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.     16+

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. 37.13).

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.