DOCSLIB.ORG

Read Full Article

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Read Full Article PEDIATRIC/CRANIOFACIAL Pharyngeal Flap Outcomes in Nonsyndromic Children with Repaired Cleft Palate and Velopharyngeal Insufficiency Stephen R. Sullivan, M.D., Background: Velopharyngeal insufficiency occurs in 5 to 20 percent of children M.P.H. following repair of a cleft palate. The pharyngeal flap is the traditional secondary Eileen M. Marrinan, M.S., procedure for correcting velopharyngeal insufficiency; however, because of M.P.H. perceived complications, alternative techniques have become popular. The John B. Mulliken, M.D. authors’ purpose was to assess a single surgeon’s long-term experience with a Boston, Mass.; and Syracuse, N.Y. tailored superiorly based pharyngeal flap to correct velopharyngeal insufficiency in nonsyndromic patients with a repaired cleft palate. Methods: The authors reviewed the records of all children who underwent a pharyngeal flap performed by the senior author (J.B.M.) between 1981 and 2008. The authors evaluated age of repair, perceptual speech outcome, need for a secondary operation, and complications. Success was defined as normal or borderline sufficient velopharyngeal function. Failure was defined as borderline insufficiency or severe velopharyngeal insufficiency with recommendation for another procedure. Results: The authors identified 104 nonsyndromic patients who required a pharyngeal flap following cleft palate repair. The mean age at pharyngeal flap surgery was 8.6 Ϯ 4.9 years. Postoperative speech results were available for 79 patients. Operative success with normal or borderline sufficient velopharyngeal function was achieved in 77 patients (97 percent). Obstructive sleep apnea was documented in two patients. Conclusion: The tailored superiorly based pharyngeal flap is highly successful in correcting velopharyngeal insufficiency, with a low risk of complication, in non- syndromic patients with repaired cleft palate. (Plast. Reconstr. Surg. 125: 290, 2010.) peech to a pediatric plastic surgeon should If the velopharyngeal sphincter is incompetent, be like vision to an ophthalmologist. Normal speech is characterized by hypernasal resonance, velopharyngeal closure, the goal of palato- possible audible nasal emission, and decreased in- S 2,3 plasty, depends on dynamic apposition of the ve- traoral pressure for pressure consonants. These lum and lateral and posterior pharyngeal walls. audible hallmarks of an incompetent velopharyn- The velopharyngeal sphincter opens to allow nasal geal sphincter (known as velopharyngeal insuffi- respiration and transmission of acoustic energy ciency) are found in 5 to 20 percent of patients 4–12 into the nasal cavities for nasal consonant produc- following repair of a cleft palate. tion (n, m, and ng in English). The sphincter closes Secondary operations to correct velopharyngeal to prevent nasal airflow and acoustic energy into insufficiency include pharyngeal flap, sphincter pha- the nasal cavities during oral sound production ryngoplasty, double-opposing Z-palatoplasty, and and to prevent food and liquid from entering the palatal muscle retropositioning. The superiorly nose during swallowing.1,2 based pharyngeal flap, with width tailored to lateral pharyngeal wall motion, is considered to be the From the Department of Plastic and Oral Surgery and the Craniofacial Centre, Children’s Hospital and Harvard Med- ical School, and the Central New York Cleft and Craniofacial Center, Upstate Medical University Hospital. Disclosure: None of the authors has any commer- Received for publication May 27, 2009; accepted July 28, cial associations, supporting funds, or financial 2009. disclosures that might pose or create a conflict of Copyright ©2009 by the American Society of Plastic Surgeons interest with information presented in this article. DOI: 10.1097/PRS.0b013e3181c2a6c1 290 www.PRSJournal.com Volume 125, Number 1 • Pharyngeal Flap Speech Outcomes standard treatment, with reported long-term suc- ciated with velopharyngeal insufficiency (e.g., cess rates of 78 to 98 percent.13–23 The goal of the glottal stops, pharyngeal fricatives, and laryngeal pharyngeal flap procedure is to enable velopha- fricatives) were identified and a therapeutic plan ryngeal closure for speech without causing ob- outlined to eliminate these patterns and to establish struction of the upper airway. This is a delicate normal oral placement for consonant production. balance, as a pharyngeal flap that is too wide can Speech assessment was based on three struc- lead to nasopharyngeal obstruction and sleep ap- turally correctable variables: resonance (nor- nea; this complication has been reported to occur mal, hyponasal, mixed hyponasal/hypernasal, in up to 20 percent of patients.17,20,24–28 Another mildly hypernasal, moderately hypernasal, or se- untoward effect of a pharyngeal flap is hypona- verely hypernasal), intraoral pressure (normal sality in 5 to 27 percent of patients.15–17,20,22,24 On or decreased), and nasal emission (normal, visi- the other end of the spectrum, a pharyngeal flap ble, audible, or turbulent). Overall velopharyn- that is too narrow may fail to correct velopharyn- geal competence was graded as follows: (1) nor- geal insufficiency.19 For these reasons, sphincter mal (normal or mildly hyponasal resonance, pharyngoplasty, double-opposing Z-palatoplasty, absence of visible nasal emission by mirror exam- and palatal muscle retropositioning have in- ination, and normal intraoral pressure); (2) bor- creased in popularity. derline sufficiency (inconsistent mildly hyperna- Our purpose was to audit a single surgeon’s sal, visible or inconsistent audible nasal emission, long experience using a tailored superiorly based normal intraoral pressure, and no personal or so- pharyngeal flap as a secondary operation to cor- cial problems); (3) borderline insufficiency (con- rect velopharyngeal insufficiency in nonsyn- sistent mildly hypernasal resonance, audible or dromic children with a repaired cleft palate. The turbulent nasal emission or inconsistent de- outcome measures were perceptual speech results creased intraoral pressure, and a personal or so- and complications. cial problem); and (4) insufficiency (moderate or severe hypernasal resonance, audible or turbulent PATIENTS AND METHODS nasal emission, and decreased intraoral pressure). All patients underwent preoperative multiview Patient Population videofluoroscopy. Patients usually must be 4 to 5 After approval by the Institutional Review years of age or older to participate in Board of the Committee on Clinical Investigation, videofluoroscopy.9,23,30,31 The plastic surgeon and we identified and reviewed the charts of all pa- speech pathologist reviewed the studies together tients who had a palatoplasty and were subse- before final consideration for a pharyngeal flap. quently diagnosed with velopharyngeal insuffi- The lateral pharyngeal wall motion (estimated ciency and treated with a pharyngeal flap under percentage of velopharyngeal sphincter closure by the supervision of the senior author (J.B.M.) at medial movement of the lateral walls), symmetry Children’s Hospital Boston between 1981 and of lateral wall motion, palatal length (very short, 2008 (n ϭ 72). Children who had primary pala- short, normal, or long), velopharyngeal gap size toplasty executed by another surgeon or at an- (pinhole, small, moderate, or gross), and defect other institution were also included (n ϭ 32). pattern (coronal, sagittal, or circular) were con- Exclusion criteria were submucous cleft palate, sidered in planning flap width (narrow, medium, identified syndrome/association, and Robin se- wide, very wide, or subobstructing).14,22,32 An oto- quence. Data collected included birth date, sex, rhinolaryngologist evaluated the tonsils preoper- hearing loss, cleft palate type, age at pharyngeal atively; tonsillectomy was performed at least 8 flap surgery, preoperative and postoperative weeks before the pharyngeal flap if tonsils were speech assessment, videofluoroscopic results, enlarged (2ϩ or greater). Thirty-seven of 104 chil- postoperative complications, history of tonsillec- dren (36 percent) had a tonsillectomy and 10 (10 tomy or adenoidectomy or both, recommenda- percent) also had an adenoidectomy. tion for another corrective procedure, and inter- val to most recent follow-up evaluation. A speech pathologist, specializing in cleft pal- Operative Technique ate, completed a preoperative perceptual speech The technique was modified from methods assessment on each patient using the Pittsburgh described previously.18,22,33–35 The velum was split Weighted Values for Speech Symptoms Associated in the midline from the uvula to approximately with Velopharyngeal Incompetence instrument.29 halfway to the hard palatal junction. Trapezoid- Deviant compensatory articulation patterns asso- shaped nasal mucosal flaps were incised and sep- 291 Plastic and Reconstructive Surgery • January 2010 arated from the oral mucosa of the velum. A su- as mean Ϯ SD. We compared proportions of pre- periorly based flap (narrow, medium, wide, very operative and postoperative speech characteristics wide, or subobstructing)14,22,32 was elevated off the using Fisher’s exact test. We used the Wilcoxon buccopharyngeal fascia to above the level of the signed rank test to compare preoperative and post- soft palate. Flap dimension was determined by operative Pittsburgh Weighted Values scores.29 All lateral pharyngeal wall motion and was relative to calculated p values were two-tailed and considered the size of the pharynx. The differences between significant for values of p Ͻ
Load more

Recommended publications
  • (FNE) and Nasal Endoscopy in Ireland During COVID-19 Pandemic Rev 1
    Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Interim Clinical Guidance on Flexible Nasendoscopy (FNE) and Nasal Endoscopy in Ireland during COVID-19 pandemic Rev 1 INTERIM CLINICAL GUIDANCE ON FLEXIBLE NASENDOSCOPY (FNE) AND NASAL ENDOSCOPY IN IRELAND DURING COVID-19 PANDEMIC Rev 1 INTERIM CLINICAL GUIDANCE ON FLEXIBLE NASENDOSCOPY (FNE) AND NASAL ENDOSCOPY IN IRELAND DURING COVID-19 PANDEMIC Table of Contents 1. Overview ............................................................................................................................................................................. 2 2. Purpose ............................................................................................................................................................................... 2 3. Authorship ......................................................................................................................................................................... 2 4. Target Audience .............................................................................................................................................................. 2 5. Introduction ....................................................................................................................................................................... 2 6. Risk of infection associated with FNE .................................................................................................................. 2 7. Aerosol Generating Procedures
    [Show full text]
  • Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
    Medical Policy Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 130 BCBSA Reference Number: 7.01.101 Related Policies None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO BlueSM and Medicare PPO BlueSM Members Uvulopalatopharyngoplasty (UPPP) may be MEDICALLY NECESSARY for the treatment of clinically significant obstructive sleep apnea syndrome (OSAS) in appropriately selected adult patients who have failed an adequate trial of continuous positive airway pressure (CPAP) or failed an adequate trial of an oral appliance (OA). Clinically significant OSA is defined as those patients who have: Apnea/hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) 15 or more events per hour, or AHI or RDI 5 or more events and 14 or less events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke. Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery, including mandibular- maxillary advancement (MMA), may be MEDICALLY NECESSARY in appropriately selected adult patients with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have failed an adequate trial of continuous positive airway pressure (CPAP) or failed an adequate trial of an oral appliance (OA). Clinically significant OSA is defined as those patients who have: AHI or RDI 15 or more events per hour, or AHI or RDI 5 or more events and 14 or less events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.
    [Show full text]
  • Home Care After Sleep Surgery-Uvulopalatopharyngoplasty (UP3) And/Or Tonsillectomy
    Home Care after Sleep Surgery-Uvulopalatopharyngoplasty (UP3) and/or Tonsillectomy The above surgeries are all performed on patients to help relieve or lessen the symptoms of sleep apnea. All address the palate, or the upper part of your throat. General Information You may lack energy for several days, and may also be restless at night. This will improve over the next 10 to 14 days. It is quite common to feel progressively worse during the first five to six days after surgery. You may also become constipated during this time for three reasons: you will not be eating a regular diet, you will be taking pain medications, and you may be less active. Wound Care All of the above surgeries are performed within the mouth on the upper throat. No external incisions are made, all are internal. Depending on the surgery, you may feel and/or see some suture on your palate (upper throat). This is normal and will dissolve over the next two weeks. No specific wound care is necessary for these procedures. Diet It is important for you to drink plenty of fluids after surgery. Drink every hour while awake. A soft diet is recommended for the first 14 days (anything that you may eat without teeth constitutes as a soft diet). Avoid hot liquids/solids. It is alright if you don’t feel like eating much, as long as you drink lots of fluids. Signs that you need to drink more are when the urine is darker in color (urine should be pale yellow). A high fever that persists may also be a sign that you are not taking in enough fluids.
    [Show full text]
  • Chapter 1 Introduction
    CHAPTER 1 INTRODUCTION And what of the god of sleep, patron of anaesthesia? The centuries themselves number more than 21 since Hypnos wrapped his cloak of sleep over Hellas. Now before Hypnos, the artisan, is set the respiring flame – that he may, by knowing the process, better the art. John W. Severinghaus When, in 1969, John Severinghaus penned that conclusion to his foreword for the first edition of John Nunn’s Applied Respiratory Physiology (Nunn 1969), he probably did not have in mind a potential interaction between surgery, anaesthesia, analgesia and postoperative sleep. It is only since then that we have identified the importance of sleep after surgery and embarked upon research into this aspect of perioperative medicine. Johns and his colleagues (Johns 1974) first suggested and examined the potential role of sleep disruption in the generation of morbidity after major surgery in 1974. It soon became clear that sleep-related upper airway obstruction could even result in death after upper airway surgery (Kravath 1980). By the mid-eighties, sleep had been implicated as a causative factor for profound episodic hypoxaemia in the early postoperative period (Catley 1985). The end of that decade saw the first evidence for a rebound in rapid eye movement (REM) sleep that might be contributing to an increase in episodic sleep- related hypoxaemic events occurring later in the first postoperative week (Knill 1987; Knill 1990). Since then, speculation regarding the role of REM sleep rebound in the generation of late postoperative morbidity and mortality (Rosenberg-Adamsen 1996a) has evolved 1 into dogma (Benumof 2001) without any direct evidence to support this assumption.
    [Show full text]
  • The Importance of Orofacial Myofunctional Therapy Before and After CO2 Laser Frenectomy in Achieving Optimal Orofacial Function
    LASERfocus The Importance of Orofacial Myofunctional Therapy Before and After CO2 Laser Frenectomy in Achieving Optimal Orofacial Function by Karen M. Wuertz, DDS, ABCDSM, DABLS, FOM, and Brooke Pettus, RDH, BSDH, COMS Frenectomy Methods ing, speaking, and breathing patterns may be Frenotomies performed with a scalpel or scissors can be accompanied by caused by incorrect oral posture and oral re- significant bleeding, obscuring the surgical field making it difficult to ensure strictions. Therefore, in the authors’ opinion, if the restriction has been completely removed. Because of the increased risk the removal of oral restrictions is necessary to of early primary closure of the site, postoperative active wound care is es- attain optimal orofacial function, and must be sential to reduce the risk of potential scarring. To properly restore and main- combined with regular pre- and post-frenecto- tain optimum function, active wound care should be implemented as soon my orofacial myofunctional therapy (OMT).1,4 as possible. However, if sutures are placed, the active wound care may be OMT helps re-educate the tongue and orofa- delayed so as not to cause early tearing of tissue. Due to the contact nature of cial muscles during movement and at rest to conventional procedure, there is a certain potential for infection; in addition, create new neuromuscular patterns for proper higher levels of postoperative pain and discomfort have been reported.1,2 Elec- oral function, including chewing, swallowing, trocautery and a hot glass tip of dental diodes may leave a fairly substantial speaking, and breathing.5,6 Camacho et al.7 zone of thermal tissue change3 and may result in delayed healing.
    [Show full text]
  • Orthodontics and Paediatric Dentistry
    Umeå University Department of Odontology Section 1 – Introduction ............................................................................................5 1.1 Introduction and General Description ...............................................5 1.2 The Curriculum ...............................................................................6 1.3 Significant Aspects of the Curriculum .............................................10 Section 2 – Facilities............................................................................................... 10 2.1 Clinical Facilities ...........................................................................10 2.2 Teaching Facilities ........................................................................10 2.3 Training Laboratories ....................................................................11 2.4 Library .........................................................................................11 2.5 Research Laboratories ..................................................................11 Section 3 – Administration and Organisation ......................................................... 13 3.1 Organizational Structures ..............................................................13 3.2 Information Technology .................................................................16 Section 4 – Staff ...................................................................................................... 16 Section 5-16 – The Dental Curriculum....................................................................
    [Show full text]
  • Tonsillotomy (Partial) and Complete Tonsillectomy
    OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY TONSILLOTOMY (PARTIAL) & COMPLETE TONSILLECTOMY - SURGICAL TECHNIQUE Klaus Stelter and Goetz Lehnerdt Acute tonsillitis is treated with steroids e.g. first and easiest-to-reach station of the dexamethasone, NSAIDs e.g. ibuprofen and mucosa associated lymphoid tissue system beta-lactam antibiotics e.g. penicillin or cef- (MALT) 2-4. As the main phase of the im- uroxime. Only 10 days of antibiotic therapy mune acquisition continues until the age of has proven to be effective to prevent rheu- 6yrs, the palatine tonsils are physiological- matic fever and glomerulonephritis. ly hyperplastic at this time 5, 6. This is followed by involution, which is reflected Tonsillectomy is only done for recurrent by regression of tonsil size until age 12yrs acute bacterial tonsillitis, or for noninfec- 7. tious reasons such as suspected neoplasia. The lymphoid tissue is separated by a cap- Partial tonsillectomy (tonsillotomy) is the sule from the surrounding muscle (superior 1st line treatment for snoring due to tonsillar pharyngeal constrictor) 8. The blood supply hyperplasia. It is low-risk, and postopera- originates from four different vessels, the tive pain and risk of haemorrhage are much lingual artery, the ascending pharyngeal less than with tonsillectomy. It is immate- artery and the ascending and descending rial whether the tonsillotomy is done with palatine arteries. These vessels radiate laser, radiofrequency, shaver, coblation, bi- mainly to the upper and lower tonsillar polar scissors or monopolar electrocautery, poles, as well as to the centre of the tonsil as long as the crypts remain open and some from laterally 9.
    [Show full text]
  • Core Curriculum for Surgical Technology Sixth Edition
    Core Curriculum for Surgical Technology Sixth Edition Core Curriculum 6.indd 1 11/17/10 11:51 PM TABLE OF CONTENTS I. Healthcare sciences A. Anatomy and physiology 7 B. Pharmacology and anesthesia 37 C. Medical terminology 49 D. Microbiology 63 E. Pathophysiology 71 II. Technological sciences A. Electricity 85 B. Information technology 86 C. Robotics 88 III. Patient care concepts A. Biopsychosocial needs of the patient 91 B. Death and dying 92 IV. Surgical technology A. Preoperative 1. Non-sterile a. Attire 97 b. Preoperative physical preparation of the patient 98 c. tneitaP noitacifitnedi 99 d. Transportation 100 e. Review of the chart 101 f. Surgical consent 102 g. refsnarT 104 h. Positioning 105 i. Urinary catheterization 106 j. Skin preparation 108 k. Equipment 110 l. Instrumentation 112 2. Sterile a. Asepsis and sterile technique 113 b. Hand hygiene and surgical scrub 115 c. Gowning and gloving 116 d. Surgical counts 117 e. Draping 118 B. Intraoperative: Sterile 1. Specimen care 119 2. Abdominal incisions 121 3. Hemostasis 122 4. Exposure 123 5. Catheters and drains 124 6. Wound closure 128 7. Surgical dressings 137 8. Wound healing 140 1 c. Light regulation d. Photoreceptors e. Macula lutea f. Fovea centralis g. Optic disc h. Brain pathways C. Ear 1. Anatomy a. External ear (1) Auricle (pinna) (2) Tragus b. Middle ear (1) Ossicles (a) Malleus (b) Incus (c) Stapes (2) Oval window (3) Round window (4) Mastoid sinus (5) Eustachian tube c. Internal ear (1) Labyrinth (2) Cochlea 2. Physiology of hearing a. Sound wave reception b. Bone conduction c.
    [Show full text]
  • Surgical Treatments for Obstructive Sleep Apnea (OSA) Policy Number: PG0056 ADVANTAGE | ELITE | HMO Last Review: 06/01/2021
    Surgical Treatments for Obstructive Sleep Apnea (OSA) Policy Number: PG0056 ADVANTAGE | ELITE | HMO Last Review: 06/01/2021 INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder terms, conditions, exclusions and limitations contract. It does not constitute a contract or guarantee regarding coverage or reimbursement/payment. Self-Insured group specific policy will supersede this general policy when group supplementary plan document or individual plan decision directs otherwise. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This medical policy is solely for guiding medical necessity and explaining correct procedure reporting used to assist in making coverage decisions and administering benefits. SCOPE X Professional _ Facility DESCRIPTION Sleep apnea is a disorder where breathing nearly or completely stops for periods of time during sleep. In obstructive sleep apnea (OSA), the brain sends the message to breathe, but there is a blockage to air flowing into the chest. It is a condition in which repetitive episodes of upper airway obstruction occur during sleep. The obstruction may be localized to one or two areas, or may encompass the entire upper airway passages to include the nasal cavity (nose), oropharynx (palate, tonsils, tonsillar pillars) and hypopharynx (tongue base). The hallmark symptom of OSA is excessive daytime sleepiness, and the typical clinical sign of OSA is snoring, which can abruptly cease and be followed by gasping associated with a brief arousal from sleep. The snoring resumes when the patient falls back to sleep, and the cycle of snoring/apnea/arousal may be repeated as frequently as every minute throughout the night.
    [Show full text]
  • 32 Surgical Treatment of Sleep-Related Breathing Disorders Donald M
    32 Surgical Treatment of Sleep-Related Breathing Disorders Donald M. Sesso Department of Otolaryngology/Head and Neck Surgery, Stanford University Medical Center, Stanford, California, U.S.A. Nelson B. Powell and Robert W. Riley Department of Otolaryngology/Head and Neck Surgery, Stanford University Medical Center and Department of Behavioral Sciences, Division of Sleep Medicine, Stanford University School of Medicine, Stanford, California, U.S.A. INTRODUCTION Snoring, upper airway resistance syndrome (UARS), obstructive sleep apnea (OSA), and obstructive sleep apnea-hypopnea syndrome (OSAHS) are collectively referred to as sleep- related breathing disorders (SRBD). These terms describe a partial or complete obstruction of the upper airway during sleep. Patency of the pharyngeal airway is maintained by two opposing forces: negative intraluminal pressure and the activity of the upper airway musculature. Anatomical or central neural abnormalities can disrupt this delicate balance and result in compromise of the upper airway. This reduction of airway caliber may cause sleep fragmentation and subsequent behavioral derangements, such as excessive daytime sleepiness (EDS) (1–3). The goal of medical and surgical therapy is to alleviate this obstruction and increase airway patency. The first therapeutic modality employed to treat SRBD was surgery. Kuhlo described placement of a tracheotomy tube in an attempt to bypass upper airway obstruction in Pickwickian patients (4). Although effective, tracheotomy does not address the specific sites of pharyngeal collapse and is not readily accepted by most patients. These sites include the nasal cavity/nasopharynx, oropharynx, and hypopharynx. Often, multilevel obstruction is present. Consequently, the surgical armamentarium has evolved to create techniques that correct the specific anatomical sites of obstruction.
    [Show full text]
  • CLEFT LIP and PALATE CARE in NIGERIA. a Thesis Submitted to The
    CLEFT LIP AND PALATE CARE IN NIGERIA. A thesis submitted to The University of Manchester for the degree of Masters of Philosophy in Orthodontics at the Faculty of Medical and Human Sciences November, 2015 Tokunbo Abigail Adeyemi School of Dentistry LIST OF CONTENTS PAGE LIST OF TABLES 09 LIST OF FIGURES 10 LIST OF APPENDICES 11 ABBREVIATIONS 12 ABSTRACT 13 DECLARATION 14 COPYRIGHT STATEMENT 15 DEDICATION 16 ACKNOWLEDGEMENTS 17 THE AUTHOR 18 THESIS PRESENTATION 19 CHAPTER 1 : INTRODUCTION 20 1.1 Background 20 1.1 Definition of Cleft lip and Palate 22 1.2 Causes of CL/P 23 1.3 Prevalence of CL/P 23 1.4 Consequences of CL/P 24 1.5 Comprehensive cleft care 25 1.5 1 Emotional support; Help with feeding/weaning 26 1.5.2 Primary surgery to improve function/alter appearance 26 1.5.3 Palatal closure, Speech development, Placement of ventilation 27 1 1.5.4 Audiology monitor hearing: support with either ear nose 28 1.5.5 Speech therapy, development and encouragement of speech diagnosis palatal dysfunction or competence 28 1.5.6 Surgical revision of lip and nose appearance to improve face aesthetic. Velopharyngeal surgery to improve speech 28 1.5.7 Orthodontic use of appliances to correct teeth for treatment 29 15.8 Psychological counseling for children with CL/P 29 1.5.9 Genetic counseling 30 1.6 Hypothesis 30 1.7Aims and Objectives 30 CHAPTER TWO : LITERATURE REVIEW 31 2.1 Background 31 2.2 Methodology 31 2.3 Prevalence of UCLP 32 2.4 Characteristics of complete clefts 32 2.5.1 Growth pattern in complete clefts 33 2.5.1.1Factorsinfluencing facial
    [Show full text]
  • DENTAL and ORAL SURGICAL PROCEDURES Policy Number: DENTAL 002.28 T2 Effective Date: March 1, 2017
    UnitedHealthcare® Oxford Administrative Policy DENTAL AND ORAL SURGICAL PROCEDURES Policy Number: DENTAL 002.28 T2 Effective Date: March 1, 2017 Table of Contents Page Related Policy INSTRUCTIONS FOR USE .......................................... 1 Temporomandibular Joint Disorders BENEFIT CONSIDERATIONS ...................................... 2 PURPOSE ................................................................ 2 POLICY ................................................................... 2 PROCEDURES AND RESPONSIBILITIES ....................... 2 APPLICABLE CODES ................................................. 3 REFERENCES ........................................................... 7 POLICY HISTORY/REVISION INFORMATION ................. 7 INSTRUCTIONS FOR USE The services described in Oxford policies are subject to the terms, conditions and limitations of the member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded members and certain insured products. Refer to the member specific benefit plan document or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit
    [Show full text]