Kosare and Madanrao Bobade: Case report on bilateral cleft palate with protuded premaxilla


Introduction

Cleft palate are congenital malformations resulting from the failure of fusion of maxillary processes during intrauterine development. Cleft palate are common birth defect in which a part of the lip and palate doesn’t completely come together or close while the baby is developing in the womb and so a split or cleft is left is in that area. Sometimes they are part of syndrome of birth defects. Cleft palate occurs in female approximately in 1in 2500 birth.1 This abnormality appears to run in families and therefore to be influence by hereditary, but no genetic factors may also be involved. Babies with the cleft lip/cleft palate need special care to ensure proper feeding and prevent complication. Surgery is done to close the cleft lip and cleft palate. Cleft lip is usually repaired by age 3 months, cleft palate by 1 years.2

Case Report

A 2 year 8 Month 27 days female child was admitted in hospital with known case of bilateral premaxilla in bilateral cleft lip palate, therefore baby was admitted for cleft palate surgery, there is no history of cough cold and fever. Bilateral cleft was operated 6 months back. During admission her family knew about the procedures / surgery. Her vitals were: Temperature 980, Respiratory rate is 26/ min Blood pressure 90/60 mm Hg Spo2- 98% Central nervous system was conscious, oriented.

  1. Physical Problem: I found that the child had difficulty in swallowing, speech problem according to her age group she only speak few word like mama, papa, yes and no, nasal sounding voice, hard and soft palate facial defect, dental problems like poor oral hygiene, halitosis.

  2. Psychological Problem: child was anxious, low self-confidence, child presented temper tantrum, child was self-involved, and lack of interest in surrounding

  3. Psychological Problem: Children with clefts may face social, emotional and behavioral problems due to differences in appearance and the stress of intensive medical care.

Operation procedure

  1. Date of surgery 11/08/2021

  2. Preoperative diagnosis: bilateral cleft palate with protruded premaxilla.

  3. Procedure performed: cleft palate repaired + vomerine setback

  4. Post operative period — during the post-operative periods all vitals were monitored and was stable, there is no oozing, bleeding from suture site. And child had smooth recovery.

Table 1

Details of the patient

Biographic Data

Patient

Age

2 years 8 month

Sex

Female

Address

Manewada road Nagpur

IP No

NHN/201226003

Education

10th class

Religion

Hindu

Date of admission

9/08/2021

Definition

Cleft plate result from failure of fusion of the hard with each other and with the soft plate. Cleft plate may be complete (Involving hard and soft plate, possibly including a gap in the palate) or incomplete (A hole in the roof of the mouth, usually in soft palate). palatoschisis

Cleft lip plate are basically divided in two category

Figure 1

Cleft lip plate

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Table 0

Book picture

Patient picture

Unilateral cleft lip and palate A cleft plate is a common birth defect which occurs in baby’s lip and palate (roof of mouth) as result is split of side of the lip extended all the ways from nose to back of palate.

Bilateral cleft lip and plate

Protruding or rotating premaxilla with bilateral cleft lip and palate was seen in my client.

Bilateral cleft, where the cleft occurs in both sides of the lip and it is very least common type.

Incidence

The incidence rate of cleft lip plate is 1 in 2500 births. And it is predominantly seen in Female approximately 15 % of the affected infant have associated with this defect. Cleft palate are facial malformation that occurs in fetus very early in pregnancy, while the baby is developing inside mother’s womb. In most Cassese, the cause is unknown. Most of the physician believe that cleft plate are occurs due to combination of genetic and environmental factors.

Figure 2

Etiopathology

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Table 2

Complication

Book Picture

Patient Picture

Feeding problem :- due to separation in the lip or opening in palate .

Difficulty in eating due to protruding premaxilla

Respiratory infection: aspiration of feeds may result in respiratory infection like pneumonia

Ear infections/hearing loss: children with cleft palate are at an increased risk of ear infections.

Speech problem: children with cleft lip or palate may have trouble in speaking

Child speaks few words and have difficulty in talking with others.

Dental problems: children with cleft are more prone to dental cavities.

Child has malformation of upper teeth, along with dental cavities.

Table 3

Diagnosis

Book Picture

Patient Picture

Maternal ultrasonography

After birth physical examination – mouth, plate, nose confirms the presence of cleft

Physical examination done and it confirmed that the child was having bilateral cleft palate with protrude premaxilla.

Visual examination

Visual examination done with above diagnosis

Table 4

Management

Book Picture

Patient Picture

Surgical Management

Client was operated for Bilateral cleft o before 6 month.

Repair often requires multiple surgeries over the course of 18 years.

The following surgical management was done

The 1st surgical repair usually occurs when the baby is between 6-12 months

Cleft palate repair + Vomerine setback operative procedure was done.

Procedure

Under GA/AAP DONE

Vomerine set back done

Children with cleft palate may need a bone graft when they are about 8 years old

Cleft palate repair done

20% of children with a cleft palate requires further surgery to help improve speech.

Gel from kep

Once the permanent teeth grow, braces may be put to straighten the teeth.

C and D done

Pharmocological management

Treatment given

Depending on the condition, pre and postoperatively,

IV fluids as per protocols

Antibiotics

Inj Taxim 500mg twice a dayx 3days

Antiemetics

Inj Metrogyl 100mg twice a day x 4days

Analgesics

Suppol suppository 170mg (3/4th )thrice a dayx 3 days

Anticholinergics

Syp. Zincovit 5mlonce a day x 4 days

Antacids

Syp. Lbugesic 5ml thrice a day x4 days.

Figure 3

Image of disease condition

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Discussion

Bilateral cleft palate with protruded premaxilla is a rare congenital anomaly, which occurs in fetus during developing in mother’s womb. It is mostly found in female, in most cases, the cause is unknown. The chance of cleft in newborn is more, if a parent or sibling has had the problem. The problem can be identified after birth of baby. Surgical management is the only way to treat condition. The first surgical repair usually occurs when the baby is between 6-12 months. This initial surgery was done for functional closer of palate, therefore it will reduce the chance of fluid entering middle ear.3

The child was 2 year 8 Month old admitted in hospital with known case of bilateral premaxilla in bilateral cleft lip palate, therefore baby was admitted for cleft palate surgery, Bilateral cleft was operated 6 months back. During admission her family knew about the procedures, Child was operated Bilateral cleft palate with protruded premaxilla and Cleft palate repaired + Vomerine setback operative procedure was performed.

Conclusion

The baby was admitted with the above –mentioned complaints. Admitted for cleft palate surgery. Blood investigation before surgery suggestive of hb-9.7, pcv-30.8, TLC-12970, platelets- 3.97, CRP-1.96, creatinine-0.52. fitness for surgery was done by pediatrician. The baby shifted OT for bilateral cleft palate surgery on 11/08/2021. The child underwent the procedure under GA and post –op, shifted to PICU for recovery. All vitals monitored and child had a smooth recovery.4 once oral feeds were established, child was shifted to wards same treatment continued in the wards. Ward stay was uneventful. There is no oozing, bleeding from suture site. Wound is healthy. At the time of discharge child is active, afebrile, accepting orally well, hemodynamically stable, passing urine and stool normally. Child was ask to come to follow up after 15 days.5, 6

Source of Funding

None.

Conflict of Interest

None.

References

1 

R Sharma Essential of pediatric Nursing : cleft lip and cleft palate1St 20133448

2 

M Dorothy Textbook of pediatric Nursing: cleft lip and palate1St 20133758

3 

A J Pomeranz Nelson's Instructions for Pediatric Patients1st 20133912



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Article History

Received : 26-10-2021

Accepted : 23-11-2021

Available online : 11-01-2022


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Digital Object Identifier (DOI)

Article DOI

https://doi.org/10.18231/j.ijpns.2021.032


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