Palatoplasty at Warwickshire Hospital

What is palatoplasty?

Palatoplasty is an operation to repair a cleft palate, where the roof of the mouth hasn't joined together properly before birth. It closes the gap between the mouth and nose and repositions the muscles of the palate to support normal speech, feeding and breathing.

What conditions does it treat?

Palatoplasty treats cleft palate, which affects roughly 1 to 25 in every 10,000 births, with rates varying by ethnic background. A cleft can affect just the soft palate at the back, extend through the bony hard palate at the front, or reach as far as the gum ridge and lip; some clefts are 'submucous', hidden beneath the lining of the mouth without an obvious gap, and are sometimes only picked up because of speech problems. About half of all cases occur alone, and the other half occur alongside a wider genetic syndrome.

Signs that suggest a problem with the palate specifically include:

• hypernasal speech, which sounds nasal
• nasal emission, the sound of air escaping through the nose while talking
• nasal turbulence, air squeezing noisily into the back of the nose
• certain sounds coming out nasal, such as 'b' sounding like 'm', or 'd' like 'n'
• food or drink, especially thin liquids, occasionally coming down the nose

What are the benefits?

Repairing the palate closes the gap between the mouth and nose, and helps develop clearer, less nasal speech by reducing or removing nasal emission and turbulence and enabling sounds, such as 'b' and 'd', that weren't possible before. It also stops food and drink passing into the nose and supports normal feeding, breathing and facial development.

Around 80% of children have normal palate function and speech after just one operation. Newer, muscle-repositioning techniques such as Furlow's double-opposing Z-plasty have been shown to give better palate lengthening and lower rates of problems than some older pushback techniques.

Are there different types or surgical approaches?

Repair can be limited to the soft palate, or include the hard palate too, depending on the extent of the cleft. Several established techniques exist, refined over decades, including Von Langenbeck, Bardach, Veau-Wardill-Kilner and Furlow's double-opposing Z-plasty; the surgical team will choose based on your child's specific cleft.

Furlow's technique specifically joins the left and right palate muscles and repositions them further back, while also lengthening the palate, using zig-zag (Z-shaped) cuts closed with dissolving stitches. Research comparing it with an older pushback technique (Veau-Wardill-Kilner) found Furlow's gave better palate lengthening and a lower rate of problems, regardless of the patient's age or the size and type of cleft.

There's also debate over timing and staging: some centres repair the whole palate in one operation, usually around 9 to 12 months old, while others prefer two stages, closing part of the palate earlier, sometimes alongside lip repair around 3 months, with the remainder repaired later. Repair is also often combined with grommet (ear tube) insertion in the same operation, since fluid in the middle ear (glue ear) is very common with cleft palate.

What happens before the procedure?

The ideal age for repair is 6 to 12 months, since speech development becomes less optimal the later beyond around 3 years old that repair happens. Beforehand, hearing checks, including tympanometry and an ear examination, are carried out, since glue ear is so common with cleft palate, and any wider genetic syndrome or additional condition is fully assessed.

Good nutrition and weight gain matter before surgery. Occasionally a feeding tube is used if feeding by mouth isn't achieving enough weight gain, and diet is sometimes changed to a thicker, spoonable consistency a few weeks beforehand, so your child is comfortable with it before it's continued after surgery.

Surgery is postponed if there's any sign of infection around the planned date, so let the team know about any illness beforehand. Fasting instructions will be given, usually allowing feeds up to around 6 hours before the operation, depending on your team's specific advice.

What happens during the procedure?

1. Your child is given a general anaesthetic, so they're fully asleep throughout, and a drip is placed for fluids and medicines.
2. The mouth, nose and throat are cleaned with an antiseptic, and the palate is injected with a local anaesthetic to reduce bleeding.
3. Working through the mouth, the surgeon separates tissue on each side of the cleft and repositions the small muscles that lift the palate into a more normal sling shape.
4. In Furlow's technique specifically, zig-zag (Z-shaped) cuts are used to swap tissue flaps over, which both closes and lengthens the palate.
5. The nasal lining, muscle layer and mouth lining are stitched closed in layers, using dissolving stitches.
6. Sometimes, tiny grommets (ear tubes) are placed during the same operation to help with persistent ear fluid.

The whole operation typically takes 2 to 3 hours.

What does recovery look like?

In hospital

Parents and carers can usually stay with their child, who is likely to be drowsy and a little irritable for the first day. Occasionally, swelling affects breathing immediately afterwards, so airway monitoring is close at this stage, with measures such as a temporary tongue stitch or a small nasal tube used if needed.

Most children stay in hospital for 1 to 3 nights, depending on how well they're eating and whether other procedures, such as grommets, were done at the same time. Occasionally, closer monitoring on a specialist ward is needed, particularly for children with other health conditions.

At home

A feeling of a lump at the back of the throat is normal for the first couple of days, and all the stitches used are dissolvable. Only soft or pureed food and drink is needed for about 2 weeks, avoiding hard, sharp or crunchy foods, such as crisps, biscuits, toast or chips, and drinking straws, since these could damage the repair or cause pain.

Rinse the mouth with plain water after food and milk for about 4 weeks, and keep up normal tooth brushing, with help for younger children; some parents find giving bio-yoghurt (with 'friendly bacteria') twice a day helps the wound heal. Give regular pain relief such as paracetamol or ibuprofen as advised, and make sure any prescribed course of antibiotics is completed.

Plan for 1 to 2 weeks off school or nursery, and avoid swimming, trampolining and contact sports for about 4 weeks. Children over about 18 months, or those who tend to put fingers or objects in their mouths, may need to wear arm splints for the first 2 weeks to protect the repair while the palate heals, which takes around 2 weeks.

A cleft nurse often visits at home within 2 weeks, and the surgeon reviews progress at around 3 months. A speech assessment around 6 months checks how speech has changed, since it can take up to a year to see the full benefit, and swelling straight after surgery can temporarily make speech sound different, better or worse, than it will eventually settle to.

Further speech and language therapy is arranged if needed, particularly for sounds made in the wrong place in the mouth, which surgery alone doesn't fix. A further assessment for speech, and occasionally further surgery, is usually carried out around age 4 to 5, once speech has largely developed.

What are the risks and complications?

As with any operation, palatoplasty carries some risks:

• swelling affecting breathing straight after surgery: uncommon, managed with close monitoring and, if needed, a temporary tongue stitch or small nasal tube
• bleeding after surgery, especially if a child cries vigorously: usually settles with a few minutes of gentle pressure
• infection at the repair site: uncommon
• a hole reforming between the mouth and nose (a fistula): the main long-term risk, with rates varying by technique and cleft size; one study of Furlow's technique found this in around 9 in 100 children, though many small fistulas cause no problems and don't need further surgery
• the palate not moving well enough for clear speech (velopharyngeal insufficiency): may need further assessment and, sometimes, another operation
• snoring or interrupted breathing during sleep: uncommon
• a voice that sounds blocked up (hyponasality): uncommon
• rarely, reduced blood flow to the repaired tissue: rare but serious
• risks related to the general anaesthetic itself, which your team will discuss with you beforehand.