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British Journal of Oral and Maxillofacial Surgery 52 (2014) 275–276
Short communication
Clinical grading system for submucous cleft palate Alistair Smyth ∗ Leeds General Infirmary, Northern and Yorkshire Regional Cleft Service, United Kingdom Accepted 28 November 2013 Available online 1 February 2014
Abstract Submucous cleft palate is a structural abnormality of the palate. The clinical features vary, as does the functional impairment, which ranges from none to severe. Although there is a poor correlation between the presenting clinical signs and the severity of velopharyngeal insufficiency during speech, a clinical grading system could assist surgical management and allow more meaningful comparisons to be made between outcome studies. The grading system described is based on clinical examination alone and reflects the likely degree of structural abnormality of the musculature of the soft palate. © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Submucous cleft palate; Grading system
Introduction Calnan described the classic presenting clinical features of submucous cleft palate as a bifid uvula, a midline transluscent zone (zona pellucida) of the soft palate, and a palpable bony notch within the posterior hard palate.1 Separation and anterior insertion of the velar muscles impair normal function and can result in difficulties with swallowing and speech. Abnormal insertion of the levator palatini muscle reduces the lift and stretch of the soft palate and can present with velopharyngeal insufficiency during speech with hypernasality and abnormal nasal emission. A classification or grading system of submucous cleft palate would allow more meaningful comparison between outcome studies and could assist clinical management, as intravelar surgery would be more appropriate in patients with more severe structural abnormality of the muscles. The classification system described by Sommerlad et al.2 includes the velar muscle abnormality as exposed at operation, and the hard palate notch palpated and seen at the time of operation. A further classification system by Khan et al.3 is based solely on the degree of involvement of the hard palate bone (no involvement, palatine bones only,
palatine and maxillary bones, and an unusual description of midline extension into the primary palate anterior to the incisive foramen). Clinically, it can be difficult to assess when the bony involvement extends from the palatine bones into the maxillary bones. Extension into the primary palate anterior to the incisive foramen is difficult to explain on embryological grounds and must be extremely rare. Our grading system of 0–3 is straightforward and based entirely on preoperative clinical examination of the soft and hard tissues of the palate. Although there is no direct correlation between the clinical grade of submucous cleft palate and the presenting degree of velopharyngeal incompetence during speech, this system could help to identify symptomatic patients who are most likely to benefit from intravelar surgery and others who may need additional operation. The scoring system is weighted in favour of features of the hard and soft palates by the application of a multiplier, which indicates the increasing embryological disruption present and the likelihood of an associated structural abnormality of the velar muscles.
Clinical grading system ∗
Tel.: +44 1133925115. E-mail address: [email protected]
Examination of the soft and hard palates and the uvula includes palpation of the posterior palate. An individual score
0266-4356/$ – see front matter © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2013.11.014
276
A. Smyth / British Journal of Oral and Maxillofacial Surgery 52 (2014) 275–276
Table 1 Clinical scoring of submucous cleft palate at presentation based on the clinical features of the uvula, and soft and hard palates. Structure and clinical feature Uvula Normal Grooved or bifid (incomplete) Bifid (complete) Soft palate Normal Midline groove at rest or during function Transluscent midline (zona pellucida) Congenital fistula Hard palate Normal Absent posterior nasal spine Palpable small bony notch Palpable and visible bony defect ≤ posterior third of hard palate Palpable and visible bony defect > posterior third of hard palate
Table 2 Allocation of clinical grades I, II and III for submucous cleft palate and likely associated structural abnormality of velar muscles. Final score
Clinical grade
Degree of structural muscle abnormality
1–6 7–12 13–20
I II III
Mild Moderate Severe
Allocated score
Multiplier
Assigned score (total score 0–20)
0 1 2
1 1 1
0 1 2
0 1 2 3
2 2 2 2
0 2 4 6
0 1 2 3 4
3 3 3 3 3
0 3 6 9 12
for these 3 features is allocated depending on the abnormality (Table 1). A multiplier of 1, 2, or 3 is applied to the scores for the uvula, soft palate, and hard palate, respectively, to assign a score for that structure. The scores are added to produce a total score with a possible range of 0–20 (Table 1). This is subdivided to produce 3 clinical grades (Table 2). The likely associated degree of structural abnormality of the velar muscle is shown as mild (grade I), moderate (grade II), or severe (grade III). A clinical example of grade III submucous cleft palate is shown in Fig. 1.
References 1. Calnan J. Submucous cleft palate. Br J Plast Surg 1954;6:264–82. 2. Sommerlad BC, Fenn C, Harland K, et al. Submucous cleft palate: a grading system and review of 40 consecutive submucous cleft palate repairs. Cleft Palate Craniofac J 2004;41:114–23. 3. Khan M, Ullah H, Naz S, et al. A revised classification of the cleft lip and palate. Can J Plast Surg 2013;21:48–50.
Fig. 1. Grade III submucous cleft palate (score 18): complete bifid uvula, midline transluscent area (zona pellucida), and palpable and visible bony defect, which is greater than the posterior third of the hard palate.
British Journal of Oral and Maxillofacial Surgery 52 (2014) 275–276
Short communication
Clinical grading system for submucous cleft palate Alistair Smyth ∗ Leeds General Infirmary, Northern and Yorkshire Regional Cleft Service, United Kingdom Accepted 28 November 2013 Available online 1 February 2014
Abstract Submucous cleft palate is a structural abnormality of the palate. The clinical features vary, as does the functional impairment, which ranges from none to severe. Although there is a poor correlation between the presenting clinical signs and the severity of velopharyngeal insufficiency during speech, a clinical grading system could assist surgical management and allow more meaningful comparisons to be made between outcome studies. The grading system described is based on clinical examination alone and reflects the likely degree of structural abnormality of the musculature of the soft palate. © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Submucous cleft palate; Grading system
Introduction Calnan described the classic presenting clinical features of submucous cleft palate as a bifid uvula, a midline transluscent zone (zona pellucida) of the soft palate, and a palpable bony notch within the posterior hard palate.1 Separation and anterior insertion of the velar muscles impair normal function and can result in difficulties with swallowing and speech. Abnormal insertion of the levator palatini muscle reduces the lift and stretch of the soft palate and can present with velopharyngeal insufficiency during speech with hypernasality and abnormal nasal emission. A classification or grading system of submucous cleft palate would allow more meaningful comparison between outcome studies and could assist clinical management, as intravelar surgery would be more appropriate in patients with more severe structural abnormality of the muscles. The classification system described by Sommerlad et al.2 includes the velar muscle abnormality as exposed at operation, and the hard palate notch palpated and seen at the time of operation. A further classification system by Khan et al.3 is based solely on the degree of involvement of the hard palate bone (no involvement, palatine bones only,
palatine and maxillary bones, and an unusual description of midline extension into the primary palate anterior to the incisive foramen). Clinically, it can be difficult to assess when the bony involvement extends from the palatine bones into the maxillary bones. Extension into the primary palate anterior to the incisive foramen is difficult to explain on embryological grounds and must be extremely rare. Our grading system of 0–3 is straightforward and based entirely on preoperative clinical examination of the soft and hard tissues of the palate. Although there is no direct correlation between the clinical grade of submucous cleft palate and the presenting degree of velopharyngeal incompetence during speech, this system could help to identify symptomatic patients who are most likely to benefit from intravelar surgery and others who may need additional operation. The scoring system is weighted in favour of features of the hard and soft palates by the application of a multiplier, which indicates the increasing embryological disruption present and the likelihood of an associated structural abnormality of the velar muscles.
Clinical grading system ∗
Tel.: +44 1133925115. E-mail address: [email protected]
Examination of the soft and hard palates and the uvula includes palpation of the posterior palate. An individual score
0266-4356/$ – see front matter © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2013.11.014
276
A. Smyth / British Journal of Oral and Maxillofacial Surgery 52 (2014) 275–276
Table 1 Clinical scoring of submucous cleft palate at presentation based on the clinical features of the uvula, and soft and hard palates. Structure and clinical feature Uvula Normal Grooved or bifid (incomplete) Bifid (complete) Soft palate Normal Midline groove at rest or during function Transluscent midline (zona pellucida) Congenital fistula Hard palate Normal Absent posterior nasal spine Palpable small bony notch Palpable and visible bony defect ≤ posterior third of hard palate Palpable and visible bony defect > posterior third of hard palate
Table 2 Allocation of clinical grades I, II and III for submucous cleft palate and likely associated structural abnormality of velar muscles. Final score
Clinical grade
Degree of structural muscle abnormality
1–6 7–12 13–20
I II III
Mild Moderate Severe
Allocated score
Multiplier
Assigned score (total score 0–20)
0 1 2
1 1 1
0 1 2
0 1 2 3
2 2 2 2
0 2 4 6
0 1 2 3 4
3 3 3 3 3
0 3 6 9 12
for these 3 features is allocated depending on the abnormality (Table 1). A multiplier of 1, 2, or 3 is applied to the scores for the uvula, soft palate, and hard palate, respectively, to assign a score for that structure. The scores are added to produce a total score with a possible range of 0–20 (Table 1). This is subdivided to produce 3 clinical grades (Table 2). The likely associated degree of structural abnormality of the velar muscle is shown as mild (grade I), moderate (grade II), or severe (grade III). A clinical example of grade III submucous cleft palate is shown in Fig. 1.
References 1. Calnan J. Submucous cleft palate. Br J Plast Surg 1954;6:264–82. 2. Sommerlad BC, Fenn C, Harland K, et al. Submucous cleft palate: a grading system and review of 40 consecutive submucous cleft palate repairs. Cleft Palate Craniofac J 2004;41:114–23. 3. Khan M, Ullah H, Naz S, et al. A revised classification of the cleft lip and palate. Can J Plast Surg 2013;21:48–50.
Fig. 1. Grade III submucous cleft palate (score 18): complete bifid uvula, midline transluscent area (zona pellucida), and palpable and visible bony defect, which is greater than the posterior third of the hard palate.
