What is revealed in this picture of a patient with a submucous cleft palate?
- Bifid uvula
- Zona pellucida: Diastasis of levator muscle with notable thinking of soft tissue at the midline, esp. with elevation of the palate.
- Anterior displacement of levator muscles (inverted V) during phonation
What history should be taken during the work-up of a patient with a cleft palate?
- Pregnancy, birth, and newborn history
- prenatal care and exposure (alcohol, smoking, anticonvulsants, corticosteroids)
- Family history of orofacial clefting
- Additional medical problems
- cleft palate without cleft lip: 40A% incidence of syndromic presentation
- Airway concerns
- Consider PRS if small jaw and airway obstruction
- Feeding and weight gain history
What is the incidence of syndromic presentation in cleft palate without cleft lip?
40%
What are the classifications used to classify the extent of cleft and structural involvement?
- Complete (soft and hard palates)
- Incomplete (soft palate alone)
- Primary and/or secondary palate (dividing point is the incisive foramen)
- Unilateral or bilateral (vomer visible on one or both sides)
- Cleft lip involvement
- Veau classification
What is the Veau cleft palate classification system used for? Describe it.
To classify the extent of cleft and structural involvement
What imaging or diagnostic studies should be performed if there is suspicion for other congenital anomalies?
- Echocardiogram
- Renal ultrasound
- X-rays of the spine
Genetic testing may also be performed if a syndrome is suspected.
What is the role of a multidisciplinary team in managing cleft palate? Name all who should be involved.
- Plastic surgery
- Pediatric otolaryngology
- Speech pathology
- Audiology
- Genetics
- Pediatric dentistry
- Orthodontics
- Oral-maxillofacial surgery
- Social work
- Nursing
*Genetics (if associated anomalies present)
Describe patient counseling needs in cleft palate cases. What are the feeding recommendations?
- Multidisciplinary team required.
- Discuss likelihood of several surgeries over the child’s lifetime.
- Feeding: risk of being underweight d/t inability to create effective suction force. The infant tires before achieving full feeding and satiation.
- Elevate head and cradle infant at 45 degrees
- Use specialized nipples/bottles: Haberman feeder (squeezable nipple), Pigeon nipple (cros hatched for faster flow), Dr. Brown’s level 2 nipple with Pigeon valve
What is the timing for cleft palate repair?
9-12 months of age
Earlier repair increases the risk of maxillary growth abnormalities; later repair (>18 months of age) delays language development»_space; worse speech outcomes, higher fistula rates, more hypernasality and VPI, more likely to require additional surgery later in lift.
What is the von Langenbeck palatoplasty technique used for? Describe the technique.
Hard palate repair - It is best used for incomplete clefts of the secondary palate without cleft lip or alveolus ( but obviously can be used for complete)
- Relaxing incisions along the lateral edge of the hard palate and incisions medially at the mucosa along the edges of the cleft. Raise bilateral bipedicled much periosteal flaps that approximate oral surface of the cleft.
What is the most commonly utilized technique for repairing complete clefts of the primary and secondary palates? Describe the technique
Two-flap palatoplasty (Bardach)
INcisions similar to von Langenbeck repair, but they meet cleft margins just behind the alveolar ridge. Anterior mucoperiosteal flaps are elevated based on greater palatine vessels. LVP freed from posterior border of hard palate and sutured across midline.
What is the purpose of the vomer flap in cleft palate repair? How is it done?
Important in the setting of bilateral, complete cleft palate. It is used to close any remaining gap in the hard palate. Vomer is exposed in the cleft gap and septal mucosa flaps are raised and are sutured to adjacent nasal mucosa laterally.
What is required for all patients postoperatively after cleft palate repair?
Airway monitoring with continuous pulse oximetry
[we also used a tongue stitch]
What surgical technique is used for an incomplete soft palate cleft (Veau I)?
Soft palate repair with intravelar veloplasty or Furlow palatoplasty
What surgical technique is used for a complete cleft of the soft and hard palate (Veau II)?
von Langenbeck repair with intravelar veloplasty or Furlow palatoplasty
What technique is used for unilateral or bilateral cleft lip and palate (Veau III and IV)?
Two-flap palatoplasty technique with either intravelar veloplasty or Furlow palatoplasty
When is surgical repair considered for submucous cleft palate?
Only after velopharyngeal insufficiency is clearly identified (usually 3-5 years of age)
Treated like Veau I clefts.
What is a key ethical consideration in cleft care?
Cleft care should be performed in multidisciplinary centers that specialize in the care of complex cases.
What complication can occur due to bleeding, edema, or tongue swelling post-surgery? How do you treat it?
Airway obstruction
May require nasopharyngeal airway or endotracheal intubation if severe. If a tongue stitch is in place, it can be used to pull the tongue forward to open the posterior airway.
What is the typical nature of bleeding after cleft palate surgery?
Usually minor and self-limited
Requires airway monitoring; severe cases may need return to the operating room.
What complication may manifest several weeks after cleft palate surgery?
Palatal fistula
This is not an emergency and can be managed electively about 6 months after initial palatoplasty.
What percentage of patients may present with velopharyngeal insufficiency after cleft palate repair? How does it present?
Up to 20%
This condition may lead to hypernasal speech.
What is necessary for the follow-up of patients treated with cleft palate repair?
Regular follow-up for many years - monitor for VPI - Requires thorough evaluation with velopharyngeal imaging (video nasendoscopy, speech videofluoroscopy).
Describe the intravelar veloplasty technique.
Most commonly used technique wherein levator veil palatini muscles are dissected out and reapproximated from the anterior malposition; repositioned in the midline wi a transverse orientation.
