Presentation on theme: "SURGICAL REPAIR OF CLEFT LIP AND PALATE"— Presentation transcript:
1SURGICAL REPAIR OF CLEFT LIP AND PALATE CAPT MUBASHIR IQBAL
2IntroductionFacial clefting is the second most common congenital deformity (after clubfoot)Affects 1 in 750 birthsProblems are cosmetic, dental, speech, swallowing, hearing, facial growth, emotionalOtolaryngologist holds key role in management
3EMBROYOLOGY 4th week FACIAL PROMINENCES Frontonasal process forms forehead ,bridge of nose, medial & lateral nasal prominencesMaxillary process forms cheeks & lateral portion of upper lipLateral nasal process forms alae of noseMedial nasal process forms nasal septum,philtrum,premaxilla & primary palateMandibular process forms lower lip
5ANATOMY Hard Palate Maxilla( Palatine Processes) + Palatine Bones(Horizontal Lamina)
6ANATOMYSoft PalateFibromuscular shelf attached like a shelf to posterior portion of hard palateTensor Veli PalatiniLevator Veli Palatini(Primary Elevator) Musculus Uvulae,PalatoglossusPalatopharyngeus
13EPIDEMIOLOGY Highest incidence in NATIVE AMERICANS ( 3.7/1000) Lowest in AFRO-CARRIBEAN (0.3/1000)Cleft lip + palate more common in boys 2 :1Cleft lip common in boys 1.5 : 1Cleft palate alone more common in girlsC/L left twice as common as rightUnilateral/bilateralComplete/incomplete
15ASSOCIATION with other SYNDROMES Increased Clefts with maternal diabetes mellitus and amniotic band syndromeCleft Lip + Palate- 50%Cleft Palate- 30%Cleft Lip- 20%Cleft Lip + Alveolus- 5%SYNDROMESvelocardiofacial syndrome, goldenhar syndrome, stickler & treacher collins syndromes
16CLEFT FORMATION Cleft result in a deficiency of tissue Cleft lip occurs when an epithelial bridge failsClefts of primary palate occur anterior to incisive foramenClefts of secondary palate occur posterior to incisive foramen
17CLEFT LIP Nasal floor communicates with oral cavity Maxilla on cleft side is hypoplasticColumella is displaced to normal sideNasal ala on cleft side is laterally, posteriorly, and inferiorly displacedLip muscles insert into ala and columella
18Palatal CleftsSoft palate muscles insert on posterior margin of remaining hard palate rather than midline raphe.Associated Dental AbnormalitiesSupernumery Teeth- 20%Dystrophic Teeth- 30%Missing Teeth- 50%Malocclusion- 100%
22MANAGEMENT Team Approach Otolaryngologist has a pivotal role Initial Head and Neck ExaminationSpeech DisordersEar DiseaseAirway ProblemsSurgical Repair
23Head and Neck Exam Head- facial symmetry Otologic- auricle and canal development and location, pneumatic otoscopy, forksRhinoscopy- identifies clefting, septal anomalies, masses, choanal atresiaOral Exam- cleft, dental, tongueUpper airway- phonation, cough, swallow
24Speech Disorders Errors in Articulation: Fricatives, Affricates Velopharyngeal Competence- Most important determinant of speech quality in cleft palate patients-75% achieve competence after initial palate surgeryIncompetence- nasal emission or snortEvaluation- Direct exam , Fiberoptic Exam
25Ear Disease Cleft Lip- Incidence similar to normal pop. Cleft Palate- Almost all with ETD, CHLETD- Due to abnormal insertion of levator veli palatini and tensor veli palatini into posterior hard palateETD- Returns to normal by mid-adolescentCleft Palate- Increased Cholesteatoma(7%)
26Ear Disease Otologic Goals For Cleft Palate Patients Adequate hearingOssicular chain continuityAdequate middle ear spacePrevent TM deteriorationIndications for Myringotomy TubesCHL, Persistent/Recurrent effusion, RetractionCleft palate: Multiple BMTs from 3mo yrs
27Airway ProblemsMore common in Cleft Palate patients with concomitant structural or functional anomalies.e.g. Pierre-Robin SequenceMicrognathia, Cleft Palate, GlossoptosisMay develop airway distress from tongue becoming lodged in palatal defect
28Surgical Repair- Cleft Lip Lip Adhesions-2 weeks of ageConverts complete cleft into incomplete cleftServes as temporizing measure for those with feeding problemsMay interfere with definitive lip repairLess often needed in recent years due to wider variety of specialty feeding nipples
29Surgical Repair- Cleft Lip Cleft lip repaired at 10 weeksRotation-advancement method- Most common in the U.S.Nine LandmarksRotation Flap cuts made firstAdvancement cuts made nextCleft side nasal ala cuts made last
30Surgical Techniques Cleft Lip Repair unilateral rotation-advancement flap developed by Millardcomplicationsdehiscenceinfectionthin white rollexcess tension
34Surgical Repair- Cleft Palate Several Techniques- Trend is towards less scarring and less tension on palateScarring of palate may cause impaired mid-facial growth(alveolar arch collapse, midface retrusion, malocclusion)Facial growth may be less affected if surgery is delayed until months, but feeding, speech, socialization may suffer.
35Surgical Repair- Cleft Palate Bardach Method- Two Flap techniqueMedial incisions made, which separate oral and nasal mucosaLateral incisions made at junction of palate and alveolar ridgeElevate flaps, preserve greater palatine artery.Detach velar muscles from posterior palateClose in 3 layers
43Non-Surgical Treatment Dental ObturatorFor high-risk patients or those that refuse surgeryAdvantage- High rate of closureDisadvantage- Need to wear a prosthesis, and need to modify prosthesis as child grows.
45ConclusionsCleft Lip and Palate are common congenital deformities that often affect speech, hearing, and cosmesis; and may at times lead to airway compromise.The otolaryngologist is a key member of the cleft palate team, and is in a unique position to identify and manage many of these problems .