Clefts: lip, palate, lip and palate
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Incidence:
More than 300 syndromes include a cleft lip, palate and lip palate.
Many non-syndromic cleft palates and cleft lips are actually multifactorial genetic diseases in which a genetic susceptibility (less severe mutations or noncoding regulatory genes) is associated with environmental factors (antiepileptic drugs, tobacco, alcohol, maternal age).
1 incomplete cleft lip
2 complete cleft lip
3 velar (velum); submucosal clefts of the velum also exist (not shown here)
4 (median) complete cleft palate
5 unilateral cleft lip and palate
6 bilateral cleft lip and palate
Anesthetic implications:
- cleft lip around 2-3 months (some teams: first week of life)
- cleft palate between 6 and 18 months (some teams: from the age of 3 months)
- if necessary, velopharyngoplasty and/or alveolar bone graft in childhood
- in all cases: oral intubation with a preformed (RAE type) or a flexible reinforced tracheal tube
- peri-operative analgesia:
1) locoregional anesthesia: cleft lip: suborbital nerve block; cleft palate or cleft lip and palate: maxillary block via the suprazygomatic route, or palatal block and suborbital block; dexamethasone intraoperatively. Clonidine or dexmedetomidine IV or combined with local anesthetic
2) infiltration of the wound by the surgeon with an adrenalinized lidocaine solution to reduce bleeding: a transient hemodynamic reaction is frequent following the mucosal resorption of adrenaline
3) postop: paracetamol + NSAIDs, morphine if analgesia is insufficient
* after the repair of a cleft palate or lip and palate: nasal intubation or placement of a nasogastric tube should be performed with extreme caution
* after a pedicled flap between the lower and the upper lip (Abbe-Estlander flap): release of the flap under sedation or nasal fiberoptic intubation
* after a velopharyngoplasty: avoid as much as possible a nasotracheal intubation. If it is absolutely necessary, the following sequence is recommended:
$ preoperative ENT examination by nasal fibroscopy to check the permeability of the patency of the nares;
$ after anesthetic induction under spontaneous ventilation, a soft-tipped small suction catheter is inserted into one nostril and directed through the nare(s) while palpating the oronasal membrane around the ipsilateral pharyngeal neo-orifice with a finger of the other hand;
$ when the exploring catheter exits through the pharyngeal neo-orifice, direct laryngoscopy can be performed using the catheter as a guide to railroad a tracheal tube softened in hot water over it.
$ an alternative technique is to perform an initial oral intubation prior to any nasopharyngeal manoeuvre : this improves safety during the nasal intubation procedure
* after the completion of a temporary flap between the dorsal surface of the tongue and the edges of a palatal fistula. The release of the flap raises an obvious problem of access to the airway without damaging the fragile mucosal flap. Options: 1) nasotracheal intubation with a fiberscope. (2) progressive release of the lingual part under sedation (inhalation anesthesia via a nasopharyngeal airway or intravenous sedation with e.g. ketamine) associated with local anesthesia.
References:
- Geneviève D, Captier G, Blanchet C.
Syndromes avec fentes labiopalatines.
In Syndromes dysmorphiques coordonné par Lacombe D et Philip N, Collection Progrès en Pédiatrie, Doin 2013, p 261-82
- Seto-Salvia N, Stanier P.
Genetics of cleft lip and/or cleft palate: association with other common anomalies.
Eur J Med Genet 2014, in press
- Dadure C, Capdevila X.
Prise en charge anesthésique pour chirurgie de fentes labiopataines de l’enfant.
Le Praticien en Anesthésie-Réanimation 2011 ; 15 : 206-10.
- Mahmoud AAA, Fouad AZ, Mansour MA, Kamal AM.
A novel intubation technique in bilateral cleft palate pediatric patients : hard gum shield-aided intubation.
Pediatr Anaesth 2013; 23: 349-54.
- Jagannathan N, Aveyard C.
Palatal dehiscence : an unusual cause of acute upper airway obstruction in an infant during induction of anesthesia.
Pediatr Anesth 2008 ; 18:1129.
- Eipe N, Pillai AD, Choudhrie R.
The tongue flap: an iatrogenic difficult airway?
Anest Analg 2006; 102:971-2.
- Hee HI, Conskunfirat ND, Wong S-Y, Chen C.
Airway management in a patient with a cleft palate after pharyngoplasty: a case report.
Can J Anesth 2003; 50: 721-4.
- Kopp VJ, Rosenfeld MJ, Turvey TA.
Nasotracheal intubation in case of a nasopharyngeal flap in children and adults.
Anesthesiology 1995; 82: 1063-4.
- Suleiman NN, Luedi MM, Joshi G Dewinter G, Wu CL, Sauter AR on behalf of the PROSPECT Working Group.
Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations.
Reg Anesth Pain Med 2024;49:635–41. doi:10.1136/rapm-2023-105024
Updated: September 2024