Chapter 5

A 10-month-old female is scheduled for repair of a cleft palate. She had her cleft lip repaired at the age of 6 months without complications. The infant was born full term and has no other medical problems.

### PREOPERATIVE CONSIDERATIONS

Cleft lip and cleft palate are among the most common congenital anomalies. They may occur alone, as part of a syndrome (there are more than 300 syndromes associated with facial clefting), or as a component of a sequence (for example, with Pierre Robin syndrome). Clefts of the palate may occur through the same mechanisms as cleft lip or be secondary to an anatomic obstruction preventing the medial fusion of the maxillary processes.

Closure of the cleft palate may result in insufficient tissue for development of the normal length or function of the soft palate and therefore may require a posterior pharyngeal flap. Velopharyngeal (VP) insufficiency is the cause of the hypernasal speech, nasal emission, and nasal turbulence.

There are many techniques for repairing a cleft palate, but all of them include a hard palate procedure and a soft palate (velar) procedure. Palatoplasties are performed with the intention of obtaining VP competence and normal speech and are typically performed before the first year of age.

Pharyngoplasties are performed to treat an incompetent VP sphincter that allows inappropriate escape of nasal air during speech, or hypernasality, defined as VP insufficiency. Pharyngoplasties are often performed as secondary speech procedures after a palatoplasty that failed to result in VP competence.

### ANESTHETIC MANAGEMENT

• Most patients with a cleft lip or palate can be induced with a standard inhalational induction or IV induction.

• Airway obstruction can usually be managed with the insertion of an oropharyngeal airway and continuous positive airway pressure.

• For the patient with an isolated cleft lip and palate, difficulty with laryngoscopy is common. Factors predicting a more difficult laryngoscopic view include bilateral clefts and retrognathia. A wide oral opening will help to prevent the laryngoscope blade from slipping into the alveolar ridge defect during laryngoscopy. The view during laryngoscopy is unusual because of the cleft soft and hard palate, but the defect usually allows good visualization of the larynx.

• Cleft patients with associated craniofacial anomalies or retrognathia may be difficult to ventilate or intubate. Adequacy of mask ventilation should be determined. The patient should remain spontaneously ventilating until the trachea is secured with an endotracheal tube.

• Surgical repair of the cleft palate using a laryngeal mask airway (LMA) has been described. However, disruption of a previous cleft palate repair during the placement of an LMA has also been described, suggesting that care should be taken when placing an LMA in a patient with a history of cleft palate repair.

• An oral Ring-Adair-Elwyn preformed tracheal tube is routinely used for the intubation because the preformed bend in the tube facilitates the use of ...

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