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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5805_Библиотеки_им_академика_М_И_Перельмана.pdf
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8 Sonoanatomy ofPalate at20Weeks
a
NB
ML
M
b
HP
SP
NB
NS
T
M
Fig. 8.4 Effect of uid in the oral cavity in visualizing
the maxillary line. (a) Midsagittal prole in a neutral position demonstrating maxillary line (ML) note that acoustic
shadowing hinders visualization of the posterior aspect of
the palate. (b) Midsagittal prole, visualization of the
entire maxillary line in the same case with uid in the oral
cavity and neck in slight extension (arrows), hard palate
The midsagittal prole view is also diagnostic in
median CLP as there will be the absence of the
premaxillary portion and shortening of the
maxillary line (Fig. 8.7c). Video 8.6 demon-
strates that the maxillary line is receding backward in median CLP.
(HP), soft palate (SP) (Video 8.2) (c) 24weeks midsagittal prole, indistinct maxillary line (arrow) in the cleft of
secondary palate (d) Fluid in oral cavity clearly demonstrates the communication (*) between oral and nasal cavity in the same case. Tongue (T), nasal septum (NS), nasal
bone (NB) and mandible (M). (Video 8.3)
An attempt should be made to visualize the
palate avoiding the shadow from the premaxilla
with the fetal neck in slight extension and uid in
the oral cavity. Figure8.8b depicts a true cleft of
the secondary palate in the parasagittal section.
The pitfalls in evaluating the maxillary line
are illustrated in Fig8.8a. In the midsagittal pro-
8.2.2 Axial Plane
le, there is shadowing from the premaxilla, and
the secondary palate cannot be visualized. This
shadowing from the premaxilla should not be
mistaken for cleft of the secondary palate.
The axial section is one of the best planes to visualize the palate. Two axial sections are needed to
assess the palate. One is the anterior axial view
ab
8.2 Planes ofEvaluating Palate
85
NB
ML
M
*
c
*
T
ML
Fig. 8.5 Effect of angle of insonation in visualizing the
palate. (a) Midsagittal prole maxillary line (ML), note
there is shadowing in the posterior aspect (*). (b)
Ultrasound beam insonated at a 45° angle depicting the
of the palate focussing on the alveolar arch of the
maxilla and soft tissue of the upper lip (Fig.8.9a).
Anterior cleft of the palate can be easily identied with this approach, and a defect can be
demonstrated in the soft tissue and in the alveolar arch.
The next axial section is taken with the ultra-
sound beam focussed below the alveolar arch to
obtain the bony posterior edge of the palate.
(Fig. 8.9b). This view helps to identify cleft of
the bony secondary palate. The horizontal plate
of the palatine bone and the pterygoid processes
can be visualized as a transverse line that demar-
entire secondary palate. (c) Additional effect of uid in
the oral cavity (*), tongue (T), nasal bone (NB) and
Mandible (M). (Video 8.4)
cates the posterior end of the bony secondary palate (Fig.8.10).
As the palate is arched and dome shaped in
mid trimester two axial sections are needed, one
to visualize the bony alveolar arch and the other
to visualize the bony posterior edge of the secondary palate. However, in early gestation, as the
palate is at and not arched both these landmarks
can be visualized in the same plane (see Chap. 4,
Fig. 4.5c, d).
The anterior axial view is ideal for evaluating cleft in the alveolar arch but does not help in
assessing cleft extension into the secondary pal-
86
8 Sonoanatomy ofPalate at20Weeks
ab
NB
ML
M
Fig. 8.6 Superimposed line sign (midsagittal section) (a) 15weeks (b) 20weeks. The vomer (V) and palate (P) con-
stitutes the posterior aspect of the maxillary line. Nasal bone (NB), maxillary line (ML), and mandible (M). (Video 8.5)
V
P
V
p
ba
NB
ML
M
c
Fig. 8.7 Normal and abnormal midsagittal prole. (a)
Normal midsagittal prole depicts the three anatomical
landmarks the nasal bone (NB), maxillary line (ML) and
mandible (M) fall in an imaginary straight line (white dot-
ted line). (b) Midsagittal prole in bilateral CLP premaxillary protrusion (arrow). (c) Midsagittal prole in median
CLP (Note the absence of premaxilla). Nasal bone (NB),
maxillary line (ML) and mandible (M) (Video 8.6)
ab
ab
8.2 Planes ofEvaluating Palate
PM
87
Fig. 8.8 Artifactual and true shortening of the maxillary
line. (a) Midsagittal prole showing incomplete visualization of maxillary line, posterior aspect of the line is not
visualized due to the shadowing (*) from premaxilla (PM)
and should not be misdiagnosed for cleft of the secondary
P
Fig. 8.9 Axial sections in evaluating palate (a) Anterior
axial view note the soft tissue of the upper lip (arrows) and
intact alveolar arch (arrowhead), Palate (P). (b) Ultrasound
palate. (b) Sagittal view shows a true cleft of the secondary palate with the absence of maxillary line (arrow) posterior to the premaxilla. (Note that the fetal neck is in
extension with uid in the oral cavity, and there is no
shadowing from the premaxilla)
beam focussed below the alveolar arch to obtain the bony
posterior edge of the palate (arrow)
ate as the tongue obscures the margins of the
8.2.3 Coronal Plane
defect (Fig. 8.11a, b). Video 8.7 depicts the
tongue movements in a case of cleft of the secondary palate, the tongue impairs visualization of
cleft extension into the secondary palate.
Hence a defect in the transverse line (i.e.)
bony posterior edge of palate denotes cleft
extension into the bony secondary palate
(Fig. 8.11c). Cleft extension into the secondary
palate can also be assessed in the transverse axial
plane [8] (Fig.8.11d).
The nose chin view (nose mouth view), which is
included in the routine protocol for mid trimester anomaly scan, is the most important view in
screening for anterior orofacial cleft.
Figure 8.12a illustrates the two nostrils, columella, vermilion border of the upper lip, lower lip
and chin.
All anterior clefts of the palate are an exten-
sion of labial clefts and can be seen in the nose
88
8 Sonoanatomy ofPalate at20Weeks
a
P
c
b
P
d
Fig. 8.10 Sonoanatomy of the inferior view of the palate
illustrated with the line diagram. (a) 19 weeks anterior
axial view arrow points to the visualized bony posterior
edge of the palate (P). (b) 20weeks. (c) Yellow line highlights the bony posterior edge of the palate. (d) Line dia-
chin view. The premaxillary triangle is a coronal
section taken posterior to the nose chin view and
serves as a valuable landmark to assess cleft
extension into the palate (Fig.8.12b) [9].
The base of the premaxillary triangle corresponds to the palate and is intact in normal cases.
There can be a lateralized defect in the base of the
triangle in unilateral CLP (Fig.8.13a). Complete
absence of the base of PMT is seen in bilateral
CLP and in median CLP (Fig.8.13b). Hence two
sections in the coronal plane, the nose chin view
and the premaxillary triangle are useful in evaluating orofacial clefts.
The nose chin view ideally should be evaluated with sufcient liquor around. Care should
be taken to avoid limbs and umbilical cord loop
gram showing the anatomical correlate of the bony
posterior edge of the palate. (Note that the yellow line
passes through the horizontal plate of the palatine bone,
thus marking the bony edge of the hard palate)
while imaging the nose chin view as shadowing
from the limbs or cord loop may mimic a labial
defect. (Fig. 8.14a). Minimal uid between the
upper and lower lip is ideal to show subtle labial
clefts (Fig.8.14b).
8.3 Palatine Biometry
Generally, there is no role of facial biometry in
diagnosing facial clefts. However, it has a role
when one looks for associations in the cleft palate. The most common association noted with
cleft palate is retrognathia.
Inferior facial angle (IFA) is calculated by
measuring the angle made by the cross-section of
ab
8.3 Palatine Biometry
89
a
b
T
T
c
*
d
*
F
F
Fig. 8.11 Abnormal appearance of axial view in cleft
palate. (a) 18 weeks defect in the alveolar arch (arrow)
Tongue (T). (b) 33weeks axial view (Note that the tongue
(T) obscures the margin of the defect (arrow). (c) 18weeks
anterior axial view arrow points to the defect in the soft
tissue of the upper lip and alveolar arch, (*) shows cleft
N
C
Fig. 8.12 Two coronal planes. (a) Nose chin view, (b) Premaxillary triangle view (Note that the premaxillary triangle
is taken just posterior to the nose chin view). Nose (N), Chin (C), Apex (A), Base (B)
extension into the secondary palate, note the defect in the
posterior edge of the bony palate with the amniotic uid
(F) seen extending into the oropharynx. (d) 21 weeks
transverse axial view demonstrating cleft extension (*)
into the secondary palate, pointers show the disruption in
the palatal shelf. (Video 8.7)
A
B
90
ab
8 Sonoanatomy ofPalate at20Weeks
a
Fig. 8.13 3D coronal section showing abnormal PMT. (a) Unilateral CLP arrow points to the lateralized defect in the
base of the triangle. (b) Complete absence of base of PMT in median CLP (arrows)
b
N
C
L
Fig. 8.14 Pitfalls in visualizing the nose chin view. (a)
Umbilical cord loop (C) and the limb (L) in the region of
the nose chin view should be avoided. Nose (N) (b) Ideal
visualization of the nose chin view illustrating the entire
a line orthogonal to the forehead at the level of
naso-frontal suture and a line from the tip of the
mentum to the anterior border of the more protrusive lip on a sagittal view. The normal value of
the inferior facial angle was about 65.5 degrees,
and an IFA value lesser than 49.2 degrees denes
retrognathia (Fig. 8.15a). Inferior facial angle
vermilion border of the upper lip (arrows) note that minimal uid(*) between upper and lower lip enhances visualization of upper lip margin
and mandibular maxillary width ratio are useful in the prediction of retrognathia [10].
Nomograms for the palate have been devised
in the axial view by Sherer etal., however, they
did not feel that there is any signicance of biometry in the diagnosis of isolated cleft palate [11]
(Fig.8.15b).
ab
References
Fig. 8.15 Facial biometry. (a) Midsagittal view showing inferior facial angle (b) Biometry of hard palate at the axial
plane
91
References
1. Faure JM, Captier G, Bäumler M, Boulot
P. Sonographic assessment of normal fetal palate
using three-dimensional imaging: a new technique.
Ultrasound Obstet Gynecol. 2007 Feb;29(2):159–65.
2. Wilhelm L, Borgers H. The ‘equals sign’: a novel
marker in the diagnosis of fetal isolated cleft palate.
Ultrasound Obstet Gynecol. 2010 Oct;36(4):439–44.
3. Wong HS, Tait J, Pringle KC. Examination of the
secondary palate on stored 3D ultrasound volumes
of the fetal face. Ultrasound Obstet Gynecol. 2009
Apr;33(4):407–11.
4. Grassi R, Farina R, Floriani I, Amodio F, Romano
S. Assessment of fetal swallowing with gray-scale
and color Doppler sonography. Am J Roentgenol.
2005 Nov;185(5):1322–7.
5. Pilu G, Segata M.A novel technique for visualization of the normal and cleft fetal secondary palate:
angled insonation and three-dimensional ultrasound.
Ultrasound Obstet Gynecol. 2007 Feb;29(2):166–9.
6. 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.
7. 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.
8. Campbell S. Prenatal ultrasound examination of
the secondary palate. Ultrasound Obstet Gynecol.
2007;29:124–7.
9. Suresh S, Vijayalakshmi R, Indrani S, Devaki G,
Bhavani K. The premaxillary triangle: clue to the
diagnosis of cleft lip and palate. J Ultrasound Med.
2006 Feb;25(2):237–42.
10. Rotten D, Levaillant JM, Martinez H, Le Pointe HD,
Vicaut E. The fetal mandible: a 2D and 3D sonographic approach to the diagnosis of retrognathia
and micrognathia. Ultrasound Obstet Gynecol. 2002
Feb;19(2):122–30.
11. Sherer DM, Sokolovski M, Santoso PG, Dalloul M,
Abulaa O. Nomograms of sonographic measurements throughout gestation of the fetal hard palate
width, length and area. Ultrasound Obstet Gynecol.
2004 Jul;24(1):35–41.
3D Techniques to Evaluate Palate
inMid Trimester
9
In the past decade, numerous specic 3D techniques have been described to visualize the palate. However visualization of the posterior palate
is impaired by artifacts caused due to acoustic
shadowing from the maxilla and surrounding
facial bones.
Various specic views have been described to
overcome this difculty, such as the “reverse
face” view, the “ipped face” view, the “oblique
face” view, the “angled insonation,” the
“inclined axial,” and the “SROP” view [1–6].
The best method with which to evaluate the palate is still a matter of debate, and none has been
universally agreed upon [7].
Volume acquisition of the fetal face is done in
the midsagittal view after adequate magnication
of the fetal face. The 3D data sets can be obtained
using a 50 to 60 degree sweep from one side of
the face to the other using optimized sonographic
settings.
The type and extent of the cleft palate can be
assessed by ofine analysis, including imaging
modalities like multiplanar, surface, and maximum mode rendering, static volume contrast
imaging (VCI), tomographic ultrasound imaging (TUI) and omni view technique.
Figure 9.1 depicts the potential benet of multiplanar imaging in evaluating palatine clefts as
Supplementary Information The online version of this
chapter (https://doi.org/10.1007/978- 981- 16- 4613- 3_9)
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_9
the cleft can be visualized simultaneously in all
three orthogonal planes. When the reference dot
is placed on a bony structure, then the anatomical
correlate can be visualized in the other two planes
as shown in Fig.9.1a. The reference dot, when
placed in the defect, illustrates the same in the
other two planes (Fig.9.1b).
In mid trimester as the tongue obscures the
defect in the axial view, visualization of the cleft
in the coronal plane serves as an efcient tool to
analyze the cleft extension into the secondary
palate. Normally, the coronal section depicts the
bony palate separating the nasal cavity from the
oral cavity, as illustrated in Fig.9.2a. Figure9.2b
illustrates the bilateral paramedian defect in
bilateral CLP. Figure 9.2c depicts lateralized
defect in unilateral CLP; note that the nasal cavity communicates with the oral cavity on the cleft
side. Video 9.1 illustrates a sweep through sections from the nose chin view to the posterior
coronal view in this case.
In a case of unilateral CLP with midline extension into the secondary palate (Fig.9.3), the anterior coronal section shows a lateralized defect
(Fig.9.3a), and posterior coronal section depicts
the midline extension of the cleft into the secondary palate. (Fig.9.3b) Note that the vomer bone
is deviated to the noncleft side and is not
attached to the palatal shelves at the base in
Fig. 9.3b (correlate with Chap. 7, Fig. 7.1c).
Video 9.2 depicts the lateralized defect in the
nose chin view extending to the secondary palate
in the coronal plane.
93
94
9 3D Techniques to Evaluate Palate inMid Trimester
TUI in the axial section simultaneously demonstrates the defect in the upper lip, defect in the
alveolar arch and defect in the bony posterior
edge of the palate in a single plane format in
complete bilateral CLP (Fig. 9.4a). TUI in the
coronal section depicts the bilateral paramedian
defect in the nose chin view and the defect in the
secondary palate in the posterior sections
(Fig.9.4b).
Sufcient liquor is needed at the time of volume acquisition to render the face as shown in
Fig. 9.5a. Figure 9.5b illustrates the lateralized
labial defect in 3D rendered image of the face in
unilateral CLP. This view particularly helps in
counseling the future parents about the defect
and also gives an idea about the type of defect.
a
9.1 Reversed Face View
This is a specic view described by Campbell
etal., which aims to evaluate the palate in the coronal view [1]. It is called the reverse face view as
the palate is approached from the reverse side of
the face in this technique. If the palate is viewed
from the front, the acoustic shadowing from the
premaxilla hinders its visualization.
The reversed face view can be obtained by
rotating the volume through 180 degrees as
shown in Fig.9.6, with the green line of the render box facing upwards on the reverse side of the
face. This technique provides an unobstructed
view of the palatal area. When the view bar is
scrolled from the anterior to the posterior part of
A
T
B
T
Fig. 9.1 Multiplanar imaging illustrating usage of the
reference dot in bilateral CLP (a) The reference dot is
placed on the vomer in plane A (i.e.) axial view, note the
position of the dot in the posterior aspect of maxillary line
in plane B and the dot in plane C is seen on the midline
echo above the tongue. Note that there is the complete
absence of the palate (arrowheads) in the coronal view
C
(plane C). (b) When the reference dot is placed at the
defect in plane A (i.e.) axial view, the parasagittal section
is highlighted in plane B, which shows the complete
absence of maxillary line, the position of the dot in plane
C corresponds to the communication between the oral
cavity and nasal cavity. (Arrow points to the bilateral
paramedian defect). Tongue (T)