Airway management in cleft lip and palate surgery.

Airway management in cleft lip and palate surgery Cleft lip and palate are the most common of the craniofacial anomalies, with an incidence of approximately 1 in 800 live births. Twenty-five percent of cases of cleft lip are bilateral, and 85 % of these are associated with cleft palate. In recent years there has been a move towards earlier surgical repair of both cleft lip and palate, with cleft lip repair being performed in the neonatal period in some centres. The presence of other associated congenital anomalies , including cardiac and renal anomalies, should always be borne in mind, particularly in children with isolated cleft palate. Over 150 syndromes have been described in association with cleft lip/palate, but fortunately all are rare. Some, however, have considerable anaesthetic implications, and many involve potential airway problems. The most well-known of these are the Pierre Robin, Treacher Collins and Goldenhar syndromes. Other, such as the Klippel-Feil syndrome, may include abnormalities of the cervical spine. Airway problems in children with cleft lip and palate were recognized by Magill more than 70 yr ago [1], and since then many methods of managing the child with the difficult airway have been described. Some, such as the use of firm pressure over the larynx to aid laryngoscopy with a bougie as a guide to tracheal intubation, are relatively simple to perform by any competent anaesthetist and are successful in most cases. Digitally assisted tracheal intubation is used rarely, but also requires no special equipment [2]. Other more sophisticated methods, such as those involving fibreoptic techniques, require special equipment, training and experience [3, 4]. The laryngeal mask has been recommended as a guide to fibreoptic intubation in children [5] and has been used successfully in Pierre Robin [6–8] Treacher Collin [9] and Goldenhar syndromes [10]. It has been used for cleft palate repair in a baby with Pierre Robin syndrome when intubation proved impossible [11]. Specially designed light wands and laryngoscopes are available for difficult intubation in children [12–14], but these are either expensive or not readily available in most anaesthetic departments. Retrograde techniques have been described in infancy [15], but their success rate is much lower than in older children or adults. Even when a guide wire or bougie is manipulated successfully into the trachea, it may prove impossible to pass a tracheal tube over it. Threading the guidewire through the Murphy eye of the tracheal tube …