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Cleft palate (general considerations)

last modified on: Tue, 03/06/2018 - 13:24

GENERAL CONSIDERATIONS

  1. Indications: The main objectives of cleft palate repair are complete closure of the palatal cleft and the creation of an adequately functioning velopharynx for production of intelligible speech.
  2. Considerations:
    1. Width of cleft: narrow considered <1cm; medium 1-1.5cm; wide >1.5cm
      1. Wider cleft -> wider strip of mucoperiosteum needs to be left on cleft margin to repair nasal side
    2. 2 structures tether the flaps laterally:
      1. greater palatine pedicle
      2. abnormal attachment of the levator veli palatini and tensor palatini muscles to the posterior hard palate
    3. Goals: 
      1. formation of competent VP sphincter
      2. closure of nasal from oral cavity
      3. preservation of midface growth
      4. functional occlusion
    4. Timing: controversial
      1. prior to 1 year > 10% rate of articulation errors, less hypernasal speech
      2. after 1 year > 86% articulation errors
      3. desire to facilitate velopharyngeal competence for adequate speech favours relatively early closure
      4. possible negative influence on maxillofacial growth and occlusion favours late closure
      5. technically more challenging in early closure
      6. usually completed at 9-12 months of age
    5. According to Bardach, the most important components of the classic two flap or three flap (V-Y) modification palatoplasty are as follows: 
      1.  Atraumatic undermining of the mucoperiosteal flaps on both oral and nasal surfaces of the cleft.
      2. Partial dissection of the neurovascular bundles from these flaps to allow for a tension free approximation of the oral surface of the flaps.
      3. Precise dissection of the soft palate musculature from their abnormal insertions on the posterior edge of the hard palate and from the nasal periosteum to allow for repositioning and creation of a physiologically appropriate velopharyngeal muscular sling.
      4. Closure of the hard palate in two layers and suturing the oral and nasal layers together in order to eliminate dead space and stabilize the flaps.
      5. Do not skimp on the nasal side - this may be limiting factor in closing nasal side of cleft, oral side much less difficult to mobilize and close
  3. Complications
    1. Oronasal fistula occurs in 2-3% of patients. This most often occurs at the junction of the hard and soft palate.
    2. Velopharyngeal insufficiency can remain an issue if the soft palate is inadequately lengthened during the case. Speech therapy is often inadequate to address this problem and it may require a palate lengthening procedure such as sphincter palatoplasty or a pharyngeal flap
    3. Prolonged operative time with the Dingman in place can lead to tongue edema. This problem can be prevented by letting the mouth gag down periodically.
  4. Types of palatoplasty
    1. von Langenbeck  
      • bipedicled flap by virtue of leaving connection anteriorly at alveolus + greater palatine pedicle posteriorly
      • can combine with 2-flap (cleft side) for unilateral complete
    2. Two-flap 
      • unipedicled flap based on posterior descending palatine --> greater palatine arteries (via greater palatine foramen)
      • indicated for complete clefts, adequate closure of the cleft alveolus
      • Can combine with z-plasty to elongate palate
      • Do not release the posterior flap from hard palate before dissecting pedicle - rely on blood supply from muscle if the pedicle is violated
    3. Three-flap (VY advancement/pushback) 
      • Indicated for repair of soft palate only or soft + posterior-only (incomplete) hard palate, suitable for wide clefts
      • provides additional palate length by allowing greater flap advancement
      • A modification of VL technique
    4. Furlow Z-plasty
      • Indicated for narrow soft palate cleft and submucous cleft

PREOPERATIVE PREPARATIONS

  1. Laboratory studies
    1.  Hemoglobin and hematocrit should be obtained. Allowable blood loss may be estimated. Consent
    2. Informed consent should be obtained
    3. Most of the time myringotomy tubes will be placed at time of palatoplasty

Basic anatomy & physiology:

  1. Embryology: Palatogenesis takes place from week 5 to 12 of embryologic development. Anteriorly the maxillary prominences grow, pushing the nasal prominences together in the midline. These fuse to form the primary palate, defined as the central maxillary alveolar arch that houses the four incisors as well as the hard palate anterior to the incisive foramen. After primary palate fusion, the secondary palate begins to develop. The palatine shelves arise from the maxillary prominence and fuse to form the secondary palate from anterior to posterior beginning at the incisive foramen at week 8 and ending with the uvula by week 12. The type and degree of palatal cleft directly result from the point at which this process is interrupted
  2. Anatomy:  The width of the palatal cleft is one of the main considerations in pre-operative planning. The wider the cleft, the wider the strip of mucoperiosteum that must be left on the medial edge of the cleft.  These strips will be turned over and used to create the nasal layer of the cleft repair. Narrow cleft is defined as gap width <1cm. Medium cleft is defined as gap width from 1 to 1.5cm. Wide cleft is defined as gap width>1.5cm.
  3. Middle ear disease - Incidence of middle ear effusion with cleft palate is higher than the general population especially in children under 2. Eustachian tube dysfunction is thought to be primarily due to the abnormal insertion and formation of the tensor and levator veli palatini in patients with cleft palate. Cartilage hypoplasia and cranial base abnormality have also been posited as potential etiologies. Any cleft palate patient undergoing general anesthesia warrants exam of ears under anesthesia for evaluation of effusion and necessity of tympanostomy tubes.

NURSING CONSIDERATIONS

  1. Room Setup< > Bed will be turned 90 degrees from anesthesia (anesthesia on right)Instrumentation and EquipmentMicroscope with 250mm lens70 degree 4mm telescopePhillipinne boardDingman retractor Monopolar Colorado tip cautery set at 8 cut, 8 coag, blend 1ToothbrushInjection: 1:200,000 Epinephrine is injected into the palate and vomer for hemostasis and hydrodissection (no longer using Vitrase as of 2016)3/4"x3/4" (Elvis) neurosurgical patties soaked in 1:200,000 Epinephrine are used for hemostasis during the case.Avitene (Microfibrillar Collagen - sheets not flour)BacitracinPeridex (for oral prep)Prep and DrapeBed is turned 90 degrees to the door. The child is laid supine on the Phillippine board with the head off of the edge of the Phillippine board onto the table in maximal extension.Prep and drape in the usual sterile fashion for an intra-oral procedureMake sure the retractor is centeredTongue exact midlineMaxillary prongs ideally are positioned within the cusp of the molarsPeridex rinse and scrub with toothbrush noneSpecial Considerations
  2. Each cleft palate must be examined carefully both pre-operatively and intraoperatively. Wide clefts will require more extensive lateral dissection to medialize the mucosal flaps and may require a vomer interposition flap.  

ANESTHESIA CONSIDERATIONS 

  1. Oral Rae endotracheal tube, taped directly in midline
  2. Antibiotics: Unasyn 50 mg/kg or equivalent should be ordered for administration prior to incision. 
  3. Steroids: Decadron 0.25 mg/kg is given at the beginning of the case.