An incidental finding of untreated cleft palate in an adult

INTRODUCTION

The incidence of orofacial cleft varies in the world but is estimated to be 1 in 700 live births. In India, this incidence is 1 in 1000 live births.^1,2 The various orofacial clefts include cleft palate, cleft lip or combination of cleft lip and cleft palate. Isolated cleft palate is the rarest congenital anomaly amongst the orofacial clefts affecting 1 per 10000 newborns worldwide.³ It is very rare to see such a case being untreated and presenting as an incidental finding in an adult.

CASE REPORT

A 52 year old patient visited the hospital with symptoms of upper respiratory tract infection. During conversation with the patient, it was noted that patient had a nasal voice and it was difficult to understand his speech. On further interrogation patient said that he had this nasal voice and speech and communication difficulties since birth. On oral cavity examination finding of a hole involving the hard palate and soft palate was noted (Figure 1). Patient also had poor oral hygiene. An incidental finding of congenital cleft palate was confirmed. On being enquired about any treatment history in the past for cleft palate, patient said that he had refused to get surgical treatment. He was given conservative treatment for upper respiratory tract infection and was advised that he can always visit a facial plastic surgeon to take expert opinion for the treatment of the cleft palate.

DISCUSSION

The failure of fusion of the palatal shelves of the maxillary processes, results in development of a cleft of the hard and/or soft palates.^4,5

The exact etiology of cleft palate is unknown but many factors have been suggested in literature such as hereditary, vascular, lymphatic, and nutritional disturbances, smoking, alcohol, anticonvulsant drugs, radiation exposure, increased maternal age, etc.⁶

People born with orofacial clefts have various clinical manifestations including facial deformity, dental and oral anomalies, hearing, speech, and respiratory defects, malnutrition, delayed growth, and psychological disorders.¹

The palate should be repaired by the age of 18 months or earlier.¹ Early cleft palate repair increases the possibility of normal speech development.^7,8 If palatal closure is delayed and abnormal speech mechanisms have developed, the possibility of normal language development is greatly reduced.⁹

A team approach is followed for management of cleft palate starting from infancy and typically includes primary care clinicians, speech-language pathologists, audiologists, genetic counselors, otolaryngologists, plastic surgeons, oral-maxillofacial surgeons, and social workers, and it may expand based on the specific needs of the patient and family.¹⁰

The main goals of palate repair are separating the oral and nasal cavity and creating a competent velopharyngeal valve for swallowing and speech, while preserving midface growth and development of functional occlusion.^11,12

The various methods of repair include Von Langenbeck’s bipedicle flap technique, Veau-Wardill-Kilner Pushback technique, Bardach’s-Pinto-Wardill two-flap technique, Furlow double opposing Z-plasty, two-stage palatal repair, whole in one repair, palatoplasty, alveolar extension palatoplasty (AEP), primary pharyngeal flap, intravelar veloplasty, vomer flap, buccal myomucosal flap.¹³

In the older age group guidelines for repairing cleft palates are controversial. It is recommended that repair of cleft palate should be done in older patients if the surgical, anesthetic, and nursing skills are available.¹⁴

CONCLUSION

Orofacial clefts such as cleft palate should be documented and managed by a multispecialty approach at an earlier age for normal development of speech.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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