Pediatric Cleft Palate Repair – Palatoplasty

What is a palatoplasty?

A palatoplasty is a surgical procedure used to correct or reconstruct the PALATE in a person with a CLEFT PALATE.

The basic goals of this surgery are to:

1. Close the abnormal opening between the nose and mouth
2. Help the patient to develop normal speech
3. Aid in swallowing, breathing, and normal development of associated structures in the mouth.

What are the indications for a palatoplasty?

Any person with any degree of cleft palate is a candidate for palatoplasty. However, surgery is individualized to each patient, therefore, your child may need a different procedure than another child with a cleft palate.

How old is the patient before palatoplasty is considered?

The ideal age for the patient is from 6 to 12 months of age. This appears to be the optimal age for repair because of the development of tissues around the cleft. This is also before any significant language development occurs, which gives the best advantage of developing normal speech. If the surgery is carried out much beyond 3 years of age, speech development may not be optimal.

What is involved BEFORE the actual procedure?

1. FEEDING – As the patient will have a cleft present until the surgery, feeding can be a challenge. Proper nutrition and weight gain must be achieved before the procedure to allow for optimal recovery. Your pediatrician or family doctor will monitor this closely. In a few instances, if feeding by mouth cannot achieve normal weight gain, a nasogastric tube (a tube through the nose that ends in the stomach) may be placed to allow food to be given directly into the stomach. In some cases, a temporary tube may be placed directly into the stomach through the skin (G-tube). About three weeks before the palatoplasty, the patient’s diet may be changed to a thicker consistency. This is known as the “cup” diet, which simply means the patient can be fed any food that can be spooned out of a cup. The patient should be comfortable eating these types of foods BEFORE the procedure so that this diet can be continued after the surgery without problems. The patient can usually be fed up to six hours before the operation, although this depends on your physician’s specific instructions.
2. SYNDROMES – Occasionally a cleft palate may be associated with other abnormalities. Any additional abnormalities must be identified and completely evaluated before palatoplasty, as they may affect the overall treatment of the child.
3. INFECTION PREVENTION – If there is any suspicion of infection in the patient around the time of surgery, the surgery may be postponed. Please notify your doctor immediately of any illness that occurs before your child’s scheduled surgery date.
4.   EAR FLUID – Because the cleft can cause ear problems, your physician may recommend that TYMPANOSTOMY TUBES be placed at the same time as the palatoplasty.

What is involved DURING the actual procedure?

Your child will be placed under general anesthesia using a “sleepy air” mask and will remain “asleep” during the entire procedure. Your child will then have an intravenous (IV) line placed (a tube going into your child’s vein). This is so medications and fluids can be given during and after the surgery.

The surgery itself is performed through the mouth. It consists of the surgeon moving tissue on both sides of the cleft and attaching these. This closes the opening to the nose and includes the muscles that lift the palate and help “pop” the ears. The repair is done in layers to create a normal palate.

The surgery requires about 2 to 3 hours. Your child will sleep most of the first day because of anesthesia effects. By the second day, your child should be acting a little more like himself, although irritable. The total hospital stay is usually two to three days.

How successful is palatoplasty in the achievement of normal speech?

As each case is different, your surgeon can give you a better idea of your child. Most of the time (80%), development of the palate and speech is normal after only one surgical procedure. However, sometimes additional speech therapy and/or a PHARYNGOPLASTY may be necessary to achieve optimal speech production.

The need for additional surgeries is usually not determined until your child reaches four to five years of age when speech development is nearing completion. At this time, a speech evaluation and assessment for risk or presence of velopharyngeal incompetence (VPI) are undertaken. VPI means that the back of the palate cannot touch the back of the throat during speech, which can result in hypernasal speech (sounds like talking through the nose).

Are there any complications from this procedure?

The most common complication is bleeding, which can be controlled if it occurs. It is kept to a minimum by using medicines and special instruments that stop bleeding. Airway blockage can also be a concern. Careful attention is paid to the airway by the surgeon (an airway specialist) and the pediatric anesthesiologist (the doctor who puts your child to “sleep”). Sometimes a small tube is placed in the nose before the child is awakened to help with any breathing problems.

Another complication may be the development of a fistula (the connection between the nose and mouth) at the site of repair. Many times these will heal spontaneously. If not, they can be surgically closed. Your ear, nose, and throat surgeon can easily address other complications, such as loss of tissue, scarring, and continued hypernasal speech. These risks and complications of palatoplasty will be discussed in detail with you before the procedure.