Cleft palate is a one of the most common craniofacial anomalies. About one in every 1,600 babies is born with cleft lip and cleft palate. Cleft palate occurs during pregnancy, when the opening in the roof of the mouth develops. It is often accompanied by cleft lip [1]. When present, cleft lip will usually be corrected when an infant is 3 months, and cleft palate at 6 months. Since cleft palate is often detected by ultrasound during pregnancy, a team of specialists, including a pediatric anesthesiologist, is often formed in advance of the birth to plan for management, surgery, and anesthesia care [2].
Cleft palate patients can pose challenges to the administration of anesthesia. The most common concern with cleft patients is the difficulty of intubation due to the unusual shape of the lip and mouth. It is recommended that, in order to avoid damaging the tissue, the cleft be packed with moist gauze during intubation [1]. The period following birth and preceding surgical repair allows the treatment team to assess any comorbidities that might impact the administration of an anesthetic. The team is primarily concerned with cardiac or airway abnormalities that may be associated with an underlying condition, as these may limit the means and methods of pain management, both during and after surgery [3]. Other anesthetic considerations include the potential for excessive blood loss, obstruction of the airway that can occur following extubation, and postoperative respiratory depression caused by opioids [4].
There are standards of practice when it comes to anesthesia in cleft palate repair. The patient will usually be administered a volatile anesthetic through inhalation [3]. For those without airway problems, intravenous induction may be used. Regardless of induction method, muscle relaxers should not be administered until after the airway is secured [1]. Local anesthetics are typically used in conjunction with general anesthesia, with a focus on blocking the infraorbital nerve. Local anesthetics can continue to provide analgesia postoperatively, thus limiting the necessity of post-surgical opioid use [3]. This is ideal given that cleft palate patients often have airway complications and are susceptible to opioid-induced respiratory depression. However, other extended opioid pain management may be required in older infants undergoing cleft palate repair [5].
Cleft palate repair is a relatively common procedure, given the frequency of this condition in the population. However, the condition poses many difficulties for the pediatric surgical team, especially when it comes to anesthesia. While there are standard practices for administering anesthesia to these patients, there are ongoing debates around which medications and methods of administration are ideal, especially when it comes to postoperative analgesia [5]. However, as with any condition, the risks and benefits of anesthetic possibilities can vary by individual. Medical advances continue to widen the scope of what is possible in cleft palate repair. Evidence supporting the benefits of in-utero repair remains experimental, but has potential for future experimentation [5]. Regardless of the extent of the surgery, an interdisciplinary team strengthened by a knowledgeable anesthesiologist remains necessary for improving quality of life for those with this congenital deformity.
References
[1] Steward, D. J. “Anesthesia for Patients With Cleft Lip and Palate.” Seminars in Anesthesia, Perioperative Medicine and Pain, vol. 26, no. 3, 2007, 126–132, doi:10.1053/j.sane.2007.06.004
[2] Sandberg, D. J., Magee, W. P., & Denk, M. J. “Neonatal Cleft Lip and Cleft Palate Repair.” AORN Journal, vol. 75, no. 3, 2002, 488–499, doi:10.1016/s0001-2092(06)61171-x
[3] Brzenski, Alyssa, et al. “Pediatric Anesthesia for Patients With Cleft Lip and Palate.” Anesthesia Topics for Plastic and Reconstructive Surgery, 2018, doi:10.5772/intechopen.74926
[4] Doyle, E., & Hudson, I. “Anaesthesia for Primary Repair of Cleft Lip and Cleft Palate: A Review of 244 Procedures.” Pediatric Anesthesia, vol. 2, no. 2, 1992, 139–145, doi:10.1111/j.1460-9592.1992.tb00189.x
[5] Somerville, Nicola, & Fenlon, Stephen. “Anesthesia for Cleft Lip and Palate Surgery.” Continuing Education in Anaesthesia Critical Care & Pain, vol. 5, no. 3, 2005, 76–79, doi:10.1093/bjaceaccp/mki021