Fig. 236.—Asymmetrical Cleft Palate extending through alveolar process on left side.
Clinical Features.—Single hare-lip is about twice as common on the left as on the right side, and it occurs more frequently in boys than in girls. In a considerable proportion of cases there is a well-marked hereditary tendency to these deformities, and they frequently occur in several members of a family.
The nose is characteristically broad and flattened, the ala being bound down to the alveolar margin of the maxilla by fibrous tissue. The margins of the cleft in the lip are also attached to the alveolus by firm reflections of the mucous membrane. The orbicularis oris and other muscles of expression about the mouth being defective, the deformity is exaggerated when the child cries or laughs. In simple hare-lip the child may have difficulty in sucking, but this can usually be overcome by some mechanical contrivance to occlude the cleft.
When the hare-lip is double and combined with cleft palate, the child is unable to suck, and food introduced into the mouth tends to regurgitate through the nose. The nutrition can only be maintained by having recourse to spoon-feeding, and in feeding the child it is necessary to throw the head well back and to introduce the food directly into the back of the pharynx. Many of these infants are of such low vitality, however, that in spite of the most careful feeding they emaciate and die.
In those who survive, the voice has a peculiar nasal twang, as in phonation the air is expelled through the nose instead of through the mouth, and the articulation, especially of certain consonants, is very indistinct. Taste and smell are deficient. The constant exposure of the nasal and pharyngeal mucous membrane renders it liable to catarrhal inflammation and granular pharyngitis.
Treatment.—The only means of correcting these deformities is by operation, and, speaking generally, it may be said that the earlier the operation is performed the better, provided the general condition of the child is equal to the strain. In simple hare-lip the best time is between the sixth and the twelfth weeks. When cleft palate coexists with hare-lip, the lip should be operated on first, as the closure of the lip often exerts a beneficial influence on the cleft in the palate, causing it to become narrower.
Considerable difference of opinion exists as to when the cleft in the palate should be dealt with. Some surgeons, notably Arbuthnot Lane, recommend that it should be done in early infancy, as soon as the viability of the child is assured. We agree with R. W. Murray, James Berry, and others in preferring to wait until the child is between two and a half and three years old. It should not be delayed longer, because, even if the cleft in the palate is repaired, the nasal character of the voice persists, as the patient cannot overcome the habit of expelling the air through the nose.
Before the operation is undertaken, the child must be got into the best possible condition; and arrangements must be made for its constant supervision by a competent nurse. Success depends largely on the avoidance of infective complications, and on absence of tension between the rawed surfaces that are brought into apposition. More than one operation is sometimes required to effect complete closure of the cleft.
Voice Training.—The treatment of cleft palate does not cease with a successful operation; the importance of voice training must be explained to the parents. The child must be taught, in speaking, to send the stream of air through the mouth, instead of through the nose. If the soft palate is not sufficiently large and mobile to shut off the mouth from the nasal cavity, little improvement in speaking can be looked for.
In adolescents and adults, if the cleft is wide and the soft tissues of the palate are thin and atrophied, better physiological results may be obtained by the use of an artificial obturator or velum. With the aid of the dentist a plate of vulcanite or gold is fitted to the teeth and kept in position by suction.