Submucous Cleft Palate Explained
By: Dr Jane Russell
The condition described as submucous cleft palate is when the palate appears to be structurally intact, but there are bony and/or muscular abnormalities underlying the skin's surface.
Sometimes, but not always, it is possible to see the signs associated with submucous cleft palate. These are a bifid uvula (the part of the palate which hangs down at the back isdivided), a bony defect in the hard palate (it looks ‘dented') and a bluish or white line in the middle of the soft palate. One parent described an obvious submucous cleft palate as: "it looks like part of the palate is made of cling film."
The diagnosis of submucous cleft palate is usually confirmed by the surgeon or another clinician feeling the palate, as well as observing any of the obvious signs. It can be very difficult, even for skilled observers, to detect some submucous clefts. It is also difficult to determine the incidence of submucous cleft palate, because many do not cause any problems and therefore remain undiagnosed.
A submucous cleft palate may occur with a cleft lip, but the majority occur in isolation. Submucous clefts can cause early feeding difficulties, speech problems and associated ear problems (e.g. glue ear).
Practice varies from place to place, but most centres do not automatically operate on submucous clefts. Each diagnosed case is carefully evaluated, with babble and speech development being monitored by a speech and language therapist. In infants, an operation may be undertaken when there is a history of significant feeding difficulties, persisting ear problems, and delayed development of babbling. Speech and language therapists will listen in particular for sounds which require pressure in the mouth, e.g. ‘d', ‘b', and ‘g'.
In other children, referral to the cleft palate team may be made because of speech problems such as those associated with inadequate palate movement, or palates which cannot reach the back wall of the throat (velopharyngeal insufficiency or VPI). In addition, there may be a history of feeding and/or ear problems. For these children, a range of investigations may be carried out.
In some cases there may be a period of diagnostic speech and language therapy to determine if the child can achieve an improvement in speech without having to undergo an operation. Some children achieve good palate function alongside an improvement in articulation skills.
When surgery is necessary, a detailed speech assessment should be carried out 6 to 8 weeks post-operatively. Children who already had good speech and language skills prior to an operation may not need formal therapy. Others, with less good articulatory skills, require therapy to help them learn to use their improved palatal musculature and to overcome ‘bad habits' in their speech patterns.
Tania is a little girl whose submucous cleft was found two days after birth,during a routine paediatric examination. She was referred to the surgeon and speech and language therapist from the Cleft Team. There were no feeding problems. From the age of 12 months, Tania was assessed at 6-monthly intervals. Tania is now six years old, and has no symptoms resulting from her submucous cleft palate. She has good language skills and normal clear speech.
Katie was referred to a community speech and language therapist by her health visitor when she was 5 years old. She had good language development, but hypernasal speech. That is, she was using correct articulation, but excess air was escaping through her nose during speech. There had been no previous feeding problems.
Katie's submucous cleft palate was diagnosed by the specialist speech and language therapist and confirmed by the plastic surgeon. Her submucous cleft was repaired and the operation was a success; no speech and language therapy was needed.
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