cleft & sinus

Question 1

how to classify cleft

Answer 1

Kernahan & Stark 1958
- cleft of primary palate
- cleft of secondary palate
- both

Question 2

list down the problems the cleft patients have

Answer 2

1) dental problems
- increased risk of perio and caries

2) malocclusion
- class iii malocclusion secondary to trauma of cleft closure
- collapsed arch
- delayed eruption of teeth in cleft

3) nasal deformity
- because cleft disrupts the normal development and fusion of tissues in face and mouth, leading to uneven growth

4) speech problems
- hypernasality: due to communication between nose and oral cavity

5) feeding problems
- for babies, there is a difficulty sucking because they cant produce negative pressure required and their musculature is underdeveloped
hence risk of aspiration

6) ear problems
- in CLP patients, middle ear remains a closed space without a drainage mechanism
- prone to serous otitis media or bacteria infection, risk of hearing loss

Question 3

what sort of mutlidisciplinary mx do they require

Answer 3

• pediatrician
• oms
• plastics
• ENT
• nutritionist
• speech therapist
• occupational therapist

Question 4

when should cleft lip and palate repairs be done and what to note for each

Answer 4

cleft lip at 3 months
- rule of 3 10s: 10 weeks age, 10 pounds weight, 10g/dL of Hb
- has to be done this early to assist feeding
- techniques: Millard rotation advancement cleft lip repair (most common) & De laire functional cheilorhinoplasty

palate repair needs to be split into hard and soft palate
soft palate repair at 8-18 months
- in order to make it for speech and lang development which starts at about 1 year

hard palate repair at 4-5 years old
- delayed to reduce inhibition of maxillary growth because operative trauma results in scar tissue which impedes maxillary growth
- results in class iii malocclusion
- technique: 2 flap technique (most common) or double reverse Z plasty

alveolar bone grafting at 7-9 years old
- need to graft more bone for canines to erupt and to close space in alveolus
- gold standard is to use autologous cancellous bone graft from iliac crest or mandible

then at puberty, can do secondary corrections like Le fort 1 surgery and lip/nose revision

Question 5

acute and chronic presentations of sinus infections

Answer 5

acute:
- facial swelling
- rapidly developing pressure, pain
- draining of pus into nose
- headache

chronic:
- nasal obstruction
- toothache

visually can see:
- swelling/ redness of cheek
- nasal discharge
- when transilluminate, there is decreased transmission of light

on palpation, tender to:
- tapping of lateral walls of sinus over cheeks
- palpation intraorally

Question 6

what can we expect to see radiographically for sinus infections

Answer 6

on DPT
- can see partial opacification in radiolucent sinus.
- or can see like a demarcation between air fluid levels
- for the radiopaque areas, look out for disruption of cortical outline

Question 7

list out disorders of maxillary sinus

Answer 7

1) developmental
- cleft palate

2) infective
further split into
- odontogenic (infection from periapical or periodontal disease)
- non odontogenic (infection from nasal cavity)

3) neoplastic
split into
- benign (nasal polyps, or antral cysts, sinus mucocele, retention cysts)
- malignant (SCC, adenoid cystic carcinoma)

4) iatrogenic
- displacement of roots into antrum
- oro antral communications
- fractured tuberosity
- penetration of sinus by implants

Question 8

what are the signs if there ewre to be a malignancy in sinus

Answer 8

• fast growing swelling
• numbness of cheek (infraorbital nerve involvement)
• headache
• upper teeth involvement (may lose sensibility due to palatine nerve invasion)
• nasal obstruction , epistaxis
• palatal swelling

Question 9

methods of closure for cleft lip

Answer 9

1) Rose thompson method
- straight line closure
- suitable only for very minimal cases
- cant be used in complete clefts without distorting philtrum and cupids bow

2) Tennison randall triangular repair
- cupids bow can be preserved
- by reotration

3) Millard’s rotation advancement cleft repair
- advancement rotation method
- most widely used
- medial side rotatd downwards by placing curved incision below columella

4) Delaire technique of functional cheilo rhinoplasty
- recon of nasolabial muscles

Question 10

techniques for repair of cleft palate

Answer 10

1) Von langenbeck technique
- make flaps and advance medially to close palatal defect
- not much dissection
- disadv is that it does not increase length of palate

2) 2 flap technique
- most commonly used for complete clefts
- flaps are rotated medially to close defect
- palate is closed in layers

3) Double reverse Z plasty Furlow technique
- can lengthen soft palate
- suitable for narrow clefts
- goal is to separate non funcitoning attachments to the posterior border of hard palate, displace muscles posteriorly