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In the name of God
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In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Jan 01, 2016

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Page 1: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

In the name of God

Page 2: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Cleft Lip

Dr. Sasan DabiriOtorhinolaryngologist – Head & Neck Surgeon

January 2011Imam Hospital complex - Tehran

Cleft Palate

Page 3: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Introduction

Orofacial clefts are the most common craniofacial birth defects

Cleft lip ± cleft palate isepidemiologically & etiologically distinct

from isolated cleft palate

Cleft Lip Cleft Palate

Page 4: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Differences Cleft Lip Cleft Palate

Yes Ethnicity effect NoYes Socioeconomic status NoMale Gender preference Female25 % Syndromic rate 50 % 1 in 1000 Incidence 1 in 2000

Concordance of cleft in monozygotic twins is 50%

Differences

Page 5: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Classification

• Complete or Incomplete

• entire vertical thickness of upper lip• often associated with an alveolar cleft

Cleft Lip Cleft Palate

Classification

Page 6: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Classification

• Complete or Incomplete

• Unilateral or Bilateral

Cleft Lip Cleft Palate

Classification

Page 7: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Classification

•Complete or Incomplete

•( incisive foramen )Primary or Secondary

•Unilateral or bilateral

Cleft Lip Cleft Palate

Classification

Page 8: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Team workCleft Lip Cleft Palate

Otolaryngologist

Maxillofacial surgeon

Orthodontist

Speech pathologist

Audiologist

Psychologist

Nurse

Plastic surgeon

Team work

Page 9: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

airway management

otologic care

evaluation of velopharyngeal insufficiency

facial reconstructive surgeon

Cleft Lip Cleft Palate

Otolaryngologist

Page 10: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Feeding

The most immediate concern in the care, other than the airway, is nutrition.

Early swallowing therapy is required in infant with complete cleft palate

to ensure near-normal feeding

Cleft Lip Cleft Palate

Feeding

Page 11: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Feeding

– squeeze bottles with cross-cut nipples

– Aerophagia

– fail to gain weight – excessive aerophagia

Cleft Lip Cleft Palate

Palatal obturator

• Frequent burping• Haberman feeder

Feeding

Page 12: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

When to Treat

• Cleft lip : the rules of ten:

– weight at least 10 pounds– Hb at least 10 g– WBC count less than 10,000/mm3– age more than 10 weeks

Cleft Lip Cleft Palate

When to Treat

Page 13: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

When to Treat

• Cleft lip :

– wide complete clefts with marked premaxillary protrusion staged repair

• lip adhesion performed at age 3 months • definitive repair performed at age 5 to 6 months

Cleft Lip Cleft Palate

When to Treat

Page 14: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

When to Treat

•Cleft Palate

Speech outcome or Facial growthThis is a question?

Cleft Lip Cleft Palate

Proposed time is roughly 1 year old

When to Treat

Page 15: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

• freshening and approximation of cleft edges

• curved incisions to allow lengthening of lip – straight-line closure

• numerous geometric repairs – produced scars that violated the philtrum)

• Millard rotation-advancement technique

Cleft Lip Cleft Palate

Surgery

Page 16: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

• Millard method:

Cleft Lip Cleft Palate

Surgery

Page 17: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

• Millard Advantages:• scar along the natural philtral border• more flexible than geometric closures• complete muscular repair and primary cleft rhinoplasty• minimizes the discarding of normal tissue

• Millard Disadvantages: • extensive undermining• risk for nostril stenosis on the cleft side

Cleft Lip Cleft Palate

Surgery

Page 18: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

• Rhinoplasty– primary rhinoplasty (at the time of lip repair)– intermediate rhinoplasty

• correct any residual lower cartilaginous deformity– V-Y advancement flaps from upper lip lengthen columella – Y-V alar advancement to narrow alar base,

with fixation of base to nasal spine with permanent suture

– Delayed rhinoplasty (after puberty)• correct any bony dorsal deformity or nasal obstruction

Cleft Lip Cleft Palate

Surgery

Page 19: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

• Complications– Notch in the vermilion– Malalignment of Cupid’s bow (whistle deformity)– Absence of median tubercle and part of Cupid’s

bow

Rx : Z-plasty c

Cleft Lip Cleft Palate

Surgery

Page 20: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

•Goals

–Closure of oronasal communication

–(velum )Correct speech pathology

•mobility depends on six paired muscles

(normally insert on soft palate)

Cleft Lip Cleft Palate

Surgery

Page 21: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgeryCleft Lip Cleft Palate

Surgery

Page 22: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

•primary veloplasty (Schweckendiek)

Cleft Lip Cleft Palate

Surgery

Page 23: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

•primary veloplasty (Schweckendiek)

•bipedicled flap palatoplasty (Von Langenbeck)

Cleft Lip Cleft Palate

Surgery

Page 24: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

•primary veloplasty (Schweckendiek)

•bipedicled flap palatoplasty (Von Langenbeck)

•V-Y pushback palatoplasty (Oxford)

•unipedicled two-flap palatoplasty (Bardach)

•double-opposing Z-plasty (Furlow)

Cleft Lip Cleft Palate

Surgery

Page 25: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgeryCleft Lip Cleft Palate

Surgery

Page 26: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

•primary veloplasty (Schweckendiek)

•bipedicled flap palatoplasty (Von Langenbeck)

•V-Y pushback palatoplasty (Oxford)

•unipedicled two-flap palatoplasty (Bardach)

•double-opposing Z-plasty (Furlow)

Cleft Lip Cleft Palate

Surgery

Page 27: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgeryCleft Lip Cleft Palate

Surgery

Page 28: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgery

•primary veloplasty (Schweckendiek)

•bipedicled flap palatoplasty (Von Langenbeck)

•V-Y pushback palatoplasty (Oxford)

•unipedicled two-flap palatoplasty (Bardach)

•double-opposing Z-plasty (Furlow)

Cleft Lip Cleft Palate

Surgery

Page 29: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

surgeryCleft Lip Cleft Palate

Surgery

Page 30: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Surgery

•Complications–The most common : velopharyngeal insufficiency

–Oronasal fistula •Technical error•Severity of cleft

–airway obstruction•Pressure of mouth gag during surgery

Cleft Lip Cleft Palate

Surgery

Page 31: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Postoperative care

Continuous pulse oximetry for first 24 to 48 hours

Intravenous hydration

Intr venous pain medications (+ acetaminophen supp)

Arm splints (first 2 wks)

Clear liquids by syringe or cup on first day (1 to 2 wks)

Discouraging nipple feeding

Cleft Lip Cleft Palate

Postoperative Care

Page 32: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

•Develops within the first months of life

•Frequency decreases with increasing age

•Due to abnormalities of cartilage and muscles

surrounding the eustachian tube

Cleft Lip Cleft Palate

Otitis media

Page 33: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

•Abnormalities of cartilage and muscles

–Hypoplasia of the lateral cartilage relative to the medial cartilage

–The curvature of the eustachian tube lumen

–width and angulation of skull base with respect to eustachian tube

–Abnormal insertions of TVP and levator veli palatini muscles

Cleft Lip Cleft Palate

Otitis media

Page 34: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

•Management

–Tympanostomy tube insertion

•Controversy : Type of VT

•Controversy : Time of VT

Cleft Lip Cleft Palate

Otitis media

Page 35: In the name of God. Cleft Lip Dr. Sasan Dabiri Otorhinolaryngologist – Head & Neck Surgeon January 2011 Imam Hospital complex - Tehran Cleft Palate.

Thanks for your attention