Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of unilateral cleft lip and palate. History significant for [Right/Left] sided cleft involving the lip, alveolar ridge, and palate. Feeding difficulties noted, including [nasal regurgitation/poor suction/prolonged feeding times]. No history of associated syndromic features or airway compromise.
Clinical Examination Findings
Physical examination reveals a [Right/Left] complete/incomplete unilateral cleft lip extending into the nasal floor. Palatal examination demonstrates a [complete/incomplete] cleft of the [soft/hard] palate. Alveolar ridge involvement confirmed. Nasal deformity noted with [ipsilateral alar base flattening/columellar deviation]. Oral mucosa is pink and moist.
Treatment Protocol
Surgical plan: Primary [Lip repair/Palatoplasty] scheduled. Pre-operative assessment includes nutritional optimization and weight gain monitoring. Nasoalveolar molding (NAM) initiated to align alveolar segments. Post-operative care involves strict adherence to feeding protocols, elbow restraints to prevent wound disruption, and topical antibiotic ointment application to the suture line.