Anatomy, Classification, Embryology, and Surgery Flashcards
Facial landmarks (7)
Nasal tip Alar base and rim Philtral ridges Philtrum Columella Cupid's bow White roll
Hard palate anatomy
The premaxilla is from the tip of the maxilla to the incisive forame. The palatine process of the maxilla runs about halfway down the hard palate, and the palatine bone is the other half, ending in the posterior nasal spine.
Soft palate anatomy
The velum attaches posteriorly to the hard palate via aponeurosis (the buffer zone for muscles to insert into). The soft palate is primarily composed of muscle and soft tissue for mobility.
Pharyngeal anatomy
Nasopharynx
Oropharynx
Laryngopharynx
Velopharyngeal muscles (7)
- Tensor veli palatini–opens the eustacian tubes
- Levator veli palatini–lifts the velum; parallel to ET
- Palatoglossus–antagonist to LVP
- Palatopharyngous–vertical fibers lower velum; horizontal fibers create a sphincter action
- Superior constrictor–creates medial displacement of the lateral pharyngeal walls
- Musculus uvulae–bulk of velum
- Salpingopharyngeous–surface of velum, little functional significance
Innervation of VPC
Motor: Pharyngeal plexus
Sensory: Trigeminal, Vagus, Facial
Closure Patterns
Coronal–Velum meets with pharyngeal wall
Saggital–Pharyngeal walls meet horizontally
Circular–Velum and pharyngeal walls meet in the middle w/ or w/o help of adenoids
Potential problems with adenoid pad
- Can cause nasal obstruction
- Can cause culdesac resonance
- Can cause VPI
Levels of an embryo
- Ectoderm–>skin, teeth, hair, lens of eye, inner ear
- Mesoderm–>muscles, connective tissues, bones, heart
- Endoderm–>digestive system, liver, respiratory system, outer ear
Neural tube
Houses the brain of an embryo
Anatomy of embryo at 4 weeks
Pharyngeal arches are present 1. Mandibular 2. Hyoid 3. Body of hyoid Maxillary process present Frontonasal process present Nasal placodes present, become nasal pits, then nostrils
Anatomy of embryo at 5-6 weeks
Median and lateral nasal processes
Eyes are still very lateral
Interruption in week 6 will cause full CLP
Anatomy of embryo at 7 weeks
Maxillary process conncets to the median nasal processes
Nasal pits present
Ears lateral and low-set
Hyoid arch is almost-complete ring of tissue around EAM
Merging of primary palate in anterior direction
Oral and nasal cavities NOT separated
Hard palate created by merging of palatine processes and premaxillae
Palatal shelves are vertical
Anatomy of embryo at 9 weeks
Mandibular growth spurt–tongue lowers, palatal shelves elevate to separate nasal and oral cavities
Fusion starts are inc=cisive foramen and moves to uvula by week 12
Interruption here causes CPO
Potential problems with ears (3)
Aural atresia (closure of EAC)
Microtia
Preauricular pits/tags
Potential problems with eyes (6)
Epibulbar dermoid (cyst on eye) Exophtalamus (bulging eyes) Hypertelorism (wide-set eyes) Coloboma (defect in eye shape) Narrow palpebral fissures Strabismus
Potential problems with tongue (2)
Micro/macroglossia
Ankyloglossia
Potential problems with jaw (3)
Micrognathia
Retrognathia
Prognathia
Potential problems with head (4)
Micro/macrocephaly
Hydrocephaly
Brachycephaly (limited anterior/posterior growth)
Craniosyntosis (premature fusion of the cranial bones)
Cause of CLP?
Multi-factorial inheritance (genetics+environment); sometimes related to syndromes
20% of cases are primarily inherited
3-5% are chromosomal
65% are primarily environmental or unknown
Incidence of CLP
Most common birth defect; 1:595
25% Lip only (cleft on left lip in 70% of these)
25% palate only
50% CLP
Lowest incidence in African American population, highest in Native American population
CLP more common in males
CPO more common in females
What percentage of children with CLP have another abnormality?
14-15%
Cleft classifications (basic)
Lip and/or palate
Complete (formed before 9th week) or incomplete (formed during 9th week)
Unilateral or bilateral
Cleft classifications (advanced)
Primary or secondary palate
Submucous cleft
8 people who may be on a cleft team
SLP Audiologist Nurse Pediatrician Prosthodontist Orthodontist Geneticist Social worker (many others as well)
Advantages of team care
Centralized and coordinated services
Maximize communication between specialists
Long-term treatment planning
Typical timeline for CLP
Lip taping=birth, in hospital typically Nasal-Alveolar molding=before 3 mo. Lip repair=3 mos., rule of 10’s Initial SLP Eval Palate repair= 12 mos. Post-op speech eval Speech follow-up every 6-12 months or sooner Lip revision= after age 5-6, ideally early teenage years (9-12yrs); avoid midface growth deficiencies Secondary surgical revision to palate if needed Maxillary expansion, 6-9 years Bone grafting, 9-12 years Orthodontics
SLP’s role on cleft team
Provide support to family Provide input to team members Re-eval yearly Initiating referrals Community resource
Types of occulsion
Class 1: Normal
Class 2: Mandibular retrusion/maxillary protrustion)
Class 3: Mandibular protrustion/maxillary retrusion)
Other dental problems
Overjet (space between top and bottom teeth) Crossbite Over/underbite Supernumerary teeth Missing teeth Rotated teeth
Palatal lift
Raises velum; good for VPI caused by reduction in velar movemetn
Palatal obturator
Prosthetic that covers cleft in CP; nonsurgical option
Speech bulb
Only worn when speaking; occludes the nasopharyngeal port to eliminate nasality
Audiological problems
Bilateral conductive hearing loss; prone to ear infections
Rule of 10s
Before surgery, child should be:
10 weeks old
10 pounds
10 hemoglobin g/dl
Primary lip repair
Occurs at 3 months. Can be a straight-line repair, a triangular repair, or a rotational advancement
Logan bar
Used to reduce tension on the surgical site after a lip repair (same function as lip tape)
Palate repair timing
Occurs between 9 and 18 months (12-15 on average)
Von Langenbeck repair
Palate repair that brings the structures in a straight midline
Wardill-Kilner repair
Palate repair that closes the palate leaving a V or Y shaped scar
Furlow Palatoplasty
Palate repair that creates a z shaped scar and lengthens the velum
Care after palatoplasty
Elbow restraints; clear diet (later upgraded to puree); restricted from bottles, passies, spoons, etc.; limited to cup drinking for feeds
Secondary lip surgery timing
Before 5 years old–typically improves facial appearance before entering school
Reasons for secondary palate repair
- Palatal fistula or dehiscience
- Correction of maxillary/mandibular problem
- Correction of VPD (occurs in 10-20%)
Sphincterpharyngeoplasty
Secondary palate repair procedure that uses the pharyngeal flaps to narrow the sphincter–good for smaller VP gaps, good velar movement/poor pharyngeal wall movement
Pharyngeal flap procedure
Secondary palate repair procedure that creates a midline pharyngeal flap with lateral ports for breathing; good for larger VP gaps with good lateral pharyngeal wall movement
Pharyngeal wall augmentation
When material is injected into the pharyngeal wall to narrow the sphincter when VP gap is small
