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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5805_Библиотеки_им_академика_М_И_Перельмана.pdf
106
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
a
UL
N
UL
c
b
d
Fig. 10.4 Unilateral CLP with a slight deformity in the
alveolar arch at 21weeks. (a) Nose chin view lateralized
defect (arrow) in the upper lip (UL), nose (N). (b) Axial
view depicts deformed alveolar arch (arrowhead) on the
depicts the deformed alveolar arch on the cleft
side but note that there is no complete interruption. The normal-appearing midsagittal prole
and the intact base of the premaxillary triangle is
shown in multiplanar imaging in Fig.10.4d.
Figure 10.5 shows the complete interruption
in the alveolar arch. Note that there is also a lateralized defect in the base of the triangle in
Fig.10.5c.
Figure 10.6 is an illustration of labioalveolar
palatal cleft or complete unilateral CLP.The nose
chin view (Fig.10.6a) depicts a lateralized defect
in the upper lip, anterior axial view (Fig.10.6b)
depicts a cleft in the alveolar arch extending into
the secondary palate. The coronal plane
(Fig. 10.6c) depicts a lateralized defect in the
cleft side. (c) Rendered view of the face. (d) Multiplanar
imaging depicting the deformed alveolar arch (arrowhead), note that the base of the triangle is intact in the
coronal section (arrow)
base of the triangle, which indicates cleft extension into the palate.
Though the midsagittal prole (Fig. 10.6e)
appears normal, the parasagittal section shows
the absence of the maxillary line on the cleft side
(Fig. 10.6f). The key pointers for the involve-
ment of the palate would be lateralized defect in
the base of the triangle in the coronal plane,
absence of maxillary line in parasagittal section
and defect in the bony posterior edge of the palate in the axial plane.
Among individuals with unilateral cleft lip and
palate (UCLP), there exists a variation in the anatomical relationship between the vomer and the
secondary hard palate. Most often, the vomer is
attached to the secondary palate on the non- cleft
10.1 Unilateral
107
a
b
c
Fig. 10.5 2D and 3D correlation in unilateral CLP 22+3
weeks. (a) Axial view showing complete interruption in
alveolar arch (arrowhead). (b) Rendered view of face,
side, but sometimes the vomer is detached from
the secondary hard palate. In the latter case, there
is a bilateral extension into the secondary hard palate (b-UCLP) (see Chap. 7, Fig. 7.1) [7].
Figure 10.7 is an illustration of unilateral CLP
with bilateral extension into the secondary palate.
Figure10.7a shows the lateralized defect in the
nose chin view and in the alveolar arch
(Fig.10.7b). Figure 10.7c shows the lateralized
defect in the premaxillary triangle, and Fig.10.7d
shows the lateralized defect in the upper lip.
Figure 10.7e shows the detached vomer and
bilateral extension of the cleft into the secondary palate in multiplanar imaging. The vomer
bone of the nasal cavity is seen as a midline
arrow points to defect. (c) Coronal view showing defect
(arrow) in the base of retronasal triangle
structure with a bilateral cleft on either side of
the vomer. Note that there is an absence of the
superimposed line sign at 13weeks in this case
(Fig.10.7f).
In complete unilateral CLP, cleft extension
into the secondary palate can be assessed by the
following planes. If there is a complete extension
of a cleft into the secondary palate in unilateral
CLP, then there would be a defect in the bony
posterior edge of the palate (Fig.10.8c), and the
uvula cannot be imaged in sagittal and axial view
as illustrated in Fig.10.8 d, e.
Third-trimester detection of CLP is most
often difcult due to unfavorable position of the
fetus. Moreover, the margins of the tongue
108
cd
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
a
b
N
UL
*
*
UL
ef
NB
ML
M
*
Fig. 10.6 Complete unilateral CLP at 22weeks. (a) Nose
chin view lateralized defect (*) in the upper lip (UL) with
nasal asymmetry (arrow). (b) Anterior axial view depicts
the cleft (arrow) extending into the alveolus, note that the
defect (*) in the bony posterior edge of the palate. (c)
Coronal view lateralized defect (arrow) in the base of the
triangle. (d) Rendered view of face. (e) Normal appearance of midsagittal prole. (f) Parasagittal section shows
the absence of the secondary palate (*) on the cleft side.
Nose (N), Maxillary line (ML), Mandible (M), Nasal
bone (NB)
10.1 Unilateral
109
obscure the palatal defect, and it is very cumbersome to assess cleft extension into the secondary palate.
The lateralized defect in the lip (Fig. 10.9a)
and cleft in the alveolar arch (Fig.10.9b) can be
assessed with conventional views, however, the
ab
UL
cleft extension into the palate cannot be assessed
due to shadowing.
Figure 10.10 is a demonstration of unilateral
CLP at 34weeks. Though the labial defect and
cleft in the alveolar arch can be diagnosed, note
that the acoustic shadows from the tooth buds
N
UL
cd
Fig. 10.7 Unilateral CLP with bilateral extension into
secondary palate 22weeks. (a) Nose chin view lateralized
defect in upper lip (arrow). (b) Axial view lateralized
defect in alveolar arch (arrow). (c) Coronal view lateralized defect (arrow) in the base of the triangle. (d) Rendered
view of face unilateral cleft lip. (e) Multiplanar imaging
shows bilateral extension of cleft (*) into the secondary
palate, vomer (V) of the nasal cavity is seen as a midline
structure with bilateral cleft on either side of the vomer. (f)
Note that at 13 weeks of gestation there is absence of
superimposed line sign. Upper lip (UL), Nose (N).
Reproduced with permission from Wiley
110
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
e
V
V
f
*
*
Fig. 10.7 (continued)
hinder further visualization of the palate
(Fig.10.10c).
In such cases, the coronal plane helps in detecting cleft extension into the palate as shown in
Fig.10.11. The sagittal view and axial view shown
in Fig.10.11b are not informative about the cleft
extension into the palate as the tongue shrouds the
defect. The posterior part of the secondary palate
is inadequately visualized due to dense shadowing from facial bones and the tongue.
Figure 10.11c coronal section posterior to
nose chin view clearly depicts the defect in the
hard palate, and there is a communication
between the oral cavity and the nasal cavity. The
posterior coronal section clearly illustrates that
there is no intervening hard palate above the
tongue (Fig. 10.11d) which indicates that the
cleft extends into the secondary palate. Note that
the vomer is deected to the non-cleft side and is
not attached to the palatal shelves below on either
sides.
Varied presentations in unilateral CLP and the
different types of cleft extension into the palate
have been illustrated. The phenotypic variations
de
10.1 Unilateral
111
a
UL
N
UL
NB
M
V
b
Fig. 10.8 Complete unilateral CLP at 20weeks. (a) Nose
chin view lateralized defect (arrow) in the upper lip (UL),
(b) rendered view of face illustrating unilateral cleft with
nasal asymmetry, (*) denotes the excess soft tissue in the
upper lip. (c) Axial view cleft extension into the palate
c
(arrow) with defect in bony posterior edge of the palate
(*). (d) Midsagittal prole depicts vomer (V) in midline
with non-visualization of secondary palate. (e) Axial view
absence of uvula (dotted white circle). Nose (N), Nasal
bone (NB), mandible (M)
a
UL
N
Fig. 10.9 Third-trimester detection of unilateral CLP
(29weeks). (a) Nose chin view lateralized defect (arrow)
UL
b
T
the alveolar arch (arrow), note that the tongue (T) obscures
the defect in late gestation. Nose (N)
in the upper lip (UL) (b) anterior axial view shows cleft in
112
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
a
N
N
UL
UL
UL
UL
b
c
Fig. 10.10 Unilateral CLP at 34 weeks. (a) Nose chin
view lateralized defect in the upper lip (UL), arrow points
to the nasal deformity. (b) HD live rendering of the face.
(c) Axial view depicting cleft extension (arrow) into the
in unilateral CLP and the different degrees of
palatal shelf separation are shown in Fig.10.12.
The anterior axial view clearly depicts the
extent of palatal shelf separation and the severity
of the defect. Though the nose chin view is the
diagnostic view in unilateral CLP, a combination of the axial, sagittal, and coronal planes
help in evaluating the degree of cleft extension.
A systematic stepwise approach to evaluate cleft
lip and palate is illustrated in the owchart
(Fig.10.13).
alveolar arch. Dense shadowing from the tooth buds does
not allow the assessment of cleft extension into the secondary palate. Nose (N)
In mediolateral cleft, there is a large lateralized defect of the upper lip involving the midline
philtrum. This type of cleft almost invariably has
a central extension into the secondary palate.
Video 10.2 illustrates a midline interruption in
the alveolar arch in the case of median CLP.
Figure 10.14a illustrates a large lateralized
defect in the nose chin view. Note that there is
also asymmetry of the nostrils. Figure 10.14b
illustrates the complete absence of maxillary line
in sagittal view showing the communication
10.2 Bilateral
ab
113
c
Fig. 10.11 3D illustration of unilateral CLP at 31weeks
(a) Rendered view of the face depicting the defect and
nasal asymmetry. (b) Multiplanar image correlation of
defect (arrow) in sagittal and axial view (c) coronal plane
T
T
d
V
T
*
*
illustrating the defect (arrow). (d) (*) depicts the communication between the oral and nasal cavity on both sides,
vomer (V). Tongue (T)
between the nasal cavity and the oral cavity.
Figure10.14c is the rendered image of the face
showing a large lateralized defect of the upper
lip.
Figure 10.15 is another case of mediolateral
CLP with extension into the secondary palate.
The defect in the upper lip is demonstrated in the
nose chin view (Fig.10.15b). Figure10.15c illus-
trates the large lateralized defect in the alveolar
arch extending centrally into the secondary
palate.
Note that there is absence of uvula in
Fig.10.15d. Figure10.15e depicts the defect in
the hard palate in the coronal section.
Figure10.15f depicts rendered image of the fetal
face.
10.2 Bilateral
Bilateral cleft lip is characterized by the upper
lip partitioned into three segments in the nose
chin view with the median process under the
nostrils. There are two clefts on either side of the
median process in the bilateral cleft. The surface
of the skin on the median process has excess
mucosa, and there tends to be a protrusion of the
median process in most cases [7].
Figure 10.16a illustrates the nose chin view in
the coronal plane, which shows the median process and the upper lip divided into three segments. Figure10.16b shows the median process
protruding in the midline with bilateral
paramedian clefts in the axial view. Figure10.16c
114
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
ab
de
Fig. 10.12 Phenotypic variation in unilateral CLP with
varying degrees of palatal shelf separation. (a, b, and c)
shows minimal to moderate degree of palatal shelf separa-
shows the premaxillary protrusion in the sagittal prole, which is the key nding in bilateral
CLP [8].
In bilateral cleft lip, the defect is conned only
to the soft tissue of the upper lip. This is best seen
in the nose chin view (Fig.10.17a) and is characterized by an intact alveolar arch in axial view
(Fig.10.17c). The midsagittal prole almost has
a normal appearance (Fig. 10.17d) and most
often, the premaxillary protrusion is very subtle
when the cleft is conned to the labium.
The cleft extension into the palate can be
assessed by evaluating the alveolar arch and the
horizontal plate of the palatine bone in axial view.
Figure 10.18 is an illustration of bilateral CLP
involving the secondary palate. The axial view
shows interruption of the alveolar arch and central extension of the cleft into the secondary palate (Fig.10.18b).
The vomer of the nasal cavity is visualized as
a midline echo with bilateral clefts extending on
either side of the vomer (Fig.10.18c). Complete
absence of the secondary palate caudal to the premaxilla is depicted in sagittal sections
(Fig.10.18d and e). In Fig.10.18e note that the
uid in the oral cavity is continuous with the
tion. (d, e, and f) shows a wide degree of palatal shelf
separation (arrows)
nasal cavity with no intervening secondary palate. Video 10.3 illustrates complete bilateral CLP
with uid in the oral cavity.
Figures 10.19 and 10.20 are two cases of bilateral CLP with varying degrees of premaxillary
protrusion. The rst case shows the typical premaxillary protrusion in axial and sagittal views
(Fig. 10.19a, d, e). Video 10.4 illustrates the
abrupt ending vomer in the midline with nonvisualization of the soft palate and the uvula in a
case of complete bilateral CLP.
Alveolopalatal extension of the cleft can be
seen in the axial view (Fig.10.19b) depicting the
maxillary arch. Figure10.19c shows the vomer in
the midline and the vomeropremaxillary junction. Note the symmetric separation of the palatal
shelves on either side.
In the second case, the premaxillary protrusion is very subtle as illustrated in the nose chin
view (Fig. 10.20a). Note there is asymmetric
separation of the labium on either side of the
median process. The sagittal views (Fig.10.20b
and c) does not show an obvious premaxillary
protrusion but clearly illustrates the absence of
the secondary palate caudal to the premaxilla.
The midline echo imaged in the midsagittal pro-
c
f
10.2 Bilateral
115
Nose chin view
Unilateral
Alveolar arch (Axial view)
Normal Slightly deformed Complete cleft
Labial cleft
Bilateral Median
Labioalveolar cleft
Premaxillary triangle (Coronal view)
Normal
Cleft confined to
premaxilla
Extended views to assess
Abnormal
Cleft extending into
secondary palate
secondary palate
Bony posterior edge of
the palate in axial view
Fig. 10.13 Algorithm to detect cleft extension into the secondary palate
le is the vomer which is situated at a slightly
superior plane (Fig. 10.20b). The transverse
axial view at the base of the skull illustrates the
absence of the uvula (Fig.10.20f).
In this type of presentation, the ultrasound
markers in the rst trimester are very subtle and
can be easily overlooked. Note that the maxil-
lary line in the midsagittal view at 12 weeks
looks almost normal, and there is a subtle
maxillary gap (Fig. 10.20g). The vomer at the
base of the retronasal triangle, along with the
artifacts, masks the defect in the base of the
RNT (Fig.10.20h). As the PMP is not evident
in the midsagittal prole, the nose chin view in
this case gives the lead clue to identify this
defect.
Uvula in
sagittal view