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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 32-35

Epidemiology and clinical profile of cleft lip and palate patients, in a tertiary institute in Punjab, India: A preliminary study


Department of Plastic Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Web Publication9-Feb-2016

Correspondence Address:
Sheerin Shah
HJ 103, Housing Board Colony, B.R.S Nagar, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-2125.176003

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  Abstract 

Objective: The purpose of this study was to report the epidemiological profile and surgeries done on patients with cleft lip and palate from August 2007 to December 2014. Materials and Methods: A retrospective study was done to evaluate the patients operated for either cleft lip (with or without alveolus), cleft palate or secondary correction. The age of operative intervention, sex distribution, type of cleft, laterality, type of surgery, and duration of stay were reported. Results: A total of 411 cleft patients were seen during this period (August 2007-December 2014). Among this 36 (8.7%) patients had an incomplete cleft lip, 57 (13.9%) had a complete cleft lip, and 29 (7%) had cleft lip with alveolus. Isolated cleft palate was seen in 104 (25%) patients and cleft lip and palate were seen in 185 (45%) patients. Eighty percentage patients were aware of the surgeries for cleft lip and palate by various hospital communications. The mean age of patients operated for cleft lip was 5.3 months and Randall Tennison modified repair was done in 88% of these patients. The mean age of patients undergoing palatoplasty was 1.6 years and the most common surgery done was pushback palatoplasty with intervelar veloplasty (73.6%). Seventy-six patients underwent a secondary correction, out of which 30 patients got lip revision and 26 got fistula repair. A total of 15 patients had other associated anomalies. The average duration of stay in hospital for a cheiloplasty patient was 7 days, of palatoplasty was 8 days and of secondary surgery was 5 days. Conclusion: This study indicates that cleft lip and palate are most common types of cleft predominantly on the left side and males being more. Newspapers, various medical institutions, and media are useful measures to spread public awareness about early surgery, follow-up, secondary corrective surgeries, speech and dental therapy. Early diagnosis and appropriate timings of these surgeries produce satisfactory results with minimal morbidity.

Keywords: Cleft lip epidemiology, cleft palate epidemiology, cleft profile, Punjab cleft


How to cite this article:
Uppal SK, Shah S, Mittal RK, Garg R, Gupta A. Epidemiology and clinical profile of cleft lip and palate patients, in a tertiary institute in Punjab, India: A preliminary study. J Cleft Lip Palate Craniofac Anomal 2016;3:32-5

How to cite this URL:
Uppal SK, Shah S, Mittal RK, Garg R, Gupta A. Epidemiology and clinical profile of cleft lip and palate patients, in a tertiary institute in Punjab, India: A preliminary study. J Cleft Lip Palate Craniofac Anomal [serial online] 2016 [cited 2021 Oct 16];3:32-5. Available from: https://www.jclpca.org/text.asp?2016/3/1/32/176003


  Introduction Top


Cleft lip and/or palate are a most common facial congenital anomaly, and its etiology has been attributed to various environmental, genetic and unknown factors. [1] The management of these anomalies is important not only for esthetics and psychosocial stigma but also for phonation, hearing, mastication, deglutition, and ventilation. The accepted standard of repair is multidisciplinary approach along with dental surgeon, speech pathologist, and audiologist. [2] The functional outcomes depend on the timing of surgery, type of repair, regular follow-up, physiotherapy, and parental interest. In developed countries, these patients are seen at birth and parents are educated about the surgery and follow-up. Early interaction with cleft care team helps in timely surgery and satisfactory outcome. [3] In developing countries like India, low socioeconomic status, illiteracy, superstitions, lack of awareness, and poverty delays the presentation to the cleft care center. [4] This study discusses the epidemiology and clinical profile of cleft lip and palate patients operated in a tertiary institute in Punjab, India.


  Materials and methods Top


This retrospective study of the clinical database was done on patients operated for cleft lip and/or palate in the period from August 2007 to December 2014. Parameters such as the age of presentation, sex, antenatal history, awareness about surgery, residence, diagnosis, type of surgery, duration of stay, and associated anomalies were studied. Patients were grouped into various types as per Nagpur and Veau classification. The Hb of >10 g/dl, the weight of 10 pounds and age of 12 weeks was taken as operative criteria for cleft lip. The collected data were processed and analyzed using descriptive statistics and Chi-square test. P < 0.05 was taken as significant.


  Results Top


A total of 411 patients who were operated for cleft lip/palate or secondary deformity in this period were evaluated. An equal number of patients had a residence in villages and towns. Hospital communications formed the major source of awareness about these surgeries, in 51.8% patients. Twenty-two percentage of them presenting to the hospital were within the age group 3-6 months and 19% were within 6 months to 1 year. 7.8% (32/411) patients were operated after 20 years age. The mean age of a patient operated for cleft lip was 5.3 months and for cleft palate was 1.6 years [Table 1] and [Table 2]. Fifty-nine point eight percentage (246/411) of the total patients were males. It was also demonstrated that cleft lip with or without cleft palate was more common in males whereas isolated cleft palate was found more common in female's (P < 0.05) [Figure 1]. The bilateral cleft was also more commonly found in males (41/15). [Figure 2] shows the incidence and laterality of various types of clefts. The most common diagnosis was cleft lip with the palate, found in 45% (185) of the patients followed by the cleft lip (29.7%). The complete cleft lip was more common than incomplete cleft lip and cleft lip with cleft alveolus. All clefts except isolated cleft palate were found more on the left side than right. In both classifications (Veau and Nagpur), the most common type was type III (150/411). Eighty-eight percentage (148) of cleft lip patients had undergone modified Randall Tension cleft lip repair and rest underwent Millard's repair. The most common palatoplasty done in these patients was V-Y (123) followed by Bardach's two-flap palatoplasty. Intervelar veloplasty was done in all cases. Only 15 patients had associated anomalies (syndromic). In these patients, 10 were males and 5 were females. Cleft palate was found in 8, unilateral cleft lip and palate in 5 and bilateral cleft lip and palate in 2 patients. Craniofacial deformity was found in 11 patients and limb deformity was found in 6 of these patients. Being a tertiary hospital, a lot of referral for secondary cleft surgery was reported. A total number of 76 patients had undergone secondary cleft surgery [Table 3], out of which 55 were primarily operated in outside centers. Lip revision was most commonly done (30/76), followed by fistula repair (26).

[Table 4] shows the duration of stay of various operated patients. On an average, an operated cleft lip case stayed for 7 days, cleft palate stayed for 8 days, and secondary surgery patient stayed for 5 days in the hospital.
Figure 1: Sex distribution of all clefts

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Figure 2: Incidence and laterality of cleft

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Table 1: Age of surgery in cleft lip

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Table 2: Age of surgery in cleft palate

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Table 3: Patients undergoing secondary surgeries*

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Table 4: Duration of stay

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  Discussion Top


Worldwide more than 10 million people have clefts of lip and palate, the reported incidence being 0.8-1.6 for every 1000 births. [1] The age of presentation is early in case of cleft lip because of obvious esthetic concerns. A patient with cleft palate usually presents late with usual complaints of nasal regurgitation, difficult phonation, and ear problems. The mean age of surgery in cleft lip patients is 5.3 Months and in cleft palate is 1.6 Years, which are both delayed than ideal age for surgery. [5] We noted that hospital and newspaper are helping in providing knowledge about the availability of cleft treatment, but a substantial lot of patients present late probably because of superstitions, lack of awareness about free treatment, difficult transportation making access to cleft center difficult and illiteracy. [4] Ibrahim et al. [6] and Hodges and Hodges [7] also reported a very delayed presentation of their patients because of lack of awareness and poverty in developing countries of Africa. The latest mobile cleft care vans are a hope to provide care to such remote poverty struck areas.

In this study, 59.8% patients were males, which is similar to worldwide sex distribution data (male:female = 60:40). [5],[8] It was also noted that isolated cleft palate was more common in females. Ibrahim et al., [6] Habib [9] and Fogh-Anderson [10] also report female predominance in their studies. Forty-five percentage of the patients had combined cleft lip and palate, followed by 29.7% with cleft lip and 25.3% with cleft palate. Mcleod et al. [11] and Ibrahim et al. [6] contrary to this see a similar occurrence in studies. The study by Spritz et al. [12] shows a higher incidence of cleft lip. This distribution has been attributed to the difference in race and ethnicity.

Unilateral clefts are more common than bilateral cleft which are seen only in 56 patients (13.6%). In our study, bilateral clefts were more common in males. Ibrahim et al. [6] see similar findings in their study.

All clefts are more common on the left side except isolated cleft palate which is more common on the right side. Similar link between female sex and the right side is reported by Rakotoarison et al. [8] Current protocol of surgical management of patients with a cleft lip wss followed. [3] In the case of secondary clefts, palatoplasty was done anywhere after 9-12 months at our center for appropriate speech development. In this study, we found that the mean age of patient operated for cleft lip was 5.8 months and 88% of them underwent modified Randall Tennison repair. The choice of repair was surgeon's preference. The most common palatoplasty done in this study was V-Y palatoplasty followed by Bardach's and Langenbeck's. Intervelar veloplasty was done in all cases. We found that combining veloplasty with V-Y palatoplasty gave us good results. Though, hypernasality and resonance were markedly decreased in all cases but because of lack of sufficient number of cleft care centers and proper multidisciplinary team, the follow-up for adequate dental treatment, speech therapy and corrective velopharyngeal insufficiency (VPI) surgery is very less. A prospective analysis of these patients for speech outcome and endoscopic evaluation of VPI can be planned in near future.

Fifteen patients (3.6%) in this study were found to have associated anomalies. Though very low, this incidence falls in the worldwide range of 1.5-63.4%. [5],[13] Because of a retrospective study, the history taken may not have been appropriate, and the actual incidence may have been underrated. We report the occurrence of these anomalies more in patients with cleft lip and palate. No such anomalies were associated with isolated cleft lip patients. The most common organ involvement seen was craniofacial, followed by limbs and cardiovascular. Similar incidence have been reported by Altunhan et al. [13] Contrary to this Ibrahim et al. [6] demonstrates the involvement of cardiovascular system as most common.

Being a tertiary hospital, a lot of referral for secondary cleft surgery was reported. A total number of 76 patients had undergone secondary cleft surgery, out of which 55 were primarily operated in outside centers. Lip revision accounts to be the most common secondary surgery done (40%) followed by fistula repair (34%). Nonavailability of trained cleft surgeons in peripheral centers in and around Punjab is the probable reason of such secondary deformities from the first surgery.

The average stay of operated case of cheiloplasty, palatoplasty, and secondary surgery was 7, 8 and 5 days. It is a regional belief and preference of patient's attendants to get discharge only after suture or pack removal. Because most of the population lives as joint families and are agriculturalists, their stay in hospital does not affect the household and work. The monetary factor is not an issue, as most of them are affording.

The pitfalls of this study are the small sample size and lack of integrative management with contributions from dentists, speech pathologist, and audiologist.


  Conclusion Top


The incidence of cleft lip and palate is similar to other countries with low socioeconomic status. We found that because of unavailability of peripheral centers for cleft awareness and its surgery, tertiary centers like ours have difficult secondary cases, prolonged hospital stay and less follow-up for dental and speech treatments. We recommend adequate public awareness and mobile cleft vans for the early management of these clefts facilitating better esthetics, feeding, speech, and dental growth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Wanjeri JK, Wachira JM. Cleft lip and palate: A descriptive comparative, retrospective, and prospective study of patients with cleft deformities managed at 2 hospitals in Kenya. J Craniofac Surg 2009;20:1352-5.  Back to cited text no. 1
    
2.
Freeman AK, Mercer NS, Roberts LM. Nasal asymmetry in unilateral cleft lip and palate. J Plast Reconstr Aesthet Surg 2013;66:506-12.  Back to cited text no. 2
    
3.
Adekeye EO, Lavery KM. Cleft lip and palate in Nigerian children and adults: A comparative study. Br J Oral Maxillofac Surg 1985;23:398-403.  Back to cited text no. 3
    
4.
Donkor P, Bankas DO, Agbenorku P, Plange-Rhule G, Ansah SK. Cleft lip and palate surgery in Kumasi, Ghana: 2001-2005. J Craniofac Surg 2007;18:1376-9.  Back to cited text no. 4
    
5.
Manyama M, Rolian C, Gilyoma J, Magori CC, Mjema K, Mazyala E, et al. An assessment of orofacial clefts in Tanzania. BMC Oral Health 2011;11:5.  Back to cited text no. 5
    
6.
Ibrahim A, Mshelbwala PM, Obiadazie AC, Ononiwu CN, Asuku ME, Ajike SO, et al. A descriptive study of clefts of the primary and secondary palate seen in a tertiary institution in Nigeria. Niger J Surg Res 2015;15:7-12.  Back to cited text no. 6
    
7.
Hodges AM, Hodges SC. A rural cleft project in Uganda. Br J Plast Surg 2000;53:7-11.  Back to cited text no. 7
    
8.
Rakotoarison RA, Rakotoarivony AE, Rabesandratana N, Razafindrabe JB, Andriambololona R, Andriambololo-Nivo R, et al. Cleft lip and palate in Madagascar 1998-2007. Br J Oral Maxillofac Surg 2012;50:430-4.  Back to cited text no. 8
    
9.
Habib Z. Factors determining occurrence of cleft lip and cleft palate. Surg Gynecol Obstet 1978;146:105-10.  Back to cited text no. 9
    
10.
Fogh-Anderson P. Incidence of cleft lip and palate: Constant or increasing? Plast Reconstr Surg 1962;29:720.  Back to cited text no. 10
    
11.
McLeod NM, Urioste ML, Saeed NR. Birth prevalence of cleft lip and palate in Sucre, Bolivia. Cleft Palate Craniofac J 2004;41:195-8.  Back to cited text no. 11
    
12.
Spritz RA, Arnold TD, Buonocore S, Carter D, Fingerlin T, Odero WW, et al. Distribution of orofacial clefts and frequent occurrence of an unusual cleft variant in the Rift Valley of Kenya. Cleft Palate Craniofac J 2007;44:374-7.  Back to cited text no. 12
    
13.
Altunhan H, Annagür A, Konak M, Ertugrul S, Ors R, Koç H. The incidence of congenital anomalies associated with cleft palate/cleft lip and palate in neonates in the Konya region, Turkey. Br J Oral Maxillofac Surg 2012;50:541-4.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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