Submucous Cleft Palate

Cleft palate is an orofacial malformation that occurs in the early stages of pregnancy, while the baby is still developing inside the mother’s womb.

It is a split or an opening in the palate or the roof of the mouth. It may involve the hard palate or the bony front portion of the roof of the mouth and/or the soft palate or the soft back portion.

Submucous cleft palate (SMCP) is a subgroup of the cleft palate which is not known by most general practitioners.

Usually, a combination of hereditary and environmental factors during the first few weeks of pregnancy contributes to the development of submucous cleft palate.

It occurs when there is insufficient tissue in the mouth or lip area, and the available tissue does not join together properly.

Read the article ahead to understand the causes, symptoms and the treatment of submucous cleft palate.

What is submucous cleft palate?

Submucous cleft palate (SMCP) occurs due to an abnormal fusion of the muscles of the soft palate when the baby is developing in utero.

In the case of submucous cleft palate, the cleft is underneath the mucous membrane, which is the tissue that covers the palatal roof. Due to this, submucous cleft palate goes undiagnosed in the initial phases.

In severe cases, it can extend anteriorly, both under the soft and hard palate. It is rare and occurs in about 1 in 1,200 children.

The primary concern with submucous cleft palate is its effect on the speech of the child. Other effects include difficulty with sucking and velopharyngeal insufficiency (VPI).

If the child does not experience any problems with early feeding or speech, then treatment is not necessary. Otherwise, various treatment modalities are available.

Depending on the severity, an SMCP can include any, or all, of the following signs of the triad (1)

  • A very wide or split (bifid) uvula
  • A translucent line of tissue along the middle of the soft palate
  • A ‘V’ shaped notch at the back of the hard palate.

All newborns undergo an examination of the mouth at birth, but it is common to miss the diagnosis of SMCP as the cleft is underneath the mucous membrane.

How to identify submucous cleft palate?

The cleft appears like a notch or depression under the mucous membrane in the center of the palate.

In some cases, the anomaly can be diagnosed when examined with a fingertip or can be seen by looking in the mouth for small bifid uvula and thin bluish soft palate. (2)

Feeding issues in the infants or leakage of breastmilk or fluid discharge through the nose or nasal sounding during speech are characteristic features of the anomaly.

Ear infections and ear effusions (fluid in the middle ear space) are also quite common.

What are the causes of submucous cleft palate?

Various factors cause a submucous cleft and they are –

  • Combination of genetic factors and environmental factors during the first few weeks of pregnancy.
  • It can occur as part of some genetic syndromes like Stickler’s syndrome and velocardiofacial syndrome.

What are the effects of submucous cleft palate?

Usually, the patient does not encounter any grave difficulty (4). However, some problems do occur-

  • Feeding issues – Getting good suction while feeding is a common issue. This takes a much longer time to feed and decreased body weight.
  • Ear defects – Children are more prone to ear infections and may suffer from complete hearing loss. It occurs because the palatal muscles are responsible for the opening and closing of the eustachian tube, which retains air in the middle ear.
  • Speech abnormalities – speech may be affected as the patient may have difficulty in air passage through the nose or mouth. Improper production of certain sounds and fluid discharge through the nose may also occur occasionally.
  • Velopharyngeal insufficiency (VPI) – it is a condition in which the soft palate is unable to close against the pharyngeal wall (back wall of the throat) while talking due to some structural abnormality. This leads to hypernasality or nasal air emission (nasal sounding) during the speech.

Treatment modalities of submucous cleft palate

When the anomaly is diagnosed, it is essential to consult a Cleft Lip and Palate Center for a thorough evaluation.

The evaluation is monitored by a speech-language pathologist who is specialized for speech training in cleft palate and Velopharyngeal Dysfunction and a surgeon who has expertise in cleft palate surgery.

A dentist, otolaryngologist, psychologist, geneticist or audiologist may also access the patient in case of some specific needs.

  • If there is no evident problem with feeding or speech, then treatment is not needed. Adenoidectomy should be avoided in such cases because the removal of adenoids can increase the risk of vocal disorders. However, the condition should be monitored over the years to detect changes in speech with growth.
  • If there is an evident problem with feeding or speech, then surgery is typically recommended.
  • Speech training therapy may be needed for some children who have articulation or language disorders.

Take home message

According to the center of disease control and Prevention (CDC), cleft lip and cleft palate are common congenital disabilities in the United States.

Cleft lip and palate occur in about 1 to 2 per 1000 births in the developed world. The number of cases being recorded each day is increasing. Hence, creating awareness is a must.

Proper treatment and guidance in cases of submucous cleft palate can solve maximum problems. Early consultation of a specialized is significant as a lot of general practitioners are unaware of this condition.

Consult a doctor before child planning and discuss the genetic and environmental factors that increase the risk of this orofacial anomaly. Simple steps at the very beginning can eliminate a grave situation.

Disturbed speech and fluid discharge can be mentally traumatizing for your child. Make sure to opt for speech training therapies and proper treatment modalities for the management.

Look for every small symptom and be aware and act in case of suspicion of the anomaly.