Transoral Endoscopically Assisted Closure of Cleft Palate in Foals

Sir: The repair of cleft palate in foals has been compared with that in humans regarding importance. Because of the anatomical differences in the oropharynx and hypopharynx between horses and humans, clefting in equines results not only in an insufficient absorption of nutrients by nasal milk escape but also, following aspiration, in a life-threatening aspiration pneumonia. Current reports suggest that cleft palate repair in foals is technically difficult and is accompanied by a high complication rate. Despite successful cleft repair, aspiration pneumonia existing before the operation can be fatal.1 The distance between a foal’s front teeth and palate is too large for a transoral approach such as that performed in humans. Until now, therefore, an extraoral access was applied by means of a symphysiotomy of the mandible, often in combination with a pharyngotomy. Thus, the vast soft-tissue wound led predominantly to uncontrollable infections and asphyxia.2–4 To avoid these complications, we decided to take a transoral approach using endoscopic instruments and technologies to bridge the distance. In a 5-week-old stallion, milk outflow off the nose during sucking was observed from birth. Increasing inflammation parameters and subtotal lung field shadowing in the lateral chest radiograph proved the diagnosis of an aspiration pneumonia. The endoscopic investigation of the oropharynx confirmed the suspicion of palatoschisis in the form of an uvula bifida and a submucous cleft palate (Fig. 1). After suitable presurgical preparation, the surgical procedure was performed with the foal in back position under general anesthesia. Because of the limited overview of the transoral approach performed, endoscopic optics were introduced to provide a view control on a screen during the proceedings. Thus, by the far less traumatic, endoscopically assisted transoral approach, the problem of exposure of the operative field was managed easily. Analogous to the setup of cleft palate repair in humans, we performed an intravelar myoplasty of the levator veli palatini muscle in the foal according to Kriens.5 Until now, this procedure has not been applied explicitly to horses, probably because when the function of the levator palatini muscle in horses is discussed, there is controversy regarding the active raising of the extremely long soft palate.3 However, a layer-wise closure of the cleft palate should decrease sore healing disturbances with dehiscences and raise the static stability of the palate. After closure of the oral layer with 2-0 and 3-0 resorptive sutures (Fig. 2), the foal recovered well from anesthesia. After postsurgical treatment, the foal was returned to the mother and was able to drink normally. After antibiotic therapy with gentamicin and Veracin, at 8 days postoperatively, the lateral chest radiograph proved clearly falling findings. The inspection of the situs showed at that time a “first-in, first-out” sore healing. The foal developed normally up to the last control, 12 months postoperatively. Nevertheless, the precise value of this surgical technique must be evaluated based on the results in other cases.Fig. 1.: Endoscopic view of the submucous cleft palate. 1, Submucous cleft palate with visible vomer; 2, lateral border of the cleft with a belly-like concavity falsely inserting into the levator veli palatini muscle.Fig. 2.: Closure of the oral layer at the end of the operation.Heico-Rüdiger Krause, Ph.D. Jan Rustemeyer, M.D. Klinik für Mund-, Kiefer-und Gesichtschirurgie Plastische Operationen Spezielle Schmerztherapie Klinikum Bremen-Mitte Bremen, Germany Marc Koene, D.V.M. Tierärztliche Klinik für Pferde Lüsche, Germany DISCLOSURE The authors have no conflicts of interest.

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