Cleft Lip and Cleft Palate HERBERT E. COE., M.D., F.A.C.S.*
THE COORDINATED TEAM
OPTIMUM care of clefts of the lip and palate is best achieved by close cooperation between members of a team possessing widely different skills. Management begins with the parents, and a team approach eliminates the confusion ariEing when diverse attendants successively treat different phases of the condition. The team members, through frequent conferences, must know in detail the abilities and problems of one another. All this is enhanced by working quarters having adjoining rooms for immediate consultation between surgeon, orthodontist, prosthodontist, otolaryngologist and speech consultant. There must be ready consultation in pediatrics, psychology, psychiatry and social service. TREATMENT OF THE PARENTS
Treatment of the parents commences as soon as the mother has recovered from her first shocking awareness of her baby's condition. Usually on the day following birth the parents can be interviewed by a member of the team who possesses a broad knowledge of the condition. Unhurriedly, with tact and sympathy, the interviewer must establish confidence and mental peace of all concerned and bring about a constructive and hopeful attitude toward the future. On this largely hinges the success of what is often a long, complicated course of treatment. Photographs, models, other patients successfully treated, are aids in painting the picture. Standardized approaches are irrational because of the complexity of human personality, intelligence and background; and, in the presence of a facial deformity in a baby, one is dealing not only with its possessor but with parents and more distant relatives as well. Certain misconceptions in the lay mind can be erased during the interview. The guilt complex, for example: No one is to blame, for the defect is beyond parental control. Needing frequently to be dispelled is the false cloud of a syphilitic factor in the present or past generations. The interviewer may tactfully discover and correct phobias which are too often unexpressed by the parents dreading confirmation of their fears.
* Chief of Surgical Services, Children's Orthopedic Hospital, Seattle, Washington. 1583
Herbert E. Coe
These deep-rooted phobias may be based on a childhood aversion to a disfigured face, "harelip" stories, false connotations of mental deficiency, and so on. The interviewer can give deeply appreciated information on prognosis with respect to appearance, speech, hearing, dentition, mentality and social adjustment, stressing the period of 12 to 15 years of treatment, observation and counseling involving at least two major and many minor operations with intervening periods for growth and development. The mother is assured that she will be given instruction in general care, feeding, care of the local condition, and a definite appointment for a follow-up observation. During the interview the hereditary factor should be explored, particularly in collateral branches of the family. Such information not only has research value but is of use when later the child plans his own family. The presence, during the first trimester, of adverse environmental factors (illness, accident, emotional stress) should be recorded. There is the possibility that such metabolism-upsetting influences may activate an underlying genetic factor. It is reasonably well recognized that cleft lip and palate is transmitted as a non-sex-linked polymerous, mendelian recessive characteristic, and geneticists are finding some evidence that simple clefts of the palate are genetically distinct from the more extensive clefts involving the lip, the former showing more evidence of sex linkage and less probability of transmission to succeeding siblings. The question of repetition of the defect in subsequent siblings, or transmission to subsequent generations is usually raised. There is genetic evidence that: (1) If neither parent is affected there is a 14 per cent (1 in 7) chance that a subsequent child will be affected. (2) If one parent is affected, there is a 17 per cent (1 in 6) chance that the next child will be affected. (3) If one parent is affected there is a 2 per cent (1 in 50) chance that the first child will be affected. 1 NEONATAL CARE PRIOR TO OPERATION
Care of the infant prior to operation has to do with general health and nutrition as well as local measures directed at the deformity. Because of the great expanse of exposed mucous membranes, constant vigilance is necessary to minimize exposure to respiratory infections, drying, and unduly long contact with milk, dust, food and other foreign material. Gentle irrigations with warm normal saline restores and main- . tains a healthy condition of the mucosa. The irrigations should be done with the head down to prevent aspiration, or entry of the fluid into the eustachian tubes. Feedings should be of the usual type and quantity. Because of the mobility of the maxillary segments, the nipples should be softened and the holes enlarged to permit free flow. A Breck feeder with a similar
Cleft Lip and Cleft Palate
nipple may be used, or an "Asepto" syringe with a 1 inch piece of soft rubber tube attached through which the feeding is deposited on the dorsum of the tongue. When feeding by gavage, at least two feedings a day should be given with a spoon or cup to stimulate salivary flow. All feedings should be given at that individual angle at which the least food escapes into the nasal cavity and with the gastric fundus higher than the pylorus. Because of the large amount of swallowed air, "burping" should be induced several times during the feeding. Local care begins not later than 12 hours after birth with gentle 50 per cent alcohol cleansings of the skin of the cheeks and lip every four hours for two days to remove the vernix and prepare the skin. The dry skin is painted with tincture of benzoin, and when it is tacky, adhesive tape is applied across the defect (Fig. 515). Applying the tape to the
Fig. 515 Fig. 516 Fig. 515. Taping the cleft. The tape extends from ear to ear; is not less than % inch wide on the cheeks, and narrows to the width of the skin between the columella and the vermilion border. If too narrow, it will roll and cut the skin. If too wide, it will slip over the mucous edge into the mouth. Fig. 516. Age 272 months. At birth the prolabium consisted of the usual small tab of tissue projecting below the nasal tip. The stimulus of consistent taping for 8 weeks resulted in the development shown.
normal side first, sufficient traction is exerted to narrow a complete cleft to about one-third of its relaxed width. During the next week the tape is changed daily with progressive increments in tension until the columella is in the midline. In bilateral clefts the tape is applied first to the prolabium, then to the cheeks drawn forward. Cleansing of the skin and changing of the tape is best done after the bath or feeding when crying is minimal. Such treatment stimulates the growth of the prolabium, increases the length of the columella, improves the curve of the tip of the affected ala, and narrows the alveolar cleft by simulating the action of the normal musculature (Fig. 517). In partial clefts of the lip in which
Herbert E. Coe
there is a complete cleft of the orbicularis oris, the edges of· the cleft may be brought into contact at once. In bilateral clefts, with the usual underdeveloped prolabium, consistent taping for six to eight weeks will double or triple the size of the prolabium (Fig. 516). The segments of the infantile maxilla are quite mobile, and the tension of the tape must be carefully regulated so that the interalveolar gap is only slightly less (2 or 3 mm.) than the width of the premaxilla. When a unilateral cleft of the lip is to be closed immediately, taping, of course, is unnecessary.
Fig. 517. Effect of tape and lip on alveolar cleft. A, Age 5 days. Tape applied. B, Age 7~ months. Closure of lip (operation delayed by frequent respiratory infections). Lateral maxillary segment being drawn inward posterior to the premaxilla by lateral pressure of taping. C, Age 9~ months. Premaxilla moving back by pressure of closed lip. D, Age 20 months. Premaxilla molded into normal position by muscular action. Lateral maxillary segment improved but still slightly collapsed and not supporting left side of lip sufficiently. OPERATIVE CONSIDERATIONS
Two concepts govern the planning and execution of an operation for cleft lip and palate during the period of rapid evolution characteristic of infancy and childhood. First, when underdeveloped muscles are given attachment, and therefore functional activity, they will increase in size and strength. Second, there is a continuing change in facial proportions from birth until the adult form is re~ched. Disregard of these fundamentals multiplies secondary surgical procedures. Inaccurate estimates of the changes in proportion and size due to rapid growth and development may give rise to imperfect results which become apparent only after several· years. A lesser factor tending to produce suboptimal results is that at certain ages the patients are notably irresponsible and uncooperative. Age of Choice for Operation
As to the best age for operation, advocates of early (neonatal) lip closure take advantage of the high neonatal resistance to trauma, the
Cleft Lip and Cleft Palate
shortened period of local lip care and feeding difficulties, and the earlier elimination of the psychologic impacts occasioned by the infant's deformity. The slightly higher mortality rate is usually due to associated congenital defects. Proponents of later operation await adjustment of the child to extrauterine life as measured by a satisfactory rate of weight gain (6 to 8 ounces per week) which is a sounder index of good condition than any arbitrary period of time. Also, there is time to evaluate associated congenital defects and for the local stimulation of growth which results from taping and which facilitates the planning and making of intricate incisions. Those advocating early closure of the palate prefer from 10 to 15 months of age. * During this period there is rapid growth of tissues required for the formation of mucoperiosteal flaps; and union of the soft palate stimulates growth which permits earlier training in speech and eating. Those who favor late closure blame early surgical intervention for the underdevelopment of the maxilla and the "concave face." They prefer to delay operation until the age of four or five years to permit stabilization of maxillary growth. Probably the interference with maxillary growth is more related to the type of operation than to the timing. CLEFTS OF THE LIP
Partial Unilateral Clefts
In rare instances, the function of the lip is normal. The defect consists merely of a skin line (Fig. 518), and cosmetic removal may result in a scar more conspicuous than the original condition. If, in a partial unilateral cleft, there is a groove extending upward from the defect, one can assume that there is a muscle defect. This involves an extension of the muscle sheath around the mesial edge of the orbicularis preventing growth of its fibers into the prolabium and union with the fibers of the opposite side. Good results are obtained with either the Mirault or Hagedorn approach, although the latter is better adapted to the repair of complete clefts.2. 3 Technique. The principal points in technique are: The incisions are outlined by methylene blue needle punctures in the skin adjacent to the vermilion border at the level of a slight change in shape and color of the vermilion border. The upper point of the incision is about 3 mm. above the upper end of the skin defect and equidistant from the previous points. The upper end of the skin incision should be extremely narrow and pointed. Even though the muscle defect is minimal, the fibers should be exposed. The skin should be widely undermined at the upper end of the incision, and the defect closed with 5-0 or 6-0 chromic gut in the mucosa and fine silk or 6-0 stainless steel wire on an atraumatic needle in the
* The author's own preference for cleft palate operation is at the age of 12 months.
Herbert E. Coe
skin. Hemostasis is imperative. In minimal clefts, support by a traction bow is unnecessary, but arm and body restraints are advisable. Complete Unilateral Clefts
Complete unilateral cleft lip is usually accompanied by a complete cleft of the palate but may be associated with varying degrees of clefts of the alveolus and palate; lip repair is complicated by these conditions. At birth the cleft of the lip is usually wide open with the columella markedly drawn toward the normal side by the action of the unopposed facial muscles. The ala is flattened and the inferior nasal cartilage starts
Fig. 518. Minimal cleft lip. Barely pnceptible skin lire and irregularity of vermilion border, but genetically significant. Fig. 519. Complete unilateral cleft. Patient aged 3 years. Lip closed at age of 3 months, making right side of lip exactly same length as left, illustrating the growth which occurs when undeveloped muscle is given the stimulus of normal function.
directly laterally from a point near the middle of the columella. The ala and the lateral side of the lip are attached to that portion of the maxilla which is displaced laterally a distance equal to the width of the cleft in the alveolus. The alveolar cleft and the rotation of the premaxilla can be markedly reduced during the first two months of life by the taping procedure described above (Figs. 515, 516, 517). Technique. With this degree of cleft the additional problems relate. to the width of the floor of the nostril, the contraction of the muscle, the varying degrees of distortion of the threshold, ala and tip of nostril, and the changes which will follow development of normal function. If the threshold is not cleft, a diamond-shaped section is excised, the tip of the ala mobilized, the edges of the defect measured, and anatomical points which would normally be together at the upper and lower ends of the
Cleft Lip and Cleft Palate
defect are marked. It will usually be apparent that the proposed incision on the mesial side of the defect is longer than that on the lateral side. This is due to the contraction of the end of the orbicularis oris and is corrected by making a curved line of incision on the lateral side equal to the straight line on the mesial side. The excision of the mucous surface in the lower third of the lip should be wider than that of the skin surface to produce the full out-turned contour so characteristic of infancy. Hemostasis by ligation should be minimized. In closing the defect, atraumatic technique, fine suture material, accurate apposition of tissues, and lack of tension are absolute essentials. There should be no attempt to make the line of union equal in length to the opposite side (Fig. 519). The nostril should not be made too small and round, remembering that by later secondary operations it is easier to reduce the size of a nostril than to increase it. In addition to the technical problems mentioned in repair of incomplete clefts of the lip, more extensive mobilization of the sides of the defect is required. Through an incision in the anterior portion of the buccal fornix the plane of cleavage overlying the maxilla can be entered and the soft tissues easily raised as far as the infraorbital foramen and edge of the nasal bone. The mobilization of the opposite side need not be so extensive, although it is recommended by some that the nasal spine and base of the septum be sectioned to permit the columella to be placed in the midline. In correcting the shape of the nostril the inferior nasal cartilage must be freed thoroughly from both skin and mucosa so that it may assume a smooth curve when the ala is drawn into position. The cartilage is so tightly adherent to the submucosa that this separation is difficult. The relation of the skin, cartilage and mucosa is maintained in the corrected position by one to three transfixing mattress sutures of fine stainless steel wire-the material of choice because of its noncapillarity. After mobilization, flaps are fashioned from each side of the nostril to build up a good threshold, and closure is similar to that noted for incomplete clefts. The Mirault type of closure gives highly satisfactory results if the alveolar cleft is not over 8 mm. wide and the premaxilla is not markedly rotated. 4 In the more exaggerated clefts the extensive shifting of the soft parts in this operation gives an immediately pleasing result but the problems of the orthodontist, prosthodontist and rhinoplastic surgeon are increased, although they may not become apparent for several years. The Hagedorn method also involves extensive mobilization. The incisions, modified and developed, form pointed and quadrilateral flaps which interdigitate to give an angulated line of union, the incisions being made by transfixing the entire thickness of the lip at right angles to the skin surface. 3 • 5 A well-formed nostril is obtained by careful undermining of the mucosa on both sides of the vestibule and the use of flaps of this
Herbert E. Coe
mucosa to form the floor of the nostril. This method of closure which has been followed by LeMesurier for over 16 years is reported to show a normal rate of growth with good contours and without the tendency to overgrowth from the physiologic stimulus of functional activity. The final results to date, especially in wide unilateral clefts, seem highly satisfactory, probably more so in LeMesurier's hands than in those of less frequent operators. Bilateral Clefts
The repair of bilateral clefts is much more complicated than that of unilateral clefts. In most instances, however, it is possible to obtain sufficiently good results so that satisfactory socio-economic relations are possible, perhaps enhanced by the fact that frequently these patients hav€ an unusually high level of intelligence. The deformity is characterized by an elongation and forward growth of the frontonasal process partially or completely unrestrained by normal soft tissue attachments. In the extreme form, the premaxilla, borne on the end of the frontonasal process, is rotated outward and projects just below the base of the columella and far anterior to the ends of the alveoli. The prolabium, presenting upward, merges with the base of the almost nonexistent columella. The anterior margins of the nostrils are drawn almost directly backward by the attachment of the alae to the maxilla. The nasal septum may be curved until it occludes one of the nasal passages. In addition to closure of the lip defect, treatment is directed at placing the premaxilla in its normal position as the center of the dental arch, development of the prolabium as the normal center of the lip, lengthening the columella, and shaping the nostrils. Technique. In reducing the projecting premaxilla, the writer has for many years used the circumferential wiring described by Ritchie. 6 The operation is performed at the weight of about 10 pounds. After mobilization by shortening the base of the septum, the premaxilla is pressed back until it rests against the ends of the alveoli, and is held by wire which also controls rotation. The procedure and the wire are well tolerated, and light tension with tape is maintained to stimulate growth of the prolabium. The lip is closed two to four weeks later in one or two stages, with closure of the anterior end of the hard palate by means of a premaxillary flap.4 Without the restraint of the wire, callus at the point of . excision of the edge of the vomer has occasionally formed so rapidly as to pu~h the premaxilla forward nearly to its original position. The wire is removed after the lip is well healed, its disadvantage being that the floor and threshold of the nostrils cannot be closed at the time of the lip repair. The choice of method for closure of the lip will vary with the prefer-
Cleft Lip and Cleft Palate
Fig. 520. Age 12 years. BilatE'ral cleft of the lip closed in infancy by uniting much of the muscle from the sides in the midline below the prolabium. In response to functional activity it has grown to such size that it cannot be raised above the edge of the teeth. Owing to its nonanatomical position in the midline instead of at the sides of the prolabium, the lip edge is tight and so shortened laterally that the lower lip is forced into eversion.
Fig. 521. Age 5 weeks. Median cleft lip. Agenesis of the frontonasal process with absence of the prolabium, premaxilla, columella and vomer. Treated by uniting the lip in the midline and transplanting a portion of the twelfth rib between the ends of the alveoli to prevent collapse of the maxillary segments. The nose was elevated by supporting cartilage resting on the transplanted bone, which also provided a foundation for the dental prosthesis. Fig. 522. Cast of palate of Figure 521 showing wide alveolar gap. Note posterior end of the base of the rudimentary vomer.
Herbert E. Coe
ences and experience of the surgeon. Whether there be one or two stages or whether the mucosal edge be completely removed from the prolabium makes little difference provided that certain fundamental principles be respected. All incisions must be so planned as to result in normal attachment of muscles and normal direction of muscle fibers. Sutures should be fine silk, cotton, stainless steel wire (gauge 36) or chromic gut (5-0 or 6-0) with atraumatic needles and technique. Shaping of the nostrils is in general as described for a unilateral cleft. Lengthening of the columella is best postponed for at least five years until growth indicates the direction and amount of correction required. If the lateral flaps are so fashioned as to bring muscle below the prolabium to form the center of the edge of the lip, the result may be pleasing for a few years but when the prolabium grows and the muscle develops, the lip is ,distorted (Fig. 520). Removal of the prolabium is a mutilation which should never be practiced except as a last resort, as it merely substitutes one type of disfigurement for another. Median cleft of the lip and palate is rare and the treatment is long and complicated (Figs. 521, 522). CLEFTS OF THE PALATE
The surgery of cleft palate is in the highest degree physiologic surgery. Development of normal function is paramount, and appearance is secondary. To this end the essentials are preservation of nerve and blood supply, respect for tissues, relaxation of flaps, absence of tension on sutures, and, especially, skilled postoperative care. Palatal clefts vary markedly in degree, but the generally accepted method of repair for all degrees is based on the procedure described by von Langenbeck in 1861. Unilateral Clefts
Clefts of the uvula are repaired only for cosmetic purposes, as there is no functional defect. A submucous cleft of the soft palate (Fig. 523) causes defective speech and deglutition, and is usually unrecognized before late childhood or even early adult life. The muscles must be exposed and united across the midline. Postoperative speech therapy is usually necessary. Closure of clefts of the soft palate usually require lateral relaxing incisions begun in the commissure posterior to the tuberosity of the maxilla and extending forward on the mesial side of the tuberosity about 12 mm. The incision is gently spread exposing the hamulus which is cut, converting the tensor palati to a levator. The soft tissues are separated from the posterior edge of the hard palate, preserving the posterior palatine artery in its foramen. The nasopalatine fascia is cut, gaining
Cleft Lip and Cleft Palate
sufficient mobility of the soft palate to permit easy overlapping of the sides of the cleft. The sides of the defect are pared to expose the muscles, and the defect is closed in layers with interrupted simple and mattress sutures of 5-0 or 6-0 chromic gut. The lateral incisions heal with surprising rapidity without sutures. The essential feature of the closure is that there must be muscle union across the midline, the muscle sheath being opened to permit this contact.
Fig. 523. Age 12 years. Cleft uvula and submucous cleft of the soft palate. Motions and appearance of the soft palate are grossly normal, but upon contraction a median groove appears between low rounded mounds of contracted muscle.
In clefts involving the hard palate, mucoperiosteal flaps are used, not only because of the firmness of the tissue but also because of their osteogenic property. A cleft involving one-half to two-thirds of the hard palate may be a part of the Pierre-Robin syndrome, being associated with micrognathia and glossoptosis. Closure of this defect is best postponed three to five years, during which time the mandible develops and the mouth can be opened to afford adequate exposure. Earlier operation is dangerous because of the inadequate airway in addition to the difficulty of exposure.
Herbert E. Coe
One variant of cleft palate resembles the shape of a horseshoe, the palatal processes being so narrow that the mucoperiosteal flaps are not equal to the width of the defect. The flaps are raised completely around the anterior end and slid mesially and posteriorly as far as possible, converting the broad defect to a V-shaped one. Mter six to ten months, when thin bone can be felt developing from the periosteum, the maneuver is repeated until a complete hard palate develops. (Success depends on delicacy in handling tissues ably assisted by much good luck!) In the usual type with partial or complete cleft of the hard palate, mucoperiosteal flaps are raised by long lateral incisions with thorough mobilization and maintenance of blood supply. It is well to retain the attachment of the flaps at the edges of the alveolar cleft if possible. In wide clefts, however, it may be necessary to include the posterior surface of the premaxilla in the formation of one flap, detaching it completely from the edge of the alveolar cleft and uniting it to the lateral flap which has not been detached completely. Closure of the anterior end of the palatal defect is much simplified if the alveolar cleft has been bridged with soft tissues at the time of the lip repair. The soft palate is closed as before noted and the edges of the mucoperiosteal flaps are everted and united with end-on mattress stitches of 5-0 chromic gut. Bilateral Clefts
The methods of closure of complete bilateral clefts vary greatly in detail, our preference being for the technique as noted for closure of unilateral clefts except that the anterior ends of the lateral flaps are completely detached, a premaxillary flap is reversed, and the ends of the lateral flaps united over it with mattress sutures of 5-0 chromic gut. The alveolar clefts are closed at the same time, or later, by flaps from the edges of the clefts or from the labial fornix. The mucoperiosteal flaps develop a firm, bony palate which usually is indistinguishable from the normal hard palate. Abnormal mobility of the premaxilla presents a major problem for the orthodontist and the prosthodontist, necessitating at times extraction of teeth and replacement by a prosthesis. Stabilization of a moveable premaxilla or a maxillary segment may in some instances be accomplished by reflecting mucoperiosteal flaps from the adjacent ends of the alveoli, in others by the use of the premaxillary flap, and in others by a bony bridge across the alveolar cleft (Fig. 524). Excellent articles on various aspects of the entire subject by Blair, Brown and associates have appeared in the medical literature during the past 30 years, and the recent comprehensive, clear, well-illustrated monograph by Holdsworth contains a wealth of information and is pleasurable reading. 2 ,5
Cleft Lip and Cleft Palate
Specialized nursing care is of the utmost importance. It is better to have one nurse well trained in the special problems inherent in this type of surgery than the usual succession of nurses on eight-hour shifts. Untrained home care can be disastrous. Antibiotics are used only when indicated. There should be special precautions against respiratory infection. Sedation in moderation is valuable. A temperature rise during the first 24 hours need not cause concern as it is probably related to absorption from denuded areas.
Fig. 524. AgE' 19 years. Stabilization of a maxillary segment. A good soft tissue union across the alveolar cleft was opened including periosteum, and the alveolar gap packed with osteoperiosteal chips from a rib. A, X-ray 5 months later shows beginning osteogenesis. B, Eight months later a firm bony ridge has developed, filmy in x-ray but clinically solid. Orthodontic bands stabilized the segment during osteogenesis.
A suction apparatus with mild pressure is excellent for clearing the mouth and nose. Normal saline is preferable for cleaning the mucous surfaces, and too-vigorous wiping is avoided. Feedings during the first three days should be clear liquids rather than milk because of the tendency of the latter to coagulate and stick to suture lines. After each feeding, a small quantity of water should be given with a spoon, allowing the tongue motion to clean the suture line. Any adhering food should be gently irrigated or swabbed off. After three days any soft foods-without hard particles-which will pass through a fine sieve can be used until the fourteenth day, when normal feedings are resumed. When the small child is fed he should be held to simulate maternal care.
Herbert E. Coe
Care of Suture Lines
For the lip, the use of Logan's traction bow eliminates all tension on suture lines. Elbow cuffs extending from above the mid-upper arm to below the mid-forearm prevent fingering of the wound. During the immediate post-operative period meticulous care keeps the suture lines clean and dry, all crusts being promptly and gently removed with hydrogen peroxide. After oozing has ceased, local hyperemia created by means of an infrared lamp (20 minutes every two hours for three days) hastens healing. Skin sutures may be removed with extreme care on the fourth or fifth day. Light anesthesia may be used to avoid trauma. At times a superficial slough may appear along a palatal suture line. Unless there is evidence of infection it should not be removed until it comes away easily. When an infant is markedly irritable and requires sedation two or three times in 24 hours, it usually means that there is tension and that the sutures will cut through-an event marked by a sudden cessation of irritability. Nonabsorbable sutures in the palate are removed on the tenth to fourteenth day. SPEECH AND HEARING PROBLEMS
Speech problems are intimately associated with dental and hearing problems and close cooperation of all members of the team is most valuable. A denture may give satisfactory support to the lip and permit adequate mastication but be an impediment to correct speech. A general consultation regarding the function and size of the soft palate will often clarify a choice between further surgery, a prosthesis, and muscle training. There is a diminution of hearing in a large percentage of cleft palate patients varying from a few decibels to almost complete deafness. This is related to mucosal changes in the vicinity of the eustachian tubes. N ormal ventilation of the tubes is also affected by local muscle changes incident to palate repair. What to do in such situations requires close cooperation with the otolaryngologist. During speech training the question of adenoidectomy often arises and, in deciding on this, one is caught between "the devil" of infection of the eustachian tubes with an adverse effect on hearing and "the deep blue sea" of interference with speech training by increasing the distance through which the soft palate must travel to effect nasopharyngeal closure. At times selective adenoidectomy, leaving the central adenoidal pad, may be advisable until speech has progressed to a satisfactory degree. COMMENT
Developmental defects such as cleft lip and palate are not suitable for study in the human animal by planned variation in factors, which is the essence of controlled experimentation. In the absence of this approach·
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we need more accurately accumulated data. Under our present method of reporting vital statistics we cannot make even a mediocre estimate of the total incidence of this condition in our population. Concentration of case care in relatively few centers where data may be collected and analyzed would be valuable as would also the general adoption of vital statistics laws similar to those of Wisconsin. 7 In recent years there has been increasing interest in this condition as indicated by more articles in the medical literature, as well as the birth of a quarterly periodical of a nationwide organization devoted to it. 8 Constant advances are being made by speech correctionists, and the American Speech and Hearing Association provides a valuable medium for the exchange of ideas and the results of research. The recognition of the value of the coordinated approach is indicated by the increasing number of teams which are being organized throughout this country in the past few years. It is manifestly impossible within the necessary limitations of this article to present more than a glimpse of so broad a subject, but the few bibliographic references will open the door at least a crack to permit fascinating vistas filled to the horizon with beautifully clear details and the accumulated wisdom of years of experience. REFERENCES l. Fogh-Anderson, P.: Inheritance of Harelip and Cleft Palate. Copenhagen, Ejnar Wunksgaard, 1943. 2. Brown, J. B., McDowell, F. and Byars, L. T.: Double Clefts of the Lip. Surg., Gynec. & Obst. 85: 20 (July) 1947. Brown, J. B. and McDowell, F.: Small Triangular Flap Operation for the Primary Repair of Single Cleft Lips. Plast. & Reconstruct. Surg. 5: 392 (May) 1950. 3. LeMesurier, A. B.: The Treatment of Complete Unilateral Harelips. Surg., Gynec. & Obst. 95: 17, 1952. 4. Coe, H. E.: The Use of the Premaxillary Flap in the Repair of Bilateral Cleft Palate. Plast. & Reconst. Surg. 12: 184 (Sept.) 1953. 5. Holdsworth, W. G.: Cleft Lip and Palate. New York, Grune & Stratton, 1951. 6. Ritchie, H. P.: Congenital Clefts of the Face and Jaws. Arch. Surg. 28: 617, 1934. 7. Slaughter, W. B. and Phair, G. M.: A Complete Cleft Palate Program. J. Speech & Hearing Disorders 17: 123 (June) 1952. 8. American ASRociation for Cleft Palate Rehabilitation: Cleft Palate Bulletin Pennsylvania State University, State College, Pennsylvania.
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