cleftlip

CLEFT LIP / PALATEANAESTHESIA MANAGEMENT

Dr.P.NARASIMHA REDDY MD;DA

Prof.&HOD. of AnaesthesiologyNarayana Medical College Nellore.

ANDHRAPRADESH.

DEFINITIION

1. Defect in the Lip

2. Defect in the Palate

3. Defect in Lip & Palate

Our problems

1. Anaesthesia for infant / Paediatric patients

2. Due to Clefts &

3. Other associated anomalies

Incidence

1. More in Asians

2. Lip common in males

3. Palate common in females

4. Genetic influence more common in CLP

EMBRYOLOGY

1. Face is formed by 5 process which surround stomodium.

2. Frontonasal one

3. Maxillary one + one

4. Mandibular one + one

5. Olfactory pits appear at fifth week of IUL

6. One on either side of midline, inferior aspects of FNP

EMBRYOLOGY contd..

7. FNP is divided into a) Central M.N. process &

b) Lateral nasal processes (two)

8. Olfactory Pits become nares

9. MNP form septum, philtrum & premaxilla

10. LNP forms side of the nose

EMBRYOLOGY contd..

11. Maxillary process forms cheek, whole upper lip, upper jaw & part of palate.

12. Mandibular process forms lower jaw.

13. So, UPL is formed by MNP + LNP on each side.

14. Failure to fuse MNP+LNP = Cleft Lip

EMBRYOLOGY contd..

15. Palate is formed by 3 components.a) Premaxilla is developed from MNP

b) 2 + 3 is from palatine process of Maxilla

16. Prepalatal (primary) Clefts are caused by lack of mesodermal development, one central + 2 lateral process (failure to fuse).

17. Post palatal (secondary) Cleft is due to failure of palatal ridges to rotate and fuse at 10-12 WKs of IUL.

CLASSIFICATION

1. Cleft Lip complete, incomplete, unilateral & bilateral.

2. Cleft palate primary, secondary, complete, incomplete, unilateral & bilateral.

3. Submucosal.

GENETICS

1. More clefts are described syndromic.

2. FOGH – ANDERSON – genetic study 1942.

3. Syndromes are a) P.R.Syndrome.

b) T.C.Syndrome.

c) Goldenhar Syndrome etc..

AETIOLOGY

1. Interaction between genetic & environmental factors.

2. Environmental factors triggers Clefting.

3. Gene TGFA.

PATHOPHYSIOLOGY

1. Pharynx is communicating with nasal fossae & oral cavity.

2. Complex process like swallowing, breathing, hearing & speech are impaired.

3. Feeding problems.4. Eustrachian tube is blocked, middle ear

infections.5. Due to regurgitation of feeds – Chronic

rhinorrhoea.

PATHOPHYSIOLOGY cont…

6. Tooth & alanasai development delayed.

7. Velopharyngeal function defective.

8. Psychological problems at the time of school age.

9. Speech problems.a) Plosives P/K/D/T

b) Fricatives S/SH/F

MEDICAL THERAPY

1. Risk of aspiration.

2. Airway obstruction.

3. Feeding difficulties.

MEDICAL THERAPY Cont..

4. Multidisciplinary approach a) Paediatrician b) Nurse practioner c) Plastic surgeon d) Dentist e) ENT specialistf) Genetist g) Speech therapist h) Psychologisti) Pead.Surgeon & finally Anaesthetist

TIMING OF SURGERIES

1. 3/12 - CL repair

2. 6/12 - Presurgical Ortho dantist.

3. 9/12 - Speech therapy

4. 9/12-1 – CP repair (development ? )

5. 1-7 yr - Ortho dantic

ANAESTHETIC MANAGEMENT It includes

1. Preparation of the patients.

2. Preparation of the parents/Grand parents.

3. Fasting guidelines &

4. Lab investigations

ANAESTHETIC MANAGEMENT Con. It is team approach Mortality & morbidity due to airway difficulty. Proper history & examination of the child. Searching for any other congenital

abnormalities. 10-15 % cardiac problems. Ch. Rhinorrhoea, Ch.airway obstruction,

right ventricular hypertrophy & corpulmonale.

ANAESTHETIC MANAGEMENT Con. Nutrition & hydration Premedication

Sedative premedication – midazolam, not indicated in CP

Fentanyl 1-2 mikes/kg followed by rectal paracetamol 20-40 mg/kg

ANAESTHETIC MANAGEMENT Con. Fasting guidelines

Clear fluides Breast milk Cow milk Solids

3 months 2 4 4 6

3-12 2 4 6 6

Child 2 - 6 6

ANAESTHETIC MANAGEMENT Con. Lab investigations

Hb % and cross matching if blood loss is expected

Any other relevant investigation depending on the complaint and system involved.

ANAESTHETIC MANAGEMENT Con. Rule of ten

Wt 10lbs, Hb 10 gr% and 10 Wk age. Monitors

Spo2

Etco2

ECG Temp. Blood loss estimation Precardial steth.

ANAESTHETIC MANAGEMENT Con. Induction

Inhalational Halothane / sevoflurane

IV induction Thio / propofol

Intubation Blade slipping into Cleft Airway abnormalities

ET tubes Oral RAE reinforced tubes

Mouth gauges Dingman, Dot , pressure on the tube

ANAESTHETIC MANAGEMENT Con. Anaesthesia circuit

Jackson rees modification of Ayre’s Tpiece Position of the patient

For lip a roll under the shoulder For palate pillow under the body of the patient and

head hyper extended. Throat pack inserted Accidental extubation

Tube fixation should not alter facial symmetry.

ANAESTHETIC MANAGEMENT Con. Ventilation

Spontaneous for lip only? Controlled – ideal

Less Co2 Less bleeding Rapid recovery

Local analgesia Lidocaine with Adri. (5-10 mikes) Bil.infra.orbi.block

No NSAIDS!

ANAESTHETIC MANAGEMENT Con. Muscle relaxants

Scoline for intubation Vecuron for maintenance

Fluids Isolyte P+0.45 saline calculating starvation time

per op losses. Blood loss more than 10% transfuse blood. Early post op oral fluids

Temperature Avoid hypothermia

ANAESTHETIC MANAGEMENT Con. Extubation

Coup Obstruction No airways inserted Minimum suction Tongue stitch Lateral / prone position

ANAESTHETIC MANAGEMENT Con. Post op management

See for blood loss Airway obstruction Hypoxia

Post op analgesia Morphine / pethidine / pentazocine in correct

calculated doses avoiding sedation Local blocks Rectal medication

ANAESTHETIC MANAGEMENT Con. In difficult situations

Awake intubation Fibre optic intubation Retrograde intubation also tried