M5: CLEFT LIP & PALATE ASSESSMENT

INCIDENCE

1.94 per 1000 live births for cleft lip and palate			CLEFT LIP: Recurrence rate of 23 per 1000 CLEFT PALATE FOR NON-SYNDROMIC CLEFTS: 14 per 1000
SYNDROMIC CONDITIONS WITH OR W/O CLEFT
CHINESE: 1.30 JAPANESE: 1.34 ASIAN: 1.47			TOTAL: 1.33 per 1000 live births
NON-SYNDROMIC CONDITIONS WITH OR W/O CLEFT
CHINESE: 1.20 JAPANESE: 1.18 OTHER ASIANS: 1.22			TOTAL: 1.19 per 1000 live births

SYNDROMIC CONDITIONS WITH OR W/O CLEFT

CHINESE: 1.30 JAPANESE: 1.34 ASIAN: 1.47

TOTAL: 1.33 per 1000 live births

NON-SYNDROMIC CONDITIONS WITH OR W/O CLEFT

CHINESE: 1.20 JAPANESE: 1.18 OTHER ASIANS: 1.22

TOTAL: 1.19 per 1000 live births

VISUAL EXAMINATION

Normal variations in structure = unusual characteristics; but not abnormal → abnormalities may have no relation in speech

Determine PHYSICAL FACTORS that appear to interfere with ARTICULATION and/or RESONANCE → other anomalies must also be noted

PHYSICAL FACTORS, ARTICULATION, RESONANCE

Determine _________ that appear to interfere with _______ and/or _______ → other anomalies must also be noted

EYES

→ spaces between the eyes 

HYPERTELORISM	HYPOTELORISM	PALPEBRAL FISSURE
Excessive space between eyes	Too little space between eyes	Narrow palpebral fissure may indicate congenital craniofacial condition

HYPERTELORISM

Excessive space between eyes

HYPOTELORISM

Too little space between eyes

PALPEBRAL FISSURE

Narrow palpebral fissure may indicate congenital craniofacial condition

EARS

→ shape, position, symmetry 

• If development interrupted = ears can be found somewhere else

NOSE AND AIRWAY

→ SHAPE: flattened nares 

→ FLARING: nasal patency → if nose is wide, so will the flare be

LIPS

→ closure during rest and speech, symmetry, scarring, lip pits, mobility 

LIP PITS	MANDIBLE
→ van der woude syndrome  → indentation in the lips  → without cleft lip = no implication in speech	→ v-shape  → indication of craniofacial condition  → narrow maxillary/mandibulary arch  → placement of tongue (macro/microglossia)

LIP PITS

→ van der woude syndrome 

→ indentation in the lips 

→ without cleft lip = no implication in speech

van der woude syndrome

lips pits are also known as ______

MANDIBLE

→ v-shape

→ indication of craniofacial condition

→ narrow maxillary/mandibulary arch

→ placement of tongue (macro/microglossia)

HARD PALATE

MUCOSA			POSITION OF ALVEOLAR RIDGE			PALATAL VAULT			MAXILLARY ARCH
Color, rugae, incisive papilla						Dome shape
SCARS OF CLEFTING				FISTULAS				SUBMUCOUS CLEFT
				Position, size, small opening on palate				Notch in the border of h/s palate

MUCOSA

Color, rugae, incisive papilla

PALATAL VAULT

Dome shape

FISTULAS

Position, size, small opening on palate

→ Anterior to velar dimple: affect resonance

→ Posterior to velar dimple: no significant effect

→ ORONASAL FISTULA: somewhere between nose and alveolar ridge

SUBMUCOUS CLEFT

Notch in the border of h/s palate

→ Bifid uvula; hypoplastic uvula 

→ HYPOPLASTIC: doesn’t move around 

→ HYPERNASALITY

Anterior to velar dimple

affect resonance

Posterior to velar dimple

no significant effect

 ORONASAL FISTULA

somewhere between nose and alveolar ridge 

COMPLETE CLEFT

From outside all the way back

HYPOPLASTIC

doesn’t move around

PALATAL FISTULA

→ Seen immediately 

→ nasal emissions present

ALVEOLUS FISTULA

→ underneath the lips 

→ most have problem with dentition

POSTERIOR AND LATERAL PHARYNGEAL WALLS

→ movement 

→ thorough evaluation of pharyngeal walls require instrumentation 

PASSAVANT’S RIDGE

→ Help occlude the pharynx → look at the movement of the muscles, both side and back in sync with elevation of the soft palate

PASSAVANT’S RIDGE

→ Help occlude the pharynx

→ look at the movement of the muscles, both side and back in sync with elevation of the soft palate

TONSILS

→ located between anterior and posterior faucial pillars

→ non-existent among adults but present in children → begin to shrink as child reaches puberty 

0	1	2	3	4
Absent	Small	Estend beyond edge of faucial pillars	Beyond the pillars	Large, meeting at the midline

EFFECTS ON VELAR MOVEMENT 

→ tonsils → in between → tonsils are enlarged, it will get in the way of your movement 

→ forcing out voice without help of palatal elevation

EFFECTS ON VELAR MOVEMENT 

→ tonsils → in between → tonsils are enlarged, it will get in the way of your movement 

→ forcing out voice without help of palatal elevation

0

Absent

1

Small

2

Extend beyond edge of faucial pillars

3

Beyond the pillars

4

Large, meeting at the midline

DENTAL AND OCCLUSION

→ alignment of mandible vs maxilla 

→ molar alignment not frontal incisors 

→ no teeth: children with CLAP = prone to poor dental hygiene (90%)

OCCLUSION
CLASS I	CLASS II	CLASS III
Normal occlusion	Retruded mandible (overbite)	Protruded mandible (underbite)

+Open bite and cross bite

CLASS I

Normal occlusion

CLASS II

Retruded mandible (overbite)

CLASS III

Protruded mandible (underbite)

MALOCCLUSION

CROSSBITE	ANTERIOR CROSSBITE	LATERAL CROSSBITE
Maxillary teeth are inside the mandibular teeth	Maxillary incisors	Small maxillary arch
DEEP BITE	OVERJET	UNDERJET
Excessive vertical overlap (crowding in oral cavity)	Incisors labioverted	Incisors are linguaverted
SUPERNUMERARY TEETH	Children with alot of teeth

+Clefts, supernumerary teeth 

CROSSBITE

Maxillary teeth are inside the mandibular teeth

ANTERIOR CROSSBITE

Maxillary incisors

LATERAL CROSSBITE

Small maxillary arch

DEEP BITE

Excessive vertical overlap (crowding in oral cavity)

OVERJET

Incisors labioverted

UNDERJET

Incisors are linguaverted

SUPERNUMERARY TEETH

Children with alot of teeth

TONGUE

Size in relation to mandibular arch, palatal arch, oral cavity, micro-macroglossia, glossoptosis		GLOSSOPTOSIS		COLOR		LINGUAL FRENULUM		MOBILITY
		Drooping of tongue		Pale-ish reddish pink		→ tiny tissue underneath the tongue  INSERTION/POSITION: has to be ¾ of the length underneath the tongue		→ Elevation, lateral, curling  → a lot of children with cleft lip and palate can still move their tongue
ANKYLOGLOSSIA tongue-tied , difficulty with vowels, alveolar sounds, some people are born with this even if they don’t have cleft
LINGUAL FRENUM					LINGUAL CLEAVAGE

GLOSSOPTOSIS

Drooping of tongue

TONGUE COLOR

Pale-ish reddish pink

LINGUAL FRENULUM

→ tiny tissue underneath the tongue 

INSERTION/POSITION: has to be ¾ of the length underneath the tongue

TONGUE INSERTION/POSITION

has to be ¾ of the length underneath the tongue

TONGUE MOBILITY

→ Elevation, lateral, curling 

→ a lot of children with cleft lip and palate can still move their tongue

ANKYLOGLOSSIA

tongue-tied , difficulty with vowels, alveolar sounds, some people are born with this even if they don’t have cleft

LINGUAL FRENUM

LINGUAL CLEAVAGE

DIRECT EVALUATION

INDIRECT EVALUATION

MANNER OF EVALUATION

DIRECT EVALUATION

→ procedures that give direct information to the examiner such as allowing examination of the anatomical and physiological defects that causes velopharyngeal dysfunction 

VIDEOFLUOROSCOPY

NASOPHARYNGOSCOPY/ENDOSCOPY

→ xray with movement; moving image of the internal part of the mouth → view of the entire length of the pharyngeal wall  → helpful in determining surgical and prosthetic options for vp dysfunction treatment  → helpful is assessing placement of prosthetic device  → evaluate effects of SURGICAL PROCEDURES  → has pre- and post-surgical information  ADVANTAGES Use of cineradiography and AUDIO RECORDING Does not require film developing/processing Reduction in the exposure to RADIATION USES Evaluate STRUCTURE and function of the VP MECHANISM Can confirm VP opening and determine size and relative shape of opening  Helpful in assessing extent and symmetry of lateral pharyngeal wall movement, upward mov’t of velum during speech

ENDOSCOPY → procedure that allows VISUALIZATION of the interior of a canal or hollow organ by means of a special instrument  → assess structure and function of the vocal tract  → provides the examiner opportunity to observe ARTICULATION, PHONATION, RESONANCE, AND SWALLOWING  NASOPHARYNGOSCOPY → commonly used in clinical setting for the evaluation of VP dysfunction → view of all structures of the VP valve and function during speech → clear rationale for design and placement of pharyngoplasty surgery; pharyngeal flaps  → INSTRUMENT TO ASSESS EFFECTIVITY OF FLAPS: sphincteroplasty or retropharyngeal implant  → examine larynx and vocal folds  → used to assess swallowing FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING (FEES)   ADVANTAGES  No radiation exposure  May be repeated frequently  Ease of administration  Generally painless Easy to record Accessible  Therapeutic applications

VIDEOFLUOROSCOPY

→ xray with movement; moving image of the internal part of the mouth

→ view of the entire length of the pharyngeal wall

→ helpful in determining surgical and prosthetic options for vp dysfunction treatment

→ helpful is assessing placement of prosthetic device

→ evaluate effects of SURGICAL PROCEDURES

→ has pre- and post-surgical information

ADVANTAGES

Use of cineradiography and AUDIO RECORDING

Does not require film developing/processing

Reduction in the exposure to RADIATION

USES

Evaluate STRUCTURE and function of the VP MECHANISM

Can confirm VP opening and determine size and relative shape of opening

Helpful in assessing extent and symmetry of lateral pharyngeal wall movement, upward mov’t of velum during speech

VIDEOFLUOROSCOPY ADVANTAGES

1. Use of cineradiography and AUDIO RECORDING

2. Does not require film developing/processing

3. Reduction in the exposure to RADIATION

VIDEOFLUOROSCOPY USES

1. Evaluate STRUCTURE and function of the VP MECHANISM

2. Can confirm VP opening and determine size and relative shape of opening 

3. Helpful in assessing extent and symmetry of lateral pharyngeal wall movement, upward mov’t of velum during speech

ENDOSCOPY

→ procedure that allows VISUALIZATION of the interior of a canal or hollow organ by means of a special instrument 

→ assess structure and function of the vocal tract 

→ provides the examiner opportunity to observe ARTICULATION, PHONATION, RESONANCE, AND SWALLOWING

NASOPHARYNGOSCOPY

→ commonly used in clinical setting for the evaluation of VP dysfunction

→ view of all structures of the VP valve and function during speech

→ clear rationale for design and placement of pharyngoplasty surgery; pharyngeal flaps 

→ INSTRUMENT TO ASSESS EFFECTIVITY OF FLAPS: sphincteroplasty or retropharyngeal implant 

→ examine larynx and vocal folds 

→ used to assess swallowing

• FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING (FEES) 

sphincteroplasty or retropharyngeal implant 

INSTRUMENT TO ASSESS EFFECTIVITY OF FLAPS:

FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING

used to assess swallowing

NASOPHARYNGOSCOPY/ENDOSCOPY ADVANTAGES

• No radiation exposure 

• May be repeated frequently 

• Ease of administration 

• Generally painless

• Easy to record

• Accessible 

• Therapeutic applications

INDIRECT EVALUATION

→ do not allow visualization of the structures. Provide OBJECTIVE DATA regarding the results of velopharyngeal function such as AIRFLOW, AIR PRESSURE, or ACOUSTIC output 

NASOMETER			ADVANTAGES
→ computer based instrument developed by Adams McCutcheon and Fletcher.  → measures the relative amount of nasal acoustic energy in an individual’s speech  → measure air flow and aerodynamics  NASALANCE = N/(N+O) X 100 Nasalance scores = compared with normative data  Acoustic energy is captured in both NASAL and ORAL sources. Value is converted → nasalance score → determines hypernasality and hyponasality			→ easy, non-invasive procedure → substantiates objective findings  → provides a visual display/feedback  → can be used for treatment
GOLD STANDARD FOR CLEFT PALATE EVALUATION
→ nasopharyngoscopy, nasometry

NASOMETER

→ computer based instrument developed by Adams McCutcheon and Fletcher. 

→ measures the relative amount of nasal acoustic energy in an individual’s speech 

→ measure air flow and aerodynamics 

NASALANCE = N/(N+O) X 100

Nasalance scores = compared with normative data 

Acoustic energy is captured in both NASAL and ORAL sources. Value is converted → nasalance score → determines hypernasality and hyponasality

NASOMETER ADVANTAGES

→ easy, non-invasive procedure

→ substantiates objective findings 

→ provides a visual display/feedback 

→ can be used for treatment

nasopharyngoscopy, nasometry

GOLD STANDARD FOR CLEFT PALATE EVALUATION

AIR PADDLE

→ use ordinary bond paper not carotolina or tissue 

→ most effective to check for NAE

DENTAL MIRROR

check misting

LISTENING TUBE

 amplify and monitor nasal airflow and resonance

STRAW

→ same as stethoscope

→ listen to audible NAE

STHETOSCOPE

→ put the tip of the tube at the entrance of a nostril 

→ listen for air or sound through the scope

SEE-SCAPE

→ u-tube glass you can buy in stores with a stopper in the end, a nasal olive, and inside there is a floater

FEEDING

Determine child’s feeding menthod

Determine amount of milk intake

Determine how much time the child is able to consume from a 4 OZ BOTTLE

Determine the child’s ability abe to chew and swallow all types of food consistencies

Determine if the child has food allergies

Determine what type of food the child eats  If the child is not a certain weight, they can’t be operated on

4 OZ BOTTLE

Determine how much time the child is able to consume from a ______