Surgical Management of Cleft Lip and Palate Term Paper

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Speech Problems and Psychological Damage From Cleft Lips and Cleft Palates

Cleft lips and cleft palates are among the most common of birth defects and if left untreated can lead to serious speech problems as well as psychological damage that can result both from those speech and communication problems as well as from the ostracism that a child with a facial deformity must endure.

However, while the consequences of cleft lips and palates can be severe and long-lasting, these can be averted by medical intervention, especially if it is done as early as possible. This paper explores the various options for surgical and medical management of cleft lips and palates and the ways in which these interventions can help children with these particular birth defects.

We should begin this discussion of treatment of cleft lips and palates by establishing what exactly is meant in medical terms by these two terms. A cleft palate occurs when the palatal plates of an individual (which lie in the roof of the mouth) for various reasons fail to come together or "close" during the second month of fetal development.

There are different degrees of severity of this birth defect. In some cases, only the soft palate while in other cases the hard palate may also be involved. In other cases, there is also involvement with the lips.

The hard palate consists of a plate of bone in the roof of the mouth that is covered by a resilient layer of mucous membrane. The major function of the hard palate, which is lined with several ridges, is to help grip food into place so that it can be more easily manipulated by the tongue and the teeth during eating. It also serves the important function that it provides an essentially rigid "floor" to the nasal cavity that rests above it. In doing so, the hard palate protects the nasal passage from being blocked by pressures in the mouth. Thus, defects in the hard palate can produce problems in breathing as well as in speech production.

Unlike the hard palate - and as one might guess from its name, the soft palate is highly flexible (although it is also very strong) because it is made up of muscle and connective tissue rather than bone. The major function of the soft palate is that when a person chews or sucks (as a nursing baby does) the soft palate rises up to block the nasal cavity and pharynx from the mouth (as well as the oral portion of the pharynx). This creates a vacuum in an individual's oral cavity, which in turn performs the essential task of keeping food out of the respiratory tract and so prevents choking.

If the cleft palate affects the hard as well as the soft palate, the individual's nasal cavity will open directly into mouth and the nasal septum may actually be absent.

Cleft palates occur both unilaterally and bilaterally and may also be accompanied by cleft lips, which is a break or discontinuity of the lip beneath the nostril. Cleft lips may also occur unilaterally or bilaterally. They were formally called harelips; this term is now generally considered to be derogatory and is no longer used as a medical term.

Both cleft lips and cleft palates occur about once in every 1000 births in the United States.

One of the first problems associated with a cleft palate is that it may lead malnutrition in an infant that cannot suck properly, either from a bottle or from the breast. This problem is usually quickly followed by speech problems.

Overview of Treatment Options

Surgery is almost always needed to provide meaningful repairs for cleft lips and cleft palates. Such surgery can create in an individual the airtight separation between the nose and mouth that most people are born with and that is essential both for clear speech production and for ease of sucking, swallowing and eating.

This surgery is usually performed at a very early age, between 18 and 24 months after birth, and is usually quite successful in alleviating the problem, although it remains the case that many children born with cleft palates and cleft lips require post-surgical follow-up care in the form of speech training. Many children remain more subject to infections in the nose, ear, and sinuses even after surgery had repaired the initial fault and thus need to be treated on an on-going basis for these recurrent conditions.

Sometimes follow-up counseling may also be required in children who do not receive surgery at a very young age and so suffer psychological problems from having a facial deformity (Elbert etal 1984)

Causes of Cleft Lip and Cleft Palate

The most efficacious method of treating cleft lips and cleft palates might well be in utero or, of course, treating any maternal or paternal conditions before conception that might lead to these birth defects.

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However, despite the common nature of these birth defects the causes for them remain unknown. Thus the only form of treatment remains treatment of the child after birth.

However, it should be noted that while in most cases the causes of cleft lips and palates are unknown, certain drugs if taken during pregnancy are known to cause clefts in the lips or palates including potentially life-saving anti-seizure drugs taken by women with epilepsy. However, the most common "drug" that leads to increased clefts in lips and palates is nicotine; even moderate smoking during pregnancy increases the chance of a woman's having a baby with a cleft dramatically.

There are also clusters of cleft lips and palates in certain ethnic groups, indicating that there are likely to be genetic predispositions for the condition rather than its being caused only be intrauterine conditions. Clefts are also more likely to occur in boys than in girls.

Cleft lips and palates may also occur as one part of an innate syndrome of multiple malformations; such syndrome usually arise from chromosomal abnormalities.

Overview of Standard Medical Treatment

The standard course of medical intervention varies according to the type and severity of the deformity as well as the overall health of the child. However, a fairly standard course of treatment includes primary repair at about 10 weeks; palatal repair (if required) at between nine and 12 months; secondary, follow-up repair at between four and six years; repair to the alveolar cleft (if needed) at between eight and ten years and final surgical repair at between 14 and 16 years.

It should be clear from this schedule that many of these procedures take place during key language-acquisition phases and so may have serious consequences for the child's ability to acquire language in a "normal" fashion - that is, without various forms of speech therapy (Bernthal & Bankson 1993).

Language acquisition, as the term implies, is simply the process by which children and adults learn a language or languages, and is differentiated into different categories. First-language acquisition is a complex process that linguists only partially understand. One thing that researchers do agree upon is that all young children have certain innate characteristics that predispose them to learn language.

Among these innate characteristics are the physiological structure of the vocal tract. In those individuals born with intact lips and clefts, the shape of the mouth is already primed for language acquisition. For those with clefts, however, the usually innate human ability to produce all of those sounds that are used in human languages is absent and must be created through surgery and/or other medical interventions in addition to (in most cases) speech therapy to return to the child skills that are innate in others (Broen etal 1983, Elbert 1984).

Because language acquisition skills seem to be neurologically linked to each other, failure to be able to produce key sounds in a language that results from cleft lips or palates may "spillover" into other language-acquisition problems, such as failing to grasp general grammatical principles (including, for example, the nature of gender and case in languages in which those constructs are important or the standard way in which plurals are created in a language).

Because language acquisition - including acquisition of grammar, syntax and an understanding of fine semantic distinction - is so complex and seems to depend in at least some measure on acquiring skills in a particular order, disruptions in language acquisition caused by cleft lips and palates can be very serious to a child's overall intellectual development.

And it because of this that medical intervention must be attempted as soon as possible to provide as little disruption as possible during key months of language acquisition (viz. Hodson etal 1983 and Hodson and Paden 1983). Even relatively minor speech disorders have the power to interrupt the normal progress of language acquisition during the key language acquisition phase of very early childhood. Moreover, even when a child with a cleft manages to overcome the physical difficulties of acquiring language, there may be lasting social and psychological consequences of facial deformities that may well manifest themselves in communication problems.

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