Cleft lip and palate — branching viva

Branch 1 — The classification, the embryology and the feeding

The candidate should classify the cleft as Veau grade III (unilateral cleft lip and palate) and explain the embryology: the cleft lip arose from failure of fusion of the medial nasal prominence (frontonasal process) with the maxillary process on the left around week six, and the cleft palate arose from failure of the palatal shelves to fuse in the midline between weeks nine and twelve. The lip forms before the palate, which is why both are affected together. [1] [2]

Probe the feeding: the candidate should explain that the cleft palate breaks the oral-nasal seal so the infant cannot generate negative intraoral suction for a standard nipple or the breast, and that the correct technique is an upright position with a squeeze bottle (Haberman or Pigeon teat) delivering milk by compression, with paced feeding and frequent burping. Push on the consequence of a standard bottle — nasal regurgitation, choking, aspiration, prolonged feeding and failure to thrive. [7]

Branch 2 — The airway in Pierre Robin sequence

Introduce a second newborn with a cleft palate, a small recessed chin (micrognathia), noisy breathing and desaturation when supine. The candidate should recognise Pierre Robin sequence (micrognathia, glossoptosis, U-shaped cleft palate) and state that the airway takes priority. The glossoptotic tongue base obstructs the pharynx, especially when supine. [8]

Probe the management: the candidate should name prone or lateral positioning as the first step, a nasopharyngeal airway as the second, and mandibular distraction osteogenesis or tongue-lip adhesion as surgical options for refractory cases. The candidate should explain that the jaw catches up with growth and the airway risk diminishes over the first years. Push on the syndromic associations — Stickler syndrome (collagen, myopia, retinal detachment) and the need for an ophthalmic review. [8]

Branch 3 — The hearing and the grommet question

Ask why the newborn hearing screen referred bilaterally and what it means. The candidate should explain that the otitis media with effusion is near-universal in cleft palate because the cleft disrupts the levator veli palatini and tensor veli palatini muscles that open the Eustachian tube, so the middle ear fills with persistent effusion and produces a conductive hearing loss. [10]

Probe the management: the candidate should state that ventilation tubes (grommets) are typically inserted at the time of palatoplasty to relieve the effusion and protect the speech and language acquisition period, and that hearing is monitored with audiometry and tympanometry through childhood because the effusion can recur. Close on the synthesis: feeding first, airway second, hearing third, then the staged surgical timeline — rule of ten lip repair at three months, palatoplasty with grommets at nine to eighteen months, alveolar bone graft at nine to eleven years — all coordinated by the multidisciplinary cleft team. [10]