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6.5 Tomographic Ultrasound Imaging
43
P
Fig. 6.6 Omni view technique in evaluating palate—13+2 weeks (TAS) Omni View line drawn along the course of the
maxillary line depicts the palate in axial view
or HD live mode. The head is tilted to view the
chin, and then by scrolling upwards in the axial
plane, the palate can be seen as a delta-shaped
echogenic plate (Fig.6.9) [3].
intervals of 0.5–1mm. The TUI images can be
displayed in 2×2 format or 2×3 format.
The appearance of the maxillary line in sagittal sections serves as a key landmark in evaluating palatine clefts [9]. The maxillary line appears
uninterrupted in all the sections (Fig.6.10). The
6.5 Tomographic Ultrasound
Imaging
vomer can mimic palate in the midsagittal section in secondary palatine clefts, and the para-
sagittal sections truly reect the presence or
Tomographic ultrasound imaging allows automatic slicing of the volume datasets displaying
multiple parallel images in any of the three orthogonal planes. After the initial volume acquisition in
the sagittal plane, volume contrast imaging can be
added to enhance visualization of the maxillary line.
The image in plane A is used for TUI, and the
image in plane B is the reference image in which
the examiner can determine the distance between
the TUI slices (Fig. 6.10). The TUI slices are
simultaneously displayed as still images at preset
absence of the palate without the confounding
factor of the vomer bone [9]. Figure6.11 depicts
TUI in bilateral CLP involving secondary palate.
Note the complete absence of the maxillary line
in parasagittal sections. Figure6.12 is a line diagram from our study depicting the appearance of
the maxillary line in sagittal and parasagittal sections in various types of palatine clefts [9].
TUI is a good tool in assessing palatine clefts
as the appearance of maxillary line in sagittal
views denes the type of cleft. The different types
44
6 3D Techniques toEvaluate Palate at 11–14Weeks
a
b
ML
ML
c
Fig. 6.7 Flipped face technique (14 weeks TAS) (a)
Volume acquisition in midsagittal plane (b) Flipping the
face through 90 degrees to make the maxillary line (ML)
horizontal as shown. (c) Render box placed on the maxil-
P
lary line with the green dotted line facing the intraoral
surface of the palate. Rendered image depicts the intact
alveolar arch and echogenic plate (P) of bone caudal to
alveolar arch
a
a
6.5 Tomographic Ultrasound Imaging
45
b
c
Fig. 6.8 Different modes of rendering the palate: (a)
Surface maximum mode rendering of the palate with the
ipped face technique (b) HD live mode (c) HD live skel-
d
eton mode. (d) Skeleton mode. (e) Surface max mode,
note that the interpalatine suture (arrows) and transverse
palatine suture (arrowheads) can be visualized at 12weeks
e
b
Fig. 6.9 Tilt and scroll method (14weeks TVS) (a) vol-
ume acquisition in the axial plane (b) Tilting the volume
to visualize the chin. (c) Scrolling through to see the man-
c
dible. (d) Further scrolling to image the alveolar arch and
palate (P)
d
P
46
6 3D Techniques toEvaluate Palate at 11–14Weeks
P
ML
M
ML
Fig. 6.10 Tomographic Ultrasound Imaging of palate (14weeks TAS): Note that the maxillary line (ML) is continuous
in midsagittal (M) and both parasagittal (P) sections when the palate is intact
of palatine clefts have a reproducible pattern
and can be easily interpreted in TUI by using
standard sections. Hence, with a given 3D dataset
by using the abovementioned approach a denitive diagnosis of palatine clefts can be made.
The advantage is that there is a high degree of
accuracy in discriminating the normal and abnormal types, and with a given volume, the manipulation needed in TUI is very minimal. TUI in
coronal planes can be used as an additional methodology to reinforce the diagnostic ndings in
sagittal sections. However, interpretation with
TUI requires a properly acquired volume data set
which remains the mainstay of diagnosis. This
approach can effortlessly be done using standard
sonographic techniques and this would be helpful
in the diagnosis of cleft palate [9].
The rst-trimester scan plays an important
role in the diagnosis of structural abnormalities,
P
ML
including orofacial cleft. If the 2D markers in
the three planes appear suspicious, then the secondary palate must be evaluated using 3D multiplanar mode.
To conclude, it is possible to visualize both
primary and secondary palate in the rst trimester and also to diagnose cleft palate with reasonable accuracy. One of the greatest advantages of
volume imaging is the ease and rapidity with
which the different planes can be assessed.
In the near future, with the advancement in
3D technology, precise information about the
extent of clefting can be given, which can predict the prognostic implications for the child.
The potential utility of multiplanar imaging
in the late rst trimester is to be explored and
is certainly advantageous over the mid trimester as acoustic shadowing is not an issue in
this period.
6.5 Tomographic Ultrasound Imaging
PM
47
p
M
pm
M
V
Fig. 6.11 TUI in complete bilateral CLP (12 weeks
TVS) Note that the maxillary line in midsagittal view (m)
is formed by vomer (V) and premaxilla (PM) with the
Normal Unilateral
PMP PMP
Bilateral
Complete
PMP PMP
M
maxillary gap (arrow) seen in between. Yellow dotted line
corresponds to parasagittal sections (p) showing complete
absence of maxillary line (arrow), mandible (M)
Bilateral
Incomplete
Median Isolated
PMP PM P
MidsagittalParasagittal
Fig. 6.12 Line diagram depicting the appearance of maxillary line in sagittal and parasagittal sections in various types
of palatine clefts
48
6 3D Techniques toEvaluate Palate at 11–14Weeks
References
1. 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.
2. Sepulveda W, Wong AE, Castro F, Adiego B, MartinezTen P. Feasibility of 3-dimensional sonographic
examination of the fetal secondary palate during the
second-trimester anatomy scan. J Ultrasound Med.
2011 Dec;30(12):1619–24.
3. Campbell S. Prenatal ultrasound examination of
the secondary palate. Ultrasound Obstet Gynecol.
2007;29:124–7.
4. Martinez-Ten P, Adiego B, Perez-Pedregosa J, Illescas
T, Wong AE, Sepulveda W.First-trimester assessment
of the nasal bones using the retronasal triangle view:
a 3-dimensional sonographic study. J Ultrasound Med.
2010 Nov;29(11):1555–61.
5. 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.
6. Sepulveda W, Caci D, Bartholomew J, Wong AE,
Martinez-Ten P.First-trimester assessment of the fetal
palate: a novel application of the volume NT algorithm. J Ultrasound Med. 2012 Sep;31(9):1443–8.
7. 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.
8. 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.
9. 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.
Protocol forDiagnosing Type
andExtent ofaCleft in First
Trimester
7
The integrity of the bony hard palate can be evaluated in the rst trimester with the help of sagittal, axial, and coronal planes [1]. Detection of
cleft lip and palate in the rst trimester 11 to
14 weeks scan has signicantly increased in
recent years [2]. This can be attributed to both
the high resolution of ultrasound equipment and
also our understanding of the newer techniques to
visualize the palate [3, 4].
The type and extent of the cleft palate can be
diagnosed with reasonable accuracy in the rst
trimester. This chapter deals with an algorithmic
approach to dene the cleft type and its extension
in the rst trimester 11 to 14weeks scan.
7.1 Unilateral Cleft Lip
andPalate
Unilateral cleft of both the lip and palate may be
complete or incomplete. In a complete unilateral
CLP, direct communication exists between the oral
and nasal cavities on the side of the palate where
the cleft is situated. The nasal septum is most often
attached to the palatal shelf on the non-cleft side.
Unilateral CLP can be conned to the primary
palate alone without extension into the secondary
palate (Fig.7.1a). In unilateral CLP, cleft exten-
Supplementary Information The online version of this
chapter (https://doi.org/10.1007/978- 981- 16- 4613- 3_7)
contains supplementary material, which is available to
authorized users.
sion into the secondary palate almost always
appears as a lateralized defect in the parasagittal
section (Fig.7.1b). The cleft extension into the
secondary palate appears paramedian due to
fusion of nasal septum with the palatal shelf on
the non-cleft side.
In the types where the nasal septum is not
fused with the palatal shelf, then the cleft in the
secondary palate appears as a bilateral extension
on either side of the vomer [5] (Fig.7.1c).
In unilateral CLP, the midsagittal view is not
diagnostic as the maxillary line appears intact
(Fig. 7.2a). The shortening of the maxillary line is
evident in the parasagittal view, as shown in
(Fig.7.2b).
The axial section depicts the lateralized defect
in the soft tissue of the upper lip (Fig.7.2c) and
also demonstrates its extension into the alveolar
arch (Fig.7.2d). The lateralized labial defect can
be seen in the nose chin view (Fig.7.2e) and the
defect in the retronasal triangle can be seen in the
coronal section (Fig.7.2f).
There can also be a complete absence of the
maxillary line in the parasagittal section, as
shown in Fig. 7.3b. Thus depending on the
degree of extension of a cleft into the secondary
palate, shortening, or complete absence of the
maxillary line is observed in the parasagittal
section on the side of cleft.
Figure 7.4 is an illustration of the utility of
axial view in evaluating unilateral CLP.Figure7.4a
clearly demonstrates the defect in the soft tissue
© 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_7
49
50
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
abc
Fig. 7.1 Phenotypic variations in unilateral CLP (a)
Cleft involving the premaxilla alone (b) Cleft involving
the premaxilla and secondary palate with vomer attached
to non-cleft side. (c) Cleft involving the premaxilla with a
a
NB
ML
M
c d
bilateral extension into the secondary palate. Note that the
vomer is deviated to the non-cleft side (Black solid line
indicates vomer)
b
*
Fig. 7.2 Unilateral CLP at 14 weeks (TAS) (a)
Midsagittal prole showing the intact maxillary line
(ML). Nasal bone (NB), Mandible (M). (b) Shortening of
the maxillary line in the parasagittal section note that the
line is absent proximally (*). (c) Axial view showing the
lateralized defect (arrow) in the soft tissue of the upper lip.
(d) Axial view depicting discontinuity of the alveolar arch
(arrow). (e) Coronal view of the upper lip showing the
labial defect (*) upper lip (UL), lower lip (LL), nose (N).
(f) Lateralized defect (*) in the base of RNT.Apex (A)
7.1 Unilateral Cleft Lip andPalate
51
e
N
UL
Fig. 7.2 (continued)
UL
*
LL
f
A
abc
NB
ML
M
NB
M
*
M
M
def
Fig. 7.3 Unilateral complete CLP at 13+4 weeks (TVS)
(a) Normal midsagittal prole showing intact maxillary
line (ML). Nasal bone (NB), mandible (M). (b) Complete
absence of maxillary line in parasagittal section. (c)
Rendered view of face depicting unilateral cleft lip (Note:
asymmetry of the soft tissues on the non-cleft side (*)).
(d) Axial view depicting defect (arrow) in the alveolar
arch. (e) Nose chin view depicts lateralized defect (*) in
the upper lip. (f) lateralized defect (arrow) in base of RNT,
apex (A)
A
M
M
52
ab
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
*
V
Fig. 7.4 Axial view in unilateral CLP at 13 weeks (a)
(TVS) Anterior axial view depicting defect (arrow) in the
soft tissue and the alveolar arch extending into the second-
of the upper lip and the degree of palatal shelf
separation. As the acoustic shadowing from the
alveolar arch of the maxilla is very minimal, the
cleft extension into the secondary palate can be
demonstrated in the axial view (Fig. 7.4a, b).
Video 7.1 demonstrates a TVS volume acquisition in the axial plane; the defect in the alveolar
arch can be demonstrated by scrolling from mandibular arch to maxillary arch.
Multiplanar imaging favors correlation of the
sonographic markers in sagittal, axial, and coronal planes. The cleft can be simultaneously visu-
alized in all three orthogonal planes in
multiplanar imaging [6].
In Fig.7.5 the reference dot is placed on the
defect in the parasagittal section where the maxillary line is absent. The defect is simultaneously
visualized in the axial plane and in the coronal
plane. Video 7.2 illustrates the position of the reference dot and its correlation in all three planes.
The added advantage of visualizing both the
midsagittal and parasagittal sections in a single
plane format is obtained with TUI [7]. Figure7.6
depicts the midsagittal section and the parasagittal
sections of the cleft and the non-cleft side simultaneously. Note that the midsagittal and the
parasagittal section on the non-cleft side shows
an intact maxillary line, whereas there is a
shortening of the maxillary line on the cleft side.
ary palate (*) (b) (TAS) Transverse axial view demonstrating unilateral defect (arrow) with the vomer (V)
attached to the palatal shelf on the non-cleft side
Video 7.3 shows the appearance of the maxillary line in sagittal sections in unilateral
CLP.Note the disappearance of the proximal portion of the maxillary line in the cleft side.
The utility of the three planes in identifying
unilateral CLP is illustrated in Fig.7.7. The midsagittal plane is not diagnostic (Fig. 7.7a), and
the coronal view shows the lateralized defect in
the base of RNT (Fig.7.7b) [8]. The axial plane
illustrates the defect in the upper lip and alveolar
arch (Fig.7.7c).
Figure 7.8 is an illustration of unilateral CLP
conned to the premaxilla with a normal appearance of midsagittal and coronal views at the
13weeks scan (Fig.7.8a, b). Follow-up scan at
19 weeks reveals a unilateral cleft of the lip in
Fig. 7.8c, e depicts interruption in the alveolar
arch. Note that the base of the premaxillary triangle is intact (Fig.7.8d).
A unilateral defect conned to the anterior
premaxilla is neither picked up by the midsagittal view nor in the retronasal triangle and is
only evident in the axial view. Hence even a
combination of the maxillary gap and retronasal triangle proposed as a good screening
method, can miss a unilateral defect conned to
the premaxilla. This shows that the axial view
has the maximum utility in identifying unilateral CLP [9].