[Life-threatening macroglossia following cleft palate palatoplasty]

Lingual Pressure During Dingman-Assisted Cleft Palate Repair

Background:

A variety of palatoplasty techniques are used for cleft palate repair, almost all involving a device called the Dingman-Grabb mouth gag (“Dingman”) to push the tongue and cheeks out of the way of the operating field. There have been numerous case reports of complications hypothesized to be due to the gag, such as lingual edema and airway obstruction. The purpose of this study is to introduce a technique for monitoring lingual pressure during Dingman-assisted palatoplasty and present preliminary data from a small series.

Methods:

Patients with a cleft palate who underwent palatoplasty with the assistance of a Dingman-Grabb retractor at the Mount Sinai Hospital were eligible. Patients underwent a palatoplasty while having their lingual pressure monitored using a 23-gauge needle inserted into the tongue and connected to a pressure monitor.

Results:

Three patients were included. Patients 1 and 2 experienced a rapid rise in lingual pressure over the course of the first 45 minutes of the palatoplasty before plateauing until the conclusion of the operation when the Dingman was released. Patient 3 plateaued almost immediately by minute 1 and then had a rise in lingual pressure during the latter half of the operation, reaching a peak pressure immediately before the end of the operation.

Conclusions:

The present study describes an easy method to monitor lingual pressure that succeeded in measuring such changes throughout 3 palatoplasties and confirming the acute rise in lingual pressure and the potential danger posed to the tongue and the airway through the use of the Dingman.

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.

The effect of steroid injection of the tongue base on reducing postoperative airway obstruction in cleft palate repair

Upper airway obstruction (UAO) is a well known complication of cleft palate repair. The aim of this study was to evaluate the efficacy of local tongue base steroid injection in preventing or reducing the lingual oedema that can cause UAO following palatoplasty. Thirty children with unilateral complete cleft palate were included. They were randomly divided into two equal groups. Children in group I received intravenous dexamethasone whilst children in group II received both intravenous dexamethasone and local betamethasone injected at the tongue base. Both groups underwent the same technique of palatoplasty, postoperative breathing was assessed and UAO was rated as mild, moderate or severe. Postoperative UAO developed in six cases (40%) in group I and in two cases (13%) in group II. In group I, it was mild in three cases, moderate in one case, and severe in two cases. In group II, it was mild in one case and moderate in another case. Despite the differences in the number and severity of the condition in both groups, comparison was statistically insignificant. Local steroid injection of the tongue base during cleft palate surgery reduced the incidence and severity of post-palatoplasty UAO.

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.

[Distance from the laryngeal mask grip to endotracheal tube tip. A crucial point during fiberoptic intubation in children]

BACKGROUND

Management of difficult airways and difficult intubation differs in pediatric and in adult patients. In conscious children, fiberoptic intubation is not feasible because of limited compliance. The specially designed laryngeal mask for blind tracheal intubation, LMA Fastrach™, is available for adolescents and adults only. Therefore, fiberoptic-guided intubation through a supraglottic airway device (SAD) is a standard technique for the management of difficult intubation in children. While performing the procedure, stabile positioning of the endotracheal tube (ETT) and prevention of dislodgement are critical issues. The relationship between the length of the ETT and the SAD is highly important and was investigated in this in vitro study.

MATERIALS AND METHODS

In this study 6 different brands of SAD in the pediatric sizes 1-3 and 2 different ETT brands (cuffed, Microcuff(®), uncuffed, Sheridan PED-SOFT™) were investigated. Using pediatric growth tables, the recommended patient weight for each SAD size was correlated to patient age and then to appropriately sized cuffed and uncuffed ETTs. The ETT size was chosen according to the manufacturer's recommendations (cuffed ETT) and according to the literature (uncuffed ETT). The various SAD-ETT pairs were assessed with regard to differences in their length. After lubrication with silicone the ETT with a firmly attached 15 mm tube adapter was maximally inserted into the SAD and the ETT tip overlapping the SAD cuff was measured. Secondarily, an adapter for fiberoptic procedures was interposed and the measurements repeated.

RESULTS

For a defined patient uncuffed ETTs were usually selected with a larger internal diameter (ID) compared to cuffed ETTs. Therefore, the uncuffed ETT is the longer one and will overlap the SAD by a longer tip. Comparing the curved SAD brands AuraOnce™ and Aura-i™, the Aura-i™ devices generally showed shorter tubes resulting in a longer protruding ETT tip (median 1.5 cm, minimum-maximum 1.0-2.4 cm). The straight brands LMA classic™, AuraStraight™ and LMA Unique™ showed similarity in tube length. In comparison with i-gel(®), for the SAD sizes 1-2.5 the former provide a longer projecting ETT tip. Only i-gel(®) together with AuraStraight™ showed the longest overlapping ETT tip for SAD size 3. If a swivel adapter was used during the fiberoptic intubation procedure, the length of the ETT could be critically reduced in relation to the length of the SAD. Using a swivel adapter from VBM Medizintechnik, (Sulz a. N., Germany) a relative reduction in ETT length of 2.3 or 3.2 cm has to be taken into account.

CONCLUSIONS

For fiberoptic-guided endotracheal intubation through an SAD, sufficient length of the ETT in relation to the SAD is mandatory. Differences in geometry between SAD and ETT brands have to be considered. The selection of a relatively small SAD in combination with an uncuffed ETT might be advantageous. Redesigned extra long ETTs would be desirable to decrease the risk for ETT dislocation and to increase the safety of the technique. Restrictive use of a swivel adapter during the procedure is important because of further and potentially critical decreases in ETT length. In addition, after successful intubation of the trachea, removal of the SAD via an airway exchange catheter and replacement of the cuffed ETT of choice in the correct position is recommended to secure the airway and provide unimpaired ventilation and oxygenation.