A 6-year-old boy with velopharyngeal incompetence is scheduled to undergo sphincter pharyngoplasty. He underwent cleft palate repair in infancy. In the sphincter pharyngoplasty procedure, which of the following muscles is elevated in the posterior tonsillar pillar?

(A) Levator veli palatini
(B) Palatoglossus
(C) Palatopharyngeus
(D) Stylopharyngeus
(E) Superior pharyngeal constrictor

The correct response is Option C.

The levator veli palatini originates from the petrous portion of the temporal bone and the eustachian tube. It travels alongside the eustachian tube to enter the soft palate. This muscle elevates the velum toward the posterior pharyngeal wall to close the velopharyngeal mechanism and pull the eustachian tube open.

The palatoglossus muscle arises from the lateral margin of the tongue. It travels in the anterior tonsillar pillar to enter into the soft palate and functions to pull the soft palate downward.

The posterior tonsillar pillar is created by the palatopharyngeus. The palatopharyngeus muscle arises from fibers that commingle with the superior pharyngeal constrictor. It enters the soft palate, where its fibers intermingle with those of the levator. The palatopharyngeus functions to depress the soft palate and provide inward motion of the lateral pharyngeal wall. In a sphincter pharyngoplasty, superiorly based flaps are elevated from the posterior tonsillar pillar, sutured together, and inset into the posterior pharyngeal wall. These flaps contain the palatopharyngeus muscle.

The superior pharyngeal constrictor originates from the posterior pharyngeal raphe and courses downward and forward to insert into the medial pterygoid plate, the pterygomandibular raphe, and the posterior part of the hyoid. The stylopharyngeal muscle arises from the styloid process. It inserts between the fibers of the superior and middle pharyngeal muscles in the pharyngeal wall. These muscles play a role in swallowing.

References:
1. Clemente CD. Anatomy: A Regional Atlas of the Human Body. 4th ed. Baltimore: Williams & Wilkins; 1997:435-576.
2. Sloan GM. Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art. Cleft Palate Craniofac J. 2000;37:112-122.
3. Wexler A. Anatomy of the head and neck. In: Ferraro JW, ed. Fundamentals of Maxillofacial Surgery. New York: Springer-Verlag; 1997:53-113.




In neonates with isolated cleft palate, which of the following percentages best represents the incidence of additional anomalies?

(A) 10%
(B) 30%
(C) 50%
(D) 70%
(E) 90%

The correct response is Option C.

Isolated cleft palate has an incidence of 1:2000 without ethnic preference and has a higher incidence of associated anomalies than cleft lip and palate (CL/P). Approximately half of the cases of cleft palate with associated anomalies will fall into established syndromes. Patients with CL/P are more common than those with cleft palate alone; the incidence is 1 in 1000 Caucasians, 1 in 2000 African-Americans, and 1 in 500 Asians. Associated anomalies in children with CL/P is approximately 10% to 15%. The type of associated anomalies would include musculoskeletal, cardiac, and neurological.

Both cleft lip and cleft palate are controlled by multifactorial inheritance. Therefore, there is no distinctive pattern of inheritance within a single family. The risk to first-degree relatives can be estimated as the square root of the population risk. The risk is much lower for a second-degree relative. Higher chance of occurrence is also seen with greater degree of severity in the affected relative. The risk for development in a sibling of an affected child increases if more than one family member has the condition.

References:
1. Vander Kolk CA. Cleft palate. In: Achauer BM, Eriksson E, Vander Kolk CA, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Vol 2. St Louis, MO: Mosby; 2000:799-807.
2. Marazita ML. Genetic etiologies of facial clefting. In: Mooney MP, Siegel MI, eds. Understanding Craniofacial Anomalies: The Etiopathogenesis of Craniosynostoses and Facial Clefting. New York: Wiley-Liss; 2003:147-161.




A 10-month-old infant with cleft palate is scheduled to undergo repair via the Veau-Wardill-Kilner V-Y technique. Which of the following structures will NOT be directly manipulated during this repair procedure?

(A) Levator veli palatini muscles
(B) Musculus uvulae
(C) Nasal lining
(D) Palatopharyngeus muscles
(E) Tensor veli palatini muscles
The correct response is Option D.


Because cleft palate does not disrupt the palatopharyngeus muscles, they do not need to be repaired. Cleft palate repair aims to eliminate the oronasal fistula and optimize the function of the soft palate. The fistula is closed by creating a lining for the nasal and oral sides of the fistula. The abnormal attachments of the levator veli palatini and tensor veli palatini muscles to the hard palate are released, and the muscles are repaired in the midline, giving them a more functional transverse orientation. Finally, the musculus uvulae is repaired in the midline. This muscle provides bulk on the upper surface of the soft palate during velopharyngeal closure. Although the palatopharyngeus muscles are involved in velopharyngeal closure, they are not disrupted by cleft palate.


References:
1. Bauer BS, Patel PKK. Cleft palate. In: Georgiade GS, Riefkohl RR, Levin LS, eds. Georgiade Plastic, Maxillofacial and Reconstructive Surgery. 3rd ed. Baltimore: Williams & Wilkins; 1997:239-246.
2. Vander Kolk CA. Cleft palate. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery Indications, Operations, and Outcomes. Vol. 2. St. Louis, MO: Mosby; 2000:799-807.