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Edited by Michael Salmo

ON CLEFT PALATE

A RESEARCH PAPER
PRESENTED TO

DR. VICTORIA S. PRIMERO


ILOILO DOCTORS COLLEGE

IN PARTIAL FULFILLMENT
FOR THE REQUIREMENTS IN

ENGLISH 105
(TECHNICAL WRITING)

BY:
JHARLENE M. JULIT
BSN III-E

MARCH 2009
INTRODUCTION

Before history began, the creation took place. God created the heaven, earth, light, darkness, and
so on. On the fifth day, “God created man in His image; in the divine image he created him;
male and female he created them.”1 After everything was settled, on the 7th day, He rested.

God is ever generous and omnipotent. He is the source of all. He is beyond time and His
creation. He is almighty. Because of these, everything was created. He prepared everything for
Man to have. This is the underlying thought on why He created Man on the fifth day, not on the
first day. He created Man, one among the lasts, because it is His priority. When everything, all
that man needs, is there, he created Man. This is a genuine strategy of God, revealing the depth
of His love and mercy to His people.

Man is said to be made in the likeness image of God. If God, who is omnipotent and perfect, can
Man be like God, in imagery? Is man’s image perfect? If man’s image perfect, then why is there
deformities on the human body? Why are there differences on the faces of every individual?

Human as we are, as much as possible, we tend to be perfect. We tend to be wholesome. We tend


to be stunning. However, as human, changes happen. With the influence of numerous factors
around us, we modify from time-to-time. This is then science takes place – to explain us how
things affect our being, as man.

One of the many forms of deformities on human body is cleft palate. It is also one of the many
irregularities of the human body which is unexpected and unavoidable but nowadays is curable.
In this research, I have tried to explore how and why this cleft palate came to be. Thus, this paper
will present answers to supply queries on the deformities of the human body.

1 Genesis 1:27
Edited by Michael Salmo

A. BACKGROUND OF THE STUDY

B. RATIONALE OF THE STUDY


The purpose of the study is to identify the factors that affect children who have cleft palate. It
will also serve information necessary for the parents of a child having cleft palate and to those
assisting care for the patient.

C. STATEMENT OF THE PROBLEM(s)


This research aims to find out the factors of cleft palate on children. Specifically, this study
intends to answer questions on what is cleft palate, how cleft palate came to be, what causes cleft
palate, and what are the clinical manifestations of it?

D. SIGNIFICANCE OF THE STUDY


In the course of my research, I will be sharing information as to how this discomfort occurs on a
person and how to manage such deformity. With this research, we will be able to know how to
respond to such case of cleft palate on people and be informed of this matter. Such as that, we
will be able to prevent cases just as this, cleft palate.

E. DEFINITION OF TERMS
What is cleft palate?

Cleft palate is a treatable birth defect in which the baby's roof of the mouth
(palate) does not develop normally during pregnancy, leaving an opening (cleft)
that may go through to the nasal cavity. Cleft palate may involve any part of the
palate, including the front part of the roof of the mouth (hard palate) or the small
tag of tissue that hangs down from the soft palate (uvula). It may also occur by
itself or along with other birth defects of the face and skull, particularly cleft lip.
Cleft palate and cleft lip are the most common congenital defects of the head and
neck. Until treated surgically, cleft palate can interfere with feeding, speech
development, and hearing.2

Incomplete cleft palate

Unilateral complete lip and palate

Bilateral complete lip and palate

What causes cleft palate?

Cleft palate may be caused by genetic and environmental factors, although the
exact relationships are not clearly understood. If you were born with a cleft palate,
your children will have an increased risk for the defect.
A baby may be at higher risk for being born with cleft palate if during pregnancy
the mother uses certain medicines, is exposed to radiation or infections, takes
illegal drugs, smokes, or drinks alcohol.3

What are the symptoms?


2 http://children.webmd.com/tc/cleft-palate-topic-overview
3 Ibid.
Edited by Michael Salmo

Some forms of cleft palate are obvious at birth because they produce distinctive
facial deformities. But the way a newborn's face looks does not always indicate
the seriousness of the condition. The most reliable indicator of severity is the
location of the cleft. For example, a nonvisible small cleft in the soft palate may
have greater long-term impact-because of its effect on speech-than a visible large
cleft.
Babies with cleft palate generally have feeding problems because they are not
able to suck and swallow normally.4

How is cleft palate diagnosed?

Cleft palate is diagnosed by a physical exam shortly after birth.


Fetal Ultrasound can sometimes detect cleft palate as early as 14 to 16 weeks of
gestation, especially if it is severe and occurs along with a cleft lip. But fetal
ultrasound is not reliable for this purpose.5
Cleft Palate Surgery
In some children, a cleft palate may involve only a tiny portion at the back of the roof of the
mouth; for others, it can mean a complete separation that extends from front to back. Just as in
cleft lip, cleft palate may appear on one or both sides of the upper mouth. However, repairing a
cleft palate involves more extensive surgery and is usually done when the child is nine to 18
months old, so the baby is bigger and better able to tolerate surgery.
To repair a cleft palate, the surgeon will make an incision on both sides of the separation, moving
tissue from each side of the cleft to the center or midline of the roof of the mouth. This rebuilds
the palate, joining muscle together and providing enough length in the palate so the child can eat
and learn to speak properly.

4 Ibid.
5 Ibid.
When the roof of the mouth doesn't grow together properly, the condition is called a cleft palate.
To repair it, the surgeon will make an incision along both sides of the cleft.
Tissue is drawn together from both sides of the cleft to rebuild the roof of the mouth.

Recovering From Cleft Palate Surgery

For a day or two, your child will probably feel some soreness and pain, which is easily controlled
by medication. During this period, you child will not eat or drink as much as usual -- so an
intravenous line will be used to maintain fluid levels. Elbow restraints may be used to prevent
your baby from rubbing the repaired area. Your doctor will advise you on how to feed your child
during the first few weeks after surgery. It's crucial that you follow your doctor's advice on
feeding to allow the palate to heal properly.

How is it treated?

Treatment for cleft palate usually involves a team of doctors and other health professionals.
Surgery is done to correct the defect; this often requires more than one procedure. Guidance from
a health professional is usually needed to help you learn how to feed a baby with cleft palate.
Usually, the initial surgery is performed when your child is between 12 months and 18 months of
age. Surgical corrections specifically for cleft palate usually are completed by your child's teen
years.
Some children with cleft palate develop problems that require special treatment, such as speech
and hearing difficulties, sinus and ear infections, or complications following surgery to correct
cleft palate. Dental problems sometimes also occur, such as having extra, misshapen, or missing
teeth.

How many surgeries are needed?

The number and type of surgery used to correct a cleft lip depends on how much of the lip is
involved, whether it occurs with cleft palate, and whether the nose is affected.
Edited by Michael Salmo

Surgery for a child with an isolated cleft lip (not occurring with cleft palate) may require:

* A single surgery if the cleft is small and affects only one area of the lip (unilateral).
* Two surgeries, if it is a wide unilateral cleft. The first surgery on the lip usually is done as soon
as possible (generally when the baby is between a few days to 6 weeks old). The second surgery
on the lip usually is done when the baby is about 2 to 3 months old.
* Two surgeries for a cleft affecting two areas of the lip (bilateral). Each area is usually
surgically repaired in separate procedures.
The type of surgery needed for a child with a cleft lip and/or other related deformities depends on
the specific combination of problems.
* A child with cleft lip and a defect of the nose usually needs two surgeries. However, some
doctors prefer to correct the nose defect during the same surgery to correct the cleft lip; they
believe that this will cause fewer problems with speech later in life. Other doctors prefer to wait
until the child is 5 or 6 years old, believing that waiting avoids problems with uneven facial
growth because the nose grows more slowly than the rest of the face.
* A child with a cleft lip and a cleft palate may need two or more surgeries.
* Additional surgeries may be needed to correct any unevenness of the lip line or scars that
formed on the lips from previous surgery. These surgeries may be done as late as the teen years.

Chances of having a child with a cleft palate or cleft lip

If a parent has a cleft lip or cleft palate or has a child with one, the chances of having another
child with the condition increase. The following table illustrates the risks.
Chances of having a child with a cleft lip or cleft palateDoes the parent have cleft lip or cleft
palate?Does the parent have a child with cleft lip or cleft palate?Chance of a child or another
child with cleft palateChance of a child or another child with cleft lip with or without cleft
palateNoNo0.04% (1 in 2,500)0.1% (1 in 1,000)NoYes, 1 child affected2% (1 in 50)4% (1 in
25)NoYes, 2 children affected8% (1 in 12)9% (1 in 11)YesNo6% (1 in 17)4% (1 in
25)YesYes15% (1 in 7)17% (1 in 6)
Common concerns when you have a baby with a cleft lip and/or palate
Some common concerns parents may have after having a baby with a cleft lip and/or cleft palate
include:
* Fearing that your child is too fragile to hold and cuddle.
* Worrying about future hardships your child may face, such as making friends.
* Worrying about whether your baby will get enough nourishment, since feeding often is more
difficult and complicated than normal.
* Worrying about the cost of surgery and other treatments.
Some common feelings parents may have after having a baby with a cleft lip and/or cleft palate
include:
* Embarrassment, shame, or guilt.
* Sadness or despair because you did not have a perfect baby.
* Denial. You may even believe that there was a mix-up in the nursery and that this is not your
baby.
* Disappointment because you are unable to breast-feed (if you have a baby with cleft palate).
However, you can feed your baby pumped breast milk with a bottle.
What Happens to People With Cleft Lip and Palate?
One of the first problems a baby with cleft palate might have is difficulty breathing or eating.
Cleft palate usually makes breastfeeding difficult because the infant has difficulty sucking
properly. The palate prevents food and liquid from going up the nose when swallowing. To
prevent liquid from passing into the nose of a newborn baby with a cleft palate, a bottle with a
special nipple may be used to feed the baby breast milk or formula.
Kids born with cleft palate may also have frequent ear infections. That's because air and fluid
can't pass normally through the eustachian (pronounced: yoo-stay-shun) tubes, the tubes that
connect the throat with the middle ear. This means fluid and germs can become trapped behind
the eardrums and cause infection. Some people with cleft palate may have had an operation to
put tubes in their ears to help the fluid drain properly. In some cases, people who had cleft palate
may have hearing loss because of repeated infections and fluid behind the eardrums.
Dental problems, such as cavities and missing or malformed teeth, also are common in people
born with cleft lip and palate.
Speaking clearly can be challenging for kids with cleft cleft palate. Sometimes the soft palate
doesn't move well enough to prevent air from leaking out through the nose during speech. This
Edited by Michael Salmo

can cause their voices to sound as if they are speaking through their nose. If the teeth don't line
up properly, a person may not be able to pronounce certain sounds.
In most children with clefts there are no other physical or learning problems. For some people,
cleft palate and cleft lip may be associated with other birth defects, such as heart defects, or other
physical problems, such as growth disorders and muscle weakness and some learning difficulty.

PATHOPHYSIOLOGY

The face develops from 5 processes in the human embryo, the single frontonasal process and the
paired maxillary and mandibular processes. These 5 processes consist mainly of neural crest
tissue and are derived from the first pair of pharyngeal arches at approximately the fourth week
of gestation. The frontonasal process begins to develop median and lateral nasal prominences
around an olfactory pit at approximately the 33rd day of gestation. The maxillary processes
continue to develop medially toward the median and lateral nasal processes of the frontonasal
process. The maxillary processes compress the MNPs, and the epithelium is believed to stretch
and break down, allowing the processes to fuse in the normal fetus.
The mesodermal penetration theory of Pohlmann and Veau emphasizes the importance of
mesodermal migration and support of the fusing structures, without which the epithelial layers
break down. This theory may be more important for the development of clefts of the primary
palate. Schendel et al investigated the muscle at the site of cleft lips by performing a biopsy, the
results of which demonstrated nonneurogenic atrophy and disorganization of the muscle fibers at
the cleft margin, yielding a metabolic explanation for poor mesenchymal migration due to
abnormal local mitochondria. These findings lend more support to the mesodermal penetration
theory at the site of primary palatal clefts.
ANATOMY

The palate consists of the hard palate and soft palate, which together form the roof of the mouth
and the floor of the nose. The palatine processes of the maxilla and horizontal lamina of the
palatine bones form the hard palate. Its blood supply is mainly from the greater palatine artery,
which passes through the greater palatine foramen. The nerve supply is via the anterior palatine
and nasopalatine nerves. The soft palate is a fibromuscular shelf made up of several muscles
attached like a sling to the posterior portion of the hard palate. It closes off the nasopharynx by
tensing and elevating, thereby contacting Passavants ridge posteriorly. The soft palate consists of
the tensor veli palatini, the levator veli palatini, the musculus uvulae, the palatoglossus, and
palatopharyngeus muscles. CN V supplies the tensor veli palatini, while CN IX and CN X
innervate the others. The levator veli palatini is the primary elevator of the palate.

EMBRYOLOGY

The primary and secondary palates are delineated according to embryological development. The
primary palate or premaxilla is a triangular area of the anterior hard palate extending from
anterior to the incisive foramen to a point just lateral to the lateral incisor teeth. It includes that
portion of the alveolar ridge containing the four incisor teeth. The secondary palate consists of
the remaining hard palate and all of the soft palate. The primary palate forms during the 4th to
7th weeks of gestation as the two maxillary swellings merge and the two medial nasal swellings
fuse to form the intermaxillary segment. The intermaxillary segment is composed of a labial
component (forms the philtrum), a maxilla component (forms alveolus and 4 incisors), and
palatal component (forms the triangular primary palate). Normally during development of the
primary palate, a cleft does not exist (unlike the secondary palate in which cleft formation occurs
as a natural stage of development). The secondary palate forms during the 6th to 9th weeks of
gestation, as the palatal shelves change from a vertical to horizontal position and fuse. The
tongue must migrate away from the shelves in an antero-inferior direction for palatal fusion to
occur.

Prognosis

A cleft palate is often easy to correct with surgery. The procedure leaves only a small amount of
scarring. It can be more difficult to treat a cleft palate because it can cause a range of problems
with speech, feeding, dental health and hearing.
Edited by Michael Salmo

A long-term structured care plan, from a dedicated team of cleft specialists, is usually required to
help children who are born with clefts.

INCIDENCE
1. Cleft lip with or without cleft palate occurs 1 in 800 live births.
2. Cleft palate alone occurs 1 in 2000 live births.
3. Highest incidence is associated with Asians and Native Americans; lowest with African
Americans.
4. Occurrence of cleft lip predominates in males.
5. Occurrence of cleft palates predominates in females.

CLINICAL MANIFESTATIONS
1. Visible unilateral or bilateral cleft lip
2. Palpable and/or visible cleft palate
3. Nasal distortion
4. Feeding difficulties

COMPLICATIONS
1. Speech difficulties—hypernasality, compensatory articulation
2. Malocclusion—abnormal tooth eruption pattern
3. Excessive dental decay not unusual
4. Hearing problems—caused by recurrent otitis media secondary to Eustachian tube dysfunction
5. Altered self-esteem and body image—affected by degree of disfigurement and scarring

LABORATORY AND DIAGNOSTIC TESTS


1. Routine preoperative workup (i.e., complete blood count)
2. Additional laboratory and diagnostic tests if other anomalies exist

SURGICAL MANAGEMENT: CLEFT PALATE REPAIR


Cleft palate surgery is usually performed when the child is 9 to 12 months of age. Palatoplasty
involves closure of the mucous membrane and restoration of the anatomic structure. Several
types of surgical repairs are used because of the many different forms of cleft palates. With a
severe defect, staged procedures may continue until the patient is 4 to 5 years of age.

NURSING INTERVENTIONS

PREOPERATIVE CARE
1. Facilitate parents’ positive adjustment to infant.
a. Assist parents in dealing with phasic reaction—shock, denial, grief, and
mourning.
b. Encourage expression of negative feelings.
c. Discuss surgery with parents and role-play the behavior strategies for coping
with the reactions of family and friends.
d. Provide information that instills hope and positive feelings for infant (e.g.,
comment on infant’s positive features, note positive aspects of parent-child
interactions).
e. Encourage parents to participate in caregiving activities.
f. Convey attitude of acceptance of infant.
g. Arrange meeting with other parents who have undergone the surgical and
medical treatment experience.
2. Provide and reinforce information to parents about infant’s prognosis and treatment.
a. Provide information regarding cause of cleft palate.
b. Explain stages of surgical intervention and expected outcome.
c. Describe feeding techniques.
3. Promote and maintain adequate fluid and nutritional intake.
a. Facilitate breast or bottle feeding using appropriate bottle and nipple—regular
nipple with enlarged hole, Breck feeder (syringe adapted with 2-inch tubing), or
other special feeding appliances.
b. Place infant in upright position and direct the flow of milk to the side of the
mouth, avoiding the cleft in the palate.
c. Directs fluids towards the back of the tongue (Brek feeder).
d. Burp infant frequently during feeding, because infant will swallow excessive
Edited by Michael Salmo

air.
e. Assess infant’s response to feeding and proceed at rate suitable to needs.
f. Follow feeding with water to cleanse formula from mouth.
g. Monitor weight.
4. Promote and maintain clear airway.
a. Monitor respiratory status (respiratory effort, breath sounds, vital signs).
b. Position infant on right side with some elevation.
c. Place suction bulb near infant at all times.
d. Feed infant in upright position and burp frequently.
PREOPERATIVE HOME CARE
1. Instruct parents about care and maintenance of presurgical orthodontic device, if used
(promotes alignment of maxilla and proper lateral arch position).
a. Remove and clean everyday
b. Replace after cleaning
c. Monitor for white pressure areas in palate.
d. Instruct parents on how to apply elbow restraints to child to prevent removal of
palate.