Cleft lip and palate management

ENT

2. CLEFT LIP / PALATE
Management
DR. GHLAM SAQULAIN
M.B.B.S,D.L.O,F.C.P.S
Head of Department of Otorhinolaryngology
CAPITAL HOSPITAL
Islamabad.

3. Cleft Lip and Palate are common
congenital deformities that often affect
speech, hearing, and cosmesis; and
may at times lead to airway
compromise.

4. MANAGEMENT
Team Approach
 Otolaryngologist has a pivotal role
 Initial Head and Neck Examination
 Speech Disorders
 Ear Disease
 Airway Problems
 Surgical Repair

5. A) Primary Management
Antenatal Diagnosis:
It is possible to diagnose by ultrasound scan after 18 weeks
of gestation. Isolated cleft palate cannot be diagnosed by
USS.
When diagnosis is confirmed referral to cleft surgeon is
appropriate for genetic counseling.
Feeding Difficulties:
Most affected babies feed well and thrive provided
appropriate advise and support to mother is given.
Some mothers are successful in breast feeding particularly
in incomplete clefts.
Soft bottles and modified teats can help

6. Airway Problems:
Major respiratory obstruction is uncommon but
can occur in some cases.
Intermittent airway obstruction is more frequent
and managed by nursing the baby prone.
More severe and persistent airway compromise
can be managed by retained nasopharyngeal
intubations.
Surgical adhesion of tongue to lip c/a
Labioglossopexy can be an alternate in first few
days but it is less commonly practiced.

7. B) Surgical Techniques
Principles of Surgery:
Surgical techniques are aimed to restore
the normal anatomy of lip, nose, and face
Normal or near normal anatomy promotes
normal function, thereby encouraging
normal growth and development of lip,
nose, palate and facial skeleton

8. Timing of Surgery:
Rule of tens
•At least 10 weeks old
•Weighs at least 10 pounds
•Has Hb. Of 10 gm.
Better results are obtained when the child
is at least 3 months.

9. Muscle Realignment:
In this condition Nasolabial
and bilabial muscle rings
are disrupted on one or both
side resulting in deformity
This has to be taken into
consideration while planning
repair.
Pre Op. Orthopaedic
Treatment:
Realignment of alveolus
prior to lip repair improves
the balance and symmetry
and future development of
mid face.

10. Operative Procedures(Cleft Lip)
Two surgical techniques are used most
widely in cleft lip surgery:
Rotation-advancement technique
Triangular flap technique
Lip adhesions – Difference of opinion.
It is first stage of two stage lip
reconstruction.

11. Rotation Advancement Technique
Millard 1957
Does not require precise
markings and
measurements
Based on surgeons
ability to use the basic
design and to adjust the
tissue as the operation
progresses until
acceptable alignment is
achieved.

12. Triangular Flap Technique
Based on idea of
using the design to
establish equal
vertical dimensions
on both lip
segments
Construction of
equilateral triangular
flaps on each side
Lip repair by Bardach technique

18. Operative Procedure(Cleft Palate)
Several Techniques- Trend is towards less
scarring and less tension on palate
Scarring of palate may cause impaired mid-
facial growth (alveolar arch collapse, mid
face retrusion, malocclusion)
Facial growth may be less affected if surgery
is delayed until 18-24 months, but feeding,
speech, socialization may suffer.

19. Hearing Management:
It has been recently recognized that a child with
craniofacial anomaly including cleft lip and palate
is at increased risk of sensori-neural hearing
deficit.
All children born with cleft lip and palate should be
assessed for SNHL and Conductive hearing loss
before 12 months of age, by ABR and
tympanometry.
•SNHL is managed by Hearing aid
•Conductive Hearing loss is managed by Surgical and
medical management of OME.
C) REHABILITATION

20. Speech Problems and
Management:
Velopharyngeal
incompetence (Increased
nasal airflow and resonance
produing nasal or hyper
nasal quality of speech)
Articulation problems:
Speech problems are
managed by
Speech and language therapy
Secondary palatal surgery
•Intravelar veloplasty
(muscular reconstruction
of soft palate
•Pharyngoplasty
Speech training devices

21. Dental Problems and Management
Delayed tooth development
Delayed eruption of teeth
Morphological abnormalities
Decreased number of teeth (hypodontia) or increased
number of teeth (Hyperdontia0
Regular examination should be done. Many patients
require orthodontic treatment
Secondary Surgery for Cleft Lip and Palate
Despite adequate primary surgery, residual
problems do occur and are managed by
appropriate secondary surgical procedures.

23. Non Surgical Treatment
Lip Adhesions
Dental Obturator
For high-risk patients or those that refuse
surgery.
Advantage- High rate of closure
Disadvantage- Need to wear a prosthesis,
and need to modify prosthesis as child
grows.

24. Questions?
Answers
Thank You

25. CLEFT LIP
A CASE REPORT
Dr. Aasma
House Surgeon, ENT Department

26. Patient Profile
Name: xyz
Address: G 7/1,
Islamabad
Age: 8 Months
Sex: Female
DOA: 25-07-06
DOD: 04-08-06

27. HISTORY
Main Complaint:
Lip deformity since birth
Natal History:
no H/O birth trauma.
Normal vaginal delivery
child cried well after birth.
No H/O Feeding Problems or breathing difficulty.
Weight of baby at birth was 2.7 Kg.
Family History:
No Family history of similar or congenital anomaly

28. Milestones:
Milestones achieved normally within time limits.
Past History:
No past H/o any significant medical disease
No Past H/o any surgery
No Past H/o Allergy
Personal History:
Seep and Appetite normal
No C/o feeding problem, vomiting, diarrhoea, constipation
No C/o Fever.

29. General Physical Examination
Baby was active, conscious,
stable well oriented, cooperative
and smiling all the time.
She was healthy according to
age.
No other anomaly noted.
Pulse: 115/min
Temp: Afebrile
Pallor: -ve
Jaundice: -ve
Dehydration: -ve
Cyanosis: -ve
Clubbing: -ve
Edema: -ve
Lymph Nodes: Not
palpable

30. Examination of Face:
Unilateral cleft lip
Deformity nose left side
No other facial anomaly
Throat Examination:
Good Hygiene
Upper lip defect, margins of cleft
normal with no inflammation
Lower lip normal
Normal palate Mucosa of oral
cavity normal
Tongue, gums normal
Lower two teeth erupted.

31. Examination of Nose
Depressed nasal ala on left side
Nasal septum and lateral walls normal
Floor normal posteriorly, anteriorly oro
nasal fistula opening in front of gum
margin.
Examination of Ear
Tympanic membranes in both ears normal
with no signs of secretry otitis media ( i.e,
retraction, buldging of TM, air bubbles, fluid
level behind TM.

32. Systemic Examination
Cardio-Respiratory System:
S1 +S2 audible in all four areas.
Chest Clear with NVB
GIT:
NAD
No Scar
No Swelling
No Tenderness
CNS:
NAD
Loco motor System:
No other congenital anomaly seen.

33. Investigations
Blood CP
Hb: 12.3 g/dl
WBC: 16.8 x10
3
/uL
RBC: 4.78 X10
6
/uL
MCV: 69.04 fL
MCH: 26.6 pg
MCHC:37 g/dl
Plt.:460 x 10
3
/uL
BT: 03min 20 sec
CT: 05min 30 sec

34. X-Ray chest (PA): Normal

35. Surgical Repair:
After through preoperative preparation
&
Anesthetic fitness
Labioplasty performed under General
Anesthesia
Date: 1.8.2008

37. Post Operative
Post Operative Treatment:
Inj. Ceftim 125 mg i/v BD for two days
Then Syp. Dynacef 125 mg tds.
Syp. Brufen ½ tsf SOS.
Post Operative recovery was uneventful
Patient discharged on third post
operative day

39. LITERATURE REVIEW
Dr. Muhammad Farooq Khan
Medical Officer
Department of E.N.T,
Head & Neck Surgery.

40. INTRODUCTION
Facial clef ting is the second most
common
congenital deformity (after clubfoot).
Affects 1 in 750 births
Problems are cosmetic, dental, speech,
swallowing, hearing, facial growth,
emotional
Otolaryngologist holds key role on CP
team

41. Incidence
Cleft Lip and Palate 1:600 Live
births
Isolated cleft palate 1:1000Live
births
In black population 1:2000
Live Births
In Native American Tribes of Montana
(USA) Highest Incidence1:276 Live
Births

42. Gender Predominance
Cleft Lip More common in
males 80%
Cleft PalateMore common in females
67%
Cleft Lip/ cleft palate … both
Predominate -
in males.

43. Types
Cleft Lip alone 15%
Cleft Lip & Cleft Palate both45%
Isolated Cleft Palate 40%

44. Etiology (Multifactorial)
Genetic predisposition
Contributory environment components
Maternal Age: Cleft lip is associated with
increasing maternal age but cleft palate has
no relation with it.
Maternal Epilepsy
Drugs During Pregnancy like:
Anticonvulsants
Steroids
Sedatives

45. EMBRYOLOGY

46. Palatal development-1