CLEFT LIP / PALATEManagement

DR. GHLAM SAQULAINM.B.B.S,D.L.O,F.C.P.S

Head of Department of OtorhinolaryngologyCAPITAL HOSPITAL

Islamabad.

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

MANAGEMENT

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

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

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.

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

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.

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.

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.

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.

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

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.

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

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

Dental Problems and Management Delayed tooth development Delayed eruption of teeth Morphological abnormalities Decreased number of teeth (hypodontia) or increased

number of teeth (Hyperdontia0Regular 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.

Non Surgical Treatment

Lip AdhesionsDental 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.

Questions?

Answers

Thank You

CLEFT LIP A CASE REPORT

Dr. AasmaHouse Surgeon, ENT Department

Patient Profile

Name: xyzAddress: G 7/1, IslamabadAge: 8 MonthsSex: FemaleDOA: 25-07-06DOD: 04-08-06

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

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.

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

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.

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 EarTympanic membranes in both ears normal with no

signs of secretry otitis media ( i.e, retraction, buldging of TM, air bubbles, fluid level behind TM.

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.

Investigations

Blood CP Hb: 12.3 g/dl WBC: 16.8 x103 /uL RBC: 4.78 X106 /uL MCV: 69.04 fL MCH: 26.6 pg MCHC: 37 g/dl Plt.: 460 x 103/uL

BT: 03min 20 sec

CT: 05min 30 sec

X-Ray chest (PA): Normal

Surgical Repair:

After through preoperative preparation &

Anesthetic fitnessLabioplasty performed under General

Anesthesia Date: 1.8.2008

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 uneventfulPatient discharged on third post

operative day

LITERATURE REVIEW

Dr. Muhammad Farooq KhanMedical OfficerDepartment of E.N.T,Head & Neck Surgery.

INTRODUCTION

Facial clef ting is the second most common

congenital deformity (after clubfoot).Affects 1 in 750 birthsProblems are cosmetic, dental, speech,

swallowing, hearing, facial growth, emotional

Otolaryngologist holds key role on CP team

Incidence

Cleft Lip and Palate 1:600 Live birthsIsolated cleft palate 1:1000Live birthsIn black population 1:2000 Live BirthsIn Native American Tribes of Montana

(USA) Highest Incidence 1:276 Live Births

Gender Predominance

Cleft Lip More common in males 80%

Cleft Palate More common in females 67%

Cleft Lip/ cleft palate … both Predominate - in males.

Types

Cleft Lip alone 15%Cleft Lip & Cleft Palate both 45%Isolated Cleft Palate 40%

Etiology (Multifactorial)

Genetic predispositionContributory environment componentsMaternal Age: Cleft lip is associated with

increasing maternal age but cleft palate has no relation with it.

Maternal EpilepsyDrugs During Pregnancy like:

Anticonvulsants Steroids Sedatives

EMBRYOLOGY

Palatal development-1