Anesthetic Management of Cleft Palate

1. Overview

• Cleft lip repair: typically at 3–6 months of age
• Cleft palate repair: typically at 9–12 months of age

2. Preoperative Assessment

2.1 General History & Examination

• Full syndrome screen — identify associated anomalies (cardiac, airway, skeletal)
• Growth and nutritional status (feeding difficulties are common)
• History of recurrent upper respiratory infections or otitis media
• Family history of anesthetic complications (malignant hyperthermia, suxamethonium apnea)
• Vaccination status and any recent URI (timing of surgery)

2.2 Airway Assessment

• Retrognathia / micrognathia: increases risk of difficult laryngoscopy and intubation
• Large or bilateral clefts: the tongue may impinge on the cleft, causing airway obstruction. The laryngoscope blade may fall into (and be lodged in) the cleft during direct laryngoscopy
• Pierre Robin sequence: micrognathia + glossoptosis + cleft palate — high-risk airway; anticipate need for awake fibreoptic intubation or video laryngoscope
• Neck mobility and mouth opening: assess Mallampati, thyromental distance, mouth opening, and cervical spine mobility
• Nasal and oral endoscopy findings if available
• Plan for difficult airway: have video laryngoscope, fibreoptic bronchoscope, and LMA available; senior anaesthetist should be present

2.3 Investigations

• Full blood count — baseline haemoglobin; infants may be borderline anaemic
• Blood grouping and crossmatch — blood loss can be significant, especially in large palate repairs
• Electrolytes, renal function — if associated syndromes
• Echocardiogram — if congenital heart disease is suspected (VSD, ASD are associated with some syndromes)
• Coagulation screen — if there is concern about hepatic or haematological disease
• ECG if cardiac anomaly is suspected
• Pre-anaesthetic chest X-ray if respiratory concerns exist

2.4 Preoperative Fasting (Standard Paediatric Guidelines)

2.5 Premedication

• Oral midazolam (0.3–0.5 mg/kg, max 15 mg) — anxiolysis in children >6 months
• Anticholinergics (glycopyrrolate or atropine) — reduce secretions, especially useful in difficult airway scenarios
• Topical EMLA over IV sites

3. Intraoperative Anesthetic Management

3.1 Induction

• Inhalational induction with sevoflurane and oxygen is standard in young infants and uncooperative children
• IV induction (propofol or thiopentone) once IV access is secured
• Difficult airway protocol:
  • Have video laryngoscope (e.g., C-MAC, GlideScope) at hand
  • Fibreoptic-guided intubation for anticipated difficult airway
  • Awake fibreoptic intubation for neonates with severe Pierre Robin sequence
  • Do NOT administer neuromuscular blocker until airway is secured

3.2 Airway Management

• Preformed (RAE) oral endotracheal tube — preferred; fits the midline groove of the Dott–Boyle–Davis mouth gag and keeps the tube away from the surgical field
• Tube should be secured at the midline of the lower lip
• Use cuffed ETT if available (reduces gas leak and contamination)
• Throat packing with a moist gauze sponge to prevent blood/secretions reaching the larynx — document clearly and remove before extubation
• Confirm correct tube position after positioning and gag placement (both can cause tube displacement or kinking)

3.3 Positioning

• Supine with neck slightly extended (roll under shoulders)
• The surgeon uses a Dott–Boyle–Davis mouth gag — this can:
  • Kink or displace the ETT
  • Compress the tongue and cause postoperative macroglossia
  • Obstruct venous drainage from the tongue → swell
• Re-check breath sounds and capnography after gag insertion

3.4 Maintenance

• Volatile agent (sevoflurane or isoflurane) with oxygen/air mixture, or TIVA (propofol ± remifentanil)
• Nitrous oxide is best avoided — risk of nausea/vomiting and risk in any unrecognised pneumothorax
• Neuromuscular blockade with atracurium or vecuronium if needed; reversal with neostigmine + glycopyrrolate or sugammadex (for rocuronium)
• Maintain normothermia with warming mattress, warm fluids, and Bair Hugger — infants are at high risk of hypothermia
• IV fluids: maintain with balanced crystalloid (Hartmann's/PlasmaLyte) at maintenance rate; replace blood loss with colloid or packed red cells if >10% EBL exceeded

3.5 Monitoring

• Standard ASA/AAGBI monitoring: SpO₂, ECG, NIBP, EtCO₂, temperature
• Secure IV access (×1 reliable cannula minimum; ×2 for extensive repairs)
• Oesophageal or precordial stethoscope — useful in infants
• Urinary catheter for long procedures

4. Emergence and Extubation

• Extubate AWAKE — this is critical in cleft palate repair
• Airway obstruction after palate repair is a significant risk due to:
  • Pharyngeal oedema
  • Haematoma
  • Reduced nasopharyngeal space post-repair
  • Residual anaesthetic effect
• Ensure full reversal of neuromuscular blockade before extubation
• Remove throat pack before extubation (check count)
• Suction oropharynx gently under direct vision
• Extubate in lateral (recovery) position or semi-prone — reduces aspiration and airway obstruction risk
• Have equipment for re-intubation immediately available
• Observe closely in recovery for a minimum of 1 hour

5. Postoperative Analgesic Management

5.1 Simple Analgesics (First-line, scheduled)

• Paracetamol (acetaminophen):
  • Oral/rectal: 15 mg/kg every 6 hours (max 60 mg/kg/day)
  • IV: 15 mg/kg every 6 hours (loading dose 20 mg/kg in children >1 year)
  • Should be given regularly, not PRN
• NSAIDs (ibuprofen, diclofenac, ketorolac):
  • Provide effective analgesia and reduce opioid requirements
  • Use with caution in infants <6 months; avoid if there is bleeding concern or renal impairment
  • Ibuprofen 5–10 mg/kg every 6–8 hours (oral, >3 months)

5.2 Opioids (Judicious use)

• Morphine IV or oral: 0.05–0.1 mg/kg every 4–6 hours PRN
• Fentanyl IV: 1–2 mcg/kg for breakthrough pain
• Use with caution — infants <3 months have reduced opioid clearance and increased apnoea risk
• All opioid-treated infants should be on continuous SpO₂ monitoring postoperatively

5.3 Regional Analgesia (Very effective)

Infraorbital Nerve Block

• Indicated for cleft lip repair (not palate)
• Provides excellent analgesia of the upper lip, nostril, and anterior cheek
• Performed intraorally or extraorally
• 0.1–0.2 mL of 0.25–0.5% bupivacaine per side

Suprazygomatic Maxillary Nerve Block

• Covers all branches of the maxillary nerve: lower eyelid, ala nasi, cheek, upper lip, superior teeth, and palatine zone
• Well-established for cleft palate surgery; provides superior postoperative analgesia compared to systemic analgesics alone
• Technique (landmark):
  • Needle entry at the angle of the superior zygomatic arch and posterior orbital rim
  • 22–25 gauge needle, perpendicular to skin, advance ~10–15 mm to sphenoid, then redirect caudally and posteriorly 35–45 mm to pterygopalatine fossa
  • Inject 0.15 mL/kg (max 5 mL) of local anesthetic per side after negative aspiration
  • Ultrasound guidance is increasingly used and improves safety
• Technically demanding — should be performed by experienced practitioners only

5.4 Summary Analgesic Ladder for Cleft Palate

6. Special Considerations & Complications

References

• Miller's Anesthesia, 2-Volume Set, 10th edition — "Cleft Lip and Palate," p. 10644
• Miller's Anesthesia, 2-Volume Set, 10th edition — "Suprazygomatic Maxillary Nerve Block," pp. 11034–11037
• Barash, Cullen & Stoelting's Clinical Anesthesia, 9th edition — "Regional Techniques—Peripheral," p. 3766