cleft palate
DESCRIPTION
kuliahTRANSCRIPT
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CLEFT PALATECLEFT PALATE
Dr. Mgs. Roni Saleh, SpB-Dr. Mgs. Roni Saleh, SpB-
SpBP(K)SpBP(K)
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I. or!al Ana"o!#I. or!al Ana"o!#
A.A. $ar% pala"e$ar% pala"e&.&. Pri!ar# (an"erior) har% pala"e' For!e% # *sionPri!ar# (an"erior) har% pala"e' For!e% # *sion
o "he ila"eral pala"ine pro+esses o "he !ailla.o "he ila"eral pala"ine pro+esses o "he !ailla.
.. Se+on%ar# (pos"erior) har% pala"e' For!e% #Se+on%ar# (pos"erior) har% pala"e' For!e% #*sion o "he ila"eral horion"al pla"es o "he*sion o "he ila"eral horion"al pla"es o "hepala"ine one.pala"ine one.
/./. In+isi0e ora!en' Separa"es "he pri!ar# ro!In+isi0e ora!en' Separa"es "he pri!ar# ro!
"he se+on%ar# har% pala"e."he se+on%ar# har% pala"e.1.1. Pre!ailla' The !ailla an"erior "o "he in+isi0ePre!ailla' The !ailla an"erior "o "he in+isi0e
ora!en, in+l*%ing "he an"erior har% pala"e an%ora!en, in+l*%ing "he an"erior har% pala"e an%al0eol*s.al0eol*s.
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B.B. So" pala"e (0el*!)' +on"ains "he !*s+lesSo" pala"e (0el*!)' +on"ains "he !*s+lesin0ol0e% in 0elophar#ngeal +los*re.in0ol0e% in 0elophar#ngeal +los*re.
&.&. Le0a"or 0eli pala"ini.Le0a"or 0eli pala"ini.
.. Ten%on o "he "ensor 0eli pala"ini.Ten%on o "he "ensor 0eli pala"ini././. Pala"ophar#nge*s.Pala"ophar#nge*s.
1.1. 20*la"e.20*la"e.
C.C. 3as+*lar an% ner0e s*ppl#3as+*lar an% ner0e s*ppl#
&.&. $ar% pala"e' The grea"er pala"ine ar"er# an%$ar% pala"e' The grea"er pala"ine ar"er# an%ner0es, "hro*gh "he grea"er pla"ine ora!en inner0es, "hro*gh "he grea"er pla"ine ora!en in"he pos"erior la"eral har% pala"e."he pos"erior la"eral har% pala"e.
.. So" pala"e' The lesser pala"ine ar"er# an%So" pala"e' The lesser pala"ine ar"er# an%ner0es.ner0es.
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II. Cle" Ana"o!#II. Cle" Ana"o!#A.A. Cle"s o "he se+on%ar# pala"eCle"s o "he se+on%ar# pala"e
&.&. A 0ariale %egree o +le"ing +an e seen.A 0ariale %egree o +le"ing +an e seen.
a.a. Bi4% *0*la.Bi4% *0*la.
.. S*!*+o*s +le" pala"e "ria%.S*!*+o*s +le" pala"e "ria%.
&)&) Bi4% *0*la.Bi4% *0*la.
)) $ar% pala"e no"+hing (palpale).$ar% pala"e no"+hing (palpale).
/)/) 5ona pell*+i%a' Mi%line 6hi"e line, %*e "o "he ano!alo*s5ona pell*+i%a' Mi%line 6hi"e line, %*e "o "he ano!alo*sinser"ion o "he pala"al !*s+*la"*re.inser"ion o "he pala"al !*s+*la"*re.
+.+. Cle" 0el*!Cle" 0el*!
%.%. Cle" o "he en"ire se+on%ar# pala"eCle" o "he en"ire se+on%ar# pala"e
.. Ano!alo*s insere"ion o "he "ensor 0eli pala"ini.Ano!alo*s insere"ion o "he "ensor 0eli pala"ini.
a.a. The nor!al ila"eral "ensor 0eli pala"ini !*s+les in"er%igi"a"eThe nor!al ila"eral "ensor 0eli pala"ini !*s+les in"er%igi"a"ean% inser" "rans0ersel# in "he pos"erior par" o "he 0el*!an% inser" "rans0ersel# in "he pos"erior par" o "he 0el*!
.. 7i"h +le"ing, "he "ensor 0eli pala"ini !*s+les +o*rse7i"h +le"ing, "he "ensor 0eli pala"ini !*s+les +o*rsean"eriorl# an% inser" on"o "he pos"erior e%ge o "he har%an"eriorl# an% inser" on"o "he pos"erior e%ge o "he har%pala"e.pala"e.
+.+. In "his posi"ion, "heir aili"# "o li" "he so" pala"e isIn "his posi"ion, "heir aili"# "o li" "he so" pala"e is
signi4+an"l# i!paire%signi4+an"l# i!paire%
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B.B. Cle"s o "he pri!ar# pala"e.Cle"s o "he pri!ar# pala"e.
&.&. The lip, nos"ril sill, al0eo*ls, an%The lip, nos"ril sill, al0eo*ls, an%pri!ar# pala"e are all +onsi%ere%pri!ar# pala"e are all +onsi%ere%
%eri0a"i0es o "he pri!ar# pala"e.%eri0a"i0es o "he pri!ar# pala"e... Cle"s o "he pri!ar# pala"e +an in0ol0eCle"s o "he pri!ar# pala"e +an in0ol0e
"he lip alone, e"en% in"o or "hro*gh"he lip alone, e"en% in"o or "hro*gh"he al0eol*s an% pri!ar# pala"e, or"he al0eol*s an% pri!ar# pala"e, or
e"en% "hro*gh "he se+on%ar# pala"e.e"en% "hro*gh "he se+on%ar# pala"e.C.C. Kernahan8s s"ripe% 9 ser0es as aKernahan8s s"ripe% 9 ser0es as a
shor"han% or re+or%ing +le" pala"eshor"han% or re+or%ing +le" pala"e
e"en".e"en".
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III. Fa+ial E!r#olog#III. Fa+ial E!r#olog#
A.A. Fi0e a+ial pro!inen+es (%e0elopFi0e a+ial pro!inen+es (%e0elop%*ring 6ee: 1 o ges"a"ion)%*ring 6ee: 1 o ges"a"ion)
&.&. Mi%line ron"onasal pro!inen+e'Mi%line ron"onasal pro!inen+e'Mesen+h#!e 0en"ral "he orerain, no"Mesen+h#!e 0en"ral "he orerain, no"a ran+hial ar+h.a ran+hial ar+h.
.. Bila"eral !aillar# pro!inen+es' Firs"Bila"eral !aillar# pro!inen+es' Firs"
ran+hial ar+h.ran+hial ar+h././. Bila"eral !an%i*lar pro!inen+es' Firs"Bila"eral !an%i*lar pro!inen+es' Firs"
ran+hial ar+h.ran+hial ar+h.
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B.B. Bila"eral nasal pla+o%esBila"eral nasal pla+o%es&.&. Appear on "he inerior ron"onasal pro!inen+e, la"e inAppear on "he inerior ron"onasal pro!inen+e, la"e in
6ee: 1.6ee: 1.
.. The !e%ial an% la"eral nasal pro!inen+es e!erge onThe !e%ial an% la"eral nasal pro!inen+es e!erge onea+h si%e o "he nasal pla+o%es.ea+h si%e o "he nasal pla+o%es.
C.C. F*sion' 6ee: ;F*sion' 6ee: ;&.&. The la"eral nasal pro!inen+e *ses 6i"h "he !aillar#The la"eral nasal pro!inen+e *ses 6i"h "he !aillar#
pro!inen+e, +onne+"ing "he nose "o "he +hee:.pro!inen+e, +onne+"ing "he nose "o "he +hee:.
.. The !e%ial nasal pro!inen+e *se.The !e%ial nasal pro!inen+e *se././. The !e%ial nasal pro!inen+e *ses 6i"h "he !aillar#The !e%ial nasal pro!inen+e *ses 6i"h "he !aillar#
pro!inen+e, +onne+"ing "he nose an% lip. Fail*re o "hepro!inen+e, +onne+"ing "he nose an% lip. Fail*re o "he*sion res*l"s in a +le" lip.*sion res*l"s in a +le" lip.
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I3. Pala"al e!r#olog#I3. Pala"al e!r#olog#
A.A. Pri!ar# pala"e an% pre!aillaPri!ar# pala"e an% pre!ailla&.&. The !e%ial nasal pro+eses *se "o or! "he !e%ianThe !e%ial nasal pro+eses *se "o or! "he !e%ian
pala"ine pro+ess in 6ee: ;.pala"ine pro+ess in 6ee: ;.
.. The !e%ian pala"ine pro+ess e+o!es "he pre!ailla.The !e%ian pala"ine pro+ess e+o!es "he pre!ailla.B.B. Se+on%ar# pala"e' 6ee:s ; "o &Se+on%ar# pala"e' 6ee:s ; "o &
&.&. The ila"eral la"eral pala"ine pro+esses %e0elop ro!The ila"eral la"eral pala"ine pro+esses %e0elop ro!"he !e%ial por"ion o "he !aillar# pro+ess."he !e%ial por"ion o "he !aillar# pro+ess.
.. The la"eral pala"ine pro+esses hang 0er"i+all#, an%The la"eral pala"ine pro+esses hang 0er"i+all#, an%
"hen li" horion"all# as "he "ong*e %rops."hen li" horion"all# as "he "ong*e %rops././. F*sion s"ars a" "he in+isi0e ora!en an% !o0esF*sion s"ars a" "he in+isi0e ora!en an% !o0es
pos"eriorl#, or!ing "he se+on%ar# pala"e.pos"eriorl#, or!ing "he se+on%ar# pala"e.
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3. Epi%e!iolog#3. Epi%e!iolog#
A.A. Ra+ial %is"ri*"ionRa+ial %is"ri*"ion&.&. Isola"e% +le" pala"eIsola"e% +le" pala"e
a.a. In+i%en+e o ao*"
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C.C. Fa!ilial %is"ri*"ionFa!ilial %is"ri*"ion
&.&. Cle" lip 6i"h or 6i"ho*" +le" pala"e an%Cle" lip 6i"h or 6i"ho*" +le" pala"e an%
isola"e% +le" pala"e appear "o eisola"e% +le" pala"e appear "o egene"i+all# %i>eren"gene"i+all# %i>eren"
.. Isola"e% +le" pala"e is !ore +o!!on inIsola"e% +le" pala"e is !ore +o!!on in
rela"i0es o +le" pala"e pa"ien"s.rela"i0es o +le" pala"e pa"ien"s././. Cle" lip?pala"e is !ore +o!!on inCle" lip?pala"e is !ore +o!!on in
rela"i0es o +le" lip ? pala"e pa"ien"srela"i0es o +le" lip ? pala"e pa"ien"s
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Tale 1-&. Proaili"# o s*se@*en" +hil%ren 6i"hTale 1-&. Proaili"# o s*se@*en" +hil%ren 6i"hisola"e% +le" pala"e or +le" lip 6i"h ? 6i"ho*" +le"isola"e% +le" pala"e or +le" lip 6i"h ? 6i"ho*" +le"pala"epala"e
Fa!il# !e!ers 6i"hFa!il# !e!ers 6i"h Proaili"# o s*se@*en"Proaili"# o s*se@*en" Proaili"#Proaili"#o s*se@*en"o s*se@*en"
Cle" Pala"eCle" Pala"e Chil% 6i"h +le" pala"e ()Chil% 6i"h +le" pala"e () Chil% 6i"h +le" lip ?-Chil% 6i"h +le" lip ?-
Cle" Pala"e ()Cle" Pala"e ()
ne a>e+"e% +hil% onl#ne a>e+"e% +hil% onl# 11
ne a>e+"e% paren" onl#ne a>e+"e% paren" onl# -1-1 -1-1
ne a>e+"e% +hil% an% ane a>e+"e% +hil% an% a Posi"i0e a!il# his"or#Posi"i0e a!il# his"or# -e+"e% paren" an%ne a>e+"e% paren" an%
ne a>e+"e% +hil%ne a>e+"e% +hil% &;&; &1-&&1-&
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3I. E"iolog#3I. E"iolog#
A.A. =ene"i+s=ene"i+s&.&. An isola"e% +le" pala"e is proaal# a single !aor geneAn isola"e% +le" pala"e is proaal# a single !aor gene
a*"oso!al re+essi0e "rai" 6i"h o"her !inor genes +on"ri*"inga*"oso!al re+essi0e "rai" 6i"h o"her !inor genes +on"ri*"ing
.. Cle" lip?pala"e is proal# pol#geni+ 6i"h !*l"iple !aor an%Cle" lip?pala"e is proal# pol#geni+ 6i"h !*l"iple !aor an%
!inor genes +on"ri*"ing!inor genes +on"ri*"ingB.B. En0iron!en"En0iron!en"
&.&. The ea+" role o ann# en0iron!en" a+"or is no" +learThe ea+" role o ann# en0iron!en" a+"or is no" +lear
.. Al+ohol has no" een +on+l*si0el# sho6n "o +a*se isola"e%Al+ohol has no" een +on+l*si0el# sho6n "o +a*se isola"e%+le" pala"e+le" pala"e
/./. S!o:ing ' Da"a are no" +on+l*si0eS!o:ing ' Da"a are no" +on+l*si0e
1.1. Man# "era"ogens ( in+l*%ing al+ohol, iso"re"inoin an% o"hers )Man# "era"ogens ( in+l*%ing al+ohol, iso"re"inoin an% o"hers )are :no6n "o +a*se !*l"iple +ongeni"al !alor!a"ions, 6hi+hare :no6n "o +a*se !*l"iple +ongeni"al !alor!a"ions, 6hi+h!a# in+l*%e +le" pala"e as par" o a series o !alor!a"ions!a# in+l*%e +le" pala"e as par" o a series o !alor!a"ions
;.;. Foli+ a+i% an% 0i"a!n B in"a:e %*ring pregnan+# !a# re%*+eFoli+ a+i% an% 0i"a!n B in"a:e %*ring pregnan+# !a# re%*+e+le" lp ? pala"e+le" lp ? pala"e
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3II. S*rgi+al goals3II. S*rgi+al goals
A.A. Clos*re o "he +le"Clos*re o "he +le"&.&. Clos*re o "he +le" pala"e separa"es "he oral an% nasalClos*re o "he +le" pala"e separa"es "he oral an% nasal
+a0i"ies+a0i"ies
.. This pre0en"s aerophagia an% reG* o oral +on"ens in"oThis pre0en"s aerophagia an% reG* o oral +on"ens in"o"he nasal +a0i"#"he nasal +a0i"#
B.B. Spee+h an% hearingSpee+h an% hearing&.&. Cle" pala"e repair !*s" e peror!e% earl# in lie "oCle" pala"e repair !*s" e peror!e% earl# in lie "o
pre0en" irreparale spee+h %ee+"spre0en" irreparale spee+h %ee+"s
.. $o6e0er,Hearl#H pala"e s*rger# is asso+ia"e% 6i"h$o6e0er,Hearl#H pala"e s*rger# is asso+ia"e% 6i"hi!paire% a+ial gro6"hi!paire% a+ial gro6"h
/./. Be+a*se a+ial s"r*+"*res +an e s*rgi+all# repaire% la"erBe+a*se a+ial s"r*+"*res +an e s*rgi+all# repaire% la"erin lie, 6hereas spee+h pa""erns +anno", !os" s*rgeonsin lie, 6hereas spee+h pa""erns +anno", !os" s*rgeonseel "ha" nor!al spee+h %e0elop!en" is !ore i!por"an"eel "ha" nor!al spee+h %e0elop!en" is !ore i!por"an""han nor!al a+ial gro6"h an% "hereore a0or earl# repair."han nor!al a+ial gro6"h an% "hereore a0or earl# repair.
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C.C. "i"is an% $earing"i"is an% $earing&.&. "i"is !e%ia"i"is !e%ia
a.a. Se+on%ar# "o e*s"a+hian "*e %#s*n+"ionSe+on%ar# "o e*s"a+hian "*e %#s*n+"ion&)&) The le0a"or 0eli pala"ini ( L3P) origina"es along "he e*s"a+hian "*eThe le0a"or 0eli pala"ini ( L3P) origina"es along "he e*s"a+hian "*e
)) An anor!al L3P inser"ion is "ho*gh" "o %e+rease !il:ing J a+"ionAn anor!al L3P inser"ion is "ho*gh" "o %e+rease !il:ing J a+"ionan% "hereore lea% "o poor 0en"ing o "he !i%%le ear.an% "hereore lea% "o poor 0en"ing o "he !i%%le ear.
.. ++*rs in al!os" all pa"ien"s 6i"h +le" pala"e, an% +an lea% "o++*rs in al!os" all pa"ien"s 6i"h +le" pala"e, an% +an lea% "oper!anen"l# i!paire% hearingper!anen"l# i!paire% hearing
.. $earling in +le" pal"e pa"ien"s generall# i!pro0es a"er$earling in +le" pal"e pa"ien"s generall# i!pro0es a"er!#ringo"o!#!#ringo"o!#
/./. The earliner "he !#ringo"o!# is peror!e% "he grea"her "heThe earliner "he !#ringo"o!# is peror!e% "he grea"her "he
i!pro0e!en" is hearing. or!al hearing is *s*all# a+hie0e%i!pro0e!en" is hearing. or!al hearing is *s*all# a+hie0e%6i"h earl# ila"eral "#!panos"o!#.6i"h earl# ila"eral "#!panos"o!#.
1.1. i" is no" +lear 6he"her repair o +le" pala"e or repair oi" is no" +lear 6he"her repair o +le" pala"e or repair o0elophar#ngeal inin+o!pe"en+e (3PI) re%*+e o"i"is !e%ia or0elophar#ngeal inin+o!pe"en+e (3PI) re%*+e o"i"is !e%ia ori!pro0es hearingi!pro0es hearing
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D.D. Fa+ial gro6"hFa+ial gro6"h&.&. Earl# pala"e s*rger# +an a%0ersel# a>e+" !aillar#Earl# pala"e s*rger# +an a%0ersel# a>e+" !aillar#
gro6"hgro6"h
.. Repair o "he pri!ar# pala"e an% al0eol*s has !oreRepair o "he pri!ar# pala"e an% al0eol*s has !oresigni4+an" e>e+"s on !aillar# gro6"h "han repair osigni4+an" e>e+"s on !aillar# gro6"h "han repair o"he se+on%ar# pala"e alone"he se+on%ar# pala"e alone
/./. Fa+ial gro6"h is less a>e+"e% i pala"oplas"# is %ela#e%Fa+ial gro6"h is less a>e+"e% i pala"oplas"# is %ela#e%*n"il & #ear o age.*n"il & #ear o age.
1.1.
For rhese reasons, so!e s*rgeons +lose "he so" pala"eFor rhese reasons, so!e s*rgeons +lose "he so" pala"eearl# ( aro*n% / !on"hs ) an% "he har% pala"e la"erearl# ( aro*n% / !on"hs ) an% "he har% pala"e la"er( ranging ro! "o & !on"hs )( ranging ro! "o & !on"hs )
;.;. Ea+h +ase !*s" e approa+he% in%i0i%*all#, +are*ll#Ea+h +ase !*s" e approa+he% in%i0i%*all#, +are*ll#+onsi%ering a+ial gro6"h an% spee+h %e0e"lop!en".+onsi%ering a+ial gro6"h an% spee+h %e0e"lop!en".
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3III. S*rgi+al repair3III. S*rgi+al repair
A.A. $ar% pala"e +le"s$ar% pala"e +le"s&.&. 3on langene+: repair3on langene+: repair
a.a. Bila"eral, ipi%i+le% !*+operios"eal Gaps.Bila"eral, ipi%i+le% !*+operios"eal Gaps.
.. La"eral relaing in+isions are !a%e ila"erall#La"eral relaing in+isions are !a%e ila"erall#
+.+. The Gaps are +lose% a" "he !%line, nasal !*+osa 4rs" an%The Gaps are +lose% a" "he !%line, nasal !*+osa 4rs" an%oral !*+osaoral !*+osa
%.%. Man# !o%i4+a"ions eis"Man# !o%i4+a"ions eis"
e.e. This repair !a# res*l" in a shor" pala"e an% +on"ri*"e "o 3PIThis repair !a# res*l" in a shor" pala"e an% +on"ri*"e "o 3PI
.. 3-9 p*sha+: ( 3ea*-7ar%ill-Kilner)3-9 p*sha+: ( 3ea*-7ar%ill-Kilner)a.a. Bila"eral !*+operios"eal Gaps, *nipe%i+le% pos"eriorl#Bila"eral !*+operios"eal Gaps, *nipe%i+le% pos"eriorl#
.. 3-9 a%0an+e!en" pos"eriorl# is peror!e%3-9 a%0an+e!en" pos"eriorl# is peror!e%+.+. An"erior epose% areas are le" open "o gran*la"e an%An"erior epose% areas are le" open "o gran*la"e an%
!*+osalie.!*+osalie.
%.%. I!pro0es 0elophar#ngeal +los*re # leng"hening "he pala"e,I!pro0es 0elophar#ngeal +los*re # leng"hening "he pala"e,!a# i!pro0e% spee+h!a# i!pro0e% spee+h
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B.B. So" pala"e +le"sSo" pala"e +le"s&.&. S"raigh"-line repair ' Separa"e nasal an% oral !*+osalS"raigh"-line repair ' Separa"e nasal an% oral !*+osal
Gaps are raise% an% approi!a"e%Gaps are raise% an% approi!a"e%
..
Do*le 5-plas"# ( F*rlo6 )Do*le 5-plas"# ( F*rlo6 )a.a. 5-plas"# Gaps o oral an% nasal !*+osa ( 6i"h L3P !*s+le5-plas"# Gaps o oral an% nasal !*+osa ( 6i"h L3P !*s+lein+l*%e%) are *se% in opposing %ire+"ions.in+l*%e%) are *se% in opposing %ire+"ions.
.. 5-plas"ies are peror!e% in la#ers, 6i"h nasal !*+osal5-plas"ies are peror!e% in la#ers, 6i"h nasal !*+osalGaps "ranspose% an% +lose%, ollo6e% # "ransposi"ionGaps "ranspose% an% +lose%, ollo6e% # "ransposi"ionan% +los*re o oral !*+osal Gapsan% +los*re o oral !*+osal Gaps
+.+. Leng"hen"s "he so" pala"eLeng"hen"s "he so" pala"e
%.%. Reorien"s "he le0a"or 0eli pala"ini !*s+lesReorien"s "he le0a"or 0eli pala"ini !*s+lese.e. Can e *se% along 6i"h har% pala"e +los*re in oneCan e *se% along 6i"h har% pala"e +los*re in one
opera"ion, or as 0eloplas"# "o e ollo6e% la"er # har%opera"ion, or as 0eloplas"# "o e ollo6e% la"er # har%pala"e +los*re ( see ao0e )pala"e +los*re ( see ao0e )
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C.C. 3o!er Gap3o!er Gap&.&. Flaps !a# e ase% ineriorl# or s*periorl# an% !a# e *nila"eral orFlaps !a# e ase% ineriorl# or s*periorl# an% !a# e *nila"eral or
ila"eralila"eral
.. $elps pro0i%e "iss*e or +los*re o 6i%e +le"s$elps pro0i%e "iss*e or +los*re o 6i%e +le"s
/./. S*periorl# ase% Gaps are *se% !ore +o!!onl#S*periorl# ase% Gaps are *se% !ore +o!!onl#
1.1. Ineriorl# ase% Gaps are *se*l or 6i%er +le"sIneriorl# ase% Gaps are *se*l or 6i%er +le"s;.;. Ma# or !a# no" i!pair !aillar# gro6"h ( +on"ro0ersial)Ma# or !a# no" i!pair !aillar# gro6"h ( +on"ro0ersial)
D.D. Al0eolar repairAl0eolar repair&.&. M*+operios"eal Gaps are raise% an% inse" as a%0an+e!en" GapsM*+operios"eal Gaps are raise% an% inse" as a%0an+e!en" Gaps
.. Bone gra"ing is er!or!e% i ne+essar#Bone gra"ing is er!or!e% i ne+essar#
/./. So!e peror! gra"ing earl# ( pri!arill#), al"ho*gh !os" preerSo!e peror! gra"ing earl# ( pri!arill#), al"ho*gh !os" preerse+onse+on%%ar# one gra"ing eore "he per!anen" +le" +anine e!erges,ar# one gra"ing eore "he per!anen" +le" +anine e!erges,%*ring "he perio% o earl# !ie% %en"i"ion, arro*n% #easrs o age%*ring "he perio% o earl# !ie% %en"i"ion, arro*n% #easrs o age
1.1. For pri!ar# gra"ing a !*+osal Gap is raise% in "he 0es"i*le o "he lipFor pri!ar# gra"ing a !*+osal Gap is raise% in "he 0es"i*le o "he lipan"erior "o "he +le", an% a ri gra" is +o!!onl# *se%an"erior "o "he +le", an% a ri gra" is +o!!onl# *se%
;.;. For se+on%ar# gra"ing, gingi0al !*+operios"eal Gaps are raise% onFor se+on%ar# gra"ing, gingi0al !*+operios"eal Gaps are raise% ono"h si%es o "he +le", 6i"h "he in+ision a" "he gingi0al s*l+*s o "heo"h si%es o "he +le", 6i"h "he in+ision a" "he gingi0al s*l+*s o "he"ee"h, an% +an+ello*s one ro! "he ili*! is *se%"ee"h, an% +an+ello*s one ro! "he ili*! is *se%
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I. Co!pli+a"ionsI. Co!pli+a"ions
A.A. Fis"*laeFis"*lae&.&. ++*r in *p "o ;e+" a+ial gro6"hLip an% al0eolar repair signi4+an"l# a>e+" a+ial gro6"h
1.1. The e"en" an% "i!ing o pala"e repair +an a>e+" a+ial gro6"h ( seeThe e"en" an% "i!ing o pala"e repair +an a>e+" a+ial gro6"h ( see
ao0e )ao0e )C.C. Air6a# os"r*+"ionAir6a# os"r*+"ion
&.&. Ma#a o++*r se+on%ar# "o pos"opera"i0e lee%ingMa#a o++*r se+on%ar# "o pos"opera"i0e lee%ing
.. More +o!!on in opera"ions "ha" in+l*%e phar#ngeal GapsMore +o!!on in opera"ions "ha" in+l*%e phar#ngeal Gaps
/./. Pa"ien"s sho*l% e !oni"ore% +lose%l# pos"opera"i0el#Pa"ien"s sho*l% e !oni"ore% +lose%l# pos"opera"i0el#
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. 3elophar#ngeal. 3elophar#ngeal
in+o!pe"en+ein+o!pe"en+eA.A. De4ni"ion ' Inappropria"e in+o!ple"e +los*re o "he 0el*!De4ni"ion ' Inappropria"e in+o!ple"e +los*re o "he 0el*!
agains" "he pos"erior phar#n %*ring spee+hagains" "he pos"erior phar#n %*ring spee+h
B.B. E"iolog#E"iolog#&.&. In +le" pala"e pa"ien"s, "he le0a"or 0eli pala"ini inser"sIn +le" pala"e pa"ien"s, "he le0a"or 0eli pala"ini inser"s
an"eriorl# on "o "he har% pala"e, an% loses i"s aili"# "o li" "hean"eriorl# on "o "he har% pala"e, an% loses i"s aili"# "o li" "heso" pala"e "o a+hie0e 0elophar#ngeal +los*reso" pala"e "o a+hie0e 0elophar#ngeal +los*re
.. Approi!a"el#
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C.C. Spee+h an% 0elophar#ngeal ins*N+ien+#Spee+h an% 0elophar#ngeal ins*N+ien+#&.&. Air es+apes ro! "he orophar#n *p "hro*ghAir es+apes ro! "he orophar#n *p "hro*gh
"he nasophar#n"he nasophar#n
.. This res*l"s in h#pernasal spee+h an% es+ape oThis res*l"s in h#pernasal spee+h an% es+ape oe+ess air ro! "he nose %*ring spee+h ( nasale+ess air ro! "he nose %*ring spee+h ( nasale!ission ) +a*sing %iN+*l"# 6i"h +onsonan"se!ission ) +a*sing %iN+*l"# 6i"h +onsonan"s
/./. The pa"ien" a%*s"s "o "hese prole!s #The pa"ien" a%*s"s "o "hese prole!s #
%e0eloping al"erna"i0e !e"ho%s or +rea"ing%e0eloping al"erna"i0e !e"ho%s or +rea"ing+er"ain 0o+al so*n%s ( phar#ngeal ri+a"i0es+er"ain 0o+al so*n%s ( phar#ngeal ri+a"i0esan% glo""al s"ops).Plosi0es 'an% glo""al s"ops).Plosi0es ' /p/,/b/,/t/,/d/,/k/,/g/;/p/,/b/,/t/,/d/,/k/,/g/;ri+a"i0es 'ri+a"i0es ' /f/,/v/,/th/,/s/,/z/,/sh/,/zh/./f/,/v/,/th/,/s/,/z/,/sh/,/zh/.
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D.D. Trea"!en" o 3PITrea"!en" o 3PI&.&. Phar#ngeal GapsPhar#ngeal Gaps
a.a. Bes" or pa"ien"s 6i"h a%e@*a"e la"eral phar#ngeal 6all !o0e!en" (Bes" or pa"ien"s 6i"h a%e@*a"e la"eral phar#ngeal 6all !o0e!en" (goo% !e%ial e+*rsion ) ase% on nasal en%os+op# orgoo% !e%ial e+*rsion ) ase% on nasal en%os+op# or0i%eoG*oros+op#0i%eoG*oros+op#
.. A !#o!*+osal Gap ro! "he pos"erior phar#ngeal 6all is ele0a"e%A !#o!*+osal Gap ro! "he pos"erior phar#ngeal 6all is ele0a"e%+.+. The Gap +on"ains !*+osa an% phar#ngeal +ons"ri+"or !*s+le,The Gap +on"ains !*+osa an% phar#ngeal +ons"ri+"or !*s+le,
eposing "he pre0er"eral as+iaeposing "he pre0er"eral as+ia
%.%. Ma# e ase% s*periorl# or ineriorl#Ma# e ase% s*periorl# or ineriorl#
e.e. The Gaps is "hen s*"*re% "o "he pos"erior so" pala"eThe Gaps is "hen s*"*re% "o "he pos"erior so" pala"e
.. This +rea"es a "iss*e ri%ge e"66n "he so" pala"e an% "heThis +rea"es a "iss*e ri%ge e"66n "he so" pala"e an% "hepos"erior phar#n, alo6ing "he la"eral phar#ngeal 6alls "o +lose inpos"erior phar#n, alo6ing "he la"eral phar#ngeal 6alls "o +lose in
an% +a*se 0elophar#ngeal +los*rean% +a*se 0elophar#ngeal +los*reg.g. This is a s"a"is repair ( "he Gap %oes no" !o0e "o +a*se por"This is a s"a"is repair ( "he Gap %oes no" !o0e "o +a*se por"
+los*re ).+los*re ).
h.h. The %i>*+*l"# is in a%*s"ing "he por" ? opening sie +orre+"l# O "ooThe %i>*+*l"# is in a%*s"ing "he por" ? opening sie +orre+"l# O "oo6i%e an opening lea0es "he pa"ien h#pernasal, 6hereas li!i"ing air6i%e an opening lea0es "he pa"ien h#pernasal, 6hereas li!i"ing airGo6 "oo !*+h in%*+es a s"a"e o h#ponasali"#Go6 "oo !*+h in%*+es a s"a"e o h#ponasali"#
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.. Phar#ngoplas"# ( %#na!i+ sphin+"er phar#ngoplas"# )Phar#ngoplas"# ( %#na!i+ sphin+"er phar#ngoplas"# )a.a. Bes" or pa"ien"s 6i"h ina%e@*a"e la"eral phar"ngeal 6allBes" or pa"ien"s 6i"h ina%e@*a"e la"eral phar"ngeal 6all
!e%ial e+*rsion!e%ial e+*rsion
.. S*periorl# ase% ila"eral Gaps "ha" in+l*%e "he pos"eriorS*periorl# ase% ila"eral Gaps "ha" in+l*%e "he pos"erior"onsillar pillars an% "he pala"ophar#nge*s !*s+les are"onsillar pillars an% "he pala"ophar#nge*s !*s+les areele0a"e% an% are se" in o0erlapping posi"ions in"o aele0a"e% an% are se" in o0erlapping posi"ions in"o a
horion"al in+ision in "he pos"erior phar#ngeal 6allhorion"al in+ision in "he pos"erior phar#ngeal 6all+.+. This is a po"en"iall# %#na!i+ repair. The sphin+"er +rea"e%This is a po"en"iall# %#na!i+ repair. The sphin+"er +rea"e%
!a# ha0e so!e !e0e!en" "o help a+hie0e por" +los*re!a# ha0e so!e !e0e!en" "o help a+hie0e por" +los*re
/./. Co!pli+a"ionsCo!pli+a"ionsa.a. Air6a# os"r*+"ion in "he a+*"e pos"opera"i0e perio% +an eAir6a# os"r*+"ion in "he a+*"e pos"opera"i0e perio% +an e
lie "hrea"ening an% pa"ien"s ho*l% ha0e apnea !onin"orslie "hrea"ening an% pa"ien"s ho*l% ha0e apnea !onin"ors
.. s"r*+"i0e sleep apnea is no" *n+o!!on in "he earl#s"r*+"i0e sleep apnea is no" *n+o!!on in "he earl#pos"opera"i0e perio%pos"opera"i0e perio%
+.+. Dehis+en+e, lee%ingg an% ine+"ion are o"her +o!li+a"ionsDehis+en+e, lee%ingg an% ine+"ion are o"her +o!li+a"ions
%.%. Pa"ien"s 6i"h 0elo+ar%ia+ial s#n%ro!e "he ris: o +aro"i%Pa"ien"s 6i"h 0elo+ar%ia+ial s#n%ro!e "he ris: o +aro"i%in*r# %*ring Gap ele0a"ion. Consi%er preopera"i0ein*r# %*ring Gap ele0a"ion. Consi%er preopera"i0eangiogra! an% ? or !agne"i+ resonan+e angiogra!. Pala"eangiogra! an% ? or !agne"i+ resonan+e angiogra!. Pala"ein"raopera"i0el# or !e%ialie% +aro"i% p*lsa"ions.in"raopera"i0el# or !e%ialie% +aro"i% p*lsa"ions.
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