CLEFT PALATE.
The sooner the cleft can be closed by operation the better, and if possible in all cases this should be done before the patient learns to speak.
When the cleft only involves the soft palate and uvula the operation of staphylarrhaphy may be performed in a few weeks after birth. The infant being chloroformed, the head is permitted to hang backwards, a gag is inserted between the gums, the edges of the cleft are neatly pared after the uvula has been seized with forceps. Sutures of horsehair, silk, or silkworm gut are inserted and the margins of the cleft are brought together. Should there be much tension, an incision may be made through the legator palati a short distance outside the line of interrupted sutures on each side or the posterior pillars of the fauces may be snipped.
The hard palate is closed by the operation of ztranop/usty, an incision internal to the alveolar border is made down to the bone on each side of the cleft, avoiding the palatine arteries; the soft parts are next separated by a raspatory from the underlying bone and the mucoperiosteal flaps freed so as to avoid tension, and for this purpose it is advisable also to sever the attachment of the soft to the hard palate. The margins of the original cleft are made raw by paring the edges with a cleft palate knife, beginning at the junction of hard and soft palate and cutting each side forwards and backwards from this point. Sutures of hair, silver wire or gut are then inserted so as to bring neatly into apposition the raw surfaces of the pared edges. Should tension exist from the stitches the original deep lateral incisions should be prolonged backwards to the anterior pillars of the fauces and forwards towards the central incisor teeth.
Lane and Davies-Colley form a long flap on one side of the cleft by making a deep incision internal to the alveolar border, dissecting this from the bone (but leaving its inner uncut margin to act like a hinge), folding it over and inserting it under a small mucoperiosteal flap made by raising the tissue from the bone on the other side of the cleft in the hard palate, after which the raw surfaces of each flap are sutured together.
Brophy's operation for closing wide clefts in the hard palate of infants consists in drawing the upper maxillie together by stout silver wires before suturing the pared edges of the cleft, the wires being afterwards removed when union has occurred.
The after-treatment of cleft palate requires great care; the child should be fed with sterilised milk from a spoon in small quantities at a time to obviate vomiting and as far as possible to prevent crying and coughing. The stitches need not be removed for 3 weeks, and the mouth should be kept sweet by spraying with a Borax or weak Carbolic lotion if this does not cause crying. At a later stage great patience may be required in teaching the child to speak and to exercise the palatal muscles properly so that the air is forced through the mouth and not through the nose. When hare-lip complicates the case the lip is operated on at once and the palate repaired at a second operation. Usually the lip is operated on when the child is a month or two old, the palate at the end of 6 to 52 months or even later. The repair of the lip is important, because it pro duces considerable narrowing of the cleft, making some inoperable cases operable.
Early operation gives better results as regards phonation than if the interference be delayed till the child has learned to talk.
In cases where operation has failed or where the nasal tone of the voice renders articulation very defective much good may often be achieved by fitting the roof of the patient's mouth with an obturator consisting of a thin gold or vulcanite plate held in position by suction; to this a tympanum of rubber may be attached posteriorly, and it may be made in front to carry any artificial teeth necessary to close up gaps in the incisors.