Chapter 18 Flashcards
Chapter 18
Surgical Management of Clefts and Velopharyngeal Insufficiency/Incompetence (VPI)
just know what each of the surgeries fix
will only be objective questions on the test
Cleft lip/palate involves more than just the lip and palate.
Affects other structural areas, including the …..
Influences many functional areas, including ….
nose, midface, upper jaw, teeth, oral cavity, and velopharyngeal sphincter
breathing, speech, voice, resonance, hearing, feeding, and psychology
Structural defects require physical management, usually in the form of _____.
Treatment procedures and approaches are becoming more standardized, yet there is still ______in techniques and philosophies among surgeons, even those in the same center.
surgery
variability
Cleft Lip Repair
_______—cleft lip repair
Goals:
Align the ___, _____ (______), and _______
Achieve symmetry of ____and _______
Achieve a _____(white roll) between the vermilion and the skin of the upper lip
Minimize the appearance of ____
Cheiloplasty
skin, muscle, (orbicularis oris), and mucous membrane
nostrils and cupids bow
nostrils
scars
Cleft Lip Repair
Continuity of lip helps ____________, particularly the premaxilla.
Scarred or tight lip can have a detrimental effect on _______
mold underlying bony structures
maxillary growth.
Cleft Lip Repair: Presurgical Management
Often done to align the lip and maxillary segments prior to the formal lip repair. Options include using the following:
Adhesive tape on the lip
Dental elastics
A headgear with Velcro bands
A palatal molding device with tape or elastics
Latham appliance—appliance that is pinned to the bony
segments and uses screws and dental chain elastics to pull the segments together
Can be combined with a nasal alveolar molding (NAM) device, which is controversial
Lip adhesion—a temporary lip repair
Techniques: unilateral cleft lip repair***
Millard Technique—rotation advancement
Tennison-Randall Technique—Z-plasty
Techniques: bilateral cleft lip repair***
Broadbent-Manchester repair
Millard repair
Cleft Lip Repair: Timing
Most centers follow the “rule of 10,” where baby must have the following:***
Usually done between…
Weight: 10 lbs. or more
Hemoglobin: 10 grams
White count: no higher than 10,000
Age: at least 10 weeks
10 and 12 weeks (3 months)
Cleft Lip Repair: Potential Complications
1.
2.
Can cause stenosis of the nasal vestibule
Can affect infant’s nasal breathing and sleep
Cleft Palate Repair
_______: cleft palate repair
Goal:
Separate _______cavities for the benefit of feeding, middle ear function, but most of all for speech
Surgical restoration of ______ helps to approximate the maxillary bony segments
Bone remains discontinuous, but is covered with _____
Palatoplasty
oral and nasal
soft tissue
mucosa
Cleft Palate Repair: Presurgical Management
Usually done between ______
Delayed if _________ (i.e., Pierre Robin sequence)
May need to ….***
9 and 12 months
mandible is small or there are significant airway problems
transition child from a bottle to a cup prior to repair
Cleft Palate Repair: Techniques
Von Langenbeck
Wardill-Kilner “V” to “Y” pushback
Intravelar veloplasty
Furlow Z-palatoplasty
Two-flap palatoplasty
Cleft Palate Repair: Potential Complications
Airway compromise
Excessive bleeding
Velopharyngeal insufficiency, despite the palate repair
Risk for postoperative dehiscence—breakdown of repair, which can cause excessive scarring or an oronasal fistula
Cleft Palate Repair: Timing
Controversy:
Does early palate repair interfere with maxillary growth, contributing to anterior crossbite and midface retrusion?
Some surgeons in Europe close the soft palate (veloplasty) during infancy, and then repair the hard palate several years later. The hard palate may be obturated in the meantime.
Cleft Palate Repair: Timing
Current thinking:
Early repair does not significantly affect facial growth.
Maxillary retrusion and midface deficiencies are inherent in the cleft palate phenotype.
Early repair is important for development of normal speech and for feeding.
Cleft Palate Repair and Speech
Difficult to determine which technique has best speech results because there are too many variables:
General agreement on these ideas:
Timing of surgery
Experience/skill of the surgeon
Experience/skill of the SLP
Definition of success
Early repair is better for speech results
Better results are obtained by experienced surgeons
Oronasal Fistula Repair: Techniques
Oronasal fistula—
Techniques:
a persistent opening between the oral and nasal cavity that occurs when the palate fails to heal after a palatoplasty
Use of local palatal tissue
Use of flaps of tissue from turbinates, buccal surface, or tongue
Oronasal Fistula Repair:
Potential Complications
Closure can be very difficult, especially if autogenous (local) tissue is used, because it is very thin. The repair can break down due to thin tissue and lack of blood supply.
Tongue flaps and buccal flaps can be challenging.
There is about a 37% or more recurrence risk with a repair, which gets higher with subsequent repairs.
Oronasal Fistula Repair: Timing
Often done with the alveolar bone graft (age 6–7)
Can be done earlier if it is large and symptomatic for speech
Temporary obturator sometimes used until fistula can be surgically repaired
Oronasal Fistula and Speech
A large ornonasal fistula…
A fistula that is smaller than a quarter will…
A fistula that is smaller than a dime…
can cause hypernasality and nasal emission
primarily cause nasal emission
may not be symptomatic, depending on its location
Oronasal Fistula and Speech
If the fistula is in the hard palate…
It is most likely to cause…
Patients may compensate by…
it will not cause nasal emission on velar sounds /k and g/
nasal emission on sibilant sounds, as tongue sends air into the fistula
holding tongue in the opening to prevent the loss of airflow
- results in palatal-dorsal production
- causes a lateral distortion
VPI Surgery
_______ of patients with palate repair will have VPI
VPI is a ______ and can not….
Goals:
1.
2.
20-30%
surgical disorder;
be corrected with speech therapy
- “Normalize” VP closure for speech
- Avoid airway compromise
