Sudha Bidani MD Assistant Professor of Anesthesiology amp Pediatrics Baylor College of Medicine Houston Texas Updated 42017 Disclosure Nothing to disclose Objectives Upon completion of this lectureslide presentation readers should be able to ID: 910984
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Slide1
Cleft Lip and Palate Repair
Sudha Bidani M.D.Assistant Professor of Anesthesiology & PediatricsBaylor College of MedicineHouston, Texas
Updated 4/2017
Slide2Disclosure
Nothing to disclose
Slide3Objectives
Upon completion of this lecture/slide presentation, readers should be able to: Evaluate a child coming in for cleft lip and/or palate repair, anticipate a difficult airway and manage it; Plan and carry out an anesthetic plan for the repair procedure; Render adequate amount of pain relief and manage the post operative care successfully.
Slide4Tessier Classification of
Soft Tissue Clefts
www.cleftline.com
Patricia Bacon Smith, MD. Jan. 2008
Slide5Tessier Classification
of Bony Clefts
www.cleftline.com
Patricia Bacon Smith, MD. Jan. 2008
Slide6Normal Palate
www.moondragon.org/obgyn/peditrics/cleft.html
Jan. 2008
Slide7Embryology
Primary palate formed in 4-7th weekSecondary palate formed in 7-12th weekFusion occurs in anterior to posterior directionPalatal deformity can be complete, incomplete and sub mucous
Slide8Epidemiology 1:800 live birthsCombined defect male: female 2:1Isolated CP: male: female 1:2Asian : Caucasians 2:1Genetic factor is commonest
10-20% associated anomalies
Isolated CL: least likely to have associated anomalies
Slide9Associated Anomalies
Skeletal anomalies of digits and limbsNeural defects: encephalocoele, anencephaly, Cervical vertebral synostosisPart of a more complex facial defects i.e. Treacher
Collins, Pierre Robin,
Apert
etc.
Slide10Unilateral Cleft Lip and Palate
Book: Human Embryology: University of Michigan Collection, EH 164. Modified from Patten: 3d edition 1968
Slide11Multiple Surgeries
Primary: lip & palate repairSecondary: CL and CP revisionCorrection of nasal deformityPalatal and/or alveolar fistulaePharyngoplasty/pharyngeal flapEar tubes
Orthodontics
Slide12Multispecialty Management
Oto-rhino-laryngologist
Geneticist
Anesthesiologist
Cardiologist
Psychiatrist
Pediatrician
Plastic surgeon
Oral surgeon
Speech therapist
Orthodontist
Slide13Surgical Aim
Restoration of facial appearanceRestore the competence of velo-pharyngeal sphincterAchieve better occlusion of maxilla and mandible
Slide14Surgical Timing
Cleft lip : 1 to 5 monthsCleft palate: 6-8 months and older
Slide15Latham or Nam device
Slide16Benefits of Delaying Surgery
Decrease in anesthetic riskDiagnosis of other anomaliesLatham/NAM deviceBetter repair of lip and noseAllows more time for parents to make mental adjustments to child with deformity
Slide17Psychological Aspects
Radical effect on appearancePresence of other anomaliesConductive hearing lossUnintelligible speechPerceived prevalence of mental retardation
Slide18Push-back
Palatoplasty
Surgical repair technique credited to Starr and Von Langenbeck, 1907-8
Slide19Furlow : Lengthening of Palate
Slide20Ann
Kummer
Ph.D. CCC-SLP, ASHA Fellow: Resonance Disorders & velopharyngeal Dysfunction: Simple low-tech and no-tech procedure for evaluation and treatment. Ph.D.
speechpathology.com
Jan. 2008
Slide21Pharyngoplasty
www.seattlechildrens.org/medical-conditions/chromosomal-genetic-conditions/vpi-treatment/
Jan. 2008
Slide22Pharyngeal Flap
Jackson IT: Sphincter Pharyngoplasty: Symposium on Cleft Lip and Cleft Palate. Clinics in Plastic Surgery . October 1985, Vol 12, No. 4 March 1988
Slide23Preoperative Evaluation
Age appropriate birth historyAssociated defectsPrior anesthetic historyURI, chest x-ray?Appropriate fasting periodsPremed?Blood availability
Post op ICU admission
Slide24Anesthetic Management
Location of equipmentLow profile endotracheal tubesLight weight yet long enough circuitStandard monitoringEye lubricationPIP, endobronchial intubationEpinephrine infiltration
Generous IV fluids
Blood loss
Slide25Airway Management/Monitoring
Kinking of endotracheal tubeMainstem migration of the tip of the tubeAccidental extubation
Slide26Extubation
Oral-nasal suction?Oral airway?Pharyngeal packTongue traction suturesAwake/asleepPain reliefArm restraints, arm board for IV
ICU admission
Slide27Pain Management
OpioidsAdjuvantsField blockNerve blocks
Slide28Intraoperative Complications
Airway…Airway…AirwayKinking of ETTDisconnection of the circuitAccidental
extubation
Endobronchial intubation
Laryngospasm
Slide29Post-operative Complications
Post-extubation croupSwelling of the uvulaSublingual oedemaForgotten pharyngeal packsReintubation
Slide30References
Aylsworth AS: Symposium on Cleft Lip and Cleft Palate: Genetic considerations. Clin. in Plastic Surgery 1985, Vol. 12, No. 4 Jackson IT: Symposium on Cleft Lip and Cleft Palate: Sphincter Pharyngoplasty.
Clin
. in Plastic Surgery 1985, Vol. 12, No. 4
Rohrich
RJ, Byrd HS: Optimal timing of Cleft Palate closure: Speech, Facial Growth and hearing considerations.
Clin
. in Plastic Surgery 1990, Vol. 17 No. 1
Slide31References
Book: Human Embryology: University of Michigan Collection, EH 164. Modified from Patten: 3d edition 1968
Slide32Acknowledgement
I was privileged to work together with Dr. Stal for thirty-five years, and to participate in plastic surgery missions organized by Mr. Tom Flood. These experiences have taught me humility and about how much I still do not know about the anesthestic management of these patients.