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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5805_Библиотеки_им_академика_М_И_Перельмана.pdf
116
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
a
N
UL
UL
b
NB
c
Fig. 10.14 Mediolateral cleft 24+5 weeks (a) Nose chin
view large lateralized defect (arrow). (b) Sagittal view
complete absence of maxillary line (*) with communica-
Figures 10.21 and 10.22 illustrate the role of
the midsagittal prole in the diagnosis of bilateral CLP. The rst case shows the typical premaxillary protrusion in the midsagittal prole
(Fig. 10.21a) and the complete absence of the
maxillary line in the parasagittal section
(Fig.10.21b). Video 10.5 Illustration of the premaxillary protrusion and the vomer in a case of
bilateral CLP at 22+6 weeks. The nose chin view
conrms the labial defect (Fig. 10.21c) and the
tion between the nasal and oral cavities. (c) Rendered
image of the face large lateralized defect of the upper lip
(UL), Nose (N), Nasal bone (NB)
cleft extension into the palate can be seen in the
axial view (Fig. 10.21d). Figure 10.21e is the
coronal view in multiplanar imaging, and the rendered face is shown in Fig.10.21f.
In the second case, the coronal view and the
axial view clearly demonstrates the bilateral
paramedian defect (Fig.10.22a, b). The midsagittal view does not give a clue (Fig.10.22c) and
the key plane in the diagnosis of the defect is in
the nose chin view. Though, the midsagittal pro-
ef
10.2 Bilateral
117
a
NB
ML
M
c
b
UL
N
UL
d
Fig. 10.15 Mediolateral CLP involving secondary palate
21weeks. (a) Normal mid sagittal prole. (b) Nose chin
view shows defect (*) in the upper lip. (c) Anterior axial
view shows a large lateralized defect (arrow) extending
centrally into the secondary palate; note that the horizon-
tal plate of the palatine bone is decient (*). (d) Absence
of uvula (dotted circle). (e) Coronal section shows a defect
(arrow) in the hard palate. (f) Rendered image of the fetal
face. Nasal bone (NB), Maxillary line (ML), Mandible
(M), Nose (N), Upper lip (UL)
118
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
a
UL
b
*
*
UL
c
M
NB
ML
Fig. 10.16 Median process in bilateral cleft lip (a) nose
chin view median process (*) and the upper lip (UL) is
divided into three segments (arrows points to bilateral
paramedian defect). (b) Axial view median process (*)
le view may not give the clue, yet the parasagittal sections (Fig.10.22d) clearly demonstrate the
cleft extension into the secondary palate.
Further conrmation can be done in multiplanar imaging, which clearly demonstrates the
complete absence of the base in the premaxillary
triangle (Fig. 10.22e). Invariably regardless of
the presence or absence of PMP in midsagittal
view, in all cases, the diagnostic plane is the
coronal and axial sections.
There can be a deviation of the premaxillary
protrusion to one side, giving the appearance of a
beaked nose. Figure10.23 is an illustration of a
bilateral paramedian clefts (arrows). (c) Midsagittal section premaxillary protrusion (arrow), Mandible (M),
Maxillary Line (ML), Nasal Bone (NB)
case with deviated premaxillary protrusion. Note
in Fig.10.23b the premaxilla is deviated to one
side in the axial view. Figure 10.23d is a 3D
depiction of the beaked nose in bilateral CLP.
Figure 10.24 is a collection of axial views in
different cases of bilateral CLP, which shows
varying degrees of labial and palatal shelf separation on either side of the premaxilla. Most
often, the defect is very subtle on one side,
and that can be mistaken as unilateral CLP
(Fig.10.24c).
The rendered image of the face illustrates the
different degrees of PMP in cases of bilateral
10.3 Median
119
a
b
N
UL
UL
c
d
Fig. 10.17 Bilateral cleft lip at 21weeks. (a) Nose chin
view illustrates bilateral paramedian defect (arrows). (b)
Axial view arrows point to the defect (c) Anterior axial
CLP (Fig. 10.25). Note the appearance of the
median process in the gures shown below.
10.3 Median
Median cleft lip is characterized by the absence
of the midline philtrum and the median process
(Fig.10.26). There is a midline defect in the soft
tissue of the upper lip.
view intact alveolar arch (arrow), (d) Normal midsagittal
prole. Upper lip (UL), Nose (N)
The absence of the median process is diagnostic of median CLP, and this also helps to differentiate from bilateral cleft lip. Figure10.27a
is an example of bilateral CLP with the presence
of median process, and Fig. 10.27b shows a
median cleft lip with the absence of median
process.
In median CLP, there is absence of premaxilla
and hence shortening of the maxillary line in
midsagittal view. The midsagittal prole is often
120
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
ab
UL
N
UL
d
NB
M
Fig. 10.18 Bilateral CLP involving the secondary palate
at 24 weeks. (a) Nose chin view bilateral paramedian
defect (arrows), Upper lip (UL), Nose (N). (b) Axial view
shows interruption of alveolar arch (arrows) and central
extension of the cleft into the secondary palate. (c) Vomer
is visualized as a midline echo with bilateral clefts on
e
either side (*). (d) Sagittal view shows complete absence
of secondary palate caudal to premaxilla (arrow). (e)
Sagittal view shows uid in the oral cavity is continuous
with the nasal cavity with no intervening secondary palate
(*). Nasal Bone (NB), Nasal septum (NS), Tongue (T),
Mandible (M), Video 10.3
c
NB
NS
*
*
*
T
M
the diagnostic plane as the proximal portion of
the maxillary line is absent. Figure10.28a illus-
trates the midsagittal prole with a small maxillary line.
Note that the posterior echogenic line, which
is seen in the midline is vomer. Figure 10.28b
illustrates the complete absence of the maxillary
line slightly off the midline. Figure10.28c depicts
the midline interruption in the alveolar arch and
the central cleft extension into the secondary palate. Note that the horizontal plate of palatine
bone is absent in the posterior aspect.
Figure10.28d is the rendered image showing the
median cleft lip.
Invariably in most cases of median CLP, there
are other associated malformations, and median
CLP is also a component of many genetic syndromes [9].
The premaxilla agenesis-holoprosencephaly
syndrome has a frontonasal deformity associated
with hypotelorism, holoprosencephaly, and facial
deformity ranging from cyclopia to midline facial
cleft with premaxillary agenesis.
The median cleft face syndrome is often associated with a nasal deformity and hypertelorism,
usually either with no or minimal brain
deformity.
Figure 10.29 is an example of median CLP
associated with holoprosencephaly. Figure10.29a
shows a at facial prole with complete absence
of maxillary line. Figure10.29b shows the nose
chin view where there is a midline defect.
bc
10.3 Median
a
M
de f
PMP
121
Fig. 10.19 Complete bilateral CLP at 22 weeks. (a)
Axial view median process (M) protruding in the midline
with bilateral paramedian clefts (pointers). (b) Axial view
alveolopalatal extension of the cleft. Arrows depict the
defect in the bony posterior edge of the palate. (c) Axial
view Vomer is visualized as a midline echo with bilateral
Figure 10.29c illustrates that the alae nasi can
mimic the paramedian cleft, and the nostril mimics the median process. This can be misdiagnosed
as bilateral CLP.Figure10.29d illustrates hypotelorism. Figure10.29e depicts the fused thalami
with cup-shaped monoventricle, suggestive of
alobar holoprosencephaly. Figure10.29f shows
the postnatal correlation.
Moreover, shadowing from the premaxilla
hinders the visualization of the maxillary line
leading to a false-positive diagnosis of cleft palate (see Chap. 8, Fig. 8.8a). On the contrary, true
cleft of the palate can be missed by mistaking the
echogenic upper border of the tongue for the
maxillary line. (Fig.10.30).
To conclude, the nose chin view is the diagnostic view in detecting unilateral, bilateral, or
clefts on either side, arrows point to vomeropremaxillary
junction, (*) palatal shelf separation. (d) Midsagittal view
premaxillary protrusion (PMP). (e) Sagittal view uid in
the oral cavity is continuous with the nasal cavity with no
intervening secondary palate (*), arrow points to PMP (f)
Rendered view of the face. (Video 10.4)
median cleft lip. A combination of the axial,
sagittal, and coronal planes helps in evaluating
the degree of cleft extension.
Premaxillary protrusion seen in midsagittal
prole is a key feature in bilateral CLP. Cleft
extension into the palate can be assessed with the
help of axial and coronal views, and sometimes
the midsagittal view is misleading.
The nasal septum and vomer can mimic the
maxillary line in bilateral CLP in midsagittal
view. The parasagittal section is extremely useful
as it shows the complete absence of the maxillary
line in complete bilateral CLP. This emphasizes
the need to correlate axial and coronal views
with ndings in the midsagittal view for the
diagnosis of cleft palate.
122
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
a
N
d
g
b
NB
M
V
e
h
c
f
Fig. 10.20 Bilateral CLP with no premaxillary protrusion
at 21weeks. (a) Nose chin view showing premaxillary protrusion is very subtle with asymmetric separation of the
labium on either side of the median process, arrows points to
defect, Nose (N). (b) and (c) shows the absence of secondary palate caudal to premaxilla(*). (d) Rendered view of the
face. (e) Axial view vomer is visualized as a midline echo
with bilateral clefts on either sides (*), arrow points to
defect. (f) Transverse axial view at the skull base illustrates
the absence of uvula (*). (g) Note that the maxillary line in
the midsagittal view at 12weeks looks almost normal, and
there is a subtle maxillary gap (arrow). (h) Vomer (arrow) in
midline and the artifacts mask the defect in the base of the
RNT.Vomer (V), Nasal bone (NB), Mandible (M)
10.3 Median
123
a
NB
ML
c
UL
N
b
M
d
PM
UL
e
Fig. 10.21 Complete bilateral CLP at 22+6 weeks (a)
Midsagittal prole shows premaxillary protrusion (arrow).
(b) Parasagittal view shows the absence of maxillary line
(arrow). (c) Nose chin view conrms the labial defect
(arrows). (d) Axial views show cleft extension into the
f
palate (*). (e) Coronal view in volume imaging arrows
points to defect. (f) Rendered view of the face. Nasal bone
(NB), Maxillary line (ML), Mandible (M), Upper lip
(UL), Nose (N) and premaxilla (PM). Video 10.5
124
cd
10 Protocol forDiagnosing Type andExtent ofaCleft inMid Trimester
a
UL
N
C
UL
ML
b
UL
M
UL
e
Fig. 10.22 Bilateral CLP with subtle premaxillary protrusion at 22weeks (a) Nose chin view bilateral cleft lip
(arrows). (b) Axial view median process (M). (c)
Midsagittal view no demonstrable premaxillary protrusion. (d) Parasagittal view absence of the maxillary line
(arrow). (e) Multiplanar imaging axial view bilateral paramedian clefts in the alveolar arch (arrows), coronal view
defect in the premaxillary triangle (arrow). Nose (N),
Chin (C), Upper lip (UL), Maxillary line (ML)
ab
cd
10.3 Median
N
PM
125
*
*
Fig. 10.23 Bilateral CLP with deviated premaxillary
protrusion at 31
CLP (*) points to defect. (b) Axial view shows premaxil-
+5
weeks (a) Nose chin view of bilateral
lary deviation to one side. (c) Midsagittal prole illustrates the beaked nose with premaxillary protrusion (PM).
(d) 3D depiction of the beaked nose. Nose (N)