CLEFT PALATE�

SURGICAL NURSING II

BY AMOS OWUSU

cleft palate

• A cleft palate is a split or opening in the roof of the mouth. A cleft palate can involve the hard palate (the bony front portion of the roof of the mouth), and/or the soft palate (the soft back portion of the roof of the mouth).
• A cleft palate may also vary in size, from a defect of the soft palate only to a complete cleft that extends through the hard palate
• It can be unilateral or bilateral and it’s more serious than cleft lip

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Incidence

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• About 1 out of 2,500 people have a cleft palate.
• Compared to boys, girls are commonly affected.

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Cause

• The exact cause is unknown.
• Cleft occurs as part of a syndrome.
• Genetic and familial
• Environmental factors
• Use of certain medications,
• Exposure to cigarette smoke, or
• lack of certain vitamins.
• Toxin while pregnant

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Pathophysiology�

• Development of the upper palate is characterized by fusion of the maxillary prominences with the lateral and medial nasal prominences.

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• This process starts during the fifth week of gestation and is completed by the twelfth week.

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• Failure of mesenchymal migration to unite one or both of the maxillary prominences with the medial nasal prominences results in a unilateral or bilateral cleft of the palate respectively.

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Clinical features�

• A split in the roof of the mouth (palate) that can affect one or both sides of the face
• A split in the roof of the mouth (palate) that doesn't affect the appearance of the face
• Difficulty swallowing
• Nasal speaking voice
• Recurring ear infections
• Difficulty sucking
• Difficulty in breathing

Diagnosis�

• A physical exam of the mouth, nose, and palate confirms the presence of cleft lip after a child's birth.
• Prenatal ultrasound can sometimes determine if a cleft exists in an unborn child.

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Management�

• The goals of treatment for cleft lip and cleft palate are to ensure the child's ability to eat;
• speak,
• Hear,
• breathe and
• to achieve a normal facial appearance.

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Management cont’�

• Treatment involves surgery to repair the defect and therapies to improve any related conditions.
• A cleft palate is usually repaired between 9 and 12 months of age.
• By repairing the palate, the soft palate muscles from each side are connected to each other and the normal barrier between the mouth and nose created.

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Pre-Op Management�

• 1. The usual cuddling given to the baby by parents may not be provided due his/her condition. It is therefore necessary for the nurse to reassure the parents and give the needed moral support.
• The nurse should encourage the parents to support the child with the following tips:
• Try not to focus on the cleft and don't allow it to define who your child is.
• Create a warm, supportive, and accepting home environment where each person's individual worth is openly celebrated.

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Pre-Op Management cont’

• Encourage your child to develop friendships with people from diverse backgrounds. Lead by example.
• Point out positive attributes in others that do not involve physical appearance.
• Encourage independence by giving your child the freedom to make decisions and take appropriate risks, letting his or her accomplishments lead to a sense of personal value

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Pre-Op Management cont’

• 2. Teach the mother on how to effectively breastfeed the child and the use of special nipple or dropper. The dropper/special nipple should be placed on the upper surface of the tongue during feeding
• 3. To prevent cracks of the lips as a result of mouth breathing, the lips should be kept clean and moist.
• 4. The child should be observed for signs of aspiration, respiratory distress and gastrointestinal disorders and treated promptly if present.

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Pre-Op Management cont’

• 5. The mother should be taught routine infant care by the nurse. These include; oral care, bath, cord care, grooming etc.

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Post-Op Management�

• The infant should be placed on the back to prevent disturbance of the sutures and to prevent the tongue from falling back thus to ensure a patent airway.

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• Following cleft palate repair nursing staff performs and record TPR and oxygen saturations on return to the ward. Thereafter, hourly TPRs are required for 4 hours.
• Hourly pulse, respirations and continuous pulse oximetry is then continued for 24 hours. Temperature measurements are performed 4th hourly.

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Post-Op Management cont’�

• Hourly pulse, respirations and continuous pulse oximetry are required until the nasopharyngeal airway is removed.
• These patients should be closely monitored by nursing staff while there is a nasopharyngeal tube in situ.
• These patients have a potential for airway obstruction due to post-operative swelling and so a nurse should be in the room to monitor for signs of respiratory distress.

Post-Op Management cont’�

• The lip and palate are vascular areas and postoperative care includes monitoring the operative sites for bleeding, excessive swallowing may be a sign of bleeding and swallowing blood
• Following pharyngeal flap and pharyngoplasty surgery children are at risk of developing Obstructive Sleep Apnoea (OSA).
• It is important for nursing staff to observe these children while they are asleep for snoring and signs of respiratory distress.

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Post-Op Management cont’�

• The head of the bed should be elevated to a 45 degree angle to allow for adequate chest expansion and airway maintenance
• Hourly suctioning of the nasopharyngeal tube is required to ensure tube patency.
• More frequent suctioning may be required in the immediate post-operative period.

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Post-Op Management cont’

• If the tube is dislodged the plastics and anaesthetic registrars should be contacted immediately.
• The nasopharyngeal tube should not be reinserted without consultation with the anaesthetic and plastics registrars.

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Post-Op Management cont’�

• After cleft lip or palate surgery, the patient often has blood stained nasal discharge and blood stained oral secretions.
• Oral suctioning may be required to assist with these secretions.
• Any oral suctioning should be performed as gently as possible and should be directed towards the sides of the mouth
• A soft tipped suction catheter should always be used for oral suctioning

Post-Op Management cont’�

• Regular oral analgesia will be necessary for several days post operatively after the initial opioid infusion has been ceased.
• Pain relief may be required half an hour before bottles or meals to provide analgesia and optimise the infant’s ability to feed.

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Post-Op Management cont’�

• Post operatively the patient will have intravenous therapy until they are tolerating oral feeds.
• After the surgery the child should not start oral fluids until they are fully awake following the anaesthetic, bleeding has stopped and there are minimal secretions from the nasopharyngeal tube

Post-Op Management cont’�

• If a nasopharyngeal tube is in situ the child is allowed oral fluids such as formula, unless the surgeon or anaesthetist has stipulated otherwise.
• Intake of solids may commence once the nasopharyngeal tube has been removed.
• Feeding can proceed using the method approved by their surgeon outlined in the post-operative care reference table.

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Post-Op Management cont’�

• Many infants will be unable to use their regular teat and squeeze bottle and will be introduced to a NUK spout.
• Many babies will find this change difficult in their feeding routine and so staff will need to assist and support parents in establishing feeds post-operatively.
• Breast feeding is suitable where infants are already breast feeding at home.

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Post-Op Management cont’�

• The child will need to adhere to a diet of smooth textured food for several weeks.
• Older children may eat a “Cleft palate, older child” diet option in the Patient Management System.
• A soft diet is not appropriate following cleft palate, palate lengthening, pharyngoplasty or alveolar bone grafting procedures.

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Post-Op Management cont’�

• Following surgery these children should not eat firm textured foods which could damage the newly repaired palate
• Oral hygiene is important following all cleft surgery.
• All oral sutures are dissolving but mouth-care is essential to promote wound healing.
• After consumption of formula or food water is used to cleanse the suture line of any food particles and coating of milk.

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Post-Op Management cont’�

• Infants and young children are given 5-10mL of water to drink after each feed and where possible, depending upon the age of the child, rinse their mouth with water.
• Older children who have had repair of their palate fistula, pharyngoplasty or alveolar bone grafting can rinse their mouth with water followed by the use a mouthwash after meals to maintain oral hygiene.

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Post-Op Management cont’�

• Following surgery the child may be required to wear arm splints.
• These splints should be released frequently to exercise the arms, to provide relief from restriction and to observe the skin for signs of irritation
• The arm splints are worn whenever the child is not supervised by a parent or staff member and should be released at least every 4 hours.

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Post-Op Management cont’�

• Nursing staff should demonstrate the application of the splints to the parents and assist the parents until they are confident removing and reapplying the splints.
• The splints are worn for 2 to 3 weeks following the surgery.

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�Parent Education

• Encourage parents to be involved in all aspects of their child’s care for example lip care, mouth washes, arm splinting, feeding etc so that they are confident in caring for their child upon discharge from hospital
• Parents should be given the appropriate written post-operative care information sheets before discharge

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�READING ASSIGNMENT

• READ ON OESOPHAGEAL ACHALASIA
• READ ON OESOPHAGEAL ATRESIA