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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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7.3 Median Cleft Lip andPalate
63
NB
PM
V
Fig. 7.16 2D vs. 3D midsagittal section in bilateral CLP
+4
at 12
weeks. (a) (TAS) midsagittal section, presence of
maxillary gap (arrowhead) with the vomer mimicking the
maxillary line. (b) (TVS) 3D midsagittal section shows
that the vomer is seen in the superior plane, and the sec-
M
a
PM
V
M
ondary palate is absent. Note that the area shown by the
yellow dot depicts the absence of the secondary palate.
Nasal bone (NB), Vomer (V), Premaxilla (PM), and
Mandible (M). (Video 7.5)
ML
Fig. 7.17 (a) TUI in complete bilateral CLP 13+6 weeks
(TVS) In midsagittal view (section 2) the maxillary line
(ML) is formed by premaxilla and vomer, in parasagittal
sections (section 1 and 3), there is complete absence of
maxillary line (arrow). (b) TUI in bilateral CLP with
intact secondary palate 13
+3
weeks (TVS). Interrupted
maxillary line is seen in midsagittal and parasagittal view
(section 1, 2, and 3) premaxillary protrusion (arrow) secondary palate (pointer). In parasagittal sections (section
1and 3), the posterior portion of the maxillary line
(pointer) is visible
64
23
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
b
Fig. 7.17 (continued)
1
midline defect in the lip is very subtle and is demonstrated in 3D image with VCI (Fig. 7.27d).
Figure 7.27e shows rendered view of the face,
and Fig.7.27f illustrates multiplanar imaging in
median CLP.Video 7.7 multiplanar imaging in
median CLP illustrating the defect in three
orthogonal planes.
TUI in median CLP shows the maxillary line
in midsagittal and parasagittal sections, the midsagittal section shows a small line posteriorly
which is the vomer, and the parasagittal sections
show a complete absence of maxillary line
(Fig.7.28).
Figure 7.29 is an illustration of ipped face
technique to render the palate in median
CLP.Note that the vomer is seen in the midline,
and there is a midline defect in the alveolar arch.
Figure 7.30a is an illustration of sagittal sections in mediolateral CLP.Coronal sections in
2D and 3D (Fig. 7.30c and d) show complete
absence of the base of RNT. The axial views
(Fig. 7.30e and f) show a large mediolateral
defect involving the secondary palate in 2D and
3D, respectively.
Figure 7.31 is an illustration of median CLP in
holoprosencephaly. The sagittal view in Fig.7.31a
illustrates at facial prole with a complete
absence of the maxillary line. Axial and coronal
views depict the midline defect (Fig.7.31b and c).
Figure7.31d shows the rendered view of the face,
and Fig.7.31e shows the fused choroid plexus in
holoprosencephaly. Video 7.8 demonstrates the
complete absence of the maxillary line in a case of
holoprosencephaly at 14weeks.
7.3 Median Cleft Lip andPalate
a
b
65
Fig. 7.18 Postnatal correlation vs. 3D rendering in two cases of bilateral CLP. (TVS) (a) 13weeks. (b) 12weeks. Note
the appearance of premaxillary protrusion in the rendered face as early as 12–13weeks of gestation
The appearance of the sagittal sections in
median CLP depends on the degree of the palatal
shelf separation. Most often, the midsagittal sec-
tion shows only the posterior aspect of the maxillary line, which is the vomer (Fig.7.32a). In the
parasagittal section, there can either be a complete absence of maxillary line or only the proxi-
mal portion of the line corresponding to the
alveolar arch may be visible.
When one moves from one side to the other to
obtain the midsagittal section, the ultrasound
beam may pass through the vomer alone or may
pass through the alveolar arch and the vomer giving the appearance of either shortened or inter-
66
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
a
NB
ML
c
b
M
d
*
*
e
Fig. 7.19 Complete bilateral CLP with no maxillary gap
+6
at 13
weeks (TAS) (a) No maxillary gap evident in the
midsagittal view, premaxillary protrusion (arrow).(Video
7.6) (b) Parasagittal section depicting the complete
absence of maxillary line caudal to premaxilla (arrow). (c)
Axial view shows bilateral cleft (arrows) in the alveolar
margin with premaxillary protrusion. (d) Defect in the
base of the RNT (arrows), (e) (TVS) Rendered view of the
face. Nasal bone (NB), mandible (M), maxillary line
(ML), * denotes vomer
de
7.4 Atypical Cleft
67
abc
NB
ML
M
PM
PM
**
Fig. 7.20 Complete bilateral CLP with no demonstrable
maxillary gap at 13 weeks. (TVS) (a) Midsagittal view
showing single line and no gap. (b) Absence of maxillary
line in parasagittal view (arrow) posterior to premaxilla
(PM) (c) Bilateral defect in the lip (arrows) in coronal
view (d) (TAS) Omni view demonstrating cleft in the secondary palate (*) (e) Rendered image of the face showing
bilateral cleft lip. Nasal bone (NB), Maxillary line (ML),
Mandible (M)
rupted maxillary line (Fig. 7.32b). Note in all
7.4 Atypical Cleft
sections, there is an “absent superimposed line
sign” [12].
Figure 7.33 is a line diagram illustrating the
2D markers in sagittal, axial, and coronal planes.
A suspicion in the 2D planes should prompt one
for an extended 3D evaluation of the palate.
Amniotic band syndrome causes bizarre atypical
clefts that do not correspond to any anatomic pattern. Figure 7.34 depicts images of an atypical
cleft in amniotic band syndrome, where only the
distal posterior portion of the palate remains [1].
68
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
a
NB
V
P
M
c
PM
v
b
PM
V
d
V
P
Fig. 7.21 Superimposed line sign and maxillary gap in
bilateral CLP (13
+6
weeks midsagittal section TAS) (a)
normal appearance of superimposed line, vomer (V) at the
posterior aspect of the maxillary line, (b) absence of
superimposed line sign with no gap in complete bilateral
CLP. (c) single line and maxillary gap (arrowhead) in
complete bilateral CLP (d) (TVS) maxillary gap (arrowhead) and presence of superimposed line sign in cleft with
intact secondary palate. Premaxilla (PM), palate (P),
Nasal bone (NB), Mandible (M)
7.4 Atypical Cleft
69
a
de
PM
b
c
f
V
g
h
i
Fig. 7.22 Bilateral CLP at 12weeks with follow-up at
15weeks and postnatal correlation (12weeks TAS a, b,
and c) (a) Midsagittal section presence of maxillary gap
(arrowhead) (b) axial section bilateral paramedian defect
(arrows). (c) Coronal section defect in base of RNT
(arrows). (15weeks d, e, and f). (d) Midsagittal section
premaxillary protrusion (PM), Vomer (V) (e) Parasagittal
section complete absence of maxillary line caudal to premaxilla (arrow denotes premaxilla). (f) Axial section
bilateral paramedian defect (pointer). (Postnatal images g,
h, and i) (g) Prole view illustrating PMP. (h) Bilateral
paramedian clefts in the upper lip. (i) Vomeropremaxillary
junction and cleft extension into the secondary palate
70
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
a
*
*
*
*
*
*
b
*
*
c
Fig. 7.23 Rendered view of the intraoral surface of the
palate illustrating variations in bilateral CLP. (a) Note the
varying degree of palatal shelf separation in cases of bilateral CLP (*) points to separated palatal shelves. (b) 13
weeks (TVS) Note that the bilateral paramedian cleft
+3
extends to the premaxilla alone and does not involve the
secondary palate (highlighted in green). (c) 13
(TVS) Note that the cleft extends into the secondary palate
(highlighted in green), the nasal septum (vomer) is seen in
the midline as there is a cleft of the secondary palate
+6
weeks
MIDSAGITTAL PARASAGITTAL
bc
7.4 Atypical Cleft
a
71
SAGITTAL
d
e
PMP
VB
P
MIDSAGITTAL PARASAGITTAL
PMP
VB
AXIAL
PMP
PMP
CORONAL
Fig. 7.24 Line diagram illustrating the 2D markers in the (a, b, and c) sagittal, axial, and coronal planes in bilateral
CLP. (d) Bilateral CLP involving the premaxilla alone. (e) Complete bilateral CLP
72
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
a
b
Fig. 7.25 Phenotypic variations in bilateral cleft lip and
palate. (a) 12
PMP
PMP
+4
weeks (TVS) bilateral CLP with axial section shows midline extension into the secondary palate
(arrows) and midsagittal section showing the premaxillary
protrusion (arrow) and maxillary gap (arrowhead), Nasal
NB
M
NB
ML
M
bone (NB), and Mandible (M). (b) 13
+6
weeks (TAS)
bilateral CLP with axial section shows midline extension
into the secondary palate (arrows) and midsagittal section
showing subtle premaxillary protrusion (arrow), maxillary line (ML)