Otolaryngology is a surgical and medical specialty concerned with head and neck disorders, including congenital malformations and the problems associated with them. In patients with craniofacial disorders, including cleft lip and palate, these areas include: surgical management of the cleft lip and/or cleft palate, airway and breathing problems, feeding and swallowing dysfunction, disorders of the ears and hearing, as well as voice, speech, and resonance disorders. Otolaryngologists interact closely with plastic surgeons, oral/maxillofacial surgeons, pediatricians, speech pathologists and audiologists on the Cleft Team due to the extensive overlap in their areas of expertise.

1. Prenatal
   The otolaryngologist may be one of the specialists to provide prenatal counseling to parents whose child has been found to have cleft lip/palate on screening or high resolution ultrasonography. Many parents have considerable anxiety and concern about the cleft, the treatment and the necessary surgical procedures their infant will face soon after birth. This consultation can provide reassurance, assistance with anticipated feeding or breathing difficulties, and information regarding the planning of the primary surgical procedures for reconstruction of the cleft lip and palate. The parents can also be counseled about anticipated ear or hearing problems. During this consultation parents can be prepared for their child's appearance by showing them pre and post treatment examples of patients with cleft lip and cleft palate.
2. Neonatal:
   • In the initial period after birth, it is critical for the child to breathe and feed well.
   • Neonates with cleft palate may demonstrate some degree of respiratory distress, especially if micrognathia is present. The otolaryngologist is often involved with the evaluation and management of the airway. Initial management of the airway may involve infant positioning, use of nasal airways, oral appliances or feeding tubes to help hold open the airway. Tests such as sleep studies, pulse oximeter monitoring and blood gases are often beneficial. When these techniques are insufficient to maintain the airway, more invasive procedures may become necessary including: intubation, mandibular distraction, tongue-lip adhesion, and tracheotomy. If children are being considered for these procedures airway studies with rigid endoscopy are often used to rule out other unexpected airway pathology.
   • It is important to differentiate between primary feeding problems and feeding problems secondary to airway issues. Babies who have difficulty maintaining a stable airway may exhibit feeding difficulties. Initially, some children with cleft palate may show some discoordination of the "breathe, suck, swallow" reflex resulting in nasal regurgitation of feeds or intermittent choking spells. These episodes often are self limited and the infant soon learns to prevent nasal regurgitation on his own and coordinate his swallowing . Assistive devices may involve use of orogastric or nasogastric tubes. Because the infant with a cleft palate is unable to generate suction, he usually has difficulty breastfeeding and using standard nipples and bottles. Specialty bottles, such as the one produced by Mead-Johnson^TM and one way valve nipples such as the Haberman^TM and Pigeon^TM systems are very helpful in feeding babies with cleft palate. Some centers may fabricate acrylic obturators to close off the palate to allow sucking and facilitate feeding. Nasogastic feeding tubes may be placed to supplement nutrition. Gastrostomy feeding tube placement may be recommended when feeding is significantly dysfunctional.
   • With universal infant hearing screening programs mandated in most states, the majority of infants will have their hearing screened prior to discharge from the hospital. If the baby is stable, it is best to perform this hearing screening within the first few days of life, as many children with cleft palate initially aerate their middle ear, only to have effusion develop soon afterward. The screening methods are most useful during this effusion-free period, as conductive hearing loss is associated with the presence of effusion resulting in a failed screening. Consultation with the otolaryngologist is recommended for children who fail to pass their hearing screen.
3. Infant
   • Surgical management of the cleft defects in the lip and palate is performed by most surgeons within the first year of life. Most cleft surgeons follow the surgical guidelines described in Infant management of the Plastic Surgery section.
   • Nearly all babies with cleft palate (and some with cleft lip only) will develop Eustachian tube dysfunction with development of middle ear effusions and associated conductive hearing loss. Surgical placement of tympanostomy tubes (or pressure equalizing tubes, PET's) is the currently recommended treatment to relieve the middle ear fluid. The timing of tube placement varies between team-based otolaryngologists, with most being placed at the time of the cleft lip repair, or with the cleft palate repair. The tube functions by allowing air to enter the middle ear through the hole in the tube, preventing fluid buildup and reducing conductive hearing loss due to the fluid. Hearing tests are recommended following the tympanostomy tube placement to confirm normalization of hearing.
   • Ongoing management of existing and identification of new airway or breathing difficulties following the primary repairs of the lip and palate continue through the first year of life.
4. Toddler through school aged children
   • Regular visits every six months are recommended to monitor the status of tympanostomy tubes and signs of normalization of middle ear function. Audiometric assessment is advised with a 6-12 month interval, or sooner if hearing loss is suspected. Tube replacement is often needed into the preschool years to treat persistent middle ear effusion. Amplification of hearing loss not due to effusion is recommended as soon as it is diagnosed. Possible interventions for hearing loss (other than due to middle ear effusion) include: traditional hearing aids, bone anchored hearing aids (BAHA), and cochlear implants.
   • Obstructive sleep apnea and nasal airway obstruction may occur during this time period and should be screened regularly. These symptoms include loud snoring, gasping or pauses in sleep breathing pattern, restlessness during sleep, enuresis after successful toilet training, and witnessed apnea. Diagnosis may require clinical sleep studies. Treatment is directed to the cause of the obstruction, with tonsillectomy being the most commonly recommended procedure. Except in very special circumstances documented by detailed study of airway pathology, adenoidectomy and septal surgery should be avoided in this age group due to speech and facial growth concerns.
   • Speech is developing in the toddler age group and frequently a referral to the speech pathologist is made for monitoring and diagnosis of disorders of articulation and resonance. Resonance disorders are screened for and may be evaluated with nasopharyngeal endoscopy and/or videofluoroscopy. Surgical or prosthetic treatment of hypernasal resonance may be warranted. Please see the section in Plastic Surgery regarding options of surgical management. Voice disorders such as hoarseness and breathiness may require further evaluation by the otolaryngologist.
   • Revision lip and nasal reconstructive surgeries may be considered for residual lip or nasal deformities prior to entering school.
   • Children with clefts of the alveolus usually require treatment of the alveolar cleft at this time. Please see the orthodontic and oral and maxillofacial surgery section for details of this treatment.
5. Adolescents and Adult
   • Teens and adult patients with cleft related nasal deformities are candidates for cleft septorhinoplasty, once facial growth has neared completion around 15-16 years of age. Correction of septal deviation and hypertrophied turbinates can be performed simultaneously with improvement of the nasal airway. Surgical management is also directed towards correction of any residual cleft nasal deformities.
   • Adult cleft palate patients with significant sinus and nasal problems may have undiagnosed nasopharyngeal reflux of food and liquids that causes nasal contamination. It is advised that these patients undergo an assessment of NP function with nasopharyngoscopy with a liquid swallowing challenge during the procedure.
   • Ear problems and obstructive sleep airway conditions may persist in this age group and require continued follow-up and treatment.

Footer

©2007 American Cleft Palate-Craniofacial Association

website by Kilpatrick Design Studio