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Submucous cleft palate, often referred to as recessive jaw cleft, is a type of cleft palate structure where the cleft is concealed beneath a thin layer of tissue. Unlike visible clefts, there are no obvious shape abnormalities except for the bifid uvula. Parents are frequently informed by pediatricians at birth that the uvula is forked, but no special attention is needed. Consequently, issues often arise later, around two or three years old, when children experience problems with hearing or speech.
For instance, two recent cases highlight how these hidden issues can affect voice and hearing.
When Emma was born, a pediatrician noted her forked uvula but advised no special care. She showed no speech issues until over two years old, prompting her to attend speech therapy classes. After a year with little improvement, she consulted a more experienced speech therapist who recommended visiting a hospital outpatient clinic. There, she was diagnosed with the three key features of submucous cleft palate and exhibited noticeable nasal speech, leading to surgical intervention.
(The three key features of submucous cleft palate include a bifid uvula, a triangular bone defect behind the hard palate detectable by touch, and a missing thin membrane in the center of the soft palate without muscle.)
Michael was born without immediate detection of a forked uvula due to a very small separation. However, he later struggled with hearing problems. An otolaryngologist diagnosed middle ear effusion impacting his hearing. The family consulted the province's top hearing specialist, who recommended hearing aids. Despite this, Michael's mother noticed inconsistent hearing and test results. Eventually, an otolaryngology clinic recommended referral to a hospital outpatient clinic, where examination revealed the three key symptoms of submucous cleft palate. Speech evaluation indicated moderate velopharyngeal insufficiency, and surgery was advised.
Submucous cleft palate is essentially a cleft palate, but the cleft is covered by a thin membrane instead of being open. The three classic features are:
Symptoms mirror those of overt cleft palate, including incomplete velopharyngeal closure, middle ear effusion, and occasional regurgitation of food into the nasal cavity.
Current standard treatments and surgical methods for submucous cleft palate were pioneered by experts in the field. Research published in reputable medical journals, such as the American Journal of Plastic Surgery, has established these as global standards.
Surgery is indicated in two main scenarios:
Not every child with submucous cleft palate needs surgery. Studies suggest that about 15% of cases ultimately require it, though exact figures are elusive since patients typically seek help only when symptomatic.
Surgery timing depends on the presence of poor velopharyngeal closure or middle ear effusion. Unlike overt cleft palate surgeries often performed at 9-15 months, submucous cases may require earlier intervention if effusion is present. In such cases, coordination with an otolaryngologist for ear tube placement is essential. Otherwise, decisions are typically made after children can undergo speech evaluation, around three years old.
Upon diagnosis, speech assessments are arranged in outpatient clinics. Younger children are generally recommended for surgical treatment as the primary approach. The first-line method is Furlow's Z-plasty. For older children, speech therapists may suggest nasopharyngeal closure observation. Velopharyngeal closure is scored from 0 to 1, where 1 indicates complete closure. Scores of 0.7-0.9 may use Furlow's Z-plasty, while below 0.7 might require pharyngeal flap surgery.
Earlier surgery benefits language development, but later procedures can still yield positive outcomes.
Surgical treatment for submucous cleft palate aligns with general cleft palate procedures. Furlow's Z-plasty is the worldwide standard, aimed at lengthening the soft palate and repositioning muscles. In older patients, pharyngeal flap surgery may sometimes be necessary. The Z-plasty method extends the soft palate length and corrects muscle misalignment.