Airway Management in Children Undergoing Cleft Lip or Cleft Palate Surgery: An 8-Year Retrospective Analysis of 274 Cases.

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.