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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5805_Библиотеки_им_академика_М_И_Перельмана.pdf
A
9.2 Flipped Face View
95
b
Fig. 9.1 (continued)
B
T
C
T
T
a b
Fig. 9.2 Coronal plane imaging in CLP (a) Arrow points
to the intact palate separating the nasal cavity from the
oral cavity. (b) Bilateral CLP (*) denotes defect in the palate with the communication between the oral and nasal
the palate, one can see the coronal reconstruction
of the palate rendered “from the inside out.” The
intact base of the premaxillary triangle can be
evaluated in the anterior section and the bony
secondary palate separating the oral cavity, and
nasal cavity can be clearly imaged in posterior
sections.
c
*
*
cavity on both sides (c) unilateral CLP, Note the communication between the oral and nasal cavity on the cleft side
(*), dotted arrow (vomer). (Video 9.1)
*
9.2 Flipped Face View
The ipped face view aims to evaluate the palate
in the axial plane [2]. This view is obtained by
using the ipped face manoeuvre by rotating the
volume through 90° from midsagittal position to
V
96
9 3D Techniques to Evaluate Palate inMid Trimester
ab
V
T
Fig. 9.3 Coronal plane imaging in unilateral CLP with
midline extension into the palate (33
depicts the lateralized defect in anterior section (b) (*)
+5
weeks) (a) (*)
obtain axial planes of the secondary palate as
shown in Fig.9.7a. The green line is placed on
the under surface of the palate after ipping the
face. Figure9.7 is an illustration of the rendered
axial view and the corresponding 2D axial view
of the palate in a case of mediolateral CLP.
9.3 Omni View Technique
inVisualizing thePalate
Accurate ultrasound imaging of the secondary
palate requires adequate volume acquisition,
presence of uid between the fetal tongue and
palate and curving the omni view line to follow
the concave structure of the palate [3, 4].
This is one of the easiest techniques to evaluate the palate provided the volume acquisition is
done in the ideal fetal position, as shown in
Fig.9.8a. Note the position of the fetus in volume
acquisition plane shown in Fig. 9.8. The fetus is
facing upwards, and the ultrasound beam is angled
to insonate the palate at an angle of about 45
degrees, as proposed by Pilu and Segata [4]. Further
uid in the oral cavity enhances visualization of the
entire bony secondary palate with this technique.
Figure 9.8b illustrates the omni view line in a
case of bilateral CLP.The rendered image clearly
depicts the communication between the oral and nasal
cavity on both sides in the posterior section, deected
vomer (V), tongue (T), (Video 9.2)
illustrates bilateral paramedian defect in the
alveolar arch and also cleft extension into the
secondary palate.
9.4 Surface-Rendered Oropalatal (SROP) View
The SROP sonographic view allows simultaneous visualization of the lips, the alveolar arch
and the secondary palate giving the necessary
information that must be communicated to the
orofacial team about the bony and soft tissue
defect [6].
Figure 9.9 is a case of bilateral CLP illustrated
in the SROP view. The nostril rim, along with its
deformation and splaying, is clearly depicted
(Fig. 9.9a). The position of both the palatal
shelves on either side can also be appreciated
(Fig.9.9b).
Figure 9.10 illustrates the SROP view in HD
live mode in a case of bilateral CLP.The degree
of protruding premaxillary protrusion can be
assessed in this view along with the degree of
asymmetry of labioalveolar cleft on either sides.
This technique is an indispensable tool in counseling prospective parents about the degree of
cleft deformity.
9.4 Surface-Rendered Oropalatal (SROP) View
a
97
*
bc
Fig. 9.4 Tomographic ultrasound imaging in bilateral
CLP (24weeks) (a) axial section arrows points to labial
defect and cleft in the alveolar arch in successive images,
(*) denotes cleft extension into the secondary palate. (b)
*
Coronal sections depicting defect in the nose chin view
(arrowheads), arrows depict that the base of the triangle is
absent with communication between the oral cavity and
nasal cavity in posterior sections
98
9 3D Techniques to Evaluate Palate inMid Trimester
a
b
N
*
C
Fig. 9.5 Rendered view of the face (a) 28weeks normal
HD live rendering of fetal face, (b) 24
view in unilateral CLP lateralized defect in the upper
+5
weeks nose chin
c
*
lip(*), Nose (N), chin (C) and (c) corresponding rendered
view of the face
9.4 Surface-Rendered Oropalatal (SROP) View
99
Fig. 9.6 Reverse face technique. Note that the green line is placed on the top with the face rotated downwards, (Pointer
denotes the intact bony palate at the base of the triangle separating the nasal cavity and oral cavity in the coronal plane)
a
b
*
*
Fig. 9.7 Flipped face technique (24+5 weeks) (a) The
ipped face view renders the palate in the axial section
demonstrating the defect (pointer) in the alveolar arch and
its extension into the secondary palate (*), (b)
Corresponding 2D axial view. Arrows points to the defect
in the alveolar arch, (*) points to cleft extension in the
secondary palate
100
9 3D Techniques to Evaluate Palate inMid Trimester
a
b
Fig. 9.8 Omni view technique (a) Omni view line show-
ing the normal palate, (b) Omni view line depicting bilateral cleft lip and palate. (Note that the vomer (V) is seen
*
*
V
in midline, indicating that the secondary palate is decient). Arrows points to the defect in the alveolar arch, (*)
points to cleft extension in the secondary palate
References
101
a
**
Fig. 9.9 SROP view (a) 21weeks bilateral CLP, (b) 31+5 weeks bilateral CLP, arrowheads points to the defect in the
alveolar arch, (*) points to cleft extension in the secondary palate
a
b
**
b
*
*
*
Fig. 9.10 HD live imaging in bilateral CLP (32weeks) (a) premaxillary protrusion (*) (b) SROP view in HD live
mode, arrowheads points to the defect in the alveolar arch, (*) points to cleft extension in the secondary palate
References
1. Campbell S, Lees C, Moscoso G, Hall P.Ultrasound
antenatal diagnosis of cleft palate by a new technique: the 3D ‘reverse face’ view. Ultrasound Obstet
Gynecol. 2005 Jan;25(1):12–8.
2. Platt LD, DeVore GR, Pretorius DH.Improving cleft
palate/cleft lip antenatal diagnosis by 3-dimensional
sonography: the “ipped face” view. J Ultrasound
Med. 2006 Nov;25(11):1423–30.
3. Ji C, Yang Z, Lu B, Deng X.EP15. 14: the application of Omni view technology of three-dimensional
ultrasonography in diagnosis of fetal cleft lip/palate.
Ultrasound Obstet Gynecol. 2019 Oct;54:320.
4. 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.
5. Faure JM, Bäumler M, Boulot P, Bigorre M, Captier
G.Prenatal assessment of the normal fetal soft palate
by three-dimensional ultrasound examination: is there
an objective technique? Ultrasound Obstet Gynecol.
2008 Jun;31(6):652–6.
6. Rotten D, Levaillant JM, Benouaiche L, Nicot R, Couly
G.Visualization of fetal lips and palate using a surfacerendered oropalatal (SROP) view in fetuses with normal
palate or orofacial cleft lip with or without cleft palate.
Ultrasound Obstet Gynecol. 2016 Feb;47(2):244–6.
7. Martínez Ten P, Perez Pedregosa J, Santacruz B,
Adiego B, Barron E, Sepulveda W.Three-dimensional
ultrasound diagnosis of cleft palate: ‘reverse face’,
‘ipped face’ or ‘oblique face’–which method is best?
Ultrasound Obstet Gynecol. 2009 Apr;33(4):399–406.
Protocol forDiagnosing Type
andExtent ofaCleft inMid
Trimester
10
The mid trimester anomaly scan includes assessment of the nose and lips for the possibility of
cleft lip anomaly. The midsagittal prole and the
nose chin view in the coronal plane are the
basic views included in the anomaly scan for the
assessment of the orofacial cleft [1].
Visualization of the secondary palate is
impaired due to shadowing from the premaxilla
and surrounding facial bones. Additional views
which are used in evaluating CLP are the axial
views and the premaxillary triangle [2, 3].
The inclusion of the sagittal, axial, and coronal views in rst-trimester evaluation of the palate had been dealt with earlier in the previous
chapters [4]. A similar three-plane approach can
be used in mid trimester to evaluate the palate.
Screening for palatine clefts always starts with
the nose chin view. All anterior clefts involving
the premaxilla can be identied with the nose
chin view. The degree of cleft extension into the
palate can be assessed by evaluating the alveolar
arch in axial view and the premaxillary triangle
in the coronal view.
Both these views aid in the diagnosis of anterior clefts of the palate, but posterior clefts of
the secondary palate cannot be identied with
the abovementioned approach. This chapter
deals with a systematic stepwise approach to cat-
Supplementary Information The online version of this
chapter (https://doi.org/10.1007/978- 981- 16- 4613- 3_10)
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_10
egorize the cleft and also to assess its extension
into the secondary palate.
10.1 Unilateral
The nose chin view shows a lateralized defect
partitioning the soft tissue of the upper lip into
two in unilateral CLP. A characteristic feature of
unilateral CLP is the asymmetry of the nostrils
and attening of the alae nasi on the side of the
cleft.
The deformation of the nostril can be described
as “falling down nose” into the pit, which is a
characteristic feature of unilateral CLP.It appears
as though the nostril on the cleft side is falling
into the defect, which is the pit (Fig.10.1).
Video 10.1 illustrates lateralized defect in the
upper lip in a case of unilateral CLP.Once cleft is
identied in nose chin view, then additional
views are needed to assess cleft extension into the
palate.
An abnormality in the nose chin view can be a
defect conned to the lip or can extend into the
alveolus, or it can be a labioalveolar palatal cleft
[2, 5]. Labial clefts can be a slight ssure or can
be a full-thickness cleft of the upper lip.
Figure 10.2a and b illustrates a furrow in the
upper lip, while Fig.10.2c depicts the intact lip in
a deeper section. Figure 10.2d shows the intact
alveolar arch and Fig.10.2e shows the rendered
view of the face.
103
104
ab
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
N
UL
UL
UL
Fig. 10.1 “Nose chin view” in Unilateral CLP. (a) 25weeks (b) 22weeks. Lateralized defect in the upper lip (UL).
Arrow points to the nasal asymmetry and shows attening of the alae nasi on the cleft side, Nose (N) (Video 10.1)
N
UL
ab c
N
UL
UL
de
Fig. 10.2 Unilateral cleft lip at 28+6 weeks. (a) and (b)
Nose chin view illustrates a furrow (arrow) in the upper
lip (UL). (c) Depicts intact lip (arrow) in a deeper section.
Figure 10.3 is an illustration of the labial cleft
where Fig. 10.3a and b shows a full-thickness
defect in the upper lip. Figure10.3c is an axial
view that depicts the defect in the soft tissue and
also shows the intact alveolar arch. Figure10.3d
shows unilateral cleft lip in the rendered view of
(d) Axial view shows the intact alveolar arch (arrowheads). (e) Rendered view of the face. Nose (N)
the face. Figure 10.3e depicts the normalappearing midsagittal prole. Demonstration of
the uvula proves that there is no associated cleft
of the secondary palate (Fig.10.3f) [6].
Unilateral CLP with a slight deformity in the
alveolar arch is shown in Fig.10.4. Figure10.4b
cd
ef
10.1 Unilateral
105
a
b
UL
N
UL
NB
ML
M
Fig. 10.3 Unilateral cleft lip at 21+4 weeks. (a) Lateralized
defect (arrow) in nose chin view (b) oblique axial view
illustrating the defect in the soft tissue of the upper lip
(pointer). (c) Anterior axial view arrow depicts defect in
the soft tissue but shows intact alveolar arch (arrowheads).
(d) Unilateral cleft lip in rendered view of the face. (e)
Normal-appearing midsagittal prole. (f) Sagittal view
shows the integrity of soft palate by demonstrating the
uvula (white circle). Nose (N), Upper lip (UL), Maxillary
line (ML), Nasal bone (NB), Mandible (M)