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Airway Management in Children Undergoing Cleft Lip or Cleft Palate Surgery: An 8-Year Retrospective Analysis of 274
Johannes Feyrer1, Andrea Irouschek1, Tobias Golditz1
1Department of Anesthesiology, University Hospital Erlangen, Faculty of Medicine, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany.
Insights
Airway management for cleft lip/palate surgery in children is challenging, especially with syndromes. Video laryngoscopy and hybrid techniques improve safety, but post-extubation care is crucial for syndromic cases.
Area of Science:
- Pediatric Anesthesiology
- Craniofacial Surgery
- Airway Management
Background:
- Orofacial malformations, particularly syndromic cleft lip and/or palate, pose significant challenges to pediatric airway management.
- Limited research exists on perioperative airway management strategies specifically for children undergoing cleft lip or palate surgery.
Purpose of the Study:
- To retrospectively analyze perioperative airway management and associated complications in pediatric patients undergoing cleft lip or palate surgery.
- To evaluate the effectiveness of different airway management techniques in this high-risk population.
Main Methods:
- Retrospective analysis of 274 patients under 2 years old undergoing cleft lip or palate surgery between 2016 and 2023.
- Assessment of patient demographics, airway management techniques employed, intubation difficulties, and adverse events.
- Comparison of outcomes between syndromic and non-syndromic cleft patients.
Main Results:
- Difficult laryngoscopy occurred in 6% of cases, with a higher incidence (16.7%) in syndromic patients.
- Failed direct laryngoscopy occurred in 1.9% of cases, significantly higher in syndromic patients (11.1%).
- Airway complications were more frequent in syndromic patients (40.7% vs. 23.5%).
Conclusions:
- Cleft lip and palate surgery in children presents unique airway challenges, with increased difficulty and complications in syndromic cases.
- Video laryngoscopy and hybrid techniques are effective for anticipated difficult airways, ensuring safe anesthesia.
- Tailored postoperative care, including potential epinephrine inhalation, is vital, especially for syndromic patients to prevent reintubation and ICU admission.
Background:
Orofacial malformations, especially when associated with syndromes, may complicate airway management in children. However, only a few studies have addressed the airway management in children undergoing cleft lip and/or palate surgery.
Aims:
To report on perioperative airway management and complications in children undergoing cleft lip or palate surgery over an 8-year retrospective period.
Methods:
We performed a retrospective analysis of patients younger than 2 years of age who underwent surgery for cleft lip or palate at the Department of Oral and Cranio-Maxillofacial Surgery of a German university hospital between 2016 and 2023. The study assessed patient demographics, airway management techniques, airway management difficulties, and adverse events.
Results:
During the observation period, 274 cases were included. Difficult laryngoscopy occurred in 16 cases (6%). Direct laryngoscopy failed in five cases (1.9%), leading to successful video-laryngoscopic intubation. There was a noticeable higher incidence of difficult laryngoscopy (16.7% vs. 5.3%) and failed direct laryngoscopy (11.1% vs. 1.2%) in cleft patients with a syndrome association. In eight cases (2.9%) with an expected difficult airway, a primary hybrid technique was used for intubation due to a proven syndromic disorder. Airway complications were significantly more common in patients associated with a syndromic disorder (40.7% vs. 23.5%; p = 0.049, φ = 0.12).
Conclusion:
Airway management in children undergoing cleft lip or palate surgery presents unique challenges, with an increased incidence of difficult and failed direct laryngoscopy and a significantly higher rate of complications in patients with a syndromic disorder. Video laryngoscopy and, if a difficult airway is anticipated, a hybrid technique for intubation is a safe and effective approach to airway management in these patients. However, the postextubation period can be very challenging, particularly in patients with associated syndromes. Epinephrine inhalation may prevent reintubation and ventilated admission to the intensive care unit.
Clinical Implications:
Cleft lip and palate significantly complicate airway management, especially in infants with syndromic conditions. It was already known that these children are at higher risk for difficult intubation and respiratory complications. The new findings of this study, analyzing 274 procedures in children under 2 years, found that the hybrid technique (video laryngoscopy combined with flexible bronchoscopy) is highly effective for anticipated difficult airways and highlights the importance of an individualized, stepwise approach to ensure safe anesthesia in cleft surgery. Additionally, the study identified a higher incidence of postextubation stridor, particularly in syndromic patients, pointing to the need for tailored postoperative care.
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