Cleft hard palate with unilateral cleft lip
ICD-10 Q37.1 is a billable code used to indicate a diagnosis of cleft hard palate with unilateral cleft lip.
Cleft hard palate with unilateral cleft lip is a congenital malformation characterized by a split or opening in the hard palate (the bony front part of the roof of the mouth) accompanied by a cleft lip on one side. This condition arises during early fetal development when the tissues that form the lip and palate do not fully come together. The severity of the cleft can vary, affecting feeding, speech, and dental development. Children with this condition may also be at risk for associated congenital anomalies, particularly those affecting the respiratory system, such as choanal atresia, which is a blockage of the nasal passage, and tracheoesophageal fistula, an abnormal connection between the trachea and esophagus. Lung hypoplasia, or underdeveloped lungs, can also occur due to associated conditions. Early diagnosis and intervention are crucial for managing feeding difficulties and preventing complications, and multidisciplinary care involving pediatricians, surgeons, speech therapists, and geneticists is often required.
Detailed records of feeding difficulties, growth parameters, and developmental milestones are essential.
Management of feeding issues in infants, preoperative assessments, and postoperative follow-ups.
Consideration of the impact of cleft conditions on speech development and the need for speech therapy.
Genetic counseling notes, family history, and any chromosomal studies performed.
Evaluation for syndromic associations, genetic testing for chromosomal abnormalities.
Awareness of potential genetic syndromes associated with clefting, such as Van der Woude syndrome.
Used during surgical intervention for cleft lip repair.
Operative reports detailing the procedure and any complications.
Pediatric surgical notes should include preoperative assessments and postoperative care plans.
Common associated conditions include choanal atresia, tracheoesophageal fistula, and lung hypoplasia. These conditions can complicate the clinical management of patients with cleft hard palate and unilateral cleft lip.
