Cleft Palate
Cleft Palates
Cleft palate is a common congenital craniofacial anomaly.
Presentation
The clinical features of cleft palate are due to an open hole between the nasal cavity and the oral cavity.
- During speech, there is entry of air into the nasal cavity which leads to a nasal quality in the voice. There are also other speech problems such as distorted speech.
- There are also problems in feeding. This causes marked problem in infants who require a proper suction mechanism in order to feed.
- Patients of cleft palate may also have breathing problems due to the open communication between the oral and nasal cavities.
- Cleft palate can also lead to difficulty in hearing. The tensor veli palatini is unable to open the Eustachian tube which will lead to an increased secretion of fluid in the middle ear. Infections such as otitis media are more common in these infants .
- Hearing problems in early life may also later lead to difficulty in articulation. This occurs due to inability of the children to mimic language due to defective hearing. Due to velopharyngeal inadequacy, there is an inability to produce some particular sounds that are required for normal speech.
- A marked increase is seen in the occurrence of psychological problems such as anxiety, depression, internalization, social withdrawal and aggressive behaviors in these patients later in life.
Entire Body System
Feeding Difficulties
- We report the cases of a father and daughter diagnosed with CPLSS who presented with respiratory and feeding difficulties at birth undergoing surgical correction.[ncbi.nlm.nih.gov]
- Furthermore, symptoms to be aware of are feeding difficulties combined with nasal regurgitation and ear problems such as conductive hearing loss and persistent otitis media.[doi.org]
- The infant’s appearance, feeding difficulties, frequent trips to the doctor and surgeries can be quite stressful. This may, in turn, have an impact on the adaptation process of both child and parents.[chla.org]
- Feeding difficulties occur more with cleft palate abnormalities. Children with cleft lip but without cleft palate do not usually have feeding difficulties.[chop.edu]
- Beyond the cosmetic abnormality, there are other possible complications that may be associated with cleft lip and cleft palate, including the following: Feeding difficulties Feeding difficulties occur more with cleft palate abnormalities.[stanfordchildrens.org]
Fatigue
- Learn More About Topic Hoarseness Hoarseness (also called dysphonia) is an abnormal change in the quality of your voice, making it sound raspy, strained, breathy, weak, higher or lower in pitch, inconsistent, or fatigued, often making it harder to talk[entnet.org]
Respiratoric
Cough
- On the clinical examination, coughing, sneezing, drainage of nasal discharge from the external nares and poor growth were found. Vital signs and results of blood examination were within normal ranges.[ncbi.nlm.nih.gov]
- On physical examination, coughing, sneezing, presence of nasal discharge from the external nares and poor growth were found. Vital signs and results of blood examination were within normal ranges.[doi.org]
- Your child has chills, a cough, or sounds congested. These are signs that your child may have an infection. Your child's skin is itchy, swollen, or has a rash. The medicine your child is taking may be causing these symptoms.[drugs.com]
Nasal Voice
- Some kids, however, will continue to sound nasal after cleft palate repair, and some may develop a nasal voice later on.[kidshealth.org]
Gastrointestinal
Choking
- Babies should be able to feed comfortably within a reasonable amount of time, without struggling to breathe, choking, or working very hard to get the milk out of the bottle.[urmc.rochester.edu]
- Make sure your child can swallow without choking, and gets good nutrition. Give you, your child, and your family help and support.[drugs.com]
- This can cause choking. Special nipples and bottles are available that can help. Your nurse, occupational therapist, or lactation specialist will help you figure out what works best for your baby. They may also help with feeding issues.[saintlukeskc.org]
- Surgical management of cleft palate Passive maxillary obturator: Is an intraoral prosthetic device that fills the palatal clefts and provides false roofing against which child can suckle Reduces the feeding difficulties like insufficient suction, choking[slideshare.net]
Dysphagia
- Learn More About Topic Dysphagia Dysphagia means that you can’t swallow well. Many factors may cause dysphagia, and most are temporary and non-life-threatening.[entnet.org]
- Related Topic Areas Aphasia Autism Craniofacial conditions Deafness Developmental speech difficulties Dysfluency Dysphagia Head and neck cancer Language disorder Learning disabilities Mental health (Adults) Social communication difficulties Social emotional[rcslt.org]
Jaw & Teeth
Malocclusion
- The authors present a 16-year-old patient with no known history of cleft palate who developed velopharyngeal insufficiency after a Le Fort I osteotomy performed for the correction of maxillary hypoplasia and a Class III malocclusion.[ncbi.nlm.nih.gov]
- Goslon yardstick Three of the authors have mentioned clinical features that they considered to be most important in categorizing the severity of malocclusion.[slideshare.net]
- […] syndrome Craniosynostosis Crouzon syndrome Pfeiffer syndrome Saethre-Chotzen syndrome Cleft lip and palate Cleft lip and palate Craniofacial clefts Pierre Robin syndrome Dentofacial and maxillofacial deformities Chin deformities Distraction osteogenesis Malocclusion[choa.org]
- When the teeth do not fit together properly (malocclusion) and there is an associated facial deformity, such as an imbalance in facial proportions.[mottchildren.org]
Skin
Delayed Wound Healing
- Early identification with prompt antiviral therapy and meticulous wound care are essential to ameliorate the scarring and delayed wound healing associated with HSV infection.[ncbi.nlm.nih.gov]
Hyperpigmentation
- The child was referred for multiple congenital anomalies: bilateral aplasia of the radius and thumb, left kidney agenesis, cardiac malformation cleft palate, bilateral cryptorchidism, ear anomalies, which were associated, in time, with facial hyperpigmentation[ncbi.nlm.nih.gov]
Musculoskeletal
Thigh Weakness
- There was no perceived thigh weakness. The surgical scar healed inconspicuously. Free flaps should no longer be considered the last resort for treatment of recalcitrant fistulas after cleft palate repair.[ncbi.nlm.nih.gov]
Ears
Hearing Problem
- Hearing problems in early life may also later lead to difficulty in articulation. This occurs due to inability of the children to mimic language due to defective hearing.[symptoma.com]
- These disorders can result in feeding problems, speech problems, hearing problems, and frequent ear infections. Less than half the time the condition is associated with other disorders.[dbpedia.org]
- Late diagnosis of the cleft palate (CP) could initially result in feeding and growth impairment, and subsequently speech and hearing problems later in life.[ncbi.nlm.nih.gov]
- […] for hearing problems An oral surgeon to reposition segments of the upper jaw when needed, to improve function and appearance and to repair the cleft of the gum An orthodontist to straighten and reposition teeth A dentist to perform routine dental care[webmd.com]
- If left untreated, children with cleft lip and palate can suffer life-long handicaps including severe facial deformities, chronic dental and hearing problems, malnutrition and even social problems.[adventisthealth.org]
Hearing Impairment
- The patients were offered individualized ear surgery (PE tube placement) only if persistent middle ear fluid was present for over 3 months with a conductive hearing impairment.[ncbi.nlm.nih.gov]
- Furthermore, this developmental language delay occurred in the absence of hearing impairment and oral motor or structural deficits such as cleft palate . For a baby who has a cleft palate only, then she has a choice.[dictionary.cambridge.org]
- impairment); to assess and monitor hearing A nurse coordinator to provide ongoing supervision of the child's health A social worker/ psychologist to support the family and assess any adjustment problems A geneticist to help parents and adult patients[webmd.com]
Psychiatrical
Low Self-Esteem
- Psychological difficulties associated with physical appearance often involve low self-esteem and social withdrawal. Diagnosis and treatment of cleft palate Cleft palate may be diagnosed before birth, via ultrasound, or at birth.[britannica.com]
- There would be endless operations, the likelihood of ostracisation, bullying, low self-esteem. The shape of the face could be affected, with the entire upper jaw recessed.[theguardian.com]
Psychiatric Symptoms
- With passage of time patient develops hearing, speech problems and psychiatric symptoms. Surgical repair is the choice of treatment. Early surgical treatment leads to improved hearing and speech.[symptoma.com]
Urogenital
Cryptorchidism
- The child was referred for multiple congenital anomalies: bilateral aplasia of the radius and thumb, left kidney agenesis, cardiac malformation cleft palate, bilateral cryptorchidism, ear anomalies, which were associated, in time, with facial hyperpigmentation[ncbi.nlm.nih.gov]
Neurologic
Convulsions
- The four main findings in this syndrome may be accompanied by severe psychomotor retardation, blindness, hypotonia, convulsions, and facial dysmorphism.[ncbi.nlm.nih.gov]
Encephalopathy
- Here, we present a similar patient who developed acute liver failure and hepatic encephalopathy after an uncomplicated cleft palate surgery.[ncbi.nlm.nih.gov]
Workup
A prenatal fetal anomaly scan can lead to early diagnosis of cleft palate. After birth, the diagnosis can be easily made clinically. No investigations are necessary.
Other Pathologies
Occipital Encephalocele
- The presence of occipital encephalocele, cleft palate, and polyps in the tongue in this patient was not reported previously in the literature.[ncbi.nlm.nih.gov]
Treatment
A specialized craniofacial team is needed to treat this condition. There are different treatment modalities according to the type and severity of cleft palate. If child has undergone surgery early in life, it will lead to improved hearing. If we wait for the eruption of permanent teeth before correcting the defect surgically, a lesser number of corrective surgeries will be needed later in life.
Cleft palate can be treated by the use of a prosthetic device which can fill the gap in the palate. It can also be treated by the insertion of pins in fourth or fifth month of life. With each passing day, the parents have to tighten the screw so that both the bones can come closer. If the gap is involving the maxilla, a piece of bone can be taken from a rib or the hip of the patient for transplantation.
In order to avoid speech and hearing problems, the patient should be treated as early as possible. Grommets or tympanostomy tubes can be used to aerate the middle ear [9] [10]. After surgical repair, the problem of speech is usually corrected.
Prognosis
- Most teratomas are benign and the prognosis is usually good. However, recurrence is not rare if germ cell carcinomatous foci are present within the teratoma.[ncbi.nlm.nih.gov]
- Prognosis Both cleft lip and cleft palate are treatable birth defects .[encyclopedia.com]
- Prognosis Treatment takes place over several years as the child grows and the palate and dentition develop. However, it is possible to achieve a normal appearance, and normal speech and eating habits, early in the process.[patient.info]
Etiology
Cleft palate results from the following etiologies.
- Genetic factors and familial factors [2] [3] [4]
- Environmental factors
- Maternal epilepsy [5] [6]
- Gestational diabetes
- Use of steroids, diazepam and phenytoin during pregnancy [7]
- Pierre Robin Sequence is the most common syndrome. In this syndrome, the patients have isolated cleft palate, posteriorly displaced tongue and posteriorly placed jaw [8].
Epidemiology
- Epidemiology of oral clefts: an international perspective. In: Wyszynski, D.F., ed. Cleft Lip and Palate: From Origin to Treatment. New York : Oxford University Press ; 2002 : 127 – 158.[dx.doi.org]
- This Maintenance of Certification review discusses the incidence and epidemiology associated with cleft palate deformity and specifics associated with patient care, including analgesia, surgical repair techniques, and complications associated with repair[ncbi.nlm.nih.gov]
- Figueiredo, Epidemiology, Etiology, and Treatment of Isolated Cleft Palate, Frontiers in Physiology, 10.3389/fphys.2016.00067, 7, (2016).[doi.org]
Pathophysiology
Cleft palate occurs due to the inability of the palatine processes to meet during development. In incomplete cleft palate, the defect usually involves the soft palate and hard palate is attached to vomer and nasal septum. In incomplete cleft palate, there is usually a disruption in the insertion of muscle fibers. If hard palate is not attached to the nasal septum or vomer, it is referred to as complete cleft palate and both the hard and soft palates are involved. There is a primary palate in front of alveolar foramen and a secondary palate behind it.
Cleft palate can occur in either U form or V form. V form is more common in isolated cases of cleft palate whereas U form is more common in Pierre Robin Sequence.
In submucous palate, there is split uvula, a ridge in soft palate and a notch at the back of the hard palate. It can occur in association with cleft lip in which there is a gap in the lip.
Prevention
- References Parker SE, Mai CT, Canfield MA, Rickard R, Wang Y, Meyer RE, Anderson P, Mason CA, Collins JS, Kirby RS, Correa A; for the National Birth Defects Prevention Network.[web.archive.org]
- A defect in the alveolus can (1) displace, tip, or rotate permanent teeth, (2) prevent permanent teeth from appearing, and (3) prevent the alveolar ridge from forming. These problems can usually be repaired through oral surgery.[webmd.com]
- Initially, p63 induces periderm formation and controls its subsequent maintenance to prevent premature adhesion between adhesion-competent, intra-oral epithelia.[ncbi.nlm.nih.gov]
- Google Scholar National Birth Defects Prevention Network (NBDPN). Birth defects surveillance data from selected states, 1999–2003. Birth Defects Res A Clin Mol Teratol. 2006 ; 76: 894 – 958.[dx.doi.org]
Summary
Cleft palate is a developmental defect in the formation of the palate. It can involve both the soft palate and the hard palate. When both the palates are involved simultaneously, the condition is known as complete cleft palate [1].
Usually maternal, genetic and family factors play an important role. Air from the mouth escapes into the nose which leads to velopharyngeal inadequacy. Patients usually present with abnormalities in feeding, hearing and speaking. Later on in life, the incidence of psychiatric symptoms such as aggressive behaviour and depression increases. Surgical correction is treatment of choice.
Patient Information
Patients of cleft palate are usually infants and present with feeding problem. On examination there is a hole in the palate. With passage of time patient develops hearing, speech problems and psychiatric symptoms. Surgical repair is the choice of treatment.
Early surgical treatment leads to improved hearing and speech. Prosthetic devices, pins and in severe form, bone from other sites of body may be used to fill the hole.