Anaesthetic Management of Cleft Lip and Cleft Palate in Children

1. Overview

2. Preoperative Assessment

2.1 Identify Associated Syndromes

2.2 Airway Evaluation

• Retrognathia or micrognathia increases risk of difficult direct laryngoscopy
• Large or bilateral clefts: the tongue may prolapse into the cleft, causing airway obstruction; the laryngoscope blade can fall into the cleft groove — use a roll of gauze or the surgeon's finger to fill the cleft before laryngoscopy
• Mouth opening, neck mobility, Mallampati class (adapted for infants)
• Check for associated choanal atresia or subglottic stenosis

2.3 Cardiac Evaluation

• Evaluate for congenital heart disease (common in syndromic patients)
• Obtain echocardiography if murmur or signs of cardiac abnormality are present

2.4 General

• Review growth and nutritional status (cleft palate → poor feeding)
• Document any prior anaesthetic history, particularly difficult airway
• Assess for active upper respiratory infection (URTI): many centres delay elective surgery by 4–6 weeks after a febrile URTI
• NPO fasting: standard paediatric guidelines (2-4-6 rule)

3. Anaesthetic Induction

3.1 Standard Cleft Lip (uncomplicated, 3–6 months)

• IV or inhalational induction is appropriate when no anticipated airway difficulty
• Sevoflurane in oxygen/air for gaseous induction, or propofol/thiopentone IV if cannula is in place
• Atropine (0.02 mg/kg IV) — commonly given to reduce oral secretions and prevent bradycardia, especially in young infants

3.2 Anticipated Difficult Airway (Syndromic, Retrognathia)

• Prepare difficult airway cart before induction:
  • Multiple laryngoscope blades (Miller/Macintosh sizes 0–2), video laryngoscope
  • Smaller ETT sizes (uncuffed and cuffed), bougie/stylet
  • Supraglottic airways (LMA): sizes 1, 1.5, 2
  • ENT surgeon on standby for emergency tracheostomy in extreme cases
• Consider awake/semi-awake fibreoptic nasotracheal intubation in cases of severe micrognathia (Pierre Robin, Treacher Collins)
• Inhalational induction with sevoflurane maintaining spontaneous breathing is preferred if airway is potentially difficult — do not give muscle relaxant until airway is secured
• Lateral or prone positioning may help displace the tongue anteriorly in Pierre Robin, facilitating intubation

4. Airway Management & Intubation

4.1 Endotracheal Tube Selection

• A preformed oral RAE tube (south-facing) or armoured/reinforced ETT is preferred — it keeps the circuit away from the surgical field and reduces kinking
• The tube must be secured at the midline of the lower lip — the surgeon will require access to the entire upper lip and philtrum for cleft lip; and the entire palatal arch for cleft palate
• Oral cuffed or uncuffed ETT: use uncuffed below 8 years by traditional convention; current evidence supports cuffed ETTs with careful pressure monitoring (< 20 cmH₂O)
• ETT size (uncuffed): (Age/4) + 4 for children >1 year; use 3.0–3.5 mm for neonates/infants

4.2 Managing the Cleft During Laryngoscopy

• The cleft groove can trap the laryngoscope blade, making visualisation difficult
• Technique: pack the cleft with a small roll of moistened gauze before laryngoscopy OR have the surgeon's finger temporarily bridge the cleft as the blade is inserted
• Use a straight Miller blade in neonates and infants
• Video laryngoscopy (C-MAC, GlideScope paediatric) improves glottic view without requiring neck extension — preferred in syndromic difficult airways

4.3 Throat Pack

• A moist throat pack is placed after intubation to prevent blood and debris from entering the airway
• Critical: document the throat pack insertion and ensure its removal before extubation — failure to remove is a life-threatening "never event"

5. Positioning and Surgical Considerations

• Patient is supine; shoulder roll placed to extend the neck slightly and improve surgical access
• For cleft palate: a Dingman mouth gag (or similar retractor) is inserted — this can displace or kink the ETT; recheck breath sounds and EtCO₂ after gag insertion
• Surgeon may infiltrate with epinephrine-containing local anaesthetic (typically 1:200,000) — inform the anaesthetist; monitor for tachycardia/arrhythmia; avoid excessive doses in neonates

6. Maintenance of Anaesthesia

• Volatile agent (sevoflurane or desflurane) in oxygen/air — typically 40–50% FiO₂
• Total intravenous anaesthesia (TIVA) with propofol + remifentanil infusion is an alternative, especially in syndromic patients with known or potential malignant hyperthermia susceptibility (avoid triggers)
• Neuromuscular blockade: short/intermediate-acting agents (cisatracurium, atracurium, rocuronium) used judiciously; spontaneous ventilation sometimes preferred in infants to detect airway compromise early
• Opioids: fentanyl (1–2 mcg/kg IV) at induction; morphine judiciously intraoperatively
• Dexamethasone (0.1–0.15 mg/kg) — reduces airway swelling, post-operative nausea/vomiting
• Fluid management: calculate and maintain maintenance fluids with isotonic crystalloid; blood loss typically minimal for lip but can be more significant for palate

7. Regional Anaesthesia & Analgesia

7.1 Infraorbital Nerve Block (for Cleft Lip)

• Provides excellent intra- and postoperative analgesia for cleft lip repair — reduces opioid requirements
• Anatomy: infraorbital foramen lies just below the infraorbital rim, ~1 cm from midline at the mid-pupillary line
• Technique: intraoral approach (through sulcus above upper canine tooth) or extraoral approach under the eyelid
• In neonates and infants, landmark palpation can be difficult; ultrasound guidance improves accuracy
• Drug: 0.5–1 mL of 0.25% bupivacaine or 0.2% ropivacaine per side
• Combined with external nasal nerve block for complete coverage of the lip and columella

7.2 Greater Palatine / Nasopalatine Nerve Block (for Cleft Palate)

• Blocks the hard palate, supplementing analgesia during palatoplasty
• Typically surgeon-administered intraoperatively

7.3 Suprazygomatic Maxillary Nerve Block

• An emerging, ultrasound-guided approach to block the maxillary nerve (V2) at the pterygopalatine fossa via the zygomatic arch — covers both lip and palate
• Evidence supports superiority over infraorbital block alone for bilateral cleft cases

7.4 Systemic Analgesia

• Paracetamol (acetaminophen): 15–20 mg/kg PO/IV/PR — regular, scheduled dosing is the cornerstone
• NSAIDs: ibuprofen or ketorolac in infants >3 months (use with caution; avoid in bleeding risk)
• Opioids: morphine 0.05–0.1 mg/kg IV judiciously; avoid routine opioid use due to respiratory risk in young infants and those with OSA
• Multimodal analgesia is strongly recommended — reduces opioid-related respiratory depression

Recent evidence: A 2025 network meta-analysis (PMID 40203658) found nerve blocks (particularly infraorbital and suprazygomatic maxillary) significantly reduce pain scores and opioid consumption in paediatric cleft lip/palate repair. A 2024 PROSPECT systematic review (PMID 38124208) issued procedure-specific recommendations for cleft palate pain management, supporting multimodal analgesia with paracetamol, NSAIDs, and regional blocks as the evidence-based standard.

8. Extubation

• Cleft lip repair: extubation may be performed either deep (if airway appears straightforward) or awake — awake extubation is generally safer
• Cleft palate repair: the patient must be extubated awake — postoperative airway obstruction is a recognised complication due to:
  • Oedema at the repair site
  • Haematoma
  • Altered anatomy of the soft palate narrowing the nasopharynx
  • Residual opioid/anaesthetic effect
• Before extubation:
  • Remove throat pack (verify and document)
  • Ensure complete reversal of neuromuscular blockade (neostigmine + atropine, or sugammadex if rocuronium used)
  • Suction oropharynx gently under direct vision (avoid disturbing the repair)
  • Patient must be awake, responsive, able to maintain airway
• After palate repair, a tongue stitch (holding suture through the tongue tip) is sometimes placed by the surgeon and left in for 24–48 hours to allow manual displacement of the tongue if acute airway obstruction occurs postoperatively

9. Postoperative Care

• Monitoring: continuous SpO₂ and respiratory rate in PACU/HDU — minimum 2–4 hours
• Positioning: prone or lateral (recovery position) helps drain secretions after palate repair
• Airway vigilance: have equipment for re-intubation at bedside; opioids should be used with caution and only with continuous monitoring
• Arm splints (no-nos): traditionally applied to prevent the child from putting fingers/objects in the mouth, but evidence for benefit is limited; many centres still use them
• Feeding: clear fluids by syringe or soft cup within 4–6 hours; avoid breast/bottle with hard teat after palate repair to protect the suture line
• Analgesia post-op: scheduled paracetamol ± ibuprofen; opioid rescue PRN with monitoring
• Discharge: typically 1–2 days post-palate repair with written analgesia instructions

10. Complications to Anticipate

Summary Algorithm

Preop: Syndrome screen → Airway assessment → Echo if cardiac murmur

↓
Difficult airway anticipated?
  YES → Awake FOB / gas induction / videolaryngoscope on standby
  NO  → Routine gaseous or IV induction

↓
Intubation: RAE tube mid-centre, fill cleft with gauze, insert throat pack

↓
Maintenance: Sevoflurane/TIVA + opioids + dexamethasone
Analgesia: Infraorbital nerve block (lip) / palatine block (palate)
           + regular paracetamol ± NSAIDs

↓
Extubation:
  Lip → awake or deep (surgeon's discretion)
  Palate → ALWAYS awake; tongue stitch in situ

↓
Post-op: SpO₂ monitoring, multimodal analgesia, syringe feeds

• Miller's Anesthesia, 10e — Cleft Lip and Palate (p. 10644)
• Barash Clinical Anesthesia, 9e — Infraorbital Nerve Block and Regional Techniques
• Miller's Anesthesia — Syndromic difficult airways (Down, Pierre Robin, Treacher Collins, Goldenhar syndromes)
• PMID 40203658 — Nerve blocks for cleft lip/palate: network meta-analysis (2025)
• PMID 38124208 — PROSPECT recommendations for cleft palate pain management (2024)