Cleft Lip and Cleft Palate

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General Information

If you rub your finger over your upper lip, you'll feel the tissue that runs between your nose and lip. That groove in between is called your philtrum (say: fill-trum). Now run your tongue over the roof of your mouth. The line that is the middle, is where your palate grew together. If you open your mouth and look into a mirror you can see that the palate goes from your teeth all the way to the back of your mouth and there are no defects or holes in your palate. The word cleft means a gap or split between two things. A cleft lip is a split in the upper lip. A cleft palate is a split in the roof of the mouth. This leaves a hole between the nose and the mouth. Cleft lip, with or without cleft palate, affects 1 in 700 to 1,000 babies in the United States each year.

QUICK CLEFT LIP & CLEFT PALATE FACTS:

There are generally three different kinds of clefts:

  1. cleft lip without a cleft palate
  2. cleft palate without a cleft lip
  3. cleft lip and cleft palate together

 

In addition, clefts can occur on one side of the mouth (unilateral clefting) or on both sides of the mouth (bilateral clefting).

More boys than girls have a cleft lip, while more girls have cleft palate without a cleft lip.

Because clefting causes specific visible symptoms, it's easy to diagnose. It can be detected through a prenatal ultrasound. If the clefting has not been detected prior to the baby's birth, it's identified immediately afterward.

How Does a Kid Get Cleft Lip or Cleft Palate?

Cleft lip and cleft palate are birth defects. In other words, this occurs during the developmental process in the womb. Normally, the mouth and nose of a baby develop between the first 6 and 12 weeks of growth. In some babies, parts of the lips and roof of the mouth don't grow together. Because the lips and the palate develop separately, it's possible to have cleft lip, cleft palate, or both.

In most cases, we simply don't know why lip and palate development go wrong. Race and gender play a small role as clefts are most common in Asians. They are less common in whites and least common in blacks. Boys are more often affected than girls.

In some families, clefts appear to be hereditary. Sometimes substances in the environment, called teratogens, may be associated with the development of clefts. But most babies with clefts have no known relatives with clefts and no known exposure to teratogens. A few babies with clefts also have other developmental abnormalities. Your baby's primary care doctor will look for these other abnormalities and tell you what he or she finds. More Cleft Lip and Cleft Palate Facts...

What Happens to a Kid With Cleft Lip or Cleft Palate?

A child with a cleft lip or palate tends to be more susceptible to colds, ear infections, hearing loss, problems with eating, speech defects, dental problems.

  • Many children with clefts are especially vulnerable to ear infections because their eustachian tubes don't drain fluid properly from the middle ear into the throat. Fluid accumulates, pressure builds in the ears, and infection may set in. This can also lead to hearing loss and poor speech development. For this reason, a child with cleft lip or palate may have special tubes surgically inserted into his or her ears at the time of the first reconstructive surgery.
  • Feeding can be another complication for an infant with a cleft lip or palate. A cleft lip can make it more difficult for a child to suck on a nipple, while a cleft palate may cause formula or breast milk to be accidentally taken up into the nasal cavity. Have you ever laughed so hard while drinking that milk or juice came out of your nose? Because there is a hole between the nose and mouth in babies with a cleft palate, they have the same problem, but it can happen every time they drink and not just when they laugh. Special nipples and other devices can help make feeding easier. And in some cases, a child with a cleft lip or palate may need to wear a prosthetic palate called an obturator to help him or her eat properly.
  • Kids with cleft lip or cleft palate may also have problems with speech. When you talk, the muscles of your palate help to keep air from blowing out of your nose instead of your mouth. Kids with cleft palate find their muscles sometimes do not move well. That gives them problems with certain sounds like "s".
  • Dental problems - such as missing, extra, malformed, or displaced teeth, and cavities - also are common in children born with cleft palates. More Cleft Lip and Cleft Palate Facts...

What Treatments are Available for Children With Cleft Lip or Cleft Palate?

Children born with a cleft lip or palate may need the skills of several medical professionals to correct the problems associated with the cleft. Medical professionals with special experience in the problems of cleft lip and palate have formed such teams all over the country to help parents plan for their child's care from birth, or even before. Members of a child's cleft lip and palate treatment team usually include:

  • an audiologist (who assesses hearing);
  • a surgeon (such as a plastic surgeon, an oral/maxillofacial surgeon, a craniofacial surgeon, or a neurosurgeon);
  • a pediatric dentist or other dental specialist (e.g., a prosthodontist, who makes prosthetic devices for the mouth);
  • an orthodontist (who straightens the teeth and aligns the jaws);
  • a geneticist (who screens patients for craniofacial syndromes and helps parents and adult patients understand the chances of having more children with these conditions);
  • a nurse (who helps with feeding problems and provides ongoing supervision of the child's health);
  • an otolaryngologist (an "ear nose and throat" doctor, or "ENT");
  • a pediatrician (to monitor overall health and development);
  • a psychologist, social worker, or other mental health specialist (to support the family and assess any adjustment problems);
  • a speech-language pathologist (who assesses not only speech but also feeding problems);

Treatment usually begins in the first few months of an infant's life, depending on the health of the infant and the extent of the cleft.

The team specialists will evaluate your child's progress regularly, examining your child's hearing, speech, nutrition, teeth, and emotional state. They will share their recommendations with you, and can forward their evaluation to your child's school, and any speech therapists that your child may be working with. More Cleft Lip and Cleft Palate Facts...

How do I Choose a Cleft Palate or Craniofacial Team?

"The Parameters for Evaluation and Treatment of Patients with Cleft Lip/Palate or Other Craniofacial Abnormalities" document summarizes the current guidelines for team care endorsed by the American Cleft Palate-Craniofacial Association. By following these guidelines, teams are promoting the best possible outcomes for children born with clefts or other craniofacial birth defects. The important factors to take into consideration include:

  • Qualifications of the individual members on the team
    All the professionals on the team should be fully trained and appropriately certified and licensed. This issue may impact your insurance coverage, as well as the quality of care the team can deliver.
  • Experience of the team
    Each team must take responsibility for assuring that team members not only possess appropriate and current credentials but also have requisite experience in evaluation and treatment of patients with cleft lip/palate and other craniofacial anomalies. You may also want to try to determine how long this group of professionals has been meeting as a team and also how much experience the various individual professionals have had.
  • Location of the team
    The distance of the team from your home may NOT be an important consideration in choosing a team. In general, the team will be seeing your child only periodically throughout his/her growing years. Usually routine treatment such as general dental care, orthodontics, speech therapy, and pediatric care will be provided by professionals in your own community who will be in regular contact with professionals on the team.
  • Communication with the team
    Your child may require care over a period of years, so you want to make sure you are comfortable communicating and working with the members of the team. Treatment recommendations should be communicated to you in writing as well as in face-to-face discussion. The team should assist you in locating parent-patient support groups and any other sources for services that are either not provided by the team itself or are better provided at the community level. More Cleft Lip and Cleft Palate Facts...

What is Surgery like for Cleft Lips/Palates?

General agreement exists that surgical correction of a cleft palate should be accomplished when patients are younger than 1 year, before significant speech development occurs. The potential benefits of an intact palate as a child begins to speak are believed to outweigh the possible complications of early closure. Surgery for both cleft palate and a cleft lip require general anesthesia.

For Cleft lip surgery, the surgeon will make an incision on each side of the cleft from the lip to the nostril. The two sides of the lip are then sutured together. Bilateral cleft lips may be repaired in two surgeries, about a month apart, and usually requires a short hospital stay.

The goal of repair in patients with cleft palate is to separate the oral and nasal cavities; this separation involves the formation of a valve that is both watertight and airtight. The valve is necessary for normal speech. The repair also helps with preserving facial growth and the development of proper dentition. Cleft palate surgery involves drawing tissue from either side of the mouth to rebuild the palate. It requires 2 or 3 nights in the hospital, with the first night spent in the intensive care unit.

The necessity for more operations often depends on the severity of the cleft, its shape, and the thickness of available tissue that can be used to create the palate. Some children with a cleft palate require more surgeries to help improve their speech. Additional surgeries may also improve the appearance of the lip and nose, close openings between the mouth and nose, help breathing, and stabilize and realign the jaw. Subsequent surgeries are usually scheduled at least 6 months apart to allow a child time to heal and to reduce the chances of serious scarring. More Cleft Lip and Cleft Palate Facts...

What should be expected post-operatively?

Immediate postoperative concerns in cleft palate repair include airway management and pain management. Repairing the palate changes the nasal/oral airway dynamics and may present problems in the immediate postoperative period. A suture is often placed through the tongue to allow forward traction on the tongue while the patient still has an airway tube in the post-operative state. This suture is removed once the child is fully alert and able to maintain his/her own airway. In infants and younger children, arm restraints or "no-no's" are used when the child is unattended to prevent the placement of fingers in the mouth because this may disrupt the repair.

Diet in the postoperative period is generally limited to liquids and soft foods that do not require chewing. The use of bottles is avoided because the nipples may interfere with the repair. The use of spoons is also avoided for similar reasons. Feeding is accomplished by using either a cup (not a sipping cup) or a Breck feeder (a red rubber catheter attached to a syringe). Normal diet and feeding may be resumed after 10-14 days, depending on the type of repair. At 3 weeks, all dietary and feeding restrictions are removed. More Cleft Lip and Cleft Palate Facts...

What is the normal regimen for follow up care?

Once discharged from the hospital, the patient should have follow-up visits at 7-10 days and at 3 weeks. If a small fistula or a wound breakdown is noted in this period, waiting at least 6 months prior to attempting closure is advised. This delay allows for maximal wound contracture and for reestablishment of the blood supply to the tissues. More Cleft Lip and Cleft Palate Facts...

What are the complications associated with cleft repair surgery?

  • Airway obstruction
    As mentioned previously, postoperative airway obstruction is the most important complication in the immediate postoperative period. This situation commonly results from the tongue falling back into the airway while the patient remains sedated from anesthetics. Placement of a tongue traction suture helps in the prevention of airway obstruction. Airway obstruction can also be a problem because of changes in airway dynamics, especially those in children with a small jaw. In some instances, placement and maintenance of a tube in the trachea is necessary until palate repair is complete.
  • Bleeding
    Intraoperative hemorrhage is a potential complication. Because of the rich blood supply of the palate, significant bleeding requiring transfusion can occur. Preoperative assessment of the hemoglobin level and the platelet count is important. Specific medication injected into the area being operated on, such as epinephrine, can help significantly decrease blood loss.
  • Palatal fistula
    Wound breakdown, also called a palatal fistula, can occur as a complication in the immediate postoperative period, or it can be a delayed problem. A palatal fistula can occur anywhere along the original cleft site. The incidence has been reported to be as high as 34%, and the severity of the original cleft has been shown to correlate with the risk of fistula occurrence.

    Postoperative cleft palate fistulas can be managed in 2 ways. In a patient without any symptoms, a dental prosthesis can be used to close the defect with good results. A patient with symptoms may require surgery. Closure of persistent fistulas should be attempted no sooner than 6-12 months after surgery, when the blood supply has had an opportunity to reestablish itself. Currently, many centers wait until the patient is older before attempting fistula repair.
  • Midface abnormalities
    Cleft palate treatments at some institutions have focused on early surgical intervention. One of the negative effects can be maxillary growth restriction in a certain percentage of patients. As many as 25% of patients with a repaired cleft palate may still need surgery to correct and inability to close their bite, midface underdevelopment, and jaw deformities. More Cleft Lip and Cleft Palate Facts...

In conclusion:

Keep in mind that surgery to repair a cleft lip or palate is only the beginning of the process. Family support is critical for your child. Love and understanding will help him or her grow up with a sense of self-esteem that extends beyond the physical defect. More Cleft Lip and Cleft Palate Facts...

 

This OnlineSurgery.com article on Cleft Lip and Cleft Palate was provided to by Dunya Atisha, M.D.

 

Disclaimer:
This information is intended only as an introduction to this procedure. This information should not be used to determine whether you will have the procedure performed nor does it guarantee results of your elective surgery. Further details regarding surgical standards and procedures should be discussed with your physician.

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