Acute airway obstruction in an infant with Pierre Robin syndrome after palatoplasty

Respiratory outcomes after cleft palate closure in Robin sequence: a retrospective study

OBJECTIVES

There is a paucity of information about the possible risk factors that could identify patients with Robin sequence (RS) who are more prone to developing obstructive airway complications after palate closure. This study aimed to compare the respiratory complication rates in patients with RS and isolated cleft palate (ICP).

MATERIALS AND METHODS

In this retrospective study, we reviewed the medical records of 243 consecutive patients with RS and ICP who were treated at Amsterdam University Medical Centers over the past 25 years. We collected preoperative data on previous treatment, diagnostic findings, surgical technique, weight, and presence of congenital anomalies.

RESULTS

During cleft palate closure, patients with RS were older (11.9 versus 10.1 months; p = 0.001) and had a lower gestational age than those with ICP (37.7 versus 38.5 weeks; p = 0.002). Patients with RS had more respiratory complications (17 versus 5%; p = 0.005), were more often non-electively admitted to the pediatric intensive care unit (PICU) (13 versus 4.1%; p = 0.022), and had a longer hospital stay duration (3.7 versus 2.7 days; p = 0.011) than those with ICP. The identified risk factors for respiratory problems were a history of tongue-lip-adhesion (TLA) (p = 0.007) and a preoperative weight of < 8 kg (p = 0.015). Similar risk factors were identified for PICU admission (p = 0.015 and 0.004, respectively).

CONCLUSIONS

The possible risk factors for these outcomes were a low preoperative weight and history of TLA. Closer postoperative surveillance should be considered for patients with these risk factors.

CLINICAL RELEVANCE

Identifying risk factors for respiratory complications could provide clinicians better insight into their patients and allows them to provide optimal care for their patients.

Preemptive analgesic effectiveness of single dose intravenous ibuprofen in infants undergoing cleft palate repair: a randomized controlled trial

Background

Correction surgery for cleft palate is recommended between 9 and 18 months of age. Patients suffer from acute pain after palatoplasty. Clinicians are hesitant to use opioids for analgesia concerning the potential high risk of respiratory adverse events. Intravenous ibuprofen perhaps be a suitable adjuvant to pain relief. We try to assess whether preoperative administration of intravenous ibuprofen can decrease opioid requirements following cleft palate repair in infants.

Methods

This single center prospective randomized clinical trial was performed from February to April 2021 at Department of Anesthesiology in Shanghai Children’s Medical Center. Forty patients ASA I-II, aged 9–24 months with isolated cleft palate and undergoing palatoplasty were randomized in a 1:1 ratio to receive either a single dose of 10 mg/kg ibuprofen intravenously or normal saline at induction. Children and infants postoperative pain scale (CHIPPS) was used for pain assessment. Those patients CHIPPS pain score equal or higher than 4 received analgesic rescue with titrating intravenous fentanyl 0.5 μg/kg and repeated in 10 min if required. The primary outcome was the amount of postoperative fentanyl used for rescue analgesia in postanesthesia care unit (PACU).

Results

Patients (n = 20 in each group) in IV-Ibuprofen group required less postoperative fentanyl than those in placebo group (p<0.001). There was no significant difference between two groups in first rescue analgesia time (p = 0.079) and surgical blood loss (p = 0.194). No incidence of obvious adverse events had been found within the first 24 h after surgery in both groups.

Conclusions

Preemptive intravenous administration ibuprofen 10 mg/kg at induction had a significant opioid sparing effect in early postoperative period without obvious adverse effects in infants undergoing palatoplasty.

Trial registration

CHICTR, CTR2100043718, 27/02/2021 http://www.chictr.org.cn/showproj.aspx?proj=122187

Perioperative complications in cleft palate repair with Robin sequence following Tuebingen palatal plate treatment

Our study aimed to evaluate perioperative complications following our institutional pre- and intraoperative management in cleft palate repair with Robin sequence (RS). RS patients who underwent cleft palate repair between 2000 and 2020 were retrospectively analysed. RS children with complete documentation and whose initial treatment involved the Tuebingen palatal plate (TPP) were included. Clinical records and operative charts were reviewed with regard to clinical characteristics as well as the neonatal and perioperative course. Results before and after adjustment of the anesthesiology protocol in 2014 were compared. 143 RS patients (41% male, 59% female) were included. Median pretherapeutic mixed-obstructive apnea index (MOAI) after birth was 9.4/hour (IQR 20.0). TPP treatment was associated with normalisation of the MOAI and adequate weight gain until surgery. At surgery, median age was 10 months (IQR 3), MOAI 0.1/h (IQR 0.5), and weight 8.7 kg (IQR 1.7). In 93% of cases (n = 133), the postoperative course was uneventful. Refinement of the anesthesiology protocol showed positive effects on the perioperative course and led to a reduction in perioperative events (10.7% vs. 2.9%). No severe perioperative complications occurred. We recommend the adoption of TPP treatment in the therapy of RS children. Our favourable results show that early TPP treatment minimizes perioperative complications in cleft palate repair by effectively and sustainably correcting upper airway obstruction.

Can Tonsillar Retractor-Induced Tongue Edema Be a New Complication in Pediatric Patients Undergoing Tonsillectomy Detected by Ultrasonography? A Prospective, Case-Controlled, Observational Study

BACKGROUND

Tonsillectomy is one of the most common surgical procedures in pediatric patients. The tonsillar retractor, which is routinely used during a tonsillectomy, applies high pressure to the patient's tongue and can lead to various complications.

AIMS

This study aimed to explore tongue edema induced by the pressure applied by tonsillar retractor, using ultrasonography in pediatric patients undergoing tonsillectomy surgeries.

MATERIALS AND METHODS

Sixty-one patients were included in the study. The tonsillectomy group included 31 patients who underwent tonsillectomy surgery, while the control group included 30 patients who underwent inguinal hernia and circumcision surgery. Submental coronal plane ultrasonography examinations of the tongue were performed twice for each patient. In the tonsillectomy group, the first examination of tongue area (TA¹) was done immediately after intubation but before the placement of tonsillar retractor. The second examination (TA²) was done at the end of the tonsillectomy surgery after the removal of the tonsillar retractor but before extubation. In the control group, the first examination (TA¹) was done immediately after intubation, whereas the second examination (TA²) was done at the end of the surgery before extubation. These results were compared with those for the control group.

RESULTS

Groups were similar in terms of demographics and intubation duration. Groups did not significantly differ in terms of TA¹ (P = .212), but they significantly differed in terms of TA² (P = .000). They also significantly differed in terms of tongue edema defined as TA² - TA¹ (P = .000).

CONCLUSIONS AND SIGNIFICANCE

Tonsillar retractor does cause tongue edema in tonsillectomy surgeries. This tongue edema seems to be a result of the pressure applied by the tonsillar retractor. This study is the first to demonstrate the possible role of ultrasonography examination in determining the tonsillar retractor-induced tongue edema in pediatric patients.

Respiratory Distress following Cleft Palate Repair in Children with Robin Sequence

Objective

The aim of this study is to assess prevalence, severity, and duration of respiratory distress following palatoplasty in children with Robin sequence and to evaluate perioperative management.

Design

Retrospective chart review study. Data were collected for patients who were born between 2009 and 2012 and underwent palatoplasty in the Sophia Children's Hospital-Erasmus Medical Center.

Result

Of the 75 patients with cleft palate, 30 with Robin sequence and a control group of 45 cleft without Robin sequence underwent palatoplasty. Prior to closure, 26 of 30 patients with Robin sequence had been treated by prone positioning, and four needed additional treatment. The mean age at closure was 12.4 months for patients with Robin sequence and 10.9 months for patients without Robin sequence (P = .05). On the basis of the results of preoperative polysomnography with palatal plate, closure was postponed in two patients with Robin sequence. In the Robin sequence group, eight of the 30 patients developed postoperative respiratory distress within 48 hours and one patient, after 7 days; whereas none within the non—Robin sequence group developed respiratory distress. In all nine cases of Robin sequence the obstructive problems resolved within a few days, with four children requiring a temporary nasopharyngeal tube (NPT). There were no significant differences between preoperative polysomnography results of the nine patients with Robin sequence who developed postoperative respiratory distress compared with those patients with Robin sequence who did not.

Conclusion

Despite delayed closure compared with children without Robin sequence, 30% of the children with Robin sequence developed respiratory distress following palatoplasty, which resolved within a few days. This study emphasizes the need for close perioperative monitoring of patients with Robin sequence who undergo palatoplasty.

Utility of Tongue Stitch and Nasal Trumpet in the Immediate Postoperative Outcome of Cleft Palatoplasty

BACKGROUND

Postoperative airway obstruction is a feared complication following cleft palate repair. The aim of this study was to evaluate the effectiveness of tongue stitches and nasal trumpets that have been used in an attempt to prevent this complication.

METHODS

An 8-year (2005 to 2013) retrospective review of palatoplasties performed at a tertiary care center was conducted. Patients were divided into three groups: those with no airway protective measure, those with a tongue stitch only, and a group with nasal trumpet and tongue stitch. Recorded variables included sex, age, Veau classification, and comorbidities. Primary outcomes measured were postoperative respiratory distress, readmission, and reoperation rates.

RESULTS

Fifty-eight patients underwent palatoplasties with no airway protective measure, 252 patients had tongue stitch only, and 87 had tongue stitch and nasal trumpet. There were no significant differences between groups with respect to comorbidities except that cleft lip was more prevalent in the no-airway protection group than in the other two groups (p = 0.04). There was no significant difference in the incidence of reintubation, intensive care unit transfer, surgery-related readmissions, or reoperation. Respiratory complications were significantly increased in the nasal trumpet group even after adjusting for age and weight. Length of stay was also significantly (p < 0.01) shortened when comparing no airway protection to those who underwent both nasal trumpet and tongue suture placement.

CONCLUSIONS

The use of a tongue stitch, with or without nasal trumpet, did not correlate with improved safety and outcomes. Patients without these airway protective measures had a shorter hospital stay.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Postoperative complications associated with extubation strategies following palatoplasty: a single-center retrospective analysis

PURPOSE

Palatoplasty carries a high risk of airway obstruction as a postoperative complication. Since 2007, the protocol in our hospital has been to leave an endotracheal tube in place after surgery while the patient is moved to the pediatric intensive care unit. Extubation is then performed after achievement of hemostasis and recovery of consciousness. We compared the cases over the 5-year periods before and after the introduction of this revised postsurgical management plan to investigate its effect on postoperative complications.

METHODS

This was a retrospective cohort study involving a single pediatric hospital. The subjects were 199 children aged 1-3 years, who underwent palatoplasty between January 2002 and July 2012. Changes in the incidence rates of postoperative complications were statistically examined.

RESULTS

There were significantly more postoperative complications among the patients who were extubated in the operating room than among those extubated in the intensive care unit (operating room group, 22/94 cases; intensive care unit group, 10/105 cases; P < 0.01). Serious complications, such as hypoxemia and airway obstruction, also occurred more frequently in the operating room group.

CONCLUSION

Extubation in an intensive care unit was possibly associated with a reduction in postoperative complications.

Appropriate Tongue Blade Length of the Dingman Mouth Gag for Japanese Pediatric Patients With Cleft Palate and Mandibular Micrognathia

Objective Our objective is to determine appropriate specifications for smaller tongue blade for Japanese pediatric patients with cleft palate (CP) and mandibular micrognathia. Patients We investigated 59 patients who underwent palatoplasty. Patients were divided into two groups: the micrognathia (MG) group consisted of 11 patients and the normognathia (NG) group consisted of 48 patients. Interventions The following five items were investigated retrospectively: (1) gender, (2) cleft type, (3) age at the time of surgery, (4) weight at the time of surgery, and (5) distance from the tongue blade base to the posterior pharyngeal wall (Dis). Results There was a significant difference (P < .01) in age at the time of surgery and in Dis between groups, but not in weight. The minimum values were 55 mm for the MG group. As for correlations between age and weight at the time of surgery, the P values for the MG and NG groups were .993 and .052, respectively. As for correlations between weight at the time of surgery and Dis, the P values for the MG and NG groups were .987 and .099, respectively. Conclusions It was difficult to predict Dis on the basis of the patient's age and weight measured preoperatively. The minimum Dis was 55 mm, equal to the length from the base to the tip of the Dingman Mouth Gag tongue blade currently in use, suggesting that a tongue blade of approximately 50 mm in length, shorter than the current minimum specifications, may be appropriate.

Massive lingual swelling following cleft palate repair

We report two cases of massive tongue edema in routine palatoplasty. All patients had uneventful recovery. We postulated that the macroglossia was secondary to ischemia and venous congestion after prolonged use of Killner Dott mouth gag with slotted tongue blade exaggerated by hyperextension of neck and Trendelenberg position.

Perioperative Risk Factors for Adverse Airway Events in Patients Undergoing Cleft Palate Repair

Objective

To establish the incidence of perioperative airway complications in a large series of pediatric patients undergoing palatoplasty and to identify which specific patient, procedural, and provider factors are associated with increased risk for perioperative adverse airway events (AAEs).

Design

Retrospective chart review.

Setting

Tertiary pediatric hospital.

Patients

Included were 300 patients who underwent primary cleft palate repair using the modified Furlow technique between 2008 and 2011. Patients were 2 years or younger at the time of the operation.

Main Outcome Measure(s)

Charts were reviewed for perioperative AAEs, which were defined as postoperative airway obstruction, oxyhemoglobin saturation ≤85% for ≥45 seconds, bronchospasm, laryngospasm, reintubation, and unplanned admission to the intensive care unit. Patient-specific factors (diagnosis of a craniofacial syndrome, Veau cleft type, preoperative pulmonary and airway history), procedural factors (operative time, anesthesia time, opioid dose, administration and reversal of neuromuscular blockers), and provider factors (experience, number of providers), were documented, and associations with AAEs were investigated.

Results

AAEs occurred in 23% of patients overall and were significantly more common in syndromic patients ( P = .003), patients with jaw or tracheal anomalies ( P = .001), and patients with a history of difficult airway ( P = .001). Other significant factors included prior history of difficult intubation ( P = .05), surgeon ( P = .02) and anesthesiologist experience ( P = .05), and operative time ( P = .02).

Conclusions

Diagnosis of a craniofacial syndrome, a history of preoperative airway problems, and provider inexperience correlated with increased risk for airway complications after palatoplasty. Recognizing patients at risk for AAEs may permit improved preoperative planning to optimize surgical outcomes and minimize complications.

Assessment of Speech in Primary Cleft Palate by Two-layer Closure (Conservative Management)

Treatment of the cleft palate has evolved over a long period of time. Various techniques of cleft palate repair that are practiced today are the results of principles learned through many years of modifications. The challenge in the art of modern palatoplasty is no longer successful closure of the cleft palate but an optimal speech outcome without compromising maxillofacial growth. Throughout these periods of evolution in the treatment of cleft palate, the effectiveness of various treatment protocols has been challenged by controversies concerning speech and maxillofacial growth. In this article we have evaluated the results of Pinto's modification of Wardill-Kilner palatoplasty without radical dissection of the levator veli palitini muscle on speech and post-op fistula in two different age groups in 20 patients. Preoperative and 6-month postoperative speech assessment values indicated that two-layer palatoplasty (modified Wardill-Kilner V-Y pushback technique) without an intravelar veloplasty technique was good for speech.

Massive macroglossia after palatoplasty: case report and review of the literature

Cleft palates are among the most common birth defects. Serious complications in perioperative airway management after palatoplasty are rare and mostly described in children with preexisting compromise of airway due to craniofacial anomalies. A very uncommon but typical and frightening complication is postoperative extreme, very rapid emergence, and life-threatening macroglossia. While macroglossia usually has its peak within 24-48 h after palatoplasty and resolves spontaneously, we report a patient with massive lingual swelling with complete obstruction of the upper airway on the fifth postoperative day requiring tracheotomy. Swelling only resolved after removing the endotracheal tube after tracheotomy. Next to the description of our case, we discuss standard care procedure in perioperative management of patients with cleft palate to prevent this life-threatening complication after palatoplasty.

CONCLUSION

Macroglossia can occur even 3-5 days after surgery and can be maintained by the pressure of the endotracheal tube to the tongue ground. Knowledge and avoidance of these risk factors are as important as early treatment of respiratory compromise.

Neonates with Tongue-Based Airway Obstruction

Objective. In this systematic review, the authors summarize the current evidence in the literature regarding diagnosis, treatment, and long-term outcomes in neonates with tongue-based airway obstruction (TBAO) and assess the level of evidence of included studies.

Data Sources. The terms Pierre Robin syndrome/sequence, micrognathia, retrognathia, and cleft palate were combined with airway obstruction, treatment, tongue-lip plication, and osteogenesis distraction to perform an Ovid literature search, yielding 341 references. The authors excluded references containing patients with isolated choanal/nasal obstruction, patients older than 12 months, and expert opinion papers, yielding 126 articles.

Review Methods. The authors searched 3 electronic databases and reference lists of existing reviews from 1980 to October 2010 for articles pertaining to the diagnosis, treatment, and outcomes of TBAO. Reviewers assigned a level of evidence score based on Oxford’s Centre for Evidence Based Medicine scoring system and recorded relevant information.

Results. Most studies were case studies and single-center findings. The lack of standardization of diagnostic and treatment protocols and the heterogeneity of cohorts both within and between studies precluded a meta-analysis. There was little evidence beyond expert opinion and single-center evaluation regarding diagnosis, treatment, and long-term outcomes of neonates with TBAO.

Conclusions. The variability in the phenotype of the cohorts studied and the absence of standardized indications for intervention preclude deriving any definitive conclusions regarding diagnostic tools to evaluate this patient population, treatment choices, or long-term outcomes. A coordinated multicenter study with a standardized diagnostic and treatment algorithm is recommended to develop evidence for the diagnosis and treatment of neonates with TBAO.

Late onset tongue edema after palatoplasty

Cleft lip palate is a congenital anomaly that requires surgical reconstruction, and patients rarely develop tongue edema after palatoplasty. We describe a 1-year-and-8-month-old boy who underwent palatoplasty for left-sided cleft lip palate accompanied by exudative otitis media. Although previous reports have described that tongue edema usually sets in early after surgery, the symptoms of edema persisted more than 4 hours postoperatively in our case. We suggest that careful observation for edema is necessary for 24 hours at least after palatoplasty.

[Life-threatening macroglossia following cleft palate palatoplasty]

The case of a 13-month-old child who developed a life-threatening macroglossia with airway obstruction following palatoplasty for a cleft palate is reported. As direct laryngoscopy was not feasible a laryngeal mask (LM) was inserted to secure the airway. Under fiber optic guidance an endotracheal tube was then introduced via the LM. In this article the incidence, pathophysiology, clinical dynamics, options for emergency anesthesia management and organizational implications of this rare but typical complication in the field of oral and craniomaxillofacial surgery are reported.

Avoiding airway obstruction after pediatric adenotonsillectomy

OBJECTIVE

To evaluate the efficacy of a protocol designed to prevent post-adenotonsillectomy airway obstruction in small children with obstructive sleep apnea.

DESIGN

Computerized retrospective review of single surgeon case series.

SETTING

Tertiary children's medical center.

METHODS

Children with sleep study proven obstructive sleep apnea or children under the age of 3 years with clinically suspected obstructive sleep apnea were treated according to a protocol that included: (1) rapid bloodless tonsillectomy; (2) repeated release of the tonsillar retractor; (3) avoidance of uvular edema; (4) routine intra-operative intranasal oxymetazoline, and placement of nasal airway; (5) extended recovery room observation. Primary outcome measures were (1) avoidance of unexpected intensive care unit admission; (2) post-extubation pulmonary edema; (3) aspiration pneumonia.

RESULTS

During the period March 2004-August 2007, 864 children underwent adenotonsillectomy by a single surgeon-604 for the indication of obstructive sleep apnea or adenotonsillar hypertrophy with obstruction. Two hundred and ten were under the age of 3 years or had sleep study proven obstructive sleep apnea. There were two unexpected admissions to the pediatric intensive care unit for persistent upper airway obstruction-none required intubation. No child developed post-obstructive pulmonary edema. Three children were treated for infiltrates consistent with aspiration pneumonitis.

CONCLUSION

Most cases of post-extubation pulmonary edema and pneumonia can be avoided in young children and those with mild-to-moderate obstructive sleep apnea following a protocol that anticipates and avoids precipitating causes of upper airway obstruction.

Parent-controlled analgesia in children undergoing cleft palate repair

The aims of this study were to find an optimal basal infusion dose of fentanyl for parent-controlled analgesia (PrCA) in children undergoing cleft palate repair and the degree of parents' satisfaction with PrCA. Thirty consecutive children between 6 months and 2 yr of age were enrolled. At the end of surgery, a PrCA device with a basal infusion rate of 2 mL/hr and bolus of 0.5 mL with lockout time of 15 min was applied. Parents were educated in patient-controlled analgesia (PCA) devices, the Wong Baker face pain scoring system, and monitoring of adverse effects of fentanyl. Fentanyl was infused 0.3 microgram/kg/hr at first, and we obtained a predetermined fentanyl regimen by the response of the previous patient to a larger or smaller dose of fentanyl (0.1 microgram/kg/hr as the step size), using an up-and-down method. ED50 and ED95 by probit analysis were 0.63 microgram/kg/hr (95% confidence limits, 0.55-0.73 microgram/kg/hr) and 0.83 microgram/kg/hr (95% confidence limits, 0.73-1.47 microgram/kg/hr), respectively. Eighty seven percent of the parents were satisfied with participating in the PrCA modality. PrCA using fentanyl with a basal infusion rate of 0.63 microgram/kg/hr can be applied effectively for postoperative pain management in children undergoing cleft palate repair with a high level of parents' satisfaction.

Pierre-Robin-Sequenz — postoperative Komplikationen nach Gaumenspaltverschluss

BACKGROUND

In a 25-year retrospective review of 1976-2000, the postoperative course after cleft palate surgery and pharyngeal flap surgery in 87 children with Pierre Robin sequence was studied.

PATIENTS AND METHODS

The study comprised 114 interventions with 87 primary palatoplasties; 17 patients required palatal fistulae repair and 10 children were treated with secondary pharyngoplasty procedures. All children were divided into three postnatal risk groups according to the severity of their symptoms at birth and in the course of the early months of life.

RESULTS

A direct correlation was seen between the incidence of early postnatal difficulties and the postoperative obstructive complications after cleft palate surgery and pharyngeal flap surgery. Thus, children experiencing obstructive problems at birth (high postnatal risk group) displayed more severe complications at the time after cleft palate repair. In children undergoing pharyngeal flap surgery not only early postoperative obstruction but also late obstructive sleep apnea can occur.