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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5805_Библиотеки_им_академика_М_И_Перельмана.pdf
7.4 Atypical Cleft
73
a
NB
M
V
b
c
Fig. 7.26 Median cleft lip and palate at 12weeks (TVS).
(a) Midsagittal view Absence of premaxillary portion
(arrow), (b) Axial view midline defect in the alveolar arch
(arrows) (c) TUI—Coronal view showing the decient
base of the retronasal triangle in all sections (pointer).
Nasal bone (NB), mandible (M), vomer (V)
74
f
abdc
NB
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
V
M
e
Fig. 7.27 2D vs. 3D imaging in median CLP at 13weeks
(a) (TVS) midsagittal section small echogenic line in the
posterior aspect formed by vomer (V). (b) (TVS) axial
section midline defect seen in the alveolar arch (arrow),
(c) (TAS) coronal plane absence of the base of RNT
f
(arrows), (d) (TVS) coronal section midline defect
(arrowhead) in upper lip in 3D with VCI, (e) (TVS)
Rendered image of the face. (f) (TVS) multiplanar imaging reference dot showing defect in three orthogonal
planes. Nasal bone (NB), mandible (M) (Video 7.7)
P
M
V
Fig. 7.28 TUI in median CLP at 13weeks. (TVS) Midsagittal section (M) shows the vomer (V) in midline and parasagittal (P) sections depicting absence of the maxillary line (arrows)
P
7.4 Atypical Cleft
75
a
Fig. 7.29 Flipped face technique in median CLP at
13weeks. (TVS) (a) Flipped face technique. (b) Rendered
view of the intraoral surface of palate. Note the midline
a
NB
V
M
b
*
discontinuity (arrow) in the alveolar arch. As the cleft
extends into the secondary palate, the vomer (*) is imaged
in midline
b
Fig. 7.30 2D vs. 3D imaging in mediolateral CLP at
12 weeks. (a) (TVS) midsagittal section maxillary line
shows a large gap (arrowhead) with a single line (V) in the
posterior aspect. (b) (TVS) rendered view of the face. (c)
2D coronal section and (d) 3D coronal section showing
defect in the base of RNT (arrows), (e) 2D axial section
and (f) 3D axial section showing mediolateral defect in
the alveolar arch (arrow). Nasal bone (NB), mandible
(M), vomer (V)
76
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
c
e
d
f
Fig. 7.30 (continued)
7.4 Atypical Cleft
77
a
M
d
b
e
Fig. 7.31 Median CLP in holoprosencephaly at
14weeks. (a) (TAS) Midsagittal section absence of maxillary line. (b) (TVS) axial view midline defect in the alveolar arch (arrow). (c) (TAS) coronal view defect in the base
c
of RNT (arrows). (d) (TVS) rendered view of the face, (e)
(TAS) Rendered view of fused choroid plexus in holoprosencephaly (*).Mandible (M) (Video 7.8)
a
NB
M
V
Fig. 7.32 Sagittal section demonstrating the varying
appearance of maxillary line in median CLP. (a) 12weeks
(TVS) arrow points to the absent premaxillary portion of
b
V
the maxillary line. (b) 13
ened and interrupted maxillary line. Nasal Bone (NB),
Mandible (M), Vomer (V)
+3
weeks (TVS) showing short-
78
SAGITTAL
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
a
VB
c
MIDSAGITTAL
AXIAL
b
PARASAGITTAL
d
CORONAL
MEDIAN
b
Fig. 7.33 Line diagram illustrating the 2D markers in median CLP. (a) Appearance of maxillary line in midsagittal and
parasagittal section in Median CLP. (b) Sagittal plane. (c) Axial plane. (d) Coronal plane
a
Fig. 7.34 Atypical cleft caused by amniotic bands.
14weeks (TAS) (a) Comparison of the alveolar arch of
the mandible and maxilla. The mandible is intact, and the
maxillary alveolar arch shows an open cleft (arrow). (b)
Sagittal view of the face arrow points to the amniotic
band. (c) Coronal view showing the retronasal triangle.
Both frontal processes of the maxilla are seen with the
absence of the base and the amniotic band (arrow) seen in
between (d) Rendered view of the face. Reproduced with
permissions from Wiley
References
79
c
Fig. 7.34 (continued)
References
1. Lakshmy SR, Deepa S, Rose N, Mookan S, Agnees
J. First-trimester sonographic evaluation of palatine
clefts: a novel diagnostic approach. J Ultrasound
Med. 2017 Jul;36(7):1397–414.
2. Syngelaki A, Chelemen T, Dagklis T, Allan L,
Nicolaides KH. Challenges in the diagnosis of fetal
non-chromosomal abnormalities at 11–13 weeks.
Prenat Diagn. 2011 Jan;31(1):90–102.
3. Syngelaki A, Hammami A, Bower S, Zidere V,
Akolekar R, Nicolaides KH.Diagnosis of fetal nonchromosomal abnormalities on routine ultrasound
examination at 11–13 weeks’ gestation. Ultrasound
Obstet Gynecol. 2019 Oct;54(4):468–76.
4. Martinez-Ten P, Adiego B, Illescas T, Bermejo C,
Wong AE, Sepulveda W.First-trimester diagnosis of
cleft lip and palate using three-dimensional ultrasound.
Ultrasound Obstet Gynecol. 2012 Jul;40(1):40–6.
5. Yamanishi T, Kobayashi C, Tsujimoto I, Koizumi
H, Miya S, Yokota Y, Okamoto R, Iida S, Aikawa
T, Kohara H, Nishio J.An uncommon cleft subtype
of unilateral cleft lip and palate. J Dent Res. 2008
Feb;87(2):164–8.
6. Platt LD, DeVore GR, Pretorius DH.Improving cleft
palate/cleft lip antenatal diagnosis by 3-dimensional
d
sonography: the “ipped face” view. J Ultrasound
Med. 2006 Nov;25(11):1423–30.
7. Lakshmy SR, Rose N, Masilamani P, Umapathy S,
Ziyaulla T.Role of TUI in rst trimester evaluation of
palate. J Fetal Med. 2019 Sep;6(3):113–21.
8. Sepulveda W, Wong AE, Martinez-Ten P, PerezPedregosa J. Retronasal triangle: a sonographic
landmark for the screening of cleft palate in the
rst trimester. Ultrasound Obstet Gynecol. 2010
Jan;35(1):7–13.
9. Lakshmy SR, Rose N, Masilamani P, Umapathy S,
Ziyaulla T.First trimester ultrasound evaluation of the
cleft palate: midsagittal, axial or coronal view-which
view is best? J Fetal Med. 2020 Sep;7(3):183–91.
10. Nyberg DA, Hegge FN, Kramer D, Mahony BS,
Kropp RJ. Premaxillary protrusion: a sonographic
clue to bilateral cleft lip and palate. J Ultrasound Med.
1993 Jun;12(6):331–5.
11. Chaoui R, Orosz G, Heling KS, Sarut-Lopez A,
Nicolaides KH.Maxillary gap at 11–13 weeks’ gestation: marker of cleft lip and palate. Ultrasound Obstet
Gynecol. 2015 Dec;46(6):665–9.
12. Lakshmy SR, Rose N, Masilamani P, Umapathy
S, Ziyaulla T. Absent ‘superimposed-line’ sign:
novel marker in early diagnosis of cleft of fetal secondary palate. Ultrasound Obstet Gynecol. 2020
Dec;56(6):906–15.
Sonoanatomy ofPalate
at20Weeks
8
There is no sonographic study presently that provides a technique to evaluate the complete fetal
secondary palate [1]. Comprehension of the real
anatomy of the fetal palate with what is visualized in ultrasound is still now an extremely difcult task. This can be attributed to the curved
nature of the palate in mid trimester and moreover, shadowing from the surrounding facial
bones hinders visualization of palate.
It is a common perception that with the help of
3D ultrasound, the secondary palate can be
imaged better. A number of three-dimensional
(3D) techniques have been proposed in imaging
the secondary palate.
However, its visualization in 3D sonography
requires adequate volume acquisition, with the
fetal neck in slight extension and the presence of
uid between the fetal tongue and palate. It also
needs expertise with the usage of 3D ultrasound
techniques. So the need of the hour is a simple 2D
ultrasound technique to assess the fetal palate.
8.1 Technique ofVisualizing
Palate
Analysis of the hard palate is difcult and considered unreliable and is not included in guidelines
for the routine anatomic survey. Though the
Supplementary Information The online version of this
chapter (https://doi.org/10.1007/978- 981- 16- 4613- 3_8)
contains supplementary material, which is available to
authorized users.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
L. R. Selvaraj, T. Ziyaullah, First and Mid Trimester Ultrasound Diagnosis of Orofacial Clefts,
https://doi.org/10.1007/978-981-16-4613-3_8
entire secondary palate cannot be imaged, visualization of uvula on ultrasound was proposed as a
surrogate marker for the intactness of the secondary palate. As cleft of the secondary palate
always starts at the uvula and proceeds along
the midline during embryonic development,
visualization of the uvula rules out a secondary
cleft palate.
The echo pattern of the normal uvula on ultrasound can be imaged as the “equals sign” in both
sagittal and axial views at the level of the oropharynx (Fig.8.1). The soft palate hangs from the
posterior margin of the hard palate and extends
backward and downward, separating the oropharynx from the nasopharynx. The soft palate can be
imaged in the sagittal section with the fetal neck
in extension and uid in the oral cavity, as shown
in Fig.8.1a.
The uvula is a good landmark for directing
the examination plane to the soft palate [2]. The
uvula can be visualized in the corresponding
transverse section at the base of the skull at the
level of the oropharynx (Fig. 8.1b). Video 8.1
illustrates the visualization of uvula as the equal
sign in axial view.
The ideal time for visualizing the soft palate
is after 20weeks of gestation. In this gestational
period, the uvula can be identied consistently as
the soft palate, and the uvula lengthens with
advancing gestation age [2, 3]. Figure 8.2 illustrates the visualization of the soft palate at
16 weeks of gestation. (Compare Fig.8.2 with
Fig.8.1a).
81
82
8 Sonoanatomy ofPalate at20Weeks
a
HP
T
SP
Fig. 8.1 Visualization of the uvula at 22weeks (a) sagit-
tal section bony hard palate (HP), soft palate (SP), uid in
the oral cavity (*), tongue (T). Note that the soft palate
(arrows) ends at the uvula (arrowhead). Arrows point to
SP
HP
b
the soft palate, and arrowhead point to the uvula. (b) Axial
view demonstrating the equal sign pointers show the
uvula
be in slight extension as shown in (Fig. 8.3b)
which enhances visualization of the bony secondary palate.
8.1.2 Swallowing Fluid Dynamics
Fig. 8.2 Visualization of the palate at 16 weeks (a)
Sagittal plane shows the bony hard palate (HP) and soft
palate (SP) with fetus in slight extension (arrow) (Video
8.1)
8.1.1 Fetal Position
The best way to image the palate is when the
fetus faces the transducer and when the head is
slightly extended. The premaxilla can be evalu-
ated in the midsagittal section of the fetus, however, the neutral position or slight exion of the
fetus is not ideal for visualization of the secondary palate (Fig.8.3a). Note that the fetus has to
The presence of uid in the oral cavity is a facilitating factor to visualize the secondary palate in
mid trimester [4]. Figure8.4a shows the midsagittal prole of the fetus in the neutral position.
Note that though the maxillary line is visible,
the entire secondary palate cannot be visualized
in this position.
In Fig.8.4b, the hard palate and the muscular
soft palate can be imaged in their entire length
with the fetus in extension position and uid in
the oral cavity. Moreover, at the time of fetal
swallowing, movements of the soft palate can be
appreciated during real-time ultrasound
evaluation. Video 8.2 illustrates uid in the oral
cavity during swallowing movements of the
fetus, which enhances visualization of the secondary palate. This is a boon to evaluate, espe-
cially the soft palate; the muscular palate moves
with fetal swallowing and hence can be clearly
assessed on simple 2D ultrasound.
Figure 8.4c is the sagittal prole of a fetus
with cleft of the secondary palate. Note that the
8.2 Planes ofEvaluating Palate
83
a
PM
*
Fig. 8.3 Fetal position in the visualization of maxillary
line (a) Sagittal section inadequate visualization of the
maxillary line due to shadowing (*) from premaxilla
maxillary line is indistinct. However, during
swallowing movement of the fetus, the entire
maxillary line is absent clearly depicting the
communication between the oral cavity and
nasal cavity (Fig.8.4d). Video 8.3 demonstrates
an absent maxillary line in the cleft of the secondary palate.
8.1.3 Angle ofInsonation
The main limitation of visualizing the entire palate is most often due to the unfavorable position
of the fetus. Figure8.5a is a fetus in the neutral
position in which the posterior aspect of the hard
palate is inadequately imaged.
To avoid acoustic shadowing from the alveolar arch, the secondary palate needs to be
insonated at a 45° angle in the sagittal plane
[5]. The beam has to be focussed on the under
surface of the palate with the fetus in a slight
extension position, as shown in Fig.8.5b.
The best results can be obtained by a combination of all three factors, namely fetal position,
angle of insonation and the presence of uid in
the oral cavity (Fig.8.5c). Video 8.4 shows visu-
alization of the secondary palate using the right
angle of insonation with the fetal face facing
upwards.
b
ML
(PM). (b) Sagittal section adequate visualization of the
maxillary line (ML) with fetal neck in slight extension in
the same case
8.2 Planes ofEvaluating Palate
8.2.1 Sagittal Plane
The midsagittal facial prole can be used to
assess the maxillary line and the primary palate.
The intact maxillary line in the sagittal prole
represents the palate. The facial prole view is
not sufcient to visualize both the hard and soft
palate (Fig.8.4a). The secondary palate needs to
be evaluated with the head in extension and uid
in the oral cavity, as shown in Fig.8.4b.
The same midsagittal prole can also be used
to evaluate the superimposed line sign, however,
this sign is well seen in the late rst trimester and
in the early mid trimester [6]. Note that the pos-
terior aspect of the maxillary line has a bid
appearance due to the presence of the vomer
and the secondary palate (Fig.8.6). This sign is
better visualized when the fetus is in neutral or in
a slight exion position. Video 8.5 depicts the
superimposed line sign at 20weeks of gestation.
The anatomical landmarks of importance in
the midsagittal prole are the nasal bone, maxillary line, and mandible. These three landmarks
in a normal fetus appear to fall on a straight line,
as shown in Fig8.7a.
The premaxillary protrusion seen in bilateral
CLP is best visualized in this view [7] (Fig.8.7b).