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Anaesthesia for cleft palate surgery
PAEDIATRICS
Anaesthesia for cleft palate surgery Philip Bolton
A failure of the two maxillary processes to fuse with the frontonasal process between 6 and 12 weeks of gestation results in cleft lip, cleft palate or both.
1 Child with cleft lip and palate intubated with a polar south tube.
Incidence: in the UK, 1/700 children are born with cleft lip or palate, cleft palate being the more common. 44% of cases have an isolated cleft palate and 34% have both. Cleft lips may also involve an underlying alveolar bone cleft.
Postoperative care should be managed in a high-dependency unit. The nasal airway usually remains patent after lip repair, though bilateral lip repair can sometimes flatten the nares. The airway can be improved by placing short nasal stents for 24–48 hours postoperatively. Palate correction separates the nasal and oropharynx. If the child is unable to breath comfortably through the mouth, they may need a nasopharyngeal tube for a couple of days until the swelling subsides and the nasal airway improves.
Timing of surgery Cleft lip repair is usually done at about 3 months of age. At this age, preoperative orthodontic alignment is possible, if required, and surgery is technically easier than in the newborn because the structures have grown slightly. It is also relatively soon after birth, when wound healing is better and postoperative feeding is simpler. Palate repair is delayed until 9 months to allow the child to adapt to breathing comfortably through their mouth, since surgery partially obstructs the nasal airway. Repair at this age allows speech development to progress normally. Alveolar bone grafting is usually done in adolescence.
Analgesia with regular paracetamol and non-steroidal anti-inflammatory drugs (for those older than 6 months) is usually sufficient. An oral opioid (e.g. dihydrocodeine) can be given in addition, if required. Infra-orbital nerve block can provide helpful analgesia after lip repair. After palate repair, children may be reluctant to eat and drink for 24 hours and usually have rectal analgesia and intravenous fluids until oral intake is re-established.
Anaesthetic management Anaesthesia is usually relatively straightforward if there is no associated syndrome. The child is intubated with a polar south tube (Figure 1) and if the palate is to be corrected, a Boyle–Davis gag is inserted, similar to that used for tonsillectomy. When the gag is opened, there is a risk of intubating the right main bronchus or kinking the tube, both of which must be excluded before surgery proceeds. The surgeon infiltrates local anaesthetic with epinephrine into the surgical field to reduce bleeding. Despite this, intra-operative stimulation can be marked because of tube movement. This can be obtunded with opioids (e.g. morphine, 0.05–0.10 mg/kg). Opioids also minimize postoperative upset, allowing the child to recover from anaesthsia gradually, reducing crying and the risks of swelling and bleeding from the operation site. Further opioid boluses can be given, if required, in recovery.
Other associated abnormalities Cleft lip and palate is seen in severe multi-system syndromes such as trisomy 13 or 18. However, it may be associated with other specific abnormalities such as cardiac lesions or, more commonly, further airway abnormalities. These associated abnormalities usually occur in children with isolated cleft palate. Pierre Robin association is the most common associated airway abnormality presenting very significant problems to the anaesthetist. The short mandible pushes the tongue upwards and backwards, making maintaining the child’s airway and intubation very difficult. Intubation often requires specialist techniques, though airway obstruction can usually be relieved with a laryngeal mask. These children usually have significant postoperative airway obstruction and should be cared for in an ICU. They usually tolerate a nasopharyngeal airway. The mandible grows disproportionately quickly in these children, so surgery is often delayed until about 12 months.
Philip Bolton is Consultant Paediatric Anaesthetist at the Royal Hospital for Sick Children, Yorkhill, Glasgow, UK. He qualified from Dundee University and trained in anaesthesia in Dundee, Vancouver and Glasgow. His main clinical interest is difficult airway management.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 7:5
157
© 2006 Elsevier Ltd
Anaesthesia for cleft palate surgery Philip Bolton
A failure of the two maxillary processes to fuse with the frontonasal process between 6 and 12 weeks of gestation results in cleft lip, cleft palate or both.
1 Child with cleft lip and palate intubated with a polar south tube.
Incidence: in the UK, 1/700 children are born with cleft lip or palate, cleft palate being the more common. 44% of cases have an isolated cleft palate and 34% have both. Cleft lips may also involve an underlying alveolar bone cleft.
Postoperative care should be managed in a high-dependency unit. The nasal airway usually remains patent after lip repair, though bilateral lip repair can sometimes flatten the nares. The airway can be improved by placing short nasal stents for 24–48 hours postoperatively. Palate correction separates the nasal and oropharynx. If the child is unable to breath comfortably through the mouth, they may need a nasopharyngeal tube for a couple of days until the swelling subsides and the nasal airway improves.
Timing of surgery Cleft lip repair is usually done at about 3 months of age. At this age, preoperative orthodontic alignment is possible, if required, and surgery is technically easier than in the newborn because the structures have grown slightly. It is also relatively soon after birth, when wound healing is better and postoperative feeding is simpler. Palate repair is delayed until 9 months to allow the child to adapt to breathing comfortably through their mouth, since surgery partially obstructs the nasal airway. Repair at this age allows speech development to progress normally. Alveolar bone grafting is usually done in adolescence.
Analgesia with regular paracetamol and non-steroidal anti-inflammatory drugs (for those older than 6 months) is usually sufficient. An oral opioid (e.g. dihydrocodeine) can be given in addition, if required. Infra-orbital nerve block can provide helpful analgesia after lip repair. After palate repair, children may be reluctant to eat and drink for 24 hours and usually have rectal analgesia and intravenous fluids until oral intake is re-established.
Anaesthetic management Anaesthesia is usually relatively straightforward if there is no associated syndrome. The child is intubated with a polar south tube (Figure 1) and if the palate is to be corrected, a Boyle–Davis gag is inserted, similar to that used for tonsillectomy. When the gag is opened, there is a risk of intubating the right main bronchus or kinking the tube, both of which must be excluded before surgery proceeds. The surgeon infiltrates local anaesthetic with epinephrine into the surgical field to reduce bleeding. Despite this, intra-operative stimulation can be marked because of tube movement. This can be obtunded with opioids (e.g. morphine, 0.05–0.10 mg/kg). Opioids also minimize postoperative upset, allowing the child to recover from anaesthsia gradually, reducing crying and the risks of swelling and bleeding from the operation site. Further opioid boluses can be given, if required, in recovery.
Other associated abnormalities Cleft lip and palate is seen in severe multi-system syndromes such as trisomy 13 or 18. However, it may be associated with other specific abnormalities such as cardiac lesions or, more commonly, further airway abnormalities. These associated abnormalities usually occur in children with isolated cleft palate. Pierre Robin association is the most common associated airway abnormality presenting very significant problems to the anaesthetist. The short mandible pushes the tongue upwards and backwards, making maintaining the child’s airway and intubation very difficult. Intubation often requires specialist techniques, though airway obstruction can usually be relieved with a laryngeal mask. These children usually have significant postoperative airway obstruction and should be cared for in an ICU. They usually tolerate a nasopharyngeal airway. The mandible grows disproportionately quickly in these children, so surgery is often delayed until about 12 months.
Philip Bolton is Consultant Paediatric Anaesthetist at the Royal Hospital for Sick Children, Yorkhill, Glasgow, UK. He qualified from Dundee University and trained in anaesthesia in Dundee, Vancouver and Glasgow. His main clinical interest is difficult airway management.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 7:5
157
© 2006 Elsevier Ltd