How do you treat a baby with a submucous cleft pallete?should we operate her and at what age?

What is a submucous cleft palate?
A submucous cleft palate is one type of cleft palate. The word “palate” refers to the roof of the mouth and the term “cleft” indicates a split in the palate. The palate consists of both a bony portion (hard palate) and a muscular portion (soft palate). At the end of the soft palate, the small finger-like projection of tissue that hangs down is called the “uvula”. The term “submucous” refers to the fact that the cleft is covered over by the lining (mucous membrane) of the roof of the mouth. This covering of mucosa makes the cleft difficult to see when looking in the mouth.

A submucous cleft of the soft palate is characterized by a midline deficiency or lack of muscular tissue and incorrect positioning of the muscles. A submucous cleft of the hard palate is defined as a bony defect in the midline or center of the bony palate. This can sometimes be felt as a notch or depression in the bony palate when the palate is palpated with a finger. Often a submucous cleft palate is associated with a bifid or cleft uvula.

What are the effects of submucous cleft palate?
When a submucous cleft is present, the muscles of the soft palate may not function properly and the individual is at risk for speech problems, middle ear disease, and swallowing difficulties. However, there are some individuals with a submucous cleft who have no apparent problems. Of importance to all persons with the submucous cleft, and their family, is the knowledge that submucous cleft has the same genetic (hereditary) risk as an obvious cleft of the palate.

How can a submucous cleft palate be identified?
The most common reason that a child is evaluated for a submucous cleft palate is abnormal nasal speech. Other symptoms may include persistent middle ear disease and feeding/swallowing difficulties. A submucous cleft palate may be identified by the presence of a bifid uvula; a very thin translucent strip of lining (mucosa) in the middle of the roof of the mouth; and, a notch at the back edge of the hard palate that can be felt by the fingertip. However, in some children, the palate may appear normal on physical examination despite the fact that the child is experiencing speech problems, persistent ear disease, and/or swallowing difficulties. In such cases, special tests are necessary to fully assess the palate. These tests include x-ray examination and nasopharyngoscopy (looking at the palate through a very small tube that is placed in the nose). These evaluations are most commonly done by members of a cleft palate team. If you suspect your child has a submucous cleft, you should contact a local cleft palate team.

Should a submucous cleft be treated?
The decision to treat a submucous cleft palate depends upon the consequences of the submucous cleft and is not based on the fact that it is present. The most common reason for treating an individual with a submucous cleft of the palate is because of abnormal speech. The speech has a nasal sound because air is lost through the nose. In such cases the child’s speech should be evaluated by a speech pathologist who, in consultation with other professionals, can diagnose the cause of the problem. If the palate cannot prevent air from escaping through the nose during speech, called velopharyngeal incompetence or VPI, then surgical repair of the palate will be required. Speech therapy alone cannot correct velopharyngeal incompetence.

Feeding/swallowing problems can sometimes be managed through the use of special techniques which the feeding consultant on the cleft palate team can suggest.

Ear problems should be treated by the child’s regular physician or by an ear, nose, throat specialist. Treatment may include the use of antibiotics and/or surgical insertion of ventilating tubes in the ear drum. Proper management of the child’s ears is essential to ensure good hearing and proper speech development.

If the feeding problems and/or chronic middle ear disease persist and are related to abnormal soft palate muscle function, then treatment of the submucous cleft palate is indicated.

What treatment is available for submucous cleft palate?
For individuals with submucous cleft and velopharyngeal incompetence, the most common treatment is surgical. The surgery consists of reconstruction of the abnormal tissues with a palatal repair with or without pharyngeal flap (pharyngoplasty). A primary goal of this surgery is to allow for normal speech production. This surgery is done in a hospital under general anesthesia. Pre- and post-surgical evaluation by members of a cleft palate team should be part of the overall treatment program.

In a limited number of cases, velopharyngeal incompetence associated with a submucous cleft palate can be treated with an appliance that fits in the mouth and attaches to the teeth. This appliance is generally made by a dental specialist (prosthodontist) associated with a cleft palate team. Again, pre- and post-treatment evaluation by the cleft palate team should be part of this treatment program.

CURRENT Diagnosis & Treatment in Otolaryngology.
Sections: Submucous Cleft Palate, Treatment, Preoperative Considerations, Cleft Lip Surgery, Timing of Lip Repair, Goals of Lip Repair, Rotation Advancement Cleft Lip Repair, Triangular Cleft Lip Repair, Bilateral Cleft Lip Repair, Nasal Deformity, Blood Supply Maintenance, Symmetrical Deformities, Primary Cleft Nasal Repair, Cleft Palate Surgery, Timing of Palate Repair, Techniques of Palate Repair, Von Langenbeck Repair, V-Y Pushback, Two-Flap Palatoplasty, Double-Opposing Z-Plasty, Levator Muscle Repair, Velopharyngeal Insufficiency, Preoperative Evaluation, Surgical Measures, Pharyngeal Flap, Sphincter Pharyngoplasty, Nonsurgical Measures, Secondary Surgical Procedures, Lip Revision, Bone Grafting, Rhinoplasty, Orthognathic Surgery.

Topics Discussed: bone transplantation; cleft lip; cleft palate; millard repair; nasal septoplasty; orthognathic operation of mandible; palatoplasty; repair of cleft lip; repair of cleft palate; rhinoplasty; submucous cleft of hard palate; velopharyngeal insufficiency; z plasty.

Excerpt: "Submucous cleft palate represents a special subset of clefts that remains confusing both in diagnosis and treatment. The diagnosis is made by the findings of the classic triad of a bifid uvula, central thinning of the soft palate, and a palpable notch in the posterior border of the hard palate (normally the location of the posterior nasal spine). Anatomically, there is the same separation of the levator palatini muscle that is seen in overt clefts.The care of children with a cleft lip and palate requires a comprehensive treatment plan from the initial diagnosis through the completion of reconstruction in adolescence. A child with a complete cleft lip and palate requires several operations as he or she develops. In general, the goal of treatment is to have as few operations as possible with the best possible outcome. Naturally, there are a variety of approaches, any of which may produce the same final result. A comparison of outcomes has been difficult because of treatment differences, as well as the fact that the experience and ability of the individual surgeon may also influence the outcome.Before..."

as a lincensed EMT i can tell you that no perfect answer exist for when to operate. the older the better chances she has fpr a quick recovery, the longer you wait the longer the dis-comfort persist.. these things are best discussed with a doctor and well thought out by you and the other parent. get medical advice, this is not the place to get such delicate data. good luck

The Doctors will tell you when is the correct time. My nephew had his firstoperation at 5 days because he had a very bad lip he has had quite a lot of operations since but still is waiting for the final operation and je is 14 years old.