75 / 280
these children may be managed with CPAP in the
acute setting and with time the sleep improves.
Some may require chronic assistance with CPAP.
Alteration of the obstructing flapmay be an effective
alternative [16].
Flexible endoscopic evaluation of the velophar-
ynx is done during speech. This will allow the assess-
ment of the palatal and lateral wall function to see if
there is an obvious area that the obstructive flap(s)
can be altered. As an example, if there was good
velar motion and the sphincter pharyngoplasty
had lateral velopharyngeal obstruction that was
unneeded for speech, the flaps can be altered to
open the lateral aspects of the velopharyngeal port
increasing the airway. These alterations need to be
done precisely with attention to reduce scaring by
closing the mucosa. There have been many reports
of the takedown of a pharyngeal flap for the
improvement of the airway with no deterioration
of the speech [17].
CONCLUSION
It is imperative that we screen children with clefts
for sleep disordered breathing. Though often the
history may be significant enough for intervention,
most of the children in this category will have
abnormal sleep studies. Understanding the severity
may assist in defining the need for intervention.
Intervention for sleep disordered breathing and
obstructive sleep apnea may vary depending on
the anatomical findings. Though tonsillectomy
and partial adenoidectomy may be the initial
approach, there is a high likelihood that this alone
will not solve the problem. Midface advancement,
mandibular distraction, flap alteration and CPAP
must all be considered in the care of these patients.
Coordination of care between cleft surgeons, otolar-
yngologists, sleep medicine and pediatrics is necess-
ary to optimize the treatment and decrease the risk
for cognitive disruption.
Acknowledgements
None.
Conflicts of interest
The author has no conflict of interest in this area.
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READING
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Muntz
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