Pharyngeal flap damage caused by nasotracheal intubation in a patient who underwent palatoplasty and pharyngoplasty

IS SURGICAL TREATMENT OF VELOPHARYNGEAL INSUFFICIENCY BY MYOMUCOSAL POSTERIOR PHARYNGEAL FLAP A CONTRAINDICATION FOR NASAL INTUBATION? A NARRATIVE REVIEW

Velopharyngeal insufficiency is a disorder where the soft palate directs the air through the nose. It is often present in patients with previous cleft or short palate, but also in many other conditions. Symptoms are primarily to be found in speech, with very distinct nasal sound. After clinical evaluation and nasal endoscopy, surgery is considered. Several surgical techniques are in use, with posterior pharyngeal flap pharyngoplasty being most widely used. This method leaves the base of the posterior pharyngeal flap attached to the posterior pharyngeal wall, with two lateral ports on each side of the flap. Permanent nasopharyngeal obstruction is a very challenging pathology for anesthesiologists in case of mandatory nasal intubation since it is a relative contraindication for nasal intubation. Patients with previous palatoplasty will regularly appear in our routine anesthetic practice, in all surgical segments. The high risk of damage to the flap with possible bleeding can put the anesthesiologist in a very unpleasant situation if not aware of the permanent effect of this surgery. During preanesthetic assessment, if there is information on a previous pharyngoplasty, one should consider alternative options for nasotracheal intubation. All nasal insertion procedures must be either avoided or carried out with great caution, under fiberoptic visual control.

Update on complications in cleft orthognathic surgery

PURPOSE OF REVIEW

To give an update on recent publications and tendencies concerning complications in cleft orthognathic surgery.

RECENT FINDINGS

Cleft-specific changes after orthognathic surgery and their impact on surgical outcomes are discussed. Focus lays on the causes and mechanisms of cleft-related surgical complications and strategies to prevent or minimize these complications. Bimaxillary surgery is seen as a safe procedure for cleft patients. Maxillary distraction, total or segmental, is pointed out as an alternative method to improve outcomes. Different techniques for osteotomies and maxillary mobilization could decrease adverse events.

SUMMARY

Cleft patients are more susceptible to the occurrence of complications because of peculiar presurgical conditions. Different surgical approaches and techniques are presented to overcome these difficulties, to achieve better results and to increase patient safety. The importance of communication between patient, family and cleft team members is emphasized.