HJAR May/Jun 2023

HEALTHCARE JOURNAL OF ARKANSAS  I  MAY / JUN 2023 51 Larry Hartzell, MD Pediatric Otolaryngologist Arkansas Children’s Hospital should determine the cleft severity soon after birth to determine if presurgical treatments are indicated. Nasoalveolar molding (NAM) is one such treatment and has been routinely available in Arkansas since 2017. This procedure allows for shaping the lip, nose, and gum line (alveolar) tissues prior to surgery. It can reduce the number of surgeries required during the infant’s lifetime and improve overall outcomes. Dental and surgical specialists receive specialized training to provide this technique. The outcomes have been remarkable and continue to improve as we gain experience and develop additional novel techniques and applications. Close monitoring of the patient’s feeding and related weight gain is essential. Speech andnutritionspecialistsprovide invaluable support during this time. Weekly weight checks and frequent communication are essential to ensure the infant gets the support needed during this critical time. Infant hearing screening is also closely monitored to ensure proper diagnosis and appropriate management. Surgery for the lip is typically performed between 3 and 6 months of age. The palate is repaired at 9 to 12 months of age in most cases. The nature of the cleft deformity and the surgeon’s preferences can lead to some variance in the type and timing of surgeries. Continued cleft care and follow-up Repairing the infant’s cleft is only the beginning of their cleft journey. Some will need revision surgeries to improve the form and function as the child grows. Others will need additional interventions, especially in the setting of the cleft palate, which has a significant impact on speech and eustachian tube function. Many chil- dren with cleft palate will require ear tube placement not just once but multiple times. They require close monitoring by experts throughout their development be- cause they are at higher risk of tympanic membrane issues such as perforations and cholesteatomas. We strongly recommend that patients born with a cleft palate have an annual, or at minimum bi-annual, eval- uation by their surgeon, speech pathol- ogist, and other indicated specialists de- pending on their progress along their cleft journey. Periodically, they will be seen by the entire cleft lip and palate team to en- sure all cleft-related facets of their growth and development are being addressed and properly managed. Some of the potential later surgeries may include procedures to improve their speech, repair their nose and septum, add bone to their alveolar ridge coordinated with orthodontic treatment, and possibly jaw surgery — all of which require experi- enced cleft providers and close monitor- ing. Besides surgical and dental manage- ment, developmental needs are essential to evaluate and address. Annual visits with a cleft-trained speech pathologist can identify some issues. Screening questions regarding school performance and self-es- teem can also identify patient or parental concerns and needs. Once correctly diag- nosed, psychologists and social workers affiliated with the cleft team can manage related issues. Adult cleft care A thorough cleft lip and palate team aims to address all areas affected by the cleft lip or palate by adulthood, but some continue to have medical needs even after they are fully grown. Ideally, a cleft team can provide related care for all individuals regardless of age. Additional procedures or surgeries may prove helpful. Alternative options to surgery are also explored and offered as needed. Some adults born with clefts may additionally have questions about the likelihood of their children being born with a cleft. Specialists on the team, especially a genetics group, can help answer these questions and provide guidance and reassurance. Most that are born with a cleft will end up having children who are unaffected. However, when a syndrome is involved or there is a positive family history of multiple individuals with clefts, the chances of having an infant with a cleft will be higher. Regardless of these circumstances, a good multidisciplinary cleft team can provide information, support, guidance, and care, whether it is to the patient, their offspring, or their medical providers. n Larry Hartzell, MD, attended Brigham Young University in Utah, where he received an undergraduate degree in zoology with a human biology emphasis. After serving a mission in Barranquilla, Colombia, where he became fluent in Spanish, Hartzell earned a medical degree at the University of Arizona College of Medicine in 2005. He completed a residency in otolaryngology (ENT) at the University of Arkansas for Medical Sciences and stayed inArkansas to pursue fellowship training in pediatric otolaryngology, including an extensive experience in the comprehensive care of cleft patients at Arkansas Children’s Hospital (ACH). He has been the director of the Cleft Lip and PalateTeam and the Velopharyngeal Insufficiency (VPI) clinic at ACH since 2012. Hartzell is board-certified by the American Board of Otolaryngology-Head and Neck Surgery and is a member of numerous medical organizations, including the American Academy of Pediatrics, American Cleft Palate-Craniofacial Association,AmericanAcademy of Facial Plastic and Reconstructive Surgery,and theAmericanAcademy of Otolaryngology-Head and Neck Surgery. His major research interests include cleft lip and palate, velopharyngeal insufficiency, hemangiomas, and surgical management of hearing loss and otologic disease.