Volume 3 / Issue 1 / January-June 2016

Volume 3

Issue 1

January-June 2016

Pages 1-???

Letters to the Editor

Trifid Uvula
Dear Sir,
The uvula continues as the posterior free border of the
soft palate. It is formed by the fusion of the palatine
shelves during the 7-12th week of intrauterine life. The
uvular clefts are considered to be a microform of cleft
palate.[1] A uvular cleft usually occurs in continuation
with the clefts of the soft and hard palate. The uvular
malformations reported in literature extend from bifid
uvula to the complete absence of uvula.[2] An isolated
cleft of the uvula is rarely seen. We present an extremely
rare presentation of trifid uvula in a child.
A 10-year-old child was brought by her parents with
complaints of a split in her uvula since birth. The
parents were concerned about a mild abnormality in the
childs speech. She had difficulty in pronouncing some
syllables. Clinical examination of the child revealed an
asymmetry in the facial appearance with a deviation of
the chin to the left side and flattening of the mandibular
arch on the left side [Figure 1a]. Clinical examination of
the facial nerve did not reveal any abnormality. Intraoral
examination revealed an asymmetrical split in the uvula
on inspection which extended further anteriorly onto
the soft palate. There was a crowding of the intraoral
structures including tongue and tonsils on the left side
[Figure 1b]. Palpation of the hard and soft palate did not
reveal any bony cleft or notching in the posterior hard
palate. Nasoendoscopic evaluation for velopharyngeal
function revealed adequate movement of the posterior
and lateral pharyngeal walls in addition to the soft
palate with a small central gap which was probably
responsible for mild hypernasality. A diagnosis of
Meskins Type D of uvular cleft was made. The child
was posted for surgery under anesthesia for correction
of the uvular cleft. Intraoperative examination with a
Dott mouth gag and a tongue blade in place revealed
three distinct uvulae on the posterior soft palate
[Figure 2a]. The hard palate was intact without any cleft
or notching of the posterior border. The tonsils, faucial
pillars, posterior tongue, and pharyngeal walls did not
reveal any other abnormality. Hence, the diagnosis was
modified to Trifid uvula.
Uvuloplasty was carried out by keeping the central
uvula intact and two lateral uvulae positioned in
the anterior midline using two interdigitating flaps
created after opening up the lateral uvulae [Figure 2b].
Intraoperative examination under magnification of
56

the palatine musculature demonstrated the musculus

uvulae extending into the central uvula, while the
lateral uvulae did not demonstrate any muscular
elements. The postoperative period was uneventful. The
interdigitating flaps healed without any complications.
Follow-up after 3 months revealed a well-healed soft
palate [Figure 3].
The role of uvula in speech and deglutition is of
considerable debate. Many authors believe that it does
not contribute to velopharyngeal closure and speech
mechanism.[3] On the other hand, few researchers
have shown that the contraction of musculus uvula

Figure 1: Asymmetry of the mandible with deviation of the chin to left side
(a) and cleft of the uvula (b)

Figure 2: Preoperative intraoral photograph showing three distinct uvulae

(a) and postoperative appearance (b)

Figure 3: Postoperative appearance at 3 months follow-up reveals a wellhealed palate

2016 Journal of Cleft Lip Palate and Craniofacial Anomalies | Published by Wolters Kluwer - Medknow

Letters to the Editor

leads to added bulk on the dorsal surface of velum and

also contributes to velar stretch.[4] The uvular clefts
are associated with several chromosomal syndromes
and may have a genetic predisposition. The frequency
of uvular clefts has been reported to be 1 in 80
white individuals[5] and is more common in males.[6]
The uvular clefts have been classified according to
morphology by Meskin et al. as Type A: Normal uvula,
Type B: Uvula bifurcated up to one-fourth of its total
length, Type C: Uvula bifurcated from one-fourth to
three-fourths of its length, and Type D: Uvula bifurcated
from three-fourths to its total length.[7]

Devi Prasad Mohapatra, Ravi Kumar Chittoria,

Friji Meethale Thiruvoth, Sudhanva Hemant Kumar
Department of Plastic Surgery, Superspeciality Block,
Jawaharlal Institute of Postgraduate Medical
Education and Research, Puducherry, India
Address for correspondence: Dr. Devi Prasad Mohapatra,
Department of Plastic Surgery, Superspeciality Block, Jawaharlal Institute
of Postgraduate Medical Education and Research,
Puducherry - 605 006, India.
E-mail: devimohapatra1@gmail.com

REFERENCES
1.

The bifid uvula, the least severe form of cleft palate

is usually associated with submucous cleft palate as
a part of Calnans triad along with zona pellucida, a
translucent zone of muscular diastasis in the soft palate
and a bony notch in the posterior edge of the hard
palate. Other congenital anomalies of uvula include a
congenital absence of uvula.

2.

A thorough search of English literature failed to reveal

any description of a cleft uvula similar as our patients.
We believe that ours could be the only report of trifid
uvula in English literature.

6.

Declaration of patient consent

The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient(s) has/have given his/her/their consent for his/
her/their images and other clinical information to be
reported in the journal. The patients understand that
their names and initials will not be published and
due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.

Financial support and sponsorship

3.
4.
5.

7.

Lindemann G, Riis B, Sewerin I. Prevalence of cleft uvula among

2,732 Danes. Cleft Palate J 1977;14:226-9.
Achalli S, Bhat S, Ram Shetty S, Babu SG, Suvarna R. Deformities
of the uvula in the oral cavity A case series. Iran Red Crescent
Med J 2012;14:676-9.
Kummer A. Cleft Palate & Craniofacial Anomalies: Effects on Speech
and Resonance. 3rd ed. New York: Cengage Learning; 2014. p. 20.
Kuehn DP, Folkins JW, Linville RN. An electromyographic study of
the musculus uvulae. Cleft Palate J 1988;25:348-55.
Neville BW, Damm DD, Allen CM, Bouquot JE. Developmental
defects in oral and maxillofacial region. In: Oral and Maxillofacial
Pathology. 3rd ed. Missouri: Saunders-Elsevier; 2009. p. 3.
Reichert PA, Philipsen HP. Color Atlas of Dental Medicine: Oral
Pathology. 1st ed. New York: George Thieme Verlag; 2000. p. 128.
Meskin LH, Gorlin RJ, Isaacson RJ. Abnormal morphology of the soft
palate. I. The prevalence of cleft uvula. Cleft Palate J 1964;35:342-6.

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DOI:
10.4103/2348-2125.176011

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Conflicts of interest
There are no conflicts of interest.

Journal of Cleft Lip Palate and Craniofacial Anomalies

Cite this article as: Mohapatra DP, Chittoria RK, Thiruvoth FM, Kumar SH.
Trifid Uvula. J Cleft Lip Palate Craniofac Anomal 2016;3:56-7.

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