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1、UnitTwentySix CleftPalateandCleftLip:aTeamApproachtoClinical ManagementandRehabilitationofthePatient Duringthe1930sand1940smostchildrenwhohadundergonesurgeryforcleftpalaterequiredspeechtherapy.Butatthattimeitwascommonpracticeforsurgeonstowaituntiltheageofthreeorfourtoclosethepalate.Naturallythech

2、ildhaddevelopedhislanguagebyagefourandfrequentlyhadacquiredcompensatoryarticulationhabitsbecauseofaconstrictedmaxillaandanonfunctionalvelopharyngealport.Hisunoperatedconditionmadei(impossibleforhimtoimpoundairwithintheoralcavity.Nasalairemissionandhypernasalresonancecouldnotbeavoided. Whensurgerywa

3、sfinallyperformedthefamilyaswellasthesurgeonwasoftendismayedtofindthatadramaticchangeintonalqualityhadnotoccurredwiththeclosingofthecleft.Thechildfrequentlycontinuedtotalkverymuchashehadtalkedbeforetheoperation,witha"cleftpalatespeech."Inmanycasesthiswasbecausehismaladaptivespeechhabitshadbecomesoin

4、grainedthathisvoicesounded"familiar"and"right"tohim.Ifhedidnotrecognizeitasabnormal,thismeantthatheandthespeechclinicianwereinfbralongsiegeoftherapy. Severaltypesofdentalprostheseswereusedin(he1930sand1940sasprimarytreatmentforseparatingtheoralandnasalcavities;'however,thecleftproblemwasconsidereda

5、nexerciseforthesurgeon.Ifandwhentherewasabreakdowninthesurgicalrepair,thesurgeonrepeatedhisproceduresinhisefforttoclosethepalataldefect.Someoftheearlypatienthistoriesattheinstituterecord10,15,and20surgicalproceduresinattemptingtoclosetheoraldefect.Hypernasalvoicequalityandmaladaptivearticulationhabi

6、tswereassociatedwiththesemultiplesurgicalfailures.SomeSurgeonfeltthatthenextlogicalstepaftersurgicalmanagementfailedwastoreferthepatienttoaprosthodontist.Fewspeechclinicianswereavailabletothesurgeonuntiltheteamconceptofcleftpalatemanagementdeveloped. Certainlytheearlysurgeonshadtheirmeasureofsucces

7、s,butthepercentageofgoodresultswasnottoswelluntilthelate1950sandearly1960s,whenplasticsurgeonsexpressedtheirawarenessofhumangrowthanddevelopmentofthemid-thirdoftheface.Withthisawarenesstheywereabletoimprovetheirtechniquesandtotime(hesurgicalprocedurestominimizeinterferencewithcentersoffacialgrowth.L

8、engtheningtheoraltissueandutilizingavomerflapgreatlyreduced(hetraumatomaxillarysegments.Moreimportanttospeechdevelopmentwastheimprovedtwostagepalatalclosuretechnique,implementedbeforethechildreached18monthsofage.Thesefactshadamarkedinfluenceonthedevelopmentofmorenormalspeechandvoicepatternsinchildre

9、nwithacleftpalate. H.KCooperrealizedthatnoone-treatmentprocedurewasapanacea.Buthisteamconcept,whichhebegantoimplementinthe1930s,emphasizethevariedadvantagesofinterdisciplinaryevaluationandtreatmentofcleftpalate.Hestressedtherehabilitativemanagementofthetotalperson,andasprofessionalmembersoftheinter

10、disciplinaryteam,werealizedweweredealingwithanintegratedpailof.thewholeperson.Thisistheconceptthathasbeendevelopedandcontinuallystressedatthelancastercleftpalateclinic. Whyateam? ItiswellrecognizedthatindividualsbomwithcleftsoftheUpandpalateorpalateonlywillfaceanumberofinterrelatedproblems.Intheea

11、rliestdaysofteammanagementofclefts,clinicalobservationsledtotherecognitionthatchildrenwithcleftlipandpalate(includingacleftofthemaxillaryalveolararch)requiredlheservicesofareconstructivesurgeontorepair(heclefts,aspeechpathologisttoaddressissueofvelopharyngealfunctionandarticulation,andadentalspecial

12、isttoaddressproblemsassociatedwithocclasionandcongenitallymissingteeth. Centerswereoftenbuiltaroundthesetreatmentspecialistsbecauseoftheirlong-terminvolvementwithpatientswithclefts.Manyteamsdidnothavepediatricians(eventhoughthemajorityofpatientswerechildren),orotolaryngdogists(eventhoughmostpatient

13、shadchronicmiddlecardisease).Initsearlyadvocacyofteams,theAmericancleftpalateAssociation(ACPA)indicatedthataproperteammusthavealaminimumaplasticsurgeon,aspeechpathologist,andanorthodontist.Wouldateamthathadonlythesespecialtiesbeabletoqualifyasacomprehensivecenter?Asthemedical,dental,andbehavioralsci

14、encesexpanded,newsubspeciakieswerebomtoaddressproblemsthatcouldnotevenbedetectedfourdecadesago.Subspecialtiessuchashumangeneticsandneuroradiologyarerecentadditionstomedicine,andspecialtytestssuchasnasopharyngoscopy,multiviewvideofluoroscopy,and3-DCTscanswerenotwidelyavailablebeforethe1980s.Asaresult

15、,organizationssuchasACPAhaverecognizedthatminimalstandardsmaynolongerbevalid,andcenterswillneedtobemorecomprehensiveinorder(omeetapatient'sneeds.Howcomprehensiveshouldateambe? TableIliststhespecialistswhowouldhaveaninterestinchildrenwithcleftingorcraniofacialanomaliesalongwiththereasonforthatintere

16、st.Wouldpatientcarebecompromisedifanyofthesespecialistswereomitted?Correctdiagnosescouldgoundetected.Propertreatmentsknownonlybycertainspecialistscouldgounadministered. Table1Specialistswhoshouldbeincludedonacraniofacialteamandthereasonfortheirpresence.When"pediatric"appearsinparentheses,theimplica

17、tionisthatthemajorityofpatientsarcpediatriccasesandshouldrequirepediatricsubspecialization. Specially reasonforinclusion Medicalspecialists PlasticSurgery Pediatrics Neurology(Pediatric)EndocrinologyOphthalmology(Pediatric) ReconstructionofcleftandstructuralmanagementofVPI"Medicalmanager"fort

18、hechild Atleast10%ofchildrenwithcleftshaveCNSanomaliesApproximately20%ofchildrenwithcleftsarcofshortstatureFrequenteyeanomalies,especiallyinSticklersyndrome(5%ofcleftpalate) Cardiology(Pediatric)Otolaryngology(Pediatric) Frequentheartanomalies(atlast10%ofchildrenwithclefs) Veryfrequentassociatio

19、nofmiddleeardiseaseandairwaydisorder Radiology/NcuoradiologyNeurosurgery(Pediatric)Pulmonology(Pediatric)Anesthesiology(Pediatric) Vidcofluoroscopy,CT,MRasfrequentdiagnosticmodalitisFrequencyofcraniosynostosisandneedforintracranialsurgeryFrequentassocialionofairwayrelatedproblems Difficultintubat

20、ionscommoninchildrenwithcraniofacialanomalies Genetics/Dysmorphology Veryhighfrequencyofassociatedsyndromesandgeneticetiologies Psychiatry Needtoassurepsychologicalwellbeingofchildrenundergoingfrequentsurgery Dentalspecialist OralSurgeiyOrthodontics Frequentfacialskeletalsurgery Universalnee

21、dfororthodontictherapyinchildrenwithcleft  lip/palate ProstheticDentistryPediatricDentistry Needfortoothreplacementinmanycasesofcompleteclefts Needtomaintaingooddentalhealthandpreventagainsttoothloss behavioralspecialist SpeechPathologySocialService Veryfrequentspeech/languagedisordersinc

22、hildrenwithcleftsSocialadjustmentproblems,hospitalrelatedproblems,fundingproblems Psychology Assessmentandmanagementofselfimageandadjustmentathomeandinschool Neuropsychology Audiology ChildlifeSpecialist OtherSpecialties Nursing Nutritionist ComputerProgrammer Psychometricassessmentfrequen

23、tlyrequiredVeryfrequenthearinglossassociatedwithcleftingFrequenthospitalizationsrequireattention Frequenthospitalservices(inandoutpatient) lowweightacommonassociatedanomaly Databasemanagementessentialtolearningabouttreatmentoutcome VOCABULARY 1. compensatory 2. articulation 3. velopharyngeal

24、 4. resonance 5. maladaptive 6. ingrain 補償?shù)?，代償?shù)模r償N,報酬的 ①連接、接合②發(fā)音、發(fā)音動作③清晰度，可值度④關(guān)節(jié)腭咽的 ①回聲，反響②共振、共鳴、諧振③叩響 不能適應(yīng)的，錯誤適應(yīng)的 ①使（原料）染色②使遺體滲透，使根深蒂固n.①原料染色②固有的品質(zhì)，本質(zhì) 7.voice ⑦說話聲，嗓音、嗓子；②聲音；③愿望，意見，發(fā)言權(quán)；④語態(tài)，聲帶振動濁音特點 8. speechclinician 9. awareness 10. lengthen 11. vomer 12. panacea 13. implement 語音治

25、療師 意識，認識，知道 使延長，延長元音音長，變長，延伸，長起來 犁骨 治百病的靈藥，萬能藥 ①工具，器具②家具，服裝vt.①貫徹、完成履行⑦給……提供方法，為……供應(yīng)器具③補充 14. pathologist 15. alveolararch 16. pediatrics 17. Neurology 18. Endocrinoiogy 19. Ophthalmology 20. Cardiology 21. Otolaryngology 22. Radiology 23. Neurosurgery 24. pulmonlogy 25. Anesthesiol

26、ogy 26. Genetics 27. Dysmorphology 28. psychiatry 病理學(xué)家 牙槽弓，牙頒弓兒科學(xué) 神經(jīng)病學(xué)內(nèi)分泌學(xué)眼科學(xué) 心臟病學(xué)、心臟學(xué) 耳鼻喉科學(xué)放射學(xué) 神經(jīng)外科學(xué) 肺科學(xué) 麻醉學(xué) 遺傳學(xué) 異形學(xué) 精神病學(xué)  29. Orthodontics 30. Behavioral 31. speech 32. psychology 33. Ncumpsyckology 34. Audiology 35. Nutritionist 36. Subspecialty 37. nasopharyngoscopy 38.

27、 multiview 39. videofluoroscopy 40. scan 正畸學(xué)、正牙學(xué) 行為的、關(guān)于行為的 ①言語、談話、說話②演說、發(fā)言、講話③民族語言、方言、專門語言④用語、引語 心理學(xué) 神經(jīng)心理學(xué) 聽覺學(xué) 營養(yǎng)學(xué)家 鬲屬專業(yè)，次級專業(yè) 鼻咽鏡 多向的 電視熒光鏡 ①細看、審視②瀏覽、粗略地看③掃描、掃掠④校驗Notes 1. Velopharyngealport：腭咽口（由軟腭、咽后壁，兩咽側(cè)壁所構(gòu)成）compensatoryarticulationhabit：代償性發(fā)音習(xí)慣 2. Nasalairemission：鼻漏氣。也可用“Nasales

28、cape”表示。為腭咽閉合不全時出現(xiàn)的- 種異常發(fā)音現(xiàn)象。 3. hypernasalresonance::過高鼻共鳴（音）Breakdowninthesurgicalrepair：外科修復(fù)術(shù)手敗。 4. hypernasalvoicequality：過高鼻音質(zhì)，與hypernasalresonance相同two-stagcpalatalclosuretechnique：腭裂兩期封閉術(shù) 5. mukiviewvideoilurorscopy：多向性電視熒光鏡（多向性光導(dǎo)電視鏡）3-DCTscan：即three-demensionCTscan：三維CT掃描 6. VPI：即velopharyngealinadequancy：腭咽閉合不全