Portal de Periódicos da CAPES

Anaesthesia for cleft lip and palate surgery

2021; Elsevier BV; Volume: 21; Issue: 10 Linguagem: Inglês

10.1016/j.bjae.2021.06.002

2058-5357

Simon Denning, Elaine Ng, Karen W. Y. Wong Riff,

Tracheal and airway disorders

Learning objectivesBy reading this article you should be able to:•Describe the incidence, embryology, and classification of cleft anomalies.•Discuss the perioperative management of patients with orofacial clefts.•Know the challenges of the shared airway in managing a patient with an orofacial cleft.Key points•Orofacial clefts are the most common craniofacial abnormality and patients with clefts require specialised multidisciplinary care from infancy through to adulthood.•Cleft anomalies are associated with numerous congenital abnormalities and patients should be assessed appropriately in the preoperative period.•Management of the airway may be challenging because of a difficult, shared airway and postoperative airway obstruction. This requires effective communication and teamwork between surgical and anaesthesia teams.•Patients should be monitored for signs of airway obstruction throughout their recovery from anaesthesia.•A multimodal approach to analgesia is important to provide optimal conditions for recovery. Orofacial clefts, encompassing cleft lip with or without cleft palate and cleft palate alone, are the most common craniofacial abnormalities. They can affect the patient's feeding; speech and hearing; dental health; appearance; and psychological health. Child abandonment or social isolation of the children and the families are common in many cultures around the world. The overall management of these patients aims to improve velopharyngeal function, and allow the patient to develop normal speech without compensatory articulations, whilst the cosmetic improvements provide psychological benefits for the patient and family. This requires multidisciplinary input from specialists in plastic and maxillofacial surgery, anaesthesia, nursing, dentistry, nutritional sciences, speech and language therapy, and audiology. This review aims to provide an overview of cleft lip and palate, and considerations for anaesthesia and perioperative management of these patients. Cleft lip refers to a fissure in the upper lip and may be incomplete or complete (through to the nasal cavity), unilateral, or bilateral. Cleft palate describes a gap in the soft palate that may or may not involve the hard palate. They may be submucous (the mildest form with no visible cleft but a failure of the palatal muscles to unite), incomplete or complete, unilateral or bilateral. There are several complex classification systems that describe the extent of individual defects; these are beyond the scope of this article. The overall incidence of orofacial clefts in the UK is around 1000 cases per year; approximately 1 in 700 live births (Table 1). There is significant international variation and published figures depend on the accuracy of the data reported. Using data from 57 registries, the WHO reported in 2003 that prevalence of cleft lip with or without cleft palate at birth ranged from 3.4 to 22.9 per 10,000 births, an average of 7.9 per 10,000 births.2World Health OrganizationGlobal registry and database on craniofacial anomalies: report of a WHO registry meeting on craniofacial anomalies. World Health Organization, Geneva2003https://apps.who.int/iris/handle/10665/42840Date accessed: March 31, 2020Google Scholar,3World Health OrganizationGlobal strategies to reduce the health-care burden of craniofacial anomalies: report of WHO meetings on International Collaborative Research on Craniofacial Anomalies, Geneva, Switzerland, 5-8 November 2000; Park City, UT, U.S.A. WHO, May 2001https://apps.who.int/iris/handle/10665/42594Date accessed: March 30, 2020Google Scholar There were regional differences; for example, Bolivia has a rate of 22.9 per 10,000 births whilst South Africa (3.5) and Israel (3.4) were significantly lower. Cleft palate prevalence varied from 1.4 to 25.3 per 10,000 births, 5.0 per 10,000 births overall, with British Columbia showing the highest rate (25.3) and Cuba the lowest (1.4).2World Health OrganizationGlobal registry and database on craniofacial anomalies: report of a WHO registry meeting on craniofacial anomalies. World Health Organization, Geneva2003https://apps.who.int/iris/handle/10665/42840Date accessed: March 31, 2020Google Scholar,3World Health OrganizationGlobal strategies to reduce the health-care burden of craniofacial anomalies: report of WHO meetings on International Collaborative Research on Craniofacial Anomalies, Geneva, Switzerland, 5-8 November 2000; Park City, UT, U.S.A. WHO, May 2001https://apps.who.int/iris/handle/10665/42594Date accessed: March 30, 2020Google Scholar Data from the International Perinatal Database Of Typical Oral Clefts (IPDTOC) in 2011 and Tanaka and colleagues in 2012 both suggest the overall rate has remained stable.4Mastroiacovo P. Maraschini A. Leoncini E. et al.Prevalence at birth of cleft lip with or without cleft palate: data from the international perinatal Database of typical oral clefts (IPDTOC).Cleft Palate Craniofac J. 2011; 48: 66-81Crossref PubMed Scopus (238) Google Scholar,5Tanaka S.A. Mahabir R.C. Jupiter D.C. Menezes J.M. Updating the epidemiology of cleft lip with or without cleft palate.Plast Reconstr Surg. 2012; 129: 511-518Crossref PubMed Scopus (129) Google Scholar In studies of immigrant populations, the prevalence of orofacial clefts is similar to their country of origin rather than the country they have moved to. It is unclear why, but cleft lip with or without cleft palate is seen more in males, whilst cleft palate is seen predominantly in females.Table 1Proportion of cleft types in patients born with clefts in the UK in 20181Ireland N. 2018 annual report on children with a cleft lip and/or palate: summary of findings for patients and parents/carers summary of 2018 CRANE annual report findings.2019Google ScholarUnilateral cleft lip22%Unilateral cleft lip and palate23%Bilateral cleft lip and palate12%Cleft palate alone43% Open table in a new tab The embryological development of the lip and palate from neural crest cells is complex and requires coordinated cell migration, growth, and differentiation. Formation of the lip and primary palate involves the fusion of the lateral and median nasal processes and maxillary mesodermal processes. This is usually complete by the sixth week after conception. Failure at any of these sites results in unilateral, bilateral, or median cleft lip. Development of the secondary palate follows; the palatal shelves fuse in the midline and the position of the hard and soft palate is formed by the 10th week of gestation. As the lip and primary palate have an embryologically distinct developmental process to the secondary palate, cleft palate may occur with or without cleft lip. The majority (61%) of orofacial clefts present as isolated anomalies in patients who are not 'syndromic'.6Tolarová M.M. Cervenka J. Classification and birth prevalence of orofacial clefts.Am J Med Genet. 1998; 75: 126-137Crossref PubMed Scopus (311) Google Scholar The aetiology of these defects is not clearly understood. There is evidence to show a genetic component in a relatively small percentage of cases, and gene variants involved in the crucial midface development process have been identified. Environmental factors may be contributory including maternal age, tobacco smoking, alcohol consumption, drug use, nutrition including folate deficiency, infection, and teratogen exposure.7Mossey P.A. Little J. Munger R.G. Dixon M.J. Shaw W.C. Cleft lip and palate.Lancet. 2009; 374: 1773-1785Abstract Full Text Full Text PDF PubMed Scopus (961) Google Scholar However, patients with orofacial clefts may have additional congenital abnormalities (~30% in cleft lip with or without cleft palate and ~20% in cleft palate), including head and neck deformities, cardiac defects, and musculoskeletal and renal issues.8Pereira A.V. Fradinho N. Carmo S. et al.Associated malformations in children with orofacial clefts in Portugal: a 31-year study.Plast Reconstr Surg Glob Open. 2018; 6: 1-7Crossref Scopus (14) Google Scholar Cleft lip with or without cleft palate are listed as possible features in more than 200 syndromes (Table 2). Prenatal diagnosis of oral clefts is beneficial for identification of associated syndromes and abnormalities, therefore assessment of the upper lip is a component of the mid-pregnancy scan and cleft lip with or without cleft palate may be visualised. Cleft palate alone is rarely detected prenatally but may be suspected if micrognathia and polyhydramnios are present.Table 2Common syndromes associated with cleft lip and palate6Tolarová M.M. Cervenka J. Classification and birth prevalence of orofacial clefts.Am J Med Genet. 1998; 75: 126-137Crossref PubMed Scopus (311) Google Scholar,7Mossey P.A. Little J. Munger R.G. Dixon M.J. Shaw W.C. Cleft lip and palate.Lancet. 2009; 374: 1773-1785Abstract Full Text Full Text PDF PubMed Scopus (961) Google Scholar,15Somerville N. Fenlon S. Anaesthesia for cleft lip and palate surgery.Contin Educ Anaesthesia, Crit Care Pain. 2005; 5: 76-79Abstract Full Text Full Text PDF Scopus (17) Google ScholarChromosomal syndromesFeaturesVelocardiofacial (DiGeorge) syndromeMicrocephaly and microstomiaFlat nasal bridge, small ears, short statureImmune deficiency, congenital cardiac diseaseVelopharyngeal incompetence with or without cleft palateLaryngeal and tracheal anomalies22q 11 deletion (FISH test)Cleft palate in 30% of casesTrisomy 21 (Down's syndrome)Microstomia and relative macroglossiaEpicanthic folds, simian creaseCongenital cardiac diseaseAtlantoaxial subluxation and instabilityMonogenic syndromesVan der Woude syndromeLower lip pitsHypodontiaCongenital cardiac diseaseMusculoskeletal issuesMost common orofacial clefting syndromeTreacher-Collins syndromeMicrognathia and maxillary hypoplasiaChoanal atresiaEye and ear malformationsIntubation may become more difficult with ageCleft palate in 30% of casesHemifacial microsomia(Goldenhar syndrome)Hemifacial and mandibular hypoplasiaCervical spine abnormalitiesEar and eye abnormalitiesIntubation may become more difficult with ageStickler syndromeProgressive connective tissue disorder (autosomal dominant)Midface hypoplasiaMicrognathia/PRSRetinal detachment and early cataractsDeafnessHypermobility of jointsSequencePierre Robin SequenceMicrognathiaGlossoptosisUnderlying syndrome/anomaliesUsually easier to intubate with ageCleft palate in 80% of cases Open table in a new tab The anaesthetic considerations include factors related to the patient, the anaesthetic, and the surgery (Table 3).Table 3Considerations for anaesthesia for cleft lip and palate surgeryPatient-related factorsUsually infants or young paediatric patientAssociated comorbidities and syndromesNutritional statusAirway obstructionPotential difficult airwayAnaesthetic factorsGeneral anaesthesia with tracheal tubeShared airwaySurgical factorsElective surgery (time to optimise) Open table in a new tab Primary repair of cleft lip may occur between 6 weeks and 6 months of age, allowing for growth of the patient, investigation of related anomalies before surgery, and avoidance of giving a general anaesthetic in the neonatal period. If cleft palate repair is required, this is generally completed between 6 and 12 months of age. The anaesthesia team is involved from an early stage, for preoperative review and counselling, or in cases where there is significant airway obstruction. A comprehensive preoperative anaesthetic assessment should be completed, being mindful of syndromes associated with orofacial clefts and comorbidities (Table 2). History and examination should include a systems review, specifically looking to identify any signs of congenital heart disease (15% of patients); upper respiratory tract infection (URTI); obstructive sleep apnoea (OSA); renal disorders; neuromuscular disorders or malnutrition.8Pereira A.V. Fradinho N. Carmo S. et al.Associated malformations in children with orofacial clefts in Portugal: a 31-year study.Plast Reconstr Surg Glob Open. 2018; 6: 1-7Crossref Scopus (14) Google Scholar,9Kasatwar A. Borle R. Bhola N. Rajanikanth K. Prasad G.S.V. Jadhav A. Prevalence of congenital cardiac anomalies in patients with cleft lip and palate – its implications in surgical management.J Oral Biol Craniofac Res. 2018; 8: 241-244Crossref PubMed Scopus (17) Google Scholar For patients who have multiple comorbidities it may be prudent to delay cleft surgery until their health has been optimised and the balance between risks and benefit is more favourable. A multidisciplinary meeting may be beneficial, allowing for exploration of functional, medical, and surgical issues with time for the family to ask any questions they may have. Routine laboratory investigations are generally not required. A discussion regarding postoperative disposition and anticipated complications should occur during preoperative planning. For uncomplicated cases, patients for primary cleft lip repair are admitted overnight to ensure recovery and oral intake. Safe day surgery has also been described at some institutions. Patients for primary cleft palate repair are generally admitted for 1–3 days as they are at higher risk of postoperative bleeding and airway obstruction. Chronic rhinorrhoea is common in patients with cleft lip with or without cleft palate and cleft palate secondary to reflux of feeds into the nasal passages. This should be distinguished from an active URTI. Patients' conditions should be optimised where possible, as these are elective procedures and may be postponed if necessary. Surgical repair of the defect will reduce rhinorrhoea and the risk of further URTI. Ultimately, the decision to proceed or delay surgery should be made after a discussion of the risks and benefits with the multidisciplinary team. Feeding issues are common in these patients. Orofacial clefts hamper the infant's ability to feed effectively from either bottle or breast whilst associated abnormalities, such as Pierre Robin sequence (PRS) and OSA, may lead to apnoea during feeding or prolonged feeding. Any signs of malnourishment or dehydration should be investigated appropriately, and the procedure postponed until they are growing well. It should also be noted that, in some centres, infants may be weaned from the nipple/bottle to a cup before surgery to protect the repair after surgery. Airway assessment is mandatory, including appraisal of syndromic features and any history of chronic airway obstruction or OSA symptoms such as snoring and apnoea during feeds. Patients with OSA are at higher risk of airway obstruction at induction, and after surgery, and are more sensitive to sedative drugs, especially opioids. In the non-syndromic patient, evidence from a study of 800 patients suggests difficult direct laryngoscopy (Cormack and Lehane grade III or IV, 7.4%), difficult intubation (between two and four attempts, 8.4%), and failed intubation (1%) in ASA 1 cleft patients has, historically, been relatively uncommon. Difficult laryngoscopy was associated with patients <6 months of age, bilateral cleft lips, and retrognathia.10Gunawardana R.H. Difficult laryngoscopy in cleft lip and palate surgery.Br J Anaesth. 1996; 76: 757-759Abstract Full Text PDF PubMed Scopus (70) Google Scholar Certain syndromes are well known to be associated with difficult intubating conditions (Table 2). Difficulty was increased in patients with cleft lip with or without cleft palate (10%) and cleft palate with PRS (23%).11Arteau-Gauthier I. Leclerc J.E. Godbout A. Can we predict a difficult intubation in cleft lip/palate patients?.J Otolaryngol Head Neck Surg. 2011; 40: 413-419PubMed Google Scholar Ideally, patients with clefts should be managed by experienced cleft teams, in specialist paediatric centres, that are able to provide the required facilities and expertise.12Colbert S.D. Green B. Brennan P.A. Mercer N. Contemporary management of cleft lip and palate in the United Kingdom. Have we reached the turning point?.Br J Oral Maxillofac Surg. 2015; 53: 594-598Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Sedative premedication can be considered in the patients who have separation anxiety. Preoperative analgesia such as p.o. acetaminophen 15–20 mg kg−1 is recommended. In patients whose airways are not anticipated to be difficult, any anaesthetic induction technique can be considered. Our practice involves gaseous induction of anaesthesia using sevoflurane in 100% oxygen with standard routine monitoring (pulse oximetry, ECG, non-invasive arterial BP, capnography, and temperature), although i.v. induction is equally appropriate. Intravenous access, if not already established, is sited as soon as adequate depth of anaesthesia is achieved. Additional medications may be given to facilitate tracheal intubation. The ideal airway device for cleft repair, allowing for optimal surgical access, is a preformed 'south facing' Ring-Adair-Elwyn (RAE) tracheal tube (TT), inserted orally and secured in the midline below the lower lip (Fig. 1). However, the preformed curve of these TTs may not perfectly fit the patient's features; careful placement of the tip, visually at intubation and with auscultation of the chest, is necessary to avoid endobronchial intubation. If the TT protrudes too far from the bottom lip it is possible to use padding, such as dental rolls or gauze, to build a platform that the TT can be secured to, to reduce the risk of inadvertent advancement of the tip. If this is still inadequate, a standard reinforced tube can be used as it is flexible enough to follow the contours of the chin but should not kink or obstruct. Cuffed or uncuffed TTs may be used. Cuffed TTs are becoming more popular in paediatric patients and confer benefits in shared airway procedures as they provide a truly secure airway and may negate the need for a throat pack. If an uncuffed tube is used, it would be slightly larger than the cuffed tube which allows for ventilation with lower resistance. It would also be easier if suctioning via the TT is required. Midline positioning, especially in cleft lip cases, is important for surgical access and ongoing assessment of landmarks. The TT should be secured so that it does not distort the tissues and for palate repair. Having the TT in the midline will prevent the mouth gag from obstructing the TT when it is positioned. If a difficult airway is anticipated, additional skilled assistants for airway management, optimisation of airway positioning, and a clear plan of approach including having the right equipment is essential. It would be very challenging to intubate these young patients' trachea when they are awake, but this may be the safest option. Most of the time, depending on the level of concern with the airway, gaseous induction with sevoflurane can be performed, or i.v. access can be established while the patient is awake to achieve an appropriate level of sedation before airway manipulation. It is ideal to maintain spontaneous ventilation and ensure ease with bag mask ventilation. Laryngoscopy should not be attempted until the patient is in a deep plane of anaesthesia, achieved by using deep inhalation anaesthesia, a propofol bolus, or spraying the vocal cords with local anaesthetic. There are pros and cons associated with use of neuromuscular blocking agents, especially where bag-mask ventilation may be difficult. Paralysis of the muscles and the cords may facilitate laryngoscopy, but respiratory efforts will be abolished. Direct laryngoscopy with techniques such as backwards, upwards, rightwards pressure (BURP) and the use of gum-elastic bougies are low-cost, simple, and effective techniques that may make the difference between a difficult and a failed intubation. Videolaryngoscopy is increasingly popular and offers a view of oral and laryngeal structures throughout the procedure, especially in patients where a difficult airway might be expected. The use of a supraglottic airway device (SAD) as a rescue device not only allows oxygenation of the patient but may also act as a conduit for 'low skill' flexible scope-assisted tracheal intubation. The use of an SAD throughout cleft repair has been described but it presents added challenges to the surgical team because of its bulk. Appropriate flexible bronchoscopes can be used for fibreoptic intubation. Finally, an elective tracheostomy may be considered in patients with extremely difficult airways. In patients with a particularly wide cleft palate, there may be a tendency for the laryngoscope to slide into the cleft offering no view of the laryngeal structures. Solutions for this include using a straight laryngoscope blade with a lateral approach or packing the cleft with gauze. When considering the 'cannot intubate, cannot ventilate' (CICV) scenario, the Paediatric Difficult Airway Guidelines group have written consensus guidelines which are available for further reference.13Paediatric Difficult Airway Guidelines | Difficult Airway Society. Available from: https://das.uk.com/guidelines/paediatric-difficult-airway-guidelines (accessed 6 May 2021).Google Scholar The shared airway poses many challenges for both surgical and anaesthetic teams. In general, considerations can be summarised with the acronym 'BADD'—blood, access, debris, dislodgement. In the case of cleft lip or palate repair, excessive bleeding is not anticipated and significant contamination of the airway is, thankfully, rare. A throat pack may be inserted to contain blood and debris. There are potential risks of circuit disconnect and TT dislodgement, including endobronchial intubation and unexpected extubation throughout the surgery. Surgical preparation will include placing the patient on a head ring and a shoulder roll, or alternatively a head ring on a Mayfield device, to extend the neck. The position of the tube should be checked whenever the patient is moved. In addition, neck extension may exacerbate the leak. For palate surgery, the insertion and adjustment of the surgical (Dingman) mouth gag may displace the TT or cause an increase in airway pressures. The surgeon may have to move the head or the position of the patient intraoperatively. Insertion or removal of the throat pack may lead to accidental extubation. The patient will be fully draped such that access to the airway, the chest (e.g. to listen to breath sounds), and the i.v. line is limited. Vigilance and open communication with the surgical team are necessary throughout the case. Anaesthesia may be maintained using either volatile agents or TIVA techniques. The addition of remifentanil reduces volatile and propofol anaesthetic requirements and may allow controlled ventilation throughout, promoting a smooth, rapid emergence. The use of muscle relaxation allows perfectly controlled ventilation which may reduce blood loss secondary to tighter control of Paco2. Spontaneous ventilation is a safe and acceptable technique, especially if there were an inadvertent extubation or disconnection. Total operative time is between 1 and 4 h depending on the repair involved. Multimodal analgesia for cleft procedures includes enteral and parenteral medication and local anaesthetic techniques. Options include perioperative acetaminophen (15–20 mg kg−1 p.o.), NSAIDs (e.g. ibuprofen 5–10 mg kg−1 p.o. or ketorolac 0.5 mg kg−1 i.v.), intraoperative opioids (e.g. fentanyl 1–2 μg kg−1 i.v.), ketamine (0.1–0.2 mg kg−1 i.v.), and surgical infiltration of local anaesthesia with adrenaline (epinephrine), which has the added benefit of further reducing blood loss. A longer-acting agent such as morphine (20–100 μg kg−1 i.v.) may be required and should be titrated to clinical effect, as the risk of perioperative respiratory adverse events (PRAE) is significant and potentially devastating. Nerve blocks can be considered for analgesia. Infraorbital nerve blocks are effective for cleft lip repair, and multiple nerve blocks have been described for cleft palate repair including greater and lesser palatine nerve blocks, nasopalatine nerve blocks, and bilateral suprazygomatic maxillary nerve blocks. Dexmedetomidine has several beneficial properties including an opioid-sparing analgesic effect, anxiolysis, and the potential to reduce incidence of emergence agitation with a low risk of respiratory depression. It may have a role when given intraoperatively, balanced with potential adverse effects such as bradycardia and hypotension.14Surana P. Parikh D.A. Patkar G.A. Tendolkar B.A. A prospective randomized controlled double-blind trial to assess the effects of dexmedetomidine during cleft palate surgery.Korean J Anesthesiol. 2017; 70: 633-641Crossref PubMed Scopus (7) Google Scholar Dexamethasone, a synthetic glucocorticoid, has both analgesic and anti-inflammatory effects (0.1–0.2 mg kg−1 i.v.) and may be useful in cleft surgery. Prevention of postoperative nausea and vomiting by using ondansetron (0.1 mg kg−1 i.v.) can be considered. Surgical blood loss is usually minimal and blood transfusion is rare. Infusion of a glucose-containing solution should be considered as patients are generally young with minimal glucose reserves, the surgical time may be relatively long, and they may not resume oral intake immediately after surgery. If there had been a relatively long fasting time, one may consider replacing the deficit with balanced crystalloid solutions. In addition, strategies to minimise heat loss, including warm ambient temperature and use of forced air blankets, should be considered. Successful extubation and recovery relies on efficient teamwork and succinct communication between surgical, nursing, and anaesthetic teams. The main concerns at the time of extubation, and during postoperative care, include airway obstruction, bleeding, and disruption of the suture lines. Once the surgical procedure is complete the oropharynx should be visualised to assess the haemostasis. Careful suction of the airway, including posterior to the palate, to remove any clots may be required. This should always be performed under direct visualisation for proper examination of the oropharynx, taking care not to disrupt the delicate suture lines. Once this is done, further instrumentation of the airway should be avoided. Airway obstruction may present at almost any stage during the emergence and extubation process. This may be related to pre-existing patient factors such as OSA or the surgical repair may lead to swelling in the oropharynx and nasopharynx. As obligate nasal breathers, infants may experience partial or complete airway obstruction. Other factors to be aware of include the residual effects of the anaesthetic agents, traumatic intubation, blood clots, retained throat packs, tongue swelling, and laryngospasm. Depending on the repair, the surgical team may have already placed a nasopharyngeal airway or nasal stents before tracheal extubation, to be removed a few days later. In selected cases a tongue suture may be used to relieve anticipated airway obstruction in the postoperative period. Arm restraints may be applied to prevent the child disturbing sutures by rubbing their face or exploring their mouths. The ideal emergence from anaesthesia involves the correct timing of full antagonism of any residual neuromuscular block to facilitate a safe extubation, whilst avoiding coughing and straining, which may lead to further bleeding. Extubation may be performed deep or awake depending on the personnel involved and patient-specific risk factors. At this critical moment, oxygen is provided via facemask and the patients' respiratory pattern and effort should be observed carefully for any signs of upper airway obstruction. Although airway problems may occur up to 48 h after surgery, most present in the immediate postoperative period. Management of actual or suspected airway obstruction should be timely and appropriate and may include:•Simple airway manoeuvres, such as repositioning the child in the lateral or prone position, or the application of CPAP while providing a jaw thrust.•Insertion of a nasopharyngeal airway, often in discussion with the surgical team as to which nostril, depending on the repair. The use of oropharyngeal airways is not contraindicated but is likely to cause more damage to the suture lines than a nasal airway.•Reintubation may be required if the above interventions are ineffective and this may be more difficult than the initial intubation because of potential swelling, bleeding, and the surgical repair. There may be tongue swelling secondary to prolonged use of the surgical mouth gag. If the patient is on the ward and reintubation is deemed necessary, if time allows, one should consider airway intervention after transfer back to the theatre where the necessary equipment and assistance are easily accessible in a familiar environment. Patients should be monitored in the PACU with supplementary oxygen until fully awake and settled, often in the lateral or semi-prone position to allow drainage of any secretions. Rescue analgesia may be required; the i.v. route is available for acetaminophen, NSAIDs (if not already given), and opioids (e.g. morphine 20 μg kg−1) with appropriate monitoring. The patient's ultimate postoperative destination may vary from a standard ward to paediatric intensive care (PICU) depending on the surgery, preoperative and intraoperative status, and comorbidities. For palate surgery, close monitoring is required for the first 12–24 h to identify potential airway obstruction, bleeding, or both. Cleft lip patients may stay overnight and usually return home the next day, whilst cleft palate patients are usually discharged between Day 1 and Day 3 after surgery. The main determinant of discharge is to ensure patients are feeding well. Oral medications including acetaminophen, ibuprofen, and morphine may be prescribed for analgesia at home and surgical follow-up will depend on the procedure completed and where the patient is on their surgical pathway. Patients with cleft lip repair are brought back for suture removal within a week if non-absorbable sutures are used. This is an outpatient procedure that involves a brief general anaesthetic. Once completely repaired, most children with an isolated cleft lip do not require further follow-up. It is interesting to note that once a cleft palate is successfully repaired, nasal intubation is not contraindicated provided a pharyngoplasty has not been performed. The soft tissue will have healed within approximately 6 weeks of the primary repair. Any patients with clefts involving the alveolus will need an alveolar bone graft at intermediate dentition (approximately 10 yrs) and those with continued velopharyngeal insufficiency may require a repeat palate procedure. As patients may require multiple surgeries, from primary closure as an infant, to alveolar bone grafting and dental surgery into adulthood, it is imperative that we understand the anaesthetic concerns relating to various development stages of the patient and the surgical considerations. The psychological impact of having to undergo repeat procedures should also be considered when interacting with these patients and their families. The authors declare that they have no conflict of interest. The associated MCQs (to support CME/CPD activity) will be accessible at www.bjaed.org/cme/home by subscribers to BJA Education. Simon Denning BMedSci FRCA is a consultant paediatric anaesthetist at Nottingham University Hospitals NHS Trust. His clinical interests include anaesthesia for head and neck surgery; plastics and burns surgery; and regional anaesthesia. Elaine Ng MD FRCPC MSHPEd is a staff paediatric anaesthesiologist at the Hospital for Sick Children in Toronto, Ontario, and associate professor at the Department of Anesthesiology and Pain Medicine at the University of Toronto. Her non-clinical interests include postgraduate education and simulation-based medical education. Karen Wong Riff MD PhD FRCSC is a consultant plastic surgeon at the Hospital for Sick Children and an assistant professor in the Division of Plastic and Reconstructive Surgery at the University of Toronto. Her research focus is in patient-reported outcomes measurement.