Cleft Lip/cleft Palate Surgery Part 2

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Secondary surgery

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reduce scar tissue symmetry of vermillion and nose straighten septum to improve airway Abbe lip flap

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Cleft lip surgeries are

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Millard
Tennison Randall
LeMesurier

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Abbe lip

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Connect lower and upper lip connecting blow flow giving bulk to upper lip . A flap of tissue is lifted off the lower lip, leaving it attached to the lip to maintain adequate blood supply, and attached like a bridge to the upper lip. The two lips are left semiattached in this fashion until a second blood supply is established from the upper lip, usually about 2 weeks, and then the lower lip attachment is severed.

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if the lip is too short the child may have difficulty producing

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bilabials

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Goals of palatal surgury includes

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intact nasal oral cavities
improve feeding
reduces URI
reduce ear infections

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Timing of surgury

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Early: 6-15 months
Late: 15-24 months
Most surgery done before age 1 or sooner

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early the repair the incidence of VPI and compensatory strategies

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are lower

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with the Von Langenback the incidence of VPI is

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high

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60% of palatal surgeries are the

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Von Langenback

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Levator is not typically addressed in

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Von Langenback

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Wardill Killner v to y pushback

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Attempts to lengthen palate
Similar to Von Langenbeck
Levator muscle not addressed
High incidence of anterior fistulae

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pushback

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pushing the anterior coursing of muscle to posterior coursing

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Intravelar veloplasty/ levator retropositioning

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reconstruction of the sling
can be done with any type of palate repair
has not been as successful as was hoped

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Z plasty Furlow

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reconstruction of the levator sling
lengthens the velum by closing it with a double opposing Z-plasty

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Primary veloplasty

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2 stage procedure closing soft palate first then hard palate

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a fistula is normally left

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In most cases, a fistula is deliberately left in the alveolus (under the lip) at the time of the primary palatoplasty and is usually closed in early-mid mixed dentition with a bone graft. This completes the dental arch and allows eruption of the permanent dentition.

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a fistula can cause

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hypernasality and food in nasal cavity

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a unintentional fistula can occur

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5 to 30 % after palatoplasty

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surgical closure of fistulas have a

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60% closure rate

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choices with alveolar repair are

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Leave unoperated
Close w/ periosteoplasty
Primary bone grafting

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Bone grafting in infancy

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can disturb maxillary growth

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alveolar repair can occur

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before canines erupt adolescence or late childhood

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when can a diagnosis of VPI be made

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after 3 when the child is producing speech

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Surgery for VPI

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3.5 to 4

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possible fistual locations include

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soft palate
oral to nasal cavity through lavial sulcus, alveolus,
area of incisive foramen
junction of hard palate/soft palate

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an adhesive strip that is often used is called

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HolliHesive

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pharyngoplasty is done

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attempt to correct VPI

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It is important to check the pharyngeal wall of children with velocardiofacial because ...

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medial placement of cartoid artery
because arteries may be where the incision needs to be made

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Evaluation of VPI may include

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nasometer, nasopharyngoscope
videofluoroscopy

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As adenoids get smaller, ____ may occur because adenoids helped in closure

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hypernasal

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factors to consider before pharyngoplasty include

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etiology
pattern of closure and size and location of the opening
experience and skill of surgeon
patient’s medical condition
size of airway
previous surgeries

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faucial pillars is something to watch

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adenoids may be in the way of surgery and may be the problem that the velum is not moving

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Considerations of VPI

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deep pharynx
closure of opening
anterior coursing of levator muscles
large adenoids preventing closure

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Considering pharyngeal flaps, lateral port control flaps used less because

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they may not be large enough

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Redo plasty Furlow

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lengthens palate reconstruction of levator sling

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orticochea is the same as a

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sphincter palatoplasty

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pharyngeal wall augmentation

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adjusting wall adding silicone, not done as often or as current

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pharyngeal flap surgury

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most common 97% with nasopharyngoscope

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orticochea involves

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a sphincter that encircles the velopharyngeal port flaps raised from posterior faucial pillars meet a small pharyngeal flap which narrows pharynx

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pharyngeal flap is used as a soft tissue ______

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obturator placed in the middle of the port lateral wall movement is important for success

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ports are put on each side of the pharyngeal flap to allow for

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nasal breathing, nasal secretions, nasal resonance

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sleep apnea post surgury

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as child is sleeping lateral walls may pull together causing breathing obstruction

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palatal obturator

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prosthetic appliance that can be used to cover an open palatal defect such as an unrepaired cleft or palatal fistula device can also be used to improve infant's ability to achieve compression of nipple for suction or can be used to closed palatal defect

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palatal lift

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appliance used to raise the velum for speech in cases where the velum is long enough to achieve velar closure but does not move well

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you must have good velar movement to make this surgury a success

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orticochea

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speech bulb

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device used when the velum is too short to close completely against the PPW device consists of a retaining appliance and a bulb

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tailpiece

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part of a palatal lift or speech bulb that extends to raise the velum or close nasopharynx behind the velum

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sibilants include

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speech sounds that are produced by the friction of air pressure a it emitted anteriorly through the incisiors /s/ /z/ /sh/ /ch/ /zh/ /j/

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superior pharyngeal constrictor is responsible for medial displacement of what walls

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lateral pharyngeal walls to effectively narrow velo port

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supernumery teeth

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extra teeth

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Waldeyer's ring

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complex of lymphoid tissue including adenoids, tonsils and lingual tonsil

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white roll

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white border tissue that surrounds the red tissue or vermillion of upper and lower lips

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bluish area in the middle of the velum that is the result of abnormal insertion of the levator veli palatini

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zona pellucida

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process where the velum elongates as it elevates to achieve velopharyngeal closure

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velar stretch

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FISH test

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procedure using a dye to look at DNA to determine deletion of chromosomes

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nasal root

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where nose begins at the level of the eyes

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forme fruste/microform cleft

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cleft where overlying skin is intact but underlying musculature, cartilage is not

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as vp port opens beyond 20mm2 air pressure in the mouth

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rapidly falls off

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3 to 8 cm H20 is needed for

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stops

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3 to 7 is needed for

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fricatives

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if there is sufficient respiratory air pressure and mouth is closed

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turbulence is created through the port will cause airflow

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high nasal pathway resistance to airflow above the port may faciliate

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buildup of intra oral air pressure and this is why some subjects with wide clefts have fairly intelligible speech

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Upper airway Turbulance can be caused

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vomer bone spurs, nasal pathway atresia, deviated septum, infected turbinates

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What does a pharyngeal flap do concerning airflow

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it creates resistance

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rarely do people with v/p opening with less than 5 mm have hypernasality or

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audible nasal emission

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Concerning VPI therapy might be attempted when orifice size is

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10 mm if therapy failes then do surgery

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sometimes very small v/p openings cause

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audible nasal emission

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children as young as 3 have airtight v/p

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closure

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in 100% of normal subjects there is zero nasal airflow

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showing complete c/p closure during the production /s/ z/z /d/ t/ /i/ in the production of iCi as well as sustained /i/ /s/ /z/

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nasal airflow was noted in all vowels preceding nasal consonants suggests

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nasal assimilation

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subjects use double respiratory effect when doing

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hypernaslity due to v/p to obtain intraoral air pressure

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double respiratory effect trying to create intraoral air pressure when an insufficient v/p valving

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demonstrate different tongue positions (compensatory) and this effort also increases audible nasal emission

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This double effort with a reduced v/p telss us that we should as SLPs do

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focus on v/p competence and teaching appropriate articulation patterns as early as possible (pinch nose what happens!)

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through nasoscopy measurements of _____ _____ can be done

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v/p openings

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microstomia

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small mouth opening

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mixed resonance

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combination of hypernasality, hyponasality cul de sac resonance during connected speech

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coupling

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sharing of acoustic energy

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cleft muscle of Veau

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abnormal velar muscle insertion due to a cleft palate levator and palatopharyngeus muscles inserted abnormally

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when giving a mech exam aura refers to

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size symmetry proportion

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cranial nerve test is given to determine

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damage during an exam

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other things to consider during a mech exam

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ramus symmetry dental occulsion uvula velum hard palate color diadiokinetic rate tonsil size

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hypoplastic uvula is a

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short and stubby uvula

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when giving a mech exam aura refers to

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size symmetry proportion

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cranial nerve test is given to determine

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damage during an exam

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other things to consider during a mech exam

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ramus symmetry dental occulsion uvula velum hard palate color diadiokinetic rate tonsil size

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hypoplastic uvula is a

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short and stubby uvula