[Functional consequences of cleft palate and its management]

On the basis of the experience with 5200 various types of orofacial cleft operations performed during 42 years (1959-2000) and of the 60-70 cases with velopharyngeal insufficiency without cleft examined yearly author stresses that the surgical closure of the cleft is not enough in the care: the functional consequences (respiratory, sucking, swallowing, speech, hearing and maxillofacial developmental disorders) should also be managed. The first symptom of Robin sequent (cleft palate associated with dysgnathia) is respiratory disorder improving mostly spontaneously but worsening sometimes after palatoplasty. Polysomnography has been performed by the author routinely before all primary palatoplasties for establishing the possible surgical risks and for choice of the optimal time for surgery. On the basis of the results in 61 infants, the surgery was contraindicated and postponed in 6 cases. The various orofacial clefts may cause swallowing problems in different phase of swallowing and different types of dysphagia: the cleft lip cause sucking problems in the preparatory phase, the cleft palate in the oral transitory phase and the velopharyngeal insufficiency in the pharyngeal phase, but the sensomotor function is more decisive in the swallowing process than the cleft itself. Use of an obturator is not necessary, long-term catheter feeding is inappropriate, early closure of the soft palate (in the age of 8-10 months) is recommended. The liquid or food reflux through the nose can be established by cinefluoroscopy with contrast material and with nasoendoscopy following the way of coloured boluses. Retarded speech development, hyperrhinophony, nasal escape, facial grimacing, articulation disorders and dysphonia are the most frequent voice and speech disorders; speech therapy is in 70%, velopharyngoplasty in 20% of the cases indicated. Anatomical result was good in 98% of 1107 flap surgeries operated on by the author, hyperrhinophony ceased in 90%. The results are assessed by a 5-grade perceptual scale. Among the instrumental procedures videofluoroscopy, videoendoscopy, and nasometry seems to be the most informative. The cause of the frequent hearing disorders is mostly the eustachian tube dysfunction. Author found pathological tympanograms in 64% of their cases. The hearing slightly improves after staphylorraphy and often after flap surgery. Adenoidectomy and grommet insertion are alternative procedures in the therapy. The surgeries have an effect on the maxillofacial growth but this is not significant. Multidisciplinary co-operation in the management of cleft patients is indispensable.