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StatPearls . Treasure Island (FL): StatPearls Publishing; 2021 Jan-.


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Introduction

Proper palate formation in the arising fetus is vital for practical phonation and also feeding after birth. The palate develops the roof of the mouth and also separates the dental cavity native the sleep cavity. The palate undergoes complex morphological transforms during embryogenesis to attain its final type and divides into an anterior immobile tough bony segment and a posterior cell phone soft palate that does not contain bone. The superior aspect of the palate develops the floor the the sleep cavities and also has a lining the ciliated pseudostratified columnar epithelium (respiratory epithelium). The inferior element of the palate develops the roof the the dental cavity and also is lined through stratified squamous epithelium (oral mucosa) that includes secretory salient glands. The difficult palate comprises around two-thirds the the total palate surface ar area, and also its underlying bony structure consists of the palatine processes of the maxilla and the horizontal bowl of the palatine bones. The soft palate is made up of muscle fibers extended by a rubber membrane, specifically 5 muscles which have a functional function in breathing and swallowing: 


Levator veli palatini muscle: elevates the soft palate and is involved in swallowing.
Musculus uvulae muscle: functions to shorten the uvula.
Palatoglossus muscle: traction the soft palate towards the tongue and also is associated in swallowing.

Structure and Function

Hard Palate

The hard palate comprises the anterior two-thirds that the palate and also is one immobile tough bony segment who underlying bony structure is composed of the palatine procedures of the maxilla and also the horizontal plates of the palatine bones. Positioned anteriorly, the palatine procedures of the maxilla comprise most of the tough palate and also cover the area in between the two sides of the maxillary dental arch. The palatine procedures of the maxilla accomplish the 2 horizontal bowl of the palatine skeletal posteriorly, which fuse down the midline. The tough palate officially separates the oral cavity indigenous the sleep cavities, creating the floor of the sleep cavity and also the roof the the oral cavity. The tough palate is covered superiorly by ciliated pseudostratified columnar epithelium (respiratory mucosa) and also inferiorly by stratified squamous epithelium (oral mucosa). Anteriorly, the difficult palate has irregular ridges or rugae, dubbed rugae palatinae, on the mucous membrane the facilitates the i of food posteriorly in the direction of the pharynx. The hard palate has three foramina/canals that offer as passageways for an important neurovascular structures that it is provided the dental cavity. These essential landmarks include the incisive canal, the better palatine foramen, and also the lesser palatine foramen. The incisive canal is located at the anterior midline that the maxilla, straight posterior to the main maxillary incisor teeth, and contains the nasopalatine nerve and also the diminish palatine artery. The better palatine foramen is situated in the posterior difficult palate medial come the 3rd molar tooth and is traversed through the greater palatine vessels and nerve. The lesser palatine foramen is situated posterior come the greater palatine foramen ~ above the basic of the pyramidal procedure and is traversed by the lesser palatine nerve. Structurally, the tough palate offers a strictly floor to the nasal cavity that prevents changes in push within the mouth native closing turn off nasal passages. Historically, babies with a slit palate could not suckle and often died from malnutrition; this is due to the fact that infants cannot successfully create an unfavorable sucking pressure without a properly formed hard palate. The hard palate is additionally essential for phonation and also contains rugae that assist in mastication and digestion.<1><2>

Soft Palate

The soft palate provides up the posterior third of the palate and is a posterior continuation of the tough palate. The soft palate consists of muscle fibers and connective tissue covered by a mucus membrane consists of a stratified squamous epithelium v secretory salient glands. Uneven the hard palate, the soft palate is really flexible and also does not contain any kind of bony structures. The soft palate serves to elevate the nasopharynx, successfully closing the communication from the oropharynx to the nasopharynx. The soft palate is made up of 5 muscles that play vital roles in breathing, phonation, and also swallowing.

Anteriorly, the soft palate is consistent with the hard palate and the palatine aponeurosis. Posteriorly, the soft palate ends together a midline projection referred to as the uvula the projects into the oral cavity. The soft palate forms the roof that the oropharyngeal isthmus, an area connecting the pharynx and also oral cavity. Two arches bind the soft palate to the tongue and also pharynx, the palatoglossal arches, and also palatopharyngeal arches, respectively. The palatine tonsils show up between these arches in the tonsillar fossa that the oropharynx.

The soft palate has five muscles that room innervated through the pharyngeal plexus that CN X, except for the tensor veli palatini muscle, i m sorry receives innervation indigenous a branch of the trigeminal nerve called the medial pterygoid nerve. The muscle that consist of the soft palate include the palatoglossus, palatopharyngeus, tensor veli palatini, musculus uvulae, and also levator veli palatini muscles. The tensor veli palatini muscle attaches come the palatine aponeurosis native its beginning at the medial pterygoid key of the sphenoid. The tensor veli palatini muscle functions to tense the soft palate during swallowing, preventing the entry of food right into the nasopharynx. The levator veli palatini muscle increase from the eustachian tube and also the petrous temporal bone prior to attaching to the palatine aponeurosis, this muscle features to elevate the soft palate during swallowing to prevent the entrance of food into the nasopharynx. The palatoglossus muscle occurs from the palatine aponeurosis and also travels inferiorly, anteriorly, and also laterally to connect into the side of the tongue—the palatoglossus muscle features to traction the soft palate in the direction of the tongue and also initiates the act of swallowing. The palatopharyngeus muscle emerges from the difficult palate and also the palatine aponeurosis and attaches come the premium border that the thyroid cartilage. The palatopharyngeus muscle tense the soft palate and draws the pharynx superiorly and also anteriorly throughout the plot of swallowing. The palatopharyngeus muscle closes the laryngeal airway during swallowing to prevent the aspiration that food. The musculus uvulae muscle derives from the palatine aponeurosis and also the posterior nasal spine and also attaches come the mucous membrane of the uvula. The musculus uvulae muscle features to shorten the uvula. Ipsilateral contraction of the musculus uvulae muscle draws increase the uvula ~ above the same side.

During the action of swallowing, the levator veli palatini muscle elevates the soft palate, approximating it through the posterior pharyngeal wall and totally blocking off the airway and also nasal passages. Together a result, the soft palate creates a vacuum in the dental cavity, maintaining food indigenous entering the respiratory tract tract. Breathing ceases briefly throughout swallowing; this is since of the physical closure of the airway by elevation of the soft palate. During a sneeze, the soft palate protects the nasal passage by diverting some secretions come the oral cavity. The soft palate plays a duty in the gag reflex, poignant the end of the soft palate or uvula evokes the gag reflex in the majority of people.<3><4><5>


Embryology

Early in embryonic development, the nasal cavity runs continuously with the dental cavity, together there is no anatomic framework separating these 2 cavities. Together embryonic advance progresses, palate development ensues, formally separating the oral and also nasal cavities from one another. Appropriate palate advancement requires the formation of a primary palate in the 6th week the development, as well as the formation of a an additional palate between the sixth and also eighth main of development. The major palate consists of the alveolar arch. The secondary palate consists of the hard and soft palate. The external human face develops in between the fourth and also sixth main of embryonic development. The major palate develops approximately the same time as the outside face, particularly the 6th week the development, together a result of the combination of the medial nasal and maxillary processes. Subsequently, between the sixth and twelfth weeks of embryonic development, the secondary palate develops as the result of the combination between palatal processes growing from the medial wall surfaces of the maxillary processes. During second palate formation, the palatal shelves extend medially and also fuse exceptional to the tongue. Together the palatal shelves expand medially, the emerging mandible continues to grow, enabling for the tongue to gain out that the way of the cultivation palatal shelves. By the ninth week that development, the palatal shelves fuse and also with the major palate anteriorly to kind the critical palate.<6><7><8>


Blood Supply and Lymphatics

The higher palatine arteries run anteriorly, native the better palatine foramen to supply the palate. The better palatine arteries offer as the primary arterial supply to the palate. Anastomosis between the ascending palatine artery and the lesser palatine artery provides collateral it is provided to the palate. The higher palatine and also lesser palatine arteries are branches that the maxillary artery, which occurs from the external carotid artery. The ascending palatine artery is a branch that the face artery, which also arises from the exterior carotid artery. The palate’s venous drainage directs towards the pterygoid venous plexus. The lymph vessels of the soft palate drainpipe into the sub-digastric and/or lateral pharyngeal nodes.<9><10><11>


Nerves

Excluding the tensor veli palatini muscle, every one of the palatal muscles space innervated by fibers from the pharyngeal plexus derived from the vagus nerve. The tensor veli palatini muscle obtain its innervation native the medial pterygoid nerve, a branch of the trigeminal nerve. The sensory innervation of the palate originates indigenous the maxillary branch the the trigeminal nerve. The maxillary division of the trigeminal nerve offers rise to many sensory branches that innervate the middle portion of the face, including the nasopalatine, greater palatine, lesser palatine, superior alveolar, center meningeal, infraorbital, zygomatic, worse palpebral, remarkable labial, and pharyngeal nerves. The better palatine nerve occurs from its canal with the higher palatine foramen and also courses anteriorly in the roof that the palate, innervating the gingivae and mucosa that the hard palate while interacting with the nasopalatine nerve anteriorly. The lesser palatine nerve runs alongside, the greater palatine nerve, arising from the lesser palatine foramen to administer sensory innervation to the tonsils, uvula, and soft palate.<12>


Muscles

The soft palate has 5 muscles that get innervation through the pharyngeal plexus the the vagus nerve, except for the tensor veli palatini muscle, i m sorry is innervated by a branch of the trigeminal nerve referred to as the medial pterygoid nerve. The muscle that comprise the soft palate include the palatoglossus, palatopharyngeus, tensor veli palatini, musculus uvulae, and levator veli palatini muscles.

The tensor veli palatini muscle attaches come the palatine aponeurosis indigenous its beginning at the medial pterygoid plate of the sphenoid. The tensor veli palatini muscle features to tense the soft palate during swallowing, preventing the entry of food into the nasopharynx.

The levator veli palatini muscle increase from the eustachian tube and also the petrous temporal bone prior to attaching to the palatine aponeurosis, this muscle features to elevate the soft palate during swallowing to prevent the entrance of food into the nasopharynx.

The palatoglossus muscle arises from the palatine aponeurosis. It travels inferiorly, anteriorly, and laterally to affix into the next of the tongue—the palatoglossus muscle features to traction the soft palate towards the tongue and initiates the plot of swallowing.

The palatopharyngeus muscle emerges from the difficult palate and also the palatine aponeurosis and attaches come the exceptional border the the thyroid cartilage. The palatopharyngeus muscle time form the soft palate and also draws the pharynx superiorly and also anteriorly throughout the action of swallowing.

The palatopharyngeus muscle close the door the laryngeal airway during swallowing to stop the aspiration of food.

The musculus uvulae muscle derives native the palatine aponeurosis and the posterior sleep spine and attaches to the mucous membrane that the uvula. The musculus uvulae muscle features to shorten the uvula. Ipsilateral contraction of the musculus uvulae muscle draws up the uvula on the exact same side.


Physiologic Variants

Studies have demonstrated the the structural and obstructive fads of the pharynx and also palate vary among the general population. That is necessary to identify these phenotypic variations and also understand just how they generate the shape and also collapsibility that the retropalatal airway. Expertise phenotypic variations in palatal anatomy space imperative in the diagnosis and also treatment that sleep apnea.

The soft palate has both distal and also proximal segment separated by a structure called the palatal genu. The palatal genu approximates the border in between the aponeurotic and muscular contents of the soft palate. The length of both the distal and proximal soft palate may vary amongst individuals, possibly predisposing particular individuals come sleep apnea. A distal palatal segment length better than fifteen millimeters has been shown to rise the danger of sleep apnea dramatically and also correlates through poorer palatopharyngoplasty outcomes.

The construction of the soft palate and the place of the palatal genu is strongly associated to the size of the levator veli palatini muscle. The levator veli palatini muscle comprises fourty percent of the soft palate length in between the difficult palate and the base of the uvula. The proximal soft palatal segment maintains a variable angle from the hard palate, termed the alpha angle, i beg your pardon is established by the length and also position of the levator veli palatini muscle.

Studies have described three palatal airway phenotypes based upon the measurement of the alpha angle; oblique, intermediate, and also vertical. In people with intermediate and also oblique palatal phenotypes, the angle between the proximal soft palate and hard palate is much less acutely downwards, permitting for the soft palate to maintain a position an ext parallel come the difficult palate. The prayer of patients with oblique and also intermediate phenotypes typically collapse circularly. In people who screen a upright palatal phenotype, the angle in between the proximal soft palate and also hard palate is more acutely downward, allowing for the soft palate to keep a position more parallel come the posterior pharyngeal wall, quite than the difficult palate. Airway collapse wake up in an anterior-posterior fashion in these patients.<13>


Surgical Considerations

Surgical techniques entailing the palate are promptly evolving to boost the high quality of life for patients further. Palate surgical treatment is typically indicated for patients with serious obstructive sleep apnea, slot palate repair, and cancer resection.

Cleft palate repair, termed palatoplasty, need to be performed in between six to twelve month of age to optimize feeding and speech development without interrupting regular maxillofacial growth. There are three varieties of palatoplasty techniques: one kind is because that soft palate repair, the second type is for hard palate repair, and the 3rd involves the operation schedule. Soft palate repair techniques are radical muscle dissection, intravelar veloplasty, primary pharyngeal flap, and dual opposing Z-plasty techniques. The tough palate repair techniques consist that the von Langenbeck, Veau-Wardill-Kilner V-Y, vomer flap, and also alveolar extension palatoplasty techniques. The operation schedule/protocol based methods are entirety in one, Malek’s, and also modified schedule through palatoplasty before lip repair. The score of surgery is come reapproximate or realign the palatal muscles. Upon completion of the surgery, this can aid expedite the advance of regular speech and also sound. Further, cleft palate repair with repositioning of muscles can likewise improve the functioning of the eustachian tube and also hearing. As soon as a surgeon repositions the palatal muscles correctly, this maneuver have the right to improve middle ear ventilation and also decrease illustration of otitis media and hearing defects.

The most usual surgical procedure offered to act obstructive sleep apnea is dubbed uvulopalatopharyngoplasty (UPPP) and also involves the repositioning and/or removed of organization at the soft palate, uvula, and also throat wall surfaces to increase airway size and also decrease organization collapse.

Soft palate implants, or the tower procedure, is a minimally invasive procedure that has demonstrated to assist with mild come moderate situations of sleep apnea. The column procedure needs the placement of three rods made of polyester right into the soft palate. These polyester rods incite an inflammatory reaction within the surrounding soft tissue, which results in a stiffening that the soft palate. This inflammatory reaction results in a stiffer soft palate that is less apt come make contact with the posterior pharyngeal wall as the muscles relax during the deep stages of sleep.

Surgical resection is the treatment for cancer the the tough palate. Extension into surrounding bone is common, and also frequently warrants removed of surrounding bone. If the tumor is small, the excision may be closed ~ surgery. If the tumor is large, a prosthetic an equipment can offer to covering the opening in the palate together the excised area cannot be closed.<1><3><13><14>


Clinical Significance

Tumors of the palate, both benign and also malignant, most often present asymptomatically or are linked with a low level that discomfort.  The appearance of benign and malignant lesions of the palate is additionally quite similar, making the of utmost prominence that the clinician have the ability to differentiate between them. Malignant squamous epithelial neoplasms such as verrucous carcinoma, carcinoma of the maxillary sinus, and also squamous cell carcinoma may appear in the difficult palate. Carcinoma that the maxillary sinus is often asymptomatic for a long time and also usually presents at an advanced stage. This tumor is linked with the elderly and also is most commonly diagnosed once the tumor broadens to fill the sinus and produces a bulge of the alveolar ridge or palatal area on physical examination. Squamous cell carcinomas constitute an ext than ninety percent of all oral cancers. Non-squamous cell carcinomas the the oral cavity are rare. Risk components for squamous cabinet carcinoma the the palate incorporate alcohol, tobacco, and also HPV infection. Primary squamous cabinet carcinoma of the soft palate is painful, reasons dysphagia, and also portends a lot worse prognosis 보다 tumors located more anteriorly. Verrucous carcinoma is a form of squamous cabinet carcinoma that hardly ever metastasizes, behaves indolently, and demonstrates a white papillary clinical appearance. The most common locations for verrucous carcinoma space the alveolar ridge and also hard palate, and also it is associated with yonsi patients who wear finish denture prosthesis. Tumors that the palate deserve to follow the palatine nerves through the greater and lesser palatine foramen and extend into surrounding bone, nerves, and soft tissue. Up to seventy percent of squamous cabinet carcinomas that the difficult palate extends past the difficult palate right into neighboring structures. Radiographically, malignant tumors the the palate may display evidence that bone destruction and sometimes expose a radioopacity produced by the neoplastic mass.<15>

Minor salient gland carcinomas represent less than five percent of oral cavity cancers, and around sixty percent of them arise top top the difficult palate. Both malignant and also benign salient gland tumors the the palate appear as well-circumscribed, smooth, dome-shaped, non-moveable swellings that demonstrate a slow expansion pattern.<16>

Pleomorphic adenoma is the most typical benign outstanding gland neoplasm discovered within the palate. The most typically discovered malignant outstanding gland tumors the the palate in descending order space adenoid cystic carcinoma, polymorphous low-grade adenocarcinoma, and mucoepidermoid carcinoma.<17><18>

Melanoma is a malignant tumor of melanocytes many often connected with cancer that the skin. Melanoma may develop anywhere melanocytes exist and also have the potential to type from melanocytes situated within the palate. Oral melanoma is very rare, accounting for less than one percent of all oral malignancies. The most common site for dental melanoma is the tough palate, which account for approximately forty percent of cases. Dental melanoma many commonly shows up on the maxillary alveolus or difficult palate and tends to have actually a much worse prognosis than cutaneous melanoma. Initially, melanoma lesions show up flat and also later end up being fixed and nodular in appearance. Melanomas often show up as light/dark brown lesions.<15>

The most usual locations of extranodal lymphoma in the head and neck space the soft palate and also posterior hard palate. Top top examination, lymphomas typically show up as a non-ulcerated, non-tender diffusive mass.

Sarcomas space malignant tumors the non-epithelial-tissue beginning that might arise anywhere in the human body, including the palate. Sarcoma that the palate shows up as ulcerated masses in the middle-aged or young patient.<15> 

Cleft palate and lip space the most usual congenital orofacial deformities in the world. Slit palate represents the 3rd most frequently occurring congenital deformity after ~ clubfoot and cleft lip. Cleft lip and also palate demonstrate a multifactorial inheritance pattern. They space the result of a mix of genetic predispositions and in-utero exposure come teratogens choose nicotine, alcohol, antiepileptics, and also folate antagonists. Slot palate results in severe facial deformities, feeding difficulties, nasal regurgitation the milk, coughing/choking throughout feeds, difficulties with phonation, dentition defects, and predisposes patients to recurrent episodes of otitis media with effusion. Cleft palate occurs in a range of chromosomal abnormalities choose the Pierre-Robin sequence, Patau syndrome (trisomy 13), and Edward syndrome (trisomy 18). Embryologically, a slit palate occurs due to a partial or full failure of fusion of the palatine prominences by the ninth week that development. Cleft palate might be unilateral or bilateral and also complete or incomplete. There space three species of cleft palate: submucosal slit palate, incomplete cleft palate, and also a complete cleft palate. In the submucosal slot palate, the palatine mucosa stays intact, yet an underlying bony palatal or muscular defect is present. Incomplete slot palate refers to clefting that the secondary palate exclusively, while finish cleft palate refers to clefting of the whole soft palate, difficult palate, and also uvula. Slit palate repair, termed palatoplasty, should be performed in between six come twelve month of period to optimize feeding and speech advance without interrupting regular maxillofacial growth.

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Repeated bouts of upper airway obstruction reason obstructive sleep apnea during the deep step of sleep together a result of the narrowing/collapse that the respiratory tract passages. Patients v obstructive sleep apnea have tendency to it is in overweight with connected peripharyngeal fat infiltration and/or boosted size of the tongue and soft palate. This anatomic abnormalities predispose patients to obstructive sleep apnea due to the fact that they to decrease the cross-sectional area of the top airway. An enhanced neck circumference coincides to raised peripharyngeal fat infiltration, especially lining the airway and at the basic of the tongue. Neck circumference must be measured as soon as obstructive sleep apnea is suspected. A neck circumference better than seventeen inch in men and greater 보다 sixteen inch in women boosts the threat for obstructive sleep apnea. One neighborhood airway element thought to be a causative certified dealer of obstructive sleep apnea is one elongated soft palate. A distal palatal segment length greater than fifteen millimeters has presented to increase the threat of sleep apnea dramatically. Initial therapy of sleep apnea is generally nonsurgical and consists of confident airway pressure therapy, most typically in the type of CPAP. Historically, countless of the surgical approaches used to exactly sleep apnea in adults were sub-optimal, and also palatopharyngoplasty approaches have developed from primarily excisional methods to those the reposition and reconstruct the palate. Instances of these more advanced surgical techniques include the development sphincter-pharyngoplasty, lateral pharyngoplasty, relocation pharyngoplasty, and uvulopalatopharyngoplasty (UPPP).<1><5>