Secondary
management
Following primary surgery, regular review by a
multi-disciplinary team is essential. Many aspects of cleft care require
long-term review.
Hearing
Eustachian tube dysfunction plays a central
role in the pathogenesis of otitis media with effusion in babies and children
born with a cleft palate. Children with a cleft lip alone exhibit the same
frequency of otitis media as their age-matched noncleft counterparts. It has
been recently recognised that a child with a craniofacial anomaly including
cleft lip and palate is at increased risk of a sensorineural hearing deficit.
All children born with a cleft lip and palate should undergo assessment before
12 months of age for sensorineural and
conductive hearing loss by auditory brainstem responses (ABR) and
tympanometry, respectively.
Sensorineural
hearing loss is managed with a hearing aid, whilst the management of secretory
otitis media remains more controversial. Early (6—12 months old) prophylactic
myringotomy and grommet temporarily eliminates middle ear effusion. Regular
audiological testing may be as appropriate, reserving surgery for established
secretory otitis media with infection. No firm evidence is available to support
the interventional approach over the conservative regime. Nevertheless, the
relationship between hearing loss and potential speech problems remains
important. Regular audiological assessment during childhood is of utmost
importance.
Speech
Initial speech assessment should be performed
early (18 months) and repeated regularly to ensure that problems are identified
early and managed appropriately.
Common
speech problems associated with cleft lip and palate are:
•
Velopharyngeal incompetence — this is associated with increased nasal
airflow and resonance producing a nasal or ‘hypernasal’ quality to speech.
It frequently reflects poor function of soft palate associated with inadequate
muscle repair.
•
Articulation problems — these either arise as a compensatory
mechanism to overcome velopharyngeal incompetence or, less commonly, are due
to jaw/dental and occlusal abnormalities.
Investigation
by:
• videofluoroscopy
•
nasal airflow studies (aerophonoscopy)
•nasendoscopy
is helpful in defining the exact mechanism of
the problem which aids management.
Speech
problems are managed by:
•
speech and language therapy;
•
secondary palatal surgery:
— intravelar
veloplasty (muscular reconstruction of soft palate);
— pharyngoplasty;
•
speech-training devices.
Dental
Dental anomalies are common findings in
children with cleft lip and/or palate. Various phenomena include delayed tooth
development and delayed eruption of teeth; morphological abnormalities are also
well documented. The number of teeth may be reduced (hypodontia) or increased (hyperdontia),
and occurs most commonly in the region of the cleft alveolus involving the
maxillary lateral incisor tooth. These abnormalities can occur in both primary
and secondary dentition.
All
children with cleft lip and palate should undergo regular dental examination.
Dental management should also include preventive measures such as dietary
advice, fluoride supplements and fissure sealants.
A
well-maintained and disease-free dentition in childhood is an absolute
prerequisite for orthodontic treatment.
Orthodontic
management
Many children with cleft lip and palate
require orthodontic treatment.
Orthodontic
treatment is commonly carried out in two phases:
•
mixed dentition (8—10 years) — to expand the maxillary arches as a
prelude to alveolar bone graft;
•
permanent dentition (14—18 years) — to align the dentition and
provide a normal functioning occlusion. This phase of treatment may also include
surgical correction of a malpositioned/retrusive maxilla by maxillary
osteotomy (Fig.
Secondary
surgery for cleft lip and palate
Good outcome in cleft lip and palate is
directly attributable to the quality of primary surgery. Poorly executed primary
surgery leads to residual deformity of the lip and nose, together with poor
speech. Impaired growth of the midface (maxilla) is now attributed to poor and
traumatic primary surgery. Surgical techniques must endeavour to minimize
scarring.
Despite
adequate primary surgery, residual problems do occur and are managed with
appropriate secondary procedures (Table 37.2).
The
management of children with cleft lip and palate is complex, requiring the skill
of a multidisciplinary team. Each team should include professionals who are
appropriately qualified with specialist training, treating an adequate number of
patients per year. Meticulous record-keeping of photography, radiology, dental
casts and speech recording are indispensable, and permit regular audit and
improved outcomes.