Cleft lip and palate are common birth defects that affect speech, hearing, breathing, and appearance. They require a team-based approach involving multiple specialists like otolaryngologists. The document discusses the management of cleft lip and palate, including the roles of different specialists in examining, diagnosing, and treating issues related to feeding, airway, speech, hearing, and surgery. Surgical techniques aim to restore normal anatomy and function through procedures on the lip and palate.
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Cleft lip and palate management
1.
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.
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
13.
14.
15.
16.
17.
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.
22.
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.
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.
35. Surgical Repair:
After through preoperative preparation
&
Anesthetic fitness
Labioplasty performed under General
Anesthesia
Date: 1.8.2008
36.
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
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 Incidence 1:276 Live
Births
42. Gender Predominance
Cleft Lip More common in
males 80%
Cleft Palate More common in females
67%
Cleft Lip/ cleft palate … both
Predominate -
in males.
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