Anatomy, Classification, Embryology, and Surgery

Question 1

Facial landmarks (7)

Answer 1

Nasal tip
Alar base and rim
Philtral ridges
Philtrum
Columella
Cupid's bow
White roll

Question 2

Hard palate anatomy

Answer 2

The premaxilla is from the tip of the maxilla to the incisive forame. The palatine process of the maxilla runs about halfway down the hard palate, and the palatine bone is the other half, ending in the posterior nasal spine.

Question 3

Soft palate anatomy

Answer 3

The velum attaches posteriorly to the hard palate via aponeurosis (the buffer zone for muscles to insert into). The soft palate is primarily composed of muscle and soft tissue for mobility.

Question 4

Pharyngeal anatomy

Answer 4

Nasopharynx
Oropharynx
Laryngopharynx

Question 5

Velopharyngeal muscles (7)

Answer 5

1. Tensor veli palatini–opens the eustacian tubes
2. Levator veli palatini–lifts the velum; parallel to ET
3. Palatoglossus–antagonist to LVP
4. Palatopharyngous–vertical fibers lower velum; horizontal fibers create a sphincter action
5. Superior constrictor–creates medial displacement of the lateral pharyngeal walls
6. Musculus uvulae–bulk of velum
7. Salpingopharyngeous–surface of velum, little functional significance

Question 6

Innervation of VPC

Answer 6

Motor: Pharyngeal plexus
Sensory: Trigeminal, Vagus, Facial

Question 7

Closure Patterns

Answer 7

Coronal–Velum meets with pharyngeal wall
Saggital–Pharyngeal walls meet horizontally
Circular–Velum and pharyngeal walls meet in the middle w/ or w/o help of adenoids

Question 8

Potential problems with adenoid pad

Answer 8

1. Can cause nasal obstruction
2. Can cause culdesac resonance
3. Can cause VPI

Question 9

Levels of an embryo

Answer 9

1. Ectoderm–>skin, teeth, hair, lens of eye, inner ear
2. Mesoderm–>muscles, connective tissues, bones, heart
3. Endoderm–>digestive system, liver, respiratory system, outer ear

Question 10

Neural tube

Answer 10

Houses the brain of an embryo

Question 11

Anatomy of embryo at 4 weeks

Answer 11

Pharyngeal arches are present
1. Mandibular
2. Hyoid
3. Body of hyoid
Maxillary process present
Frontonasal process present
Nasal placodes present, become nasal pits, then nostrils

Question 12

Anatomy of embryo at 5-6 weeks

Answer 12

Median and lateral nasal processes
Eyes are still very lateral
Interruption in week 6 will cause full CLP

Question 13

Anatomy of embryo at 7 weeks

Answer 13

Maxillary process conncets to the median nasal processes
Nasal pits present
Ears lateral and low-set
Hyoid arch is almost-complete ring of tissue around EAM
Merging of primary palate in anterior direction
Oral and nasal cavities NOT separated
Hard palate created by merging of palatine processes and premaxillae
Palatal shelves are vertical

Question 14

Anatomy of embryo at 9 weeks

Answer 14

Mandibular growth spurt–tongue lowers, palatal shelves elevate to separate nasal and oral cavities
Fusion starts are inc=cisive foramen and moves to uvula by week 12
Interruption here causes CPO

Question 15

Potential problems with ears (3)

Answer 15

Aural atresia (closure of EAC)
Microtia
Preauricular pits/tags

Question 16

Potential problems with eyes (6)

Answer 16

Epibulbar dermoid (cyst on eye)
Exophtalamus (bulging eyes)
Hypertelorism (wide-set eyes)
Coloboma (defect in eye shape)
Narrow palpebral fissures
Strabismus

Question 17

Potential problems with tongue (2)

Answer 17

Micro/macroglossia

Ankyloglossia

Question 18

Potential problems with jaw (3)

Answer 18

Micrognathia
Retrognathia
Prognathia

Question 19

Potential problems with head (4)

Answer 19

Micro/macrocephaly
Hydrocephaly
Brachycephaly (limited anterior/posterior growth)
Craniosyntosis (premature fusion of the cranial bones)

Question 20

Cause of CLP?

Answer 20

Multi-factorial inheritance (genetics+environment); sometimes related to syndromes

20% of cases are primarily inherited
3-5% are chromosomal
65% are primarily environmental or unknown

Question 21

Incidence of CLP

Answer 21

Most common birth defect; 1:595

25% Lip only (cleft on left lip in 70% of these)
25% palate only
50% CLP

Lowest incidence in African American population, highest in Native American population

CLP more common in males
CPO more common in females

Question 22

What percentage of children with CLP have another abnormality?

Answer 22

14-15%

Question 23

Cleft classifications (basic)

Answer 23

Lip and/or palate

Complete (formed before 9th week) or incomplete (formed during 9th week)

Unilateral or bilateral

Question 24

Cleft classifications (advanced)

Answer 24

Primary or secondary palate

Submucous cleft

Question 25

8 people who may be on a cleft team

Answer 25

``` SLP Audiologist Nurse Pediatrician Prosthodontist Orthodontist Geneticist Social worker (many others as well) ```

Question 26

Advantages of team care

Answer 26

Centralized and coordinated services Maximize communication between specialists Long-term treatment planning

Question 27

Typical timeline for CLP

Answer 27

``` Lip taping=birth, in hospital typically Nasal-Alveolar molding=before 3 mo. Lip repair=3 mos., rule of 10’s Initial SLP Eval Palate repair= 12 mos. Post-op speech eval Speech follow-up every 6-12 months or sooner Lip revision= after age 5-6, ideally early teenage years (9-12yrs); avoid midface growth deficiencies Secondary surgical revision to palate if needed Maxillary expansion, 6-9 years Bone grafting, 9-12 years Orthodontics ```

Question 28

SLP's role on cleft team

Answer 28

``` Provide support to family Provide input to team members Re-eval yearly Initiating referrals Community resource ```

Question 29

Types of occulsion

Answer 29

Class 1: Normal Class 2: Mandibular retrusion/maxillary protrustion) Class 3: Mandibular protrustion/maxillary retrusion)

Question 30

Other dental problems

Answer 30

``` Overjet (space between top and bottom teeth) Crossbite Over/underbite Supernumerary teeth Missing teeth Rotated teeth ```

Question 31

Palatal lift

Answer 31

Raises velum; good for VPI caused by reduction in velar movemetn

Question 32

Palatal obturator

Answer 32

Prosthetic that covers cleft in CP; nonsurgical option

Question 33

Speech bulb

Answer 33

Only worn when speaking; occludes the nasopharyngeal port to eliminate nasality

Question 34

Audiological problems

Answer 34

Bilateral conductive hearing loss; prone to ear infections

Question 35

Rule of 10s

Answer 35

Before surgery, child should be: 10 weeks old 10 pounds 10 hemoglobin g/dl

Question 36

Primary lip repair

Answer 36

Occurs at 3 months. Can be a straight-line repair, a triangular repair, or a rotational advancement

Question 37

Logan bar

Answer 37

Used to reduce tension on the surgical site after a lip repair (same function as lip tape)

Question 38

Palate repair timing

Answer 38

Occurs between 9 and 18 months (12-15 on average)

Question 39

Von Langenbeck repair

Answer 39

Palate repair that brings the structures in a straight midline

Question 40

Wardill-Kilner repair

Answer 40

Palate repair that closes the palate leaving a V or Y shaped scar

Question 41

Furlow Palatoplasty

Answer 41

Palate repair that creates a z shaped scar and lengthens the velum

Question 42

Care after palatoplasty

Answer 42

Elbow restraints; clear diet (later upgraded to puree); restricted from bottles, passies, spoons, etc.; limited to cup drinking for feeds

Question 43

Secondary lip surgery timing

Answer 43

Before 5 years old--typically improves facial appearance before entering school

Question 44

Reasons for secondary palate repair

Answer 44

1. Palatal fistula or dehiscience 2. Correction of maxillary/mandibular problem 3. Correction of VPD (occurs in 10-20%)

Question 45

Sphincterpharyngeoplasty

Answer 45

Secondary palate repair procedure that uses the pharyngeal flaps to narrow the sphincter--good for smaller VP gaps, good velar movement/poor pharyngeal wall movement

Question 46

Pharyngeal flap procedure

Answer 46

Secondary palate repair procedure that creates a midline pharyngeal flap with lateral ports for breathing; good for larger VP gaps with good lateral pharyngeal wall movement

Question 47

Pharyngeal wall augmentation

Answer 47

When material is injected into the pharyngeal wall to narrow the sphincter when VP gap is small