Palatal Fistula and Syndromes associated with CLCP

Part - I

Dr. Amit T. Suryawanshi

Oral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.com

Mobile No - 9405622455

• The dictionary meaning of cleft is a crack, fissure, split or a gap.

• The zones affected by common orofacialclefts are as follows:– Upper lip

– Alveolar ridge

– Hard palate

– Soft palate

– Nose (not so common)

– Eyes (not so common).

INTRODUCTION

BIRTH DEFECTS

ParentsFamily Members

Patients

Severe

Psychological

stress

• Feeding problems

• Improper growth of face

• Delayed & Improper Speech

• Delayed or abnormal tooth eruption

• Ear infections & hearing problems

• Recurrent chest infections

• Social & Psychological problems

EFFECTS ON CHILD

• In India: (C.M.C. Vellore) 1:700

• Racial variations: (By Gopalkrishnan: Dharwad Cleft Unit)– American Black 0.21 - 0.41

– Japanese 1.14 – 2.13

– Caucasian 0.77 – 1.40

– Indian 0.13 – 1.90

INCIDENCE

• Clefts may be caused by hereditary

– Sex-linked recessive gene.

– Family history of cleft lip and palate (40%)

• Environmental

– Infections during pregnancy (viral)– Nutrition deficiencies ( Folic acid)– Anemia , seizures during pregnancy– Harmful drug intake– Excessive consumption of alcohol

ETIOLOGY

Cleft Lip:

Failure of fusion of medial nasal process and maxillary processes

Cleft Palate:

Failure of fusion of palatine processes of maxilla

EMBRYOLOGY

INTERMAXILLARY SEGMENT – formed by Median nasal process fusion at deeper level .

Composed of labial componentupper jaw componentPRIMARY PALATE portion of nasal septum

DEVELOPMENT OF PALATE

DEVELOPMENT OF PALATE

Palate develops from the primary palate & secondary palate

Secondary palate derived from maxillary prominences

Outgrowth of palatine shelves appear in sixth week & on each side of tongue

In 7th week palatine shelves attain horizontal position & fuse with each other to form secondary palate

Secondary palate fuse with nasal septum and posterior part of primary palate

Bone extend from maxilla to ossify hard palate

DEVELOPMENT OF PALATE

DEVELOPMENT OF PALATE

Posterior part of palatine process do not get ossified and extend posteriorly to form soft palate

The median palatine raphe indicates line of fusion of processes

Nasopalatine canal

persists in median

plane between

premaxilla and

secondary palate &

represented in adult

as incisive fossa.

DEVELOPMENT OF PALATE

Incomplete cleft palate

Unilateral complete cleft lip and palate

Complete Cleft Palate

Bilateral complete CLP

TYPES OF CLEFT PALATE

• Kernahan has simplified it

• representing various clefts in the form of Y.

• Anterior portion of Y depict the lip (1 and 4)

• Middle alveolus (2 and 5)

• Incisive foramina and the posterior portion (3 and 6)

• Posterior to the incisive foramen, the hard (7 and 8) and the soft (9) palate.

MUSCLES OF PALATE

Tensor veli palatini (TVP)

• Function-stiffens soft palate and opens eustachian tube

• Innervation-Cranial nerve V3

Levator veli palatini (LVP)

• Function-elevates soft palate in speech and swallowing

• Innervation-Cranial nerve IX and X

Uvula• Fnction-elevates uvula• Innervation-Cranial nerve IX and X

Palatopharyngeus• Function-narrow and seal nasal pharynx• Innervation-Cranial nerve IX and X

Complete Cleft Palate :

Palatal shelves fail to fuse

The greater palatine foramen is located more anteriorly and laterally

Gap in the soft palate does not always correspond to the gap of the hard palate

A layer of the mucosa can extend and conceal a long underlying cleft in the bone structure

The palatal aponeurosis is missing at the midline

Major muscles, levatorveli palatini and palatopharyngeus do not join on the midline, fibres run parallel to the margins of the cleft

Two halves of the uvula are converged towards one another

There is a difference in the colour of the mucosa, oral mucosa is paler, nasal mucosa is redder

Cleft Palate Team

– Cleft Audiologist

– Orthodontics

– Cleft surgeon

– Social worker

– Psychologist

20

Assessment and Treatment of Cleft Palate.

Cleft Palate Team

– Cleft Audiologist

– Orthodontics

– Cleft surgeon

– Social worker

– Psychologist

21

Assessment and Treatment of Cleft Palate.

Preoperative Evaluation• Pediatric evaluation • Anesthetic evaluation• Blood investigation• Ear infection• Malnutrition• Anaemia• Other congenital anomalies particularly

cardiac.• Milestones• Chest x-ray

– Upper respiratory tract infection

• Several Techniques- Trend is towards less scarring and less tension on palate

• Scarring of palate may cause impaired mid-facial growth(alveolar arch collapse, midface retrusion, malocclusion)

• Facial growth may be less affected if surgery is delayed until 18-24 months, but feeding, speech, socialization may suffer.

Surgical Repair- Cleft Palate

Complications

- Palatal Fistula

• Introduction:

Palatal defects are common complications seen after primary

cleft palate repair. Small fistulas may be asymptomatic while

large fistulas produce various symptoms. There are many

methods proposed for closure of palatal defects.

• Symptomatic fistula may cause :

Regurgitation of food and fluid to the nasal cavity,

Malodor

Escape of air during speech resulting in hyper nasality

Impaired suction

Increased nasal discharge

(Cleft palate journal, january 1978, vol. 15 No. 1 )

Most Common Site :Hard Palate ( most often at the junction of Hard &

soft Palate)

Incidence :

0% to 34%

(Cohen SR, Kalinowaski J et al : Cleft palate fistula: A multivariate stastical

analysis of prevalence, etiology & surgical management. Plast Reconstr Surg 87:

1041, 1991)

27

• Causes of fistula formation:

type of cleft,

type of repair,

wound tension,

single-layer repair,

infection and

dead space deep to the mucoperiosteal flap

(International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–1057)

Classification

A. By Shultz

1. Pinpoint

2. Slit

3. Oval or Total dehiscence

B. Based on anatomical location by Smith:

type I referred to bifid uvula;

type II means fistula in the soft palate;

type III means fistula at junction of the soft and hard palates;

type IV means fistula in the hard palate;

type V indicates that the fistula at junction of the primary and

secondary palates;

type VI means lingual alveolar fistula; and

type VII means labial alveolar fistula

(International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–1057)

B. According to site :

1. Anterior

2. Middle

3. Posterior

C. ( According to size)

1. Small ( < 3mm )

2. Medium ( 3-5mm)

3. Large ( > 5mm )

(Cohen SR, Kalinowaski J et al : Cleft palate fistula: A multivariate stastical

analysis of prevalence, etiology & surgical management. Plast Reconstr Surg 87:

1041, 1991)

Causes of Fistula

Improper Mobilization

Tension Across the Suture Line

Compromised Vascularity

Flap Necrosis

Infections

dead space deep to the mucoperiosteal flap

(International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–

1057)

Closure of Palatal Fistula

Principals of fistula closure:

1) Elevation of large palatal flaps based on the

original incisions

2) Excision of the scarred margins of the fistula;

No scar epithelium can be left traversing the

fistula anywhere around its perimeter,

3) Accurate tension free closure of the nasal &

oral mucosa

4 )Use of additional unscarred tissue to close

anterior defects or large palatal defects;

Mucobuccal flap & tongue flap are most

useful;

5) Bone graft when indicated;

But it is not necessary for successful fistula

closure.