Cleft palate lateral synechia syndrome. Review of the literature and case report

Cleft palate lateral synechia syndrome in two patients and literature review

Cleft palate lateral synechia (CPLS) syndrome is an extremely rare congenital malformation syndrome of unknown origin, characterized by the association of cleft palate and one or more intraoral lateral synechiae (OMIM # 119550). Fewer than 20 cases have been described to date. The clinical and histological findings and results of genetic investigations for two additional cases of CPLS are presented herein, in order to better delineate this syndrome, within the context of the relevant literature. The first case presented with a U-shaped cleft palate, bilateral synechiae, and Pierre Robin sequence, requiring early sectioning of the synechiae because of severe feeding problems. The second case presented with a V-shaped cleft palate and a single synechia, running from the left border of the cleft to the floor of the mouth, and was without feeding difficulties. In both cases, histopathological examination of the synechiae revealed an aspect of mucous membranes macroscopically, while staining of sections indicated lymphocyte infiltrates and parakeratosis with stratified squamous epithelium, associated with vessel and connective tissue abnormalities. Sequencing of candidate genes did not identify a genetic cause. Accurate clinical descriptions, histopathological diagnosis, and genetic investigations of patients with synechiae are lacking in the literature. Better characterization of future cases of CPLS will give new insights into its developmental causes.

Congenital Maxillomandibular Syngnathia: Review of Literature and Proposed New Classification System

PURPOSE

Maxillomandibular fusion (syngnathia) is a rare craniofacial anomaly. It occurs as either fibrous (synechiae) or bony (synostosis) fusion of jaw or fusion of mandible to zygoma, tuberosity, hard palate and temporal bone. There are several documentations delineating this condition but owing to its varying presentation, association with both intraoral and extraoral anomalies and syndromes, reviewing it has been as uphill task. The non-unanimous description of cases in the literature and the use of different nomenclatures make it difficult to classify this condition.

METHODS

Extensive search of the literature was done from the year 1936 to 2018 which included a total of 118 cases with 62 cases of bony fusion, 48 cases of fibrous fusion and 8 cases of combined fusion, i.e., fibrous on one site and bony on another side.

RESULTS

This paper proposes a novel, simple and explicit classification system on the basis of nature of fusing tissues, location and extent, association with syndrome after reviewing the existing literature. Furthermore, this review reports 4 new cases of syngnathia along with their clinical, radiographic features and their management protocol.

CONCLUSIONS

This classification can be generalized to all the cases of syngnathia and can further facilitate in its appropriate diagnosis and treatment plan.

Congenital Lateral Palatal Synechia Associated With Cleft Palate: A Case Report With Long-Term Follow-Up and Review of the Literature

Lateral palatal synechiae are rare congenital adhesions running from the free borders of the cleft palate to the lateral parts of the tongue or the oral cavity floor, typically found in cleft palate lateral synechiae syndrome. We present a case of congenital lateral palatal synechia associated with a cleft palate that we treated and followed up for 10 years. We present the long-term prognosis. We also discuss variations in intraoral synechiae associated with cleft palate and the etiology of lateral palatal synechiae through a literature review.

Patients With Cleft Lip and Palate Associated With Intraoral Fibrous Bands: A Report of 3 Cases and Review of Literature

In rare instances, cleft lip and palate occur in association with synechia, intraoral fibrous bands connecting the maxilla and mandible. The main concern in synechia is a restricted mouth opening that leads to airway and feeding problems. This study reports our experience in the treatment of 3 cases and includes a review of the literature. Three patients with intraoral fibrous bands received treatment and follow-ups in our center. Division of the bands and reconstruction of the lip and palate were successfully performed. All reported cases in the literature were collected for a summary of clinical presentations and as references for management. Early management of the synechia improves the mouth opening and facilitates the treatment of associated anomalies.

Frenum-like oral synechiae of the lip and vestibule

Two cases where aberrant tissue was attached to the lower lip mimicking the inferior labial frenum were reported. The frenum-like tissue extended from the gingival margin between the lower left deciduous central and lateral incisors in case 1 and between the lower right deciduous central and lateral incisors in case 2, to the dry lower lip. Histologically, the resected specimen was regarded as normal oral mucosa covered with stratified squamous epithelium, without a clear amniotic band. The frenum-like tissue of the lower lip found in both our patients was diagnosed as a category of oral synechiae, of unknown origin.

Nonsyndromic palate Synechia with floor of mouth

To discuss the embryological basis, sequela and management of intraoral synechia, and to report on the incidence of this condition at a facial cleft deformity clinic (FCDC), with specific attention to two rare cases of mucosal bands involving the floor of the mouth and palate. Review of the literature and a retrospective analysis of FCDC and case report of two cases. During the period of 30 years (1983–2013), the FCDC - University of Pretoria has managed in excess of 4000 cases. A review of the clinic statistics revealed only six cases in which intraoral synechiae occurred. The rarity of this condition at the FCDC is in keeping with the rare incidence in the international literature. Four syndromic cases were identified. Three cases were cleft palate lateral synechia syndrome, and one was an orofacial digital syndrome. Two nonsyndromic cases were identified, and both cases involved the floor of the mouth and palate. The attending physicians and surgeons should be aware of the most appropriate timing for management of this condition, in order to avoid unwanted sequelae. Supportive care should be provided, and emergency airway protocol should be available for all cases. A differential diagnosis should be considered which includes syndromic conditions.

Congenital intra-oral adhesions: a surgical approach to cleft palate lateral synechia syndrome

An array of genetic syndromes has been associated with intra-oral adhesions in neonates. The primary medical issues arise from airway obstruction, feeding difficulties and poor oral development, specifically with cleft palate lateral synechia syndrome (CPLSS). Despite this, a paucity of data exists for the clinical management of intra-oral adhesions in this population. We report the cases of a father and daughter diagnosed with CPLSS who presented with respiratory and feeding difficulties at birth undergoing surgical correction. Early surgical ligation of intra-oral bands allows for a stabilization of the airway, improved feeding and oral development with a good long-term outcome.

A case of syngnathia, cleft palate and hypospadias: an isolated case or syndromic syngnathism?

Syngnathia occurs when an ectopic membrane forms a fibrous or bony adhesion between the maxillary and mandibular alveolar processes. A case of congenital syngnathia is presented.

Cleft palate lateral synechia syndrome: an opportunity for unique surgical closure

OBJECTIVES

To report two cases of cleft palate lateral synechia (CPLS) syndrome in a single family and describe surgical closure using the synechia.

STUDY DESIGN

Case report and literature review.

METHODS

A case report is presented with a review of the literature of cleft palate in conjunction with lateral synechia. Clinical presentation with photographic images of surgical repair is presented as well as a genetic workup with pedigree.

RESULTS

A 6-week-old male presented for evaluation of a cleft palate. Mucosa-lined, fibromuscular tissue bands were noted connecting the floor of mouth and the free edges of a bilateral complete secondary cleft palate. No other craniofacial, digital, genital or limb defects were noted. The patient's 13-month-old sister had similar synechial bands and cleft palate at birth. Another older sibling had cleft palate without synechia. The patient's mother and maternal great grandmother had cleft palates at birth without synechia. The three children share a common mother but have three different fathers. Genetic analysis failed to reveal chromosomal defects or a mutation in the interferon regulatory factor 6 (IRF6) gene, a locus linked to Van der Woude syndrome. At 2 years of age, the index patient was growing and feeding well. His intra-oral bands remained intact and were incorporated in the surgical repair using a novel approach.

CONCLUSIONS

Since more otolaryngologists are performing cleft surgeries, the awareness of the differential diagnoses associated with a cleft palate is important. CPLS is an extremely rare condition. The report of this family supports the suspected pattern of autosomal dominant inheritance with variable expressivity. The unusual surgical approach will be discussed.

Congenital alveolar fusion

Congenital fusion of the jaws is rare. It may be unilateral or bilateral and may involve only the soft tissues or both the hard and soft tissues. This anomaly may be seen separately or in association with other syndromes. Congenital alveolar fusion restricts mouth opening, causing problems with feeding, swallowing, and respiration. Case 1 had membranous bands between the alveoli that required tracheostomy for stabilization, followed by osteotomy for release. Postoperatively, both patients had adequate mouth opening.

Isolated and Syndromic Syngnathism

We present 2 contrasting cases of congenital interalveolar synechiae. The first occurred in the setting of Van der Woude syndrome and was associated with a cleft palate. In the second case, it was an isolated abnormality and there was no contributory family history or syndromic associations. We review the literature on interalveolar synechiae and discuss its management, implications, and genetics. Interalveolar synechiae is a condition with an excellent prognosis; its presence necessitates careful examination for associated abnormalities and syndromes.

Congenital alveolar synechiae — a case report

Congenital alveolar synechiae is rarely seen as an isolated disease. It is generally observed together with various syndromes such as Van der Woude and cleft palate lateral alveolar synechiae syndrome, and is concomitant with other anomalies in the maxillofacial or other regions of the body. Prior to this case report , eight cases of isolated congenital alveolar synechiae have been reported. This paper reports a case of isolated congenital alveolar synechiae in a 10-month-old baby girl. The report concentrates on the clinical features of isolated congenital alveolar synechiae, the likely aetiological causes and the treatment.

Cleft-palate lateral synechia syndrome: insight into the phenotypic spectrum of Fryns syndrome?

BACKGROUND

In 1972, Fuhrmann et al. (Humangenetik 1972;14:196-203) described a novel syndrome consisting of cleft palate (CP) and lateral synechiae (LS) between the palate and the floor of the mouth. This constellation of malformations, since denoted as cleft-palate lateral synechiae syndrome (CPLS), is a rare syndrome; only five cases have been reported since the original description. Because of the paucity of recognized cases, little is known regarding the phenotypic spectrum of this presumably autosomal dominant condition.

CASES

We report two unrelated patients who presented with remarkably similar phenotypic features, including multiple intraoral synechiae (filiforme intraalveolar bands), cleft palate, micrognathia, and redundant lower lip tissue. Their phenotypic findings indicate a diagnosis of CPLS; however, case 3 (the monozygotic twin of case 2) had classic phenotypic features of Fryns syndrome.

CONCLUSIONS

This report presents two new cases of CPLS, and suggests that the CPLS phenotype may represent the mild end of the Fryns syndrome phenotypic spectrum. Supplementary material for this article can be found on the Birth Defects Research (Part A) website (http://www.interscience.wiley.com/ jpages/1542-0752/suppmat/67/fig5.xls).

A recessively inherited non-lethal form of popliteal pterygium syndrome

Two siblings, a 10-year-old boy and a 6-month-old girl, born in a Palestinian family, with manifestations of popliteal pterygium syndrome are presented. This rare form of syndrome is usually assumed to be autosomal dominant. Parental consanguinity and lack of phenotype manifestation in the ancestry of the present family favoured an interpretation of determination by an autosomal recessive trait.

Recurrent trismus: twenty-year follow-up result

The authors encountered an unusual case of recurrent trismus in a patient who had oral synechia, cleft lip and palate, digital anomalies, and external genital anomaly. Mandibular movement was severely restricted by congenital soft-tissue adhesion in the retromolar region. Despite aggressive surgical efforts and postoperative manipulations, limitation of mouth opening recurred soon after each operation. Furthermore, congenital and postoperative soft-tissue adhesion resulted in severe subsequent jaw deformities, which needed combined maxillary and mandibular advancement.

Syngnathia: a report of two cases

Syngnathia is a rare anomaly involving soft tissue or bony adhesions between the maxilla and mandible. Two cases of congenital syngnathia secondary to interalveolar soft tissue synechia are presented. These children present problems with airway protection and feeding in the immediate neonatal period. Most have multiple associated anomalies requiring concurrent management. Less than 50 cases have been described, most commonly in association with popliteal pterygium syndrome. Surgical management involves division of the adhesions in the first few days of life. Depending on the severity, these patients may present formidable anesthetic challenges. The prognosis is generally favorable in cases of soft tissue adhesions with eventual restoration of normal mandibular motion and function.

Alveolar synechia, ankyloblepharon, and ectodermal disorders: an autosomal recessive disorder?

A male patient with alveolar synechia and ankyloblepharon filiforme adnatum is reported. He also had bilateral commissural lip pits, inferiorly attached frenulum, generalized hypoplastic nails, and wooly scalp hair. He was a product of consanguineous parents. The disease seemed to be an autosomal recessive syndrome with heterozygote expression.