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Khairan IrmansyahDepartement Of Otolaryngology
MEDICAL SCHOOL OF PADJADJARAN UNIVERSITY
BANDUNG
2010
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Incidence And Epidemiology Greater in female (3/4)The incidence
of submucous CP is 1 per 1600 birthsThe incidence of bivid uvula is
1 per 800 live births
Cleft Palate :Schism in the roof of the oral
cavity.01/22/2010*kh-lr
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EtiologyStrongly dependent on genetic factorsClefting is
heterogenous and result also from enviromental insultsEnviromental
Factors:- Fetal alcohol exposure- cigarette smoking- folic acid
deficiency or antagonist- phenytoin- retinoic acid derivatives
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Amniotic band syndromeMaternal diabetes4. Multivitamins with
folic acid likely reduce the incidence of clefting
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Anatomy & Physiology The palate is the scaffold for midface
structures. Consists : Hard palate (anterior) Soft palate
(posterior) 01/22/2010*kh-lr
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Hard PalateIncisive foramen (delimits the
anterior)Premaxilla(centrally)Draped the prepalatal structures,
alveolus, lip, nasal floor, alar cartilages
Soft palateBony maxillaeContigous palatine bonesLateral
pterygoid laminaeInterposed hamulus
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Skeletal Anatomy01/22/2010*kh-lr
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Muscle & Skeletal Anatomy01/22/2010*kh-lr
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MuscleTensor veli palatiniBroadFlatNearly vertical paired
musculotendinous structuresArises from the major wing of the
sphenoidal spine superiorly and posteriorly and from the
anterolateral part of the eustachian tube Function: - Stabilizing
the velum at the level of the hamulus- dilating the eustachian tube
in concert with the tensor tympani- with tensor palatini retracting
the eardrum and increasing tubal pressure01/22/2010*kh-lr
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Levator veli palatiniCylindrical paired musclesPosterior bundles
arises from the base of skull & the external carotid
foramenForm a sling to swing the velum backward &
upwardParticipate in swallowing and speech
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Passavants bar: Midline posterior portion of pharyngeal
sphincter, which may become thickened during sphincter contraction
to facilitate closure
Velopharyngeal mechanism swallowing & passing air (during
speaking, whistling, or blowing) innervated by the vagus &
glossopharyngeus (for swallowing), and the facial nerve (for
speech)01/22/2010*kh-lr
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Hence four major muscles arches or sling exist:The
levatorSuperior constrictorPalatopharyngeusPalatoglossus
Palatopharyngeal sphincter of Willis:During active constraction
the two loops of the superior pharyngeal constrictor and levator
form a sphincteric closure of theVelopharyngeal space and
jointly01/22/2010*kh-lr
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Greater Palatine foramen:a greater palatine arterya greater
palatine nervus01/22/2010*kh-lr
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Innervation Anatomy01/22/2010*kh-lr
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Blood Suply Anatomy 01/22/2010*kh-lr
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ClasificationBivid uvulaIncomplete cleft of secondary
palateUnilat. Complete CL & CPBilat. Complete CL &
CP01/22/2010*kh-lr
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SpeechNormaly consonans build up of nasal pressureCleft patients
produce speech marked by :HypernasalityNasal air emissionsWeak
pressure consonants or plosivesCompensatory articulation
The earliest age at which formal speech therapy is ussualy
innitiated as approximately 4 years01/22/2010*kh-lr
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Clinical EvaluationHealt history :- family history of clefting-
history of illness or maternal ingestion of medication during the
1st trimester- other deformities to incriminate a particular
syndrome (ex. Pierre Robin or KlippelFeil)Physical examination: -
the defect is associated with a cleft lip or not- whether the cleft
is complete or incompleteand unilateral or
bilateral01/22/2010*kh-lr
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- Determine whether there are associated:1. 1st branchial arch
or nasal deformities2. Narrowing of the interocular distance3.
Extensive defect- Examine the tympanic membranes for serous otitis,
hypernasality01/22/2010*kh-lr
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CLEFT PALATE REPAIRPreoperative Diagnostic MeasuresGeneral
examinationClinical findingsRadiographic examination Lateral
teleradiographs
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Indications and Timing of SurgerySpeech patologists end of the
first year of lifeOrthodonthists recommendWith the development of
atraumatic cleft palate surgery, a consensus has emerged in favor
of an early repairA single-stage palate repair 12-15 mounth of
age
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Two-stage palate repair:a. Anterior to posterior (AP) sequence :
Total cleft, the hard palate repaired at 9-12 months, soft palate
at 12-15 monthsb. Posterior to anterior (PA) sequence :Prymary
veloplasty 6 monthsCleft hard palate after eruption of the prymary
dentition
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Cleft Palate Repair01/22/2010*kh-lr
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Preoperative PreparationsPosition :-Supine with the neck
slightly hyperextended01/22/2010*kh-lr
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Special Instrument01/22/2010*kh-lr
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Operation Technique01/22/2010*kh-lr
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The Schwenkendiek two stage repair closes the sof palate cleft
and leaves the hard palate cleft for obturation with a prothesis
until delayed closure at 4 to 5 years. Minimal disturbance of
facial growth. Requires frequent changes of prothesis. Result in
significant speech disorder if not properly obturated. Management
SURGICAL REPAIRPalatoplasty technique01/22/2010*kh-lr
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Von Langenbacecks palatoplasty advances bipedicle mucopeiosteal
flaps : Easy to perform,Decreased denuded palatal bone, Does not
provide increased palatal lengthManagement SURGICAL
REPAIRPalatoplasty technique01/22/2010*kh-lr
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V-Y Push Back Palatoplasty retrodisplaces two posteriorly based
mucoperiosteal flaps by a V to Y closure techq: Lengthens the
palate, Leaves a large, raw palatal surface Management SURGICAL
REPAIRPalatoplasty technique01/22/2010*kh-lr
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Two Flap Palatoplasty (Bardach) utilizes two posterioly placed
mucoperiosteal flap that extend to the alveolar cleft. Good for
complete cleft of palatal/alveolusManagement SURGICAL
REPAIRPalatoplasty technique01/22/2010*kh-lr
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The Furlow Palatoplasty utilizes a double reversing Z plasty of
musculomucosa and mucosa only flaps to repair the palatal cleft.
Usually used for submucosal or soft palate cleft. Good speech
results with proper muscle aligment. Dificult for wide
cleftSURGICAL REPAIRPalatoplasty technique01/22/2010*kh-lr
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Operative TechniquePedicle flaps01/22/2010*kh-lr
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V-Y advancement01/22/2010*kh-lr
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Management SURGICAL REPAIRUnilateral Cleft Palate
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Management SURGICAL REPAIRUnilateral Cleft Palate
Repair01/22/2010*kh-lr
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Management SURGICAL REPAIRUnilateral Cleft Palate
Repair01/22/2010*kh-lr
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Management SURGICAL REPAIRBilateral Cleft Palate
Repair01/22/2010*kh-lr
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Management SURGICAL REPAIRCleft Palate
Repair01/22/2010*kh-lr
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Reference Points and PitfallsA few landmarks are important in
cleft palate repair: The incisive foramen The posterior nasal spine
The greater palatine foramen The hamulus and the fascia of the
medial pterygoid muscle01/22/2010*kh-lr
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Several potential hazards should be noted: Bleeding from the
palatine artery Post operative bleeding Tearing of the nasal layer
during its dissection behind the hard palate Tearing of the
vomerine flap during its dissection at the neck of the premaxilla
Necrosis at the anterior tip of a long palate flap
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If the soft palate is drawn againts the pharyngeal wall by a
suction tube passed into a nostril at the end of the operation
while the nostril are held shut, this is considered proof that the
length and function of the velum are
satisfactory01/22/2010*kh-lr
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Postoperative Care Palatal tissue are apposed to the underlying
bone by pledget held in place with sutures.Nasogastric
tubeProphylactic antibioticsPatient out of bed on the 1st
op.dayPacking is remove after 5 days
The sutures are removed from the palatal mucosa on day
12Exercises puffing and blowing (in small children)Systematic
speech therapy (4 years of age)
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Complications Hemorrhage respiratory obstruction Suture line
dehiscence Fistula
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Highlights Cleft lip and palate occurs in 1 in 1,000 births;
cleft palate alone occurs in 1 in 2,000 births. Cleft palate and
lip is the most common congenital malformation involving the head
and neck, and a cleft palate team approach best provides long term
multidiscipliary management. Cleft palate repair is ussually
performed at 9 to 12 months of ages as long as the child is gaining
weight and growing in a normal fashion01/22/2010*kh-lr
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