, and require cooperation on the child's behalf. Obturation is practical beginning at ages 3 to 4 years. The principle advantage is achieving as high or a higher rate of velopharyngeal competence than with surgery while avoiding potential surgical complications, such as restricted maxillary growth.
Cleft patients are capable of normal facial skeleton development, but corrective surgical procedures are known to impair maxillary growth and may lead to midface retrusion. Fewer maxillary growth complications are seen with procedures that produce less tension on the palate, and as a result produce less scar tissue on the denuded palate. Optimal timing of cleft palate repair must take into account other medical conditions and speech development. Early repair has been shown to benefit speech development, but may inhibit facial growth to a greater extent as transverse facial growth is not complete until 5 years of age.
In the past, surgery on the palate was often delayed until maxillary growth was completed or when deciduous molars achieved proper occlusion. Recently, speech outcomes have taken precedence and as a result, most experts repair cleft palates beginning at 10 months of age.
Surgery on isolated soft palate clefts has been advocated as early as 3 months of age. The most common surgical techniques for repair of the soft palate are the Furlow double-opposing Z-plasty Fig. The bony palate is often repaired using the Von Langenbeck palatoplasty, the Veau-Wardill-Kilner palatoplasty, or a Bardach two-flap palatoplasty.
Vomer flaps are used in conjunction with the above hard palate repairs to repair the nasal mucosa. Pre- and postoperative pictures status postfistula repair with a Furlow Z-plasty.
Surgical markings are shown. The most common complications following surgical repair of cleft palate include palatal fistula, persistent velopharyngeal insufficiency and sleep apnea. Fistula rates exhibit a wide variation by surgeon and type of repair. Some report, the Veau-Wardill-Kilner repair has a higher rate of fistula formation than the Von Langenbeck repair, which has a higher rate than the Furlow palatoplasty and intravelar veloplasty.
Wide and bilateral clefts also suffer from higher fistula rates. It is unclear whether timing of repair has an influence on fistula formation. Speech disturbances, including VPI, are often not evaluated until ages 5 to 6 when a child can cooperate with a speech exam.
At that time, recommendations can be made for speech therapy, palatoplasty revision, or another compensatory procedure such as a pharyngoplasty or pharyngeal flap. Primary palate repair appears to affect maxillary growth to a greater extent than repair of the secondary palate. Age at operation should be carefully considered, taking care to minimize growth disturbance of the midface while balancing the need for proper development of speech.
Sleep apnea typically affects patients with Pierre Robin sequence to a greater extent than nonsyndromic cleft palate patients.
Careful monitoring of these patients is needed to assess for symptoms of sleep apnea. In these patients, cleft palate repair may need to be delayed until airway compromise is treated with a tongue-lip adhesion or mandibular distraction. Our understanding of cleft palates has come a long way since the early days of treatment. While closure of the defect is a primary goal, a thorough understanding of cleft palates and their associated problems will ensure that patients have successful long-term outcomes and adequate speech development.
Optimal management of these children consists of a multidisciplinary team and a skilled surgeon. National Center for Biotechnology Information , U. Journal List Semin Plast Surg v. Semin Plast Surg. Tomasz R. Kosowski , MD, 1 William M. Weathers , MD, 2 Erik M.
Wolfswinkel , BS, 2 and Emily B. Ridgway , MD 1. William M. Erik M. Emily B. Author information Copyright and License information Disclaimer. Address for correspondence Emily B. Show references Wilkins-Haug L.
Accessed April 3, Crockett DJ, et al. Cleft lip and palate. Cleft lip and palate repair: Correcting abnormal development. American Society of Plastic Surgeons. Campbell A, et al. Cleft lip and palate surgery: An update of clinical outcomes for primary repair.
Facts about cleft lip and cleft palate. Centers for Disease Control and Prevention. Cleft lip and cleft palate. American Speech-Language-Hearing Association. Brown A. Allscripts EPSi. Mayo Clinic, Rochester, Minn. March 5, Cleft lip and cleft palate pediatric. Early education can help ease some of the fears parents may have.
Jeffrey Goldhagen, M. Jessica Shepherd, M. See All Trying Birth After. Raising Kids. Facebook Twitter LinkedIn Syndicate. Cleft Palate with Cleft Lip. Minus Related Pages. Cleft palate with cleft lip. Diagnosis Prenatal. Clinical and epidemiologic notes Rarer conditions that can be confused with typical cleft lip are the atypical or Tessier type clefts and the amniotic band spectrum. Amniotic band spectrum can cause facial disruptions that involve both the lip and palate, and often include atypical skull and brain lesions e.
Additional clinical tips: Always check the palate when you see a cleft lip — the diagnosis is important both for surveillance and for clinical care.
Check for lip pits in the lower lip Fig.
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