Cleft Lip and Palate
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Direct answer
Cleft lip and palate is a congenital defect in which the lip, the palate or both fail to fuse during early embryonic development, and it is the commonest orofacial cleft. The open communication between the oral and nasal cavities causes feeding difficulty, recurrent middle ear disease and hypernasal speech. Management is staged and multidisciplinary, with lip repair commonly at about three months and palate repair during infancy.
What you must remember
- Embryology: the lip forms by fusion of the medial nasal and maxillary processes, while the palate forms from the palatal shelves, which fuse by about the twelfth week.
- Types: cleft lip with or without cleft palate, and isolated cleft palate, which is more often associated with syndromes.
- Feeding: the infant cannot generate negative intraoral pressure, so special bottles and, in some centres, presurgical nasoalveolar moulding help.
- Middle ear: abnormal insertion of the palatal muscles impairs eustachian tube function, leading to otitis media with effusion and conductive hearing loss.
- Speech: velopharyngeal insufficiency causes hypernasal speech and nasal air escape, and speech therapy is the first step.
- Repair timing: lip repair is commonly done at about three months, and palate repair in infancy, timed to protect speech development.
- Associations: Pierre Robin sequence, with micrognathia and glossoptosis, can cause neonatal airway obstruction.
- Prevention: periconceptional folic acid is associated with a lower risk of orofacial clefts, as well as neural tube defects.
Staging repair across childhood
A neonate born with a cleft palate needs airway, feeding and parental support before any surgery. Care follows a staged pathway, and the steps below show how the team sequences its decisions.
- Secure the airway and feeding: check for respiratory distress and Pierre Robin features, then use a specialised feeding bottle or a nasogastric tube if the infant cannot feed.
- Counsel the family early: explain the cause, the recurrence risk and the treatment timeline, and arrange review by a cleft team.
- Presurgical moulding: in some centres, nasoalveolar moulding narrows the alveolar gap before lip repair.
- Lip repair around three months: the commonly cited rule of tens is about 10 weeks of age, 10 pounds weight and haemoglobin of about 10 g/dL.
- Palate repair in infancy: palatoplasty closes the palate and sets up the muscles needed for speech, usually in the second half of the first year.
- Long-term review: audiology, speech therapy, orthodontics and dental care continue into adolescence.
- Alveolar bone grafting: done in mid-childhood, before the canine teeth erupt, to close the gap in the alveolar ridge.
Where the examiner expects a team answer
Questions on cleft care test sequencing, timing and which team member manages which problem.
- Trap: choosing palate repair at three months because lip repair is done then. Correct: lip repair is done around three months, while palate repair waits until infancy to balance growth and speech development.
- Trap: assuming feeding problems resolve once the lip is repaired. Correct: the palate defect causes the feeding problem because the infant cannot seal the oral cavity, so palate management matters more for feeding.
- Trap: continuing speech therapy alone when hypernasality persists. Correct: speech therapy is first-line, but persistent velopharyngeal insufficiency may need surgical correction after assessment by nasendoscopy.
Frequently asked questions
What is the usual timing of lip repair in cleft lip?
Primary lip repair is commonly done at about three months of age, a timing taught as the rule of tens: about 10 weeks old, 10 pounds weight and haemoglobin around 10 g/dL. The exact timing is individualised by the surgical team, depending on fitness for anaesthesia.
Why is cleft palate associated with recurrent otitis media?
Cleft palate impairs eustachian tube function because the abnormally inserted palatal muscles fail to open the tube properly. Recurrent otitis media with effusion can then cause conductive hearing loss, which affects speech development in the child. Ventilation tubes are considered when the effusion persists.
Which condition causes neonatal airway obstruction with cleft palate?
Pierre Robin sequence is the classic condition, with cleft palate, micrognathia and glossoptosis causing upper airway obstruction in the neonate. The infant may need prone positioning or airway support in the early weeks. The airway is the first priority before any surgical plan is made.
What is velopharyngeal insufficiency?
Velopharyngeal insufficiency is failure of the soft palate to close against the posterior pharyngeal wall during speech. It causes hypernasal speech and nasal air escape, and it is assessed with speech therapy and nasendoscopy. Surgery may be needed if speech therapy does not correct the problem.
When is alveolar bone grafting done in cleft lip and palate?
Alveolar bone grafting is usually done in mid-childhood, typically around eight to ten years and before the canine teeth erupt. The graft fills the gap in the alveolar ridge, supports tooth eruption and stabilises the maxillary segments.