UnitTwentySixCleftPalateandCleftLip:aTeamApproachtoClinicalManagementandRehabilitationofthePatientDuringthe1930sand1940smostchildrenwhohadundergonesurgeryforcleftpalaterequiredspeechtherapy.Butatthattimeitwascommonpracticeforsurgeonstowaituntiltheageofthreeorfourtoclosethepalate.Naturallythechildhaddevelopedhislanguagebyagefourandfrequentlyhadacquiredcompensatoryarticulationhabitsbecauseofaconstrictedmaxillaandanonfunctionalvelopharyngealport.Hisunoperatedconditionmadeitimpossibleforhimtoimpoundairwithintheoralcavity.Nasalairemissionandhypernasalresonancecouldnotbeavoided.Whensurgerywasfinallyperformedthefamilyaswellasthesurgeonwasoftendismayedtofindthatadramaticchangeintonalqualityhadnotoccurredwiththeclosingofthecleft.Thechildfrequentlycontinuedtotalkverymuchashehadtalkedbeforetheoperation,witha"cleftpalatespeech."Inmanycasesthiswasbecausehismaladaptivespeechhabitshadbecomesoingrainedthathisvoicesounded"familiar"and"right"tohim.Ifhedidnotrecognizeitasabnormal,thismeantthatheandthespeechclinicianwereinforalongsiegeoftherapy.Severaltypesofdentalprostheseswereusedinthe1930sand1940sasprimarytreatmentforseparatingtheoralandnasalcavities;'however,thecleftproblemwasconsideredanexerciseforthesurgeon.Ifandwhentherewasabreakdowninthesurgicalrepair,thesurgeonrepeatedhisproceduresinhisefforttoclosethepalataldefect.Someoftheearlypatienthistoriesattheinstituterecord10,15,and20surgicalproceduresinattemptingtoclosetheoraldefect.Hypernasalvoicequalityandmaladaptivearticulationhabitswereassociatedwiththesemultiplesurgicalfailures.SomeSurgeonfeltthatthenextlogicalstepaftersurgicalmanagementfailedwastoreferthepatienttoaprosthodontist.Fewspeechclinicianswereavailabletothesurgeonuntiltheteamconceptofcleftpalatemanagementdeveloped.Certainlytheearlysurgeonshadtheirmeasureofsuccess,butthepercentageofgoodresultswasnottoswelluntilthelate1950sandearly1960s,whenplasticsurgeonsexpressedtheirawarenessofhumangrowthanddevelopmentofthemid-thirdoftheface.Withthisawarenesstheywereabletoimprovetheirtechniquesandtotimethesurgicalprocedurestominimizeinterferencewithcentersoffacialgrowth.Lengtheningtheoraltissueandutilizingavomerflapgreatlyreducedthetraumatomaxillarysegments.Moreimportanttospeechdevelopmentwastheimprovedtwostagepalatalclosuretechnique,implementedbeforethechildreached18monthsofage.Thesefactshadamarkedinfluenceonthedevelopmentofmorenormalspeechandvoicepatternsinchildrenwithacleftpalate.H.KCooperrealizedthatnoone-treatmentprocedurewasapanacea.Buthisteamconcept,whichhebegantoimplementinthe1930s,emphasizethevariedadvantagesofinterdisciplinaryevaluationandtreatmentofcleftpalate.Hestressedtherehabilitativemanagementofthetotalperson,andasprofessionalmembersoftheinterdisciplinaryteam,werealizedweweredealingwithanintegratedpartof.thewholeperson.Thisistheconceptthathasbeendevelopedandcontinuallystressedatthelancastercleftpalateclinic.Whyateam?ItiswellrecognizedthatindividualsbornwithcleftsoftheUpandpalateorpalateonlywillfaceanumberofinterrelatedproblems.Intheearliestdaysofteammanagementofclefts,clinicalobservationsledtotherecognitionthatchildrenwithcleftlipandpalate(includingacleftofthemaxillaryalveolararch)requiredtheservicesofareconstructivesurgeontorepairtheclefts,aspeechpathologisttoaddressissueofvelopharyngealfunctionandarticulation,andadentalspecialisttoaddressproblemsassociatedwithocclasionandcongenitallymissingteeth.Centerswereoftenbuiltaroundthesetreatmentspecialistsbecauseoftheirlong-terminvolvementwithpatientswithclefts.Manyteamsdidnothavepediatricians(eventhoughthemajorityofpatientswerechildren),orotolaryngdogists(eventhoughmostpatientshadchronicmiddleeardisease).Initsearlyadvocacyofteams,theAmericancleftpalateAssociation(ACPA)indicatedthataproperteammusthaveataminimumaplasticsurgeon,aspeechpathologist,andanorthodontist.Wouldateamthathadonlythesespecialtiesbeabletoqualifyasacomprehensivecenter?Asthemedical,dental,andbehavioralsciencesexpanded,newsubspecialtieswereborntoaddressproblemsthatcouldnotevenbedetectedfourdecadesago.Subspecialtiessuchashumangeneticsandneuroradiologyarerecentadditionstomedicine,andspecialtytestssuchasnasopharyngoscopy,multiviewvideofluoroscopy,and3-DCTscanswerenotwidelyavailablebeforethe1980s.Asaresult,organizationssuchasACPAhaverecognizedthatminimalstandardsmaynolongerbevalid,andcenterswillneedtobemorecomprehensiveinordertomeetapatient'sneeds.Howcomprehensiveshouldateambe?Tablelliststhespecialistswhowouldhaveaninterestinchildrenwithcleftingorcraniofacialanomaliesalongwiththereasonforthatinterest.Wouldpatientcarebecompromisedifanyofthesespecialistswereomitted?Correctdiagnosescouldgoundetected.Propertreatmentsknownonlybycertainspecialistscouldgounadministered.TablelSpecialistswhoshouldbeincludedonacraniofacialteamandthereasonfortheirpresence.When"pediatric"appearsinparentheses,theimplicationisthatthemajorityofpatientsarepediatriccasesandshouldrequirepediatricsubspecialization.SpecialtyreasonforinclusionMedicalspecialistsPlasticSurgeryReconstructionofcleftandstructuralmanagementofVPIPediatrics"Medicalmanager"forthechildNeurology(Pediatric)Atleast10%ofchildrenwithcleftshaveCNSanomaliesEndocrinologyApproximately20%ofchildrenwithcleftsareofshortstatureOphthalmology(Pediatric)Frequenteyeanomalies,especiallyinSticklersyndrome(5%ofcleftpalate)Cardiology(Pediatric)Frequentheartanomalies(atlast10%ofchildrenwithclefs)Otolaryngology(Pediatric)VeryfrequentassociationofmiddleeardiseaseandairwaydisorderRadiology/NeuoradiologyVideofluoroscopy,CT,MRasfrequentdiagnosticmodalitisNeurosurgery(Pediatric)FrequencyofcraniosynostosisandneedforintracranialsurgeryPulmonology(Pediatric)FrequentassociationofairwayrelatedproblemsAnesthesiology(Pediatric)DifficultintubationscommoninchildrenwithcraniofacialanomaliesGenetics/DysmorphologyVeryhighfrequencyofassociatedsyndromesandgeneticetiologiesPsychiatryNeedtoassurepsychologicalwellbeingofchildrenundergoingfrequentsurgeryDentalspecialistOralSurgeryFrequentfacialskeletalsurgeryOrthodonticsUniversalneedfororthodontictherapyinchildrenwithcleftlip/palateProstheticDentistryNeedfortoothreplacementinmanycasesofcompletecleftsPediatricDentistryNeedtomaintaingooddentalhealthandpreventagainsttoothlossbehavioralspecialistSpeechPathologyVeryfrequentspeech/languagedisordersinchildrenwithcleftsSocialServiceSocialadjustmentproblems,hospitalrelatedproblems,fundingproblemsPsychologyAssessmentandmanagementofselfimageandadjustmentathomeandinschoolNeuropsychologyPsychometricassessmentfrequentlyrequiredAudiologyVeryfrequenthearinglossassociatedwithcleftingChildlifeSpecialistFrequenthospitalizationsrequireattentionOtherSpecialtiesNursingFrequenthospitalservices(inandoutpatient)NutritionistlowweightacommonassociatedanomalyComputerProgrammerDatabasemanagementessentialtolearningabouttreatmentoutcomeVOCABULARYl.compensatory補償的，代償的，賠償N，報酬的2.articulation①連接、接合②發音、發音動作③清晰度，可值度④關節3.velopharyngeal腭咽的4.resonance①回聲，反響②共振、共鳴、諧振③叩響5.maladaptive不能適應的，錯誤適應的6.ingrain①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，本質7.voice⑦說話聲，嗓音、嗓子；②聲音；③愿望，意見，發言權；④語態，聲帶振動濁音特點8.speechclinician語音治療師9.awareness意識，認識，知道10.lengthen使延長，延長元音音長，變長，延伸，長起來11.vomer犁骨12.panacea治百病的靈藥，萬能藥13.implement①工具，器具②家具，服裝vt．①貫徹、完成履行⑦給……提供方法，為……供應器具③補充14.pathologist病理學家15.alveolararch牙槽弓，牙頒弓16.pediatrics兒科學17.Neurology神經病學18.Endocrinoiogy內分泌學19.Ophthalmology眼科