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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 55-59

Airway consideration in cleft patients-challenges and approaches

1 Department of Anesthesia, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Anesthesia and Critical Care, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission17-Jun-2021
Date of Acceptance03-Aug-2021
Date of Web Publication01-Jan-2022

Correspondence Address:
Dr. Tanmay Tiwari
Department of Anesthesia and Critical Care, King George's Medical University, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_25_21

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Over the last few decades, there is a paramount shift in the implementation of pediatric anesthesia. Although for most of the time, difficult airway scenarios are well-planned and executed, occasionally an unanticipated difficult situation may still arise. This is more common in patients with orofacial anomalies such as cleft lip and palate which constitute one of the most common craniofacial anomalies. Various approaches to difficult airway management in an infant undergoing cleft repair have been described in the literature. However, no approach is considered ideal. It depends on age, associated anomalies, at hand resources, and the skill of the anesthesiologist. The unique anatomical and physiological features of pediatric airways impose additional challenges. The evolution of advanced airway modalities such as video laryngoscopes (VLs) and fiber-optic bronchoscopes had a major impact on the practice of anesthesia and the management of difficult airway scenarios in children and neonates. This article focuses on airway assessment and various current techniques and equipment used in airway management of cleft anomalies. Pediatric airway devices such as supraglottic airways, VLs, and fiber-optic bronchoscopes are briefly discussed with the benefits and limitations of each device. Recent studies describe specific problems as well as advantages with the usage of these devices.

Keywords: Cleft lip, cleft palate, difficult airway, intubation, pediatric anesthesia

How to cite this article:
Gupta N, Nagar K, Dixit P, Tiwari T, Srivastava VK, Singh PR. Airway consideration in cleft patients-challenges and approaches. J Cleft Lip Palate Craniofac Anomal 2022;9:55-9

How to cite this URL:
Gupta N, Nagar K, Dixit P, Tiwari T, Srivastava VK, Singh PR. Airway consideration in cleft patients-challenges and approaches. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2023 Jun 6];9:55-9. Available from: https://www.jclpca.org/text.asp?2022/9/1/55/333641

  Introduction Top

Orofacial anomalies are one of the most common congenital facial anomalies responsible for significant mortality and morbidity in infants and children. Considering this fact, the WHO in 2008 added cleft anomalies in the Global Disease Burden initiative.[1]

Etiology and presenting features

With an incidence of approximately 1 in every 500–550 births, they involve either lip, palate, or both. Cleft lip is more seen in males whereas cleft palate is common in females. While presenting as an isolated abnormality majority of the time, few defects (28%–47%), mainly cleft palate, are associated with various syndromes, commonly being Pierre Robin sequence,  Treacher Collins syndrome More Details, and Goldenhar syndrome.[2]

These result from defective palate growth in first trimester of pregnancy. Although a definite etiology is unknown, environmental and genetic factors are the main contributing factors.

The patients are often malnourished and present with anemia due to inadequate nutrition leading to failure to thrive. They may also present with feeding difficulties and upper respiratory infection.[3]


Surgery is usually planned to achieve normal developmental goals, mainly speech, hearing, and maxillofacial growth. The timing of surgery is 3 months for cleft lip and 6 months for cleft palate. However, there are no definite guidelines for the same and final decision is made by a surgical and anesthesia team depending on current airway problems, age of infant, and site of defect. Hence, a multidisciplinary approach is required in management of cleft defects.[4]

Preoperative evaluation requires a detailed history and thorough examination to rule out any other associated anomalies. Patients with active symptoms of respiratory infections (running nose, purulent discharge, fever, etc.) are postponed for 4–6 weeks for surgery.

  Airway Evaluation and Challenges Top

Sharing of airway with surgeons has been a nightmare for anesthetists since ages. The inherent sensitive anatomical and physiological characteristics of a pediatric patient make it further challenging. There is high incidence of airway complications which include desaturation, tube dislodgment or disconnection, and aspiration. Patients with preexisting upper respiratory infections are more prone to bronchospasm and laryngospasm due to reactive airways.[5]

The anesthesia development history for cleft surgeries has been quite fascinating.

From John Snow using ether and chloroform on 3–6-week-old infants undergoing cleft lip repair in 1847 to using pharyngeal insufflation method in 1900, it was only in the late 1930s when an efficient technique in the form of endotracheal anesthesia was found by Magil.[6]

The approach to anesthetic management depends on resources available, level of cooperation from the patient, site of airway involvement, and skill of anesthetist.

Even though a lot of literature is available on airway management in patients with cleft defects, no definite criteria is yet available.

Unlike adults, not many parameters are available for airway evaluation in pediatric population. An otherwise normal facial examination is a reassurance in terms of airway management and rules out retrognathia.

However, few studies have used radiological imaging for the same which involves assessment of maxillopharyngeal angle.[7] In older children, Mallampati grading can be used for predictor of difficult airway. A study done by Aycan et al. also shows that both cleft lip and palate are associated with high Mallampati scores.[8]

Difficult airway is defined as difficulty in face mask ventilation, laryngoscopy, and intubation. The incidence of difficult face mask ventilation is rare in patients with cleft defects. However, if present, it can be managed with oral or nasal airway or laryngeal mask airway (LMA), as done routinely. Surprisingly, the incidence of difficult laryngoscopy as compared to intubation is high in such patients and is related to age, site, and extent of deformities and micrognathia.

Xue et al. conducted a retrospective study in 985 infants and found a difficulty in laryngoscopy in 4.77% of cases.[9] Infants <6 months with combined bilateral cleft defects and micrognathia contributed a major risk group for difficult laryngoscopy. Gunawardana conducted a prospective study in 800 infants and found that 86% of cases of difficult intubation were associated with Cormack and Lehane Grade III–IV and only 2% had lower grading. This grading was done after application of external laryngeal pressure. Difficulty was more seen in bilateral cleft lip, retrognathia, and infants under 6 months.[10]

The abovementioned studies can be used as a guide for preoperative airway assessment in infants without any syndromes. Furthermore, larger palatal defects or left-sided defects can be filled with gauze packs to facilitate the advancement of laryngoscope blade. Association of dental surgeons in the management of cleft surgeries can also be sought.

  Advanced Modalities For Airway Management in Cleft Anomalies Top

Airway management in pediatric patients requires refined skills and technical help, particularly when associated with cleft anomalies such as cleft lip and palate.

Various airway adjuncts have been used for the same.[11] These include variants of laryngoscope blades, supraglottic devices, stylets, and video laryngoscopy. However, due to various pros and cons associated with them [Table 1] these devices are used depending upon their availability, skill of anesthetist and demands regular maintenance and care.
Table 1: Summary of various airway devices used in cleft anomalies

Click here to view

Video laryngoscopes

The invention of video technology in anesthesia has enhanced our airway management skills. Video laryngoscopes (VLs) in recent times have emerged out to be one such novel device for difficult airway in cleft anomalies.[12] These are laryngoscopes with video chip that helps in visualization of the laryngeal inlet and correct placement of the endotracheal tube.

Compared to conventional laryngoscopes, they provide an expanded, high-resolution view of the airway anatomy right from the oropharynx till the glottic opening. The technique of insertion of VL is mostly the same as that of direct laryngoscope (DL), however the blade of VL is inserted in the midline while avoiding tongue sweep. External laryngeal maneuverer may also be needed to improve the view.[13]

However, one needs to be careful as too much focus on just viewing the video monitor can lead to injury of the oral cavity (best view does not always correspond with best chance of intubation). Adopting a “patient-screen-patient” approach while navigating the endotracheal tube through oral cavity and glottic opening can minimize injuries and increase success chance. A plenty of studies are mentioned in the literature to prove their effectiveness.[14] Despite being a good choice for difficult airway in cleft defects, VL may fail in certain circumstances, especially with coexistent anomalies and lack of expertise. There may be difficulty in the advancement of the endotracheal tube despite a good view of the glottis.[14]

Developing skills with VL require regular use rather than occasional use during cleft surgeries. Hospitals should consider multiple aspects such as cost, portability, use of disposable blades, and disinfection before placing VL orders.

Various types of VLs are available and most commonly classified as:

  • Nonchanneled: These include GlideScope (Verathon Inc., USA), McGrath (Medtronic, USA), and C-MAC (KARL STORZ SE and Co. KG, Germany). Based on conventional Macintosh design, these devices have both features of DL and VL and generally require a stylet for insertion
  • Channeled: These include devices like Airtraq (Airtraq, USA). They have groove to accommodate ETT and advance it toward the image viewed. They do not require stylet for most of the time
  • Optical stylet: The tube is preloaded over the stylet, for example, Karl Storz.

Sharma et al. conducted a study where they utilized Airtraq as a primary intubation device with Ring Adair Elvin tube in children planned for cleft surgeries and found success in 98.2% of cases. A malleable stylet was used to load the tube in the guide channel. There was less hemodynamic stimulation and minor trauma compared to conventional laryngoscope.[15]

Srinivasan et al. conducted a similar study comparing McGrath video laryngoscopy with a conventional laryngoscope and observed that intubation time was longer with VL while the need for external laryngeal manipulation was less and tachycardia was also less. Thus, it proved to be a safe and effective alternative to Macintosh laryngoscope.[16] One limitation of both of these studies was that they excluded patients with craniofacial abnormalities.

Although complications associated with VL are rare and account for 1% minor injuries and 0.3% severe, during insertion of ETT, these can be extensive and can involve soft palate and hypopharynx. However, these are more common in adults.[17]

Kuş et al. reported a case of a failed VL intubation in a 6-month-old infant, posted for cleft palate surgery, possibly due to poor shaping of endotracheal tube. Eventually, they placed a supraglottic device (ProSeal LMA) to secure airway and intubated the patient through pediatric fiber-optic bronchoscope loaded with endotracheal tube.[18]

Although generally used as a rescue device in failed intubation, VL can be considered to be used as a primary device in pediatric cleft palate cases to avoid catastrophe events following failed intubation attempts through conventional laryngoscope.

  Supraglottic Airway Devices Top

Supraglottic devices are well-established noninvasive devices for ventilation and oxygenation in adults. However, in recent times, they are gaining popularity in pediatric population as well. Based on sealing mechanism and evolution, they are classified as first- generation and second-generation devices. They are available in total 7 sizes, out of which sizes 1, 1.5, 2, 2.5, and 3 are suitable for infants and children of all ages. Size is decided on the basis of weight and is mentioned on the device along with cuff volume. First-generation devices include classical LMA which is a simple airway tube.

On the other hand, second-generation devices offer better sealing pressure and have a gastric channel for drainage, common device being ProSeal LMA.[19]

LMA is generally used for temporary stabilization of airway meanwhile preparation for alternative modalities is done. They are also used during endotracheal intubation while using a fiber-optic bronchoscope. In general, second-generation devices are used which have better safety profile and insertion rates.

They are reported to be used as a successful alternative to face mask for preoxygenation in infants with large facial deformities.[20] Like adults, they can be used for cannot intubate and cannot ventilate scenarios for neonatal resuscitation.

Kundra et al. conducted a prospective study involving 66 children posted for palatoplasty, to compare the efficacy of LMA with endotracheal tube.[21]

They found less leakage, better airway pressures, and smooth emergence with LMA.

  Fiber-Optic Intubation Top

Classically fiber-optic bronchoscope-assisted tracheal intubation is the gold standard for pediatric difficult airway management. However, it could be challenging, mainly when associated with facial dysmorphism. There is difficulty in manipulation of the device due to the smaller airway leading to poor visualization.

Flexible fiber-optic devices are available with or without suction channel. The route of insertion is either nasal or oral commonly through LMA.[22]

Due to lack of cooperation in pediatric patients, awake or invasive approach is not preferred and most intubations are performed under general anesthesia or deep sedation.

Furthermore, from a physiologic perspective, children have higher rates of oxygen consumption, significantly shortening the period of apnea that can be safely tolerated.[23]

Successful intubation with fiber-optic devices generally requires good oxygenation, availability of airway equipment, skilled assistance, and a backup plan.[24]

Johnson and Sim described a case of an infant with Goldenhar's syndrome where awake fiber-optic intubation was done successfully via a laryngeal mask.[25]

Combining various devices has also proved to be a good approach to secure pediatric airway with anatomical variations. Zhang and Yi utilized a combination of Airtraq® laryngoscope and a fiber-optic bronchoscope and successfully intubated a 3-year-old boy with Pierre-Robin sequence.[26]

  Summary Top

Airway management is the most difficult part when dealing with cleft anomalies, particularly due to associated craniofacial defects.

With recent airway advancement, many devices are available for airway management. However, one needs to understand the limitation of each device and ensure the availability of alternative strategies and the presence of an experienced anesthesiologist.

Methods such as external laryngeal manipulation, use of straight laryngoscope blade, lateral approach, and placement of gauze piece in cleft defect are surely helpful. VL demands more research to determine successful endotracheal intubation, short intubation time, and first-attempt success rate so that it can be considered a potential replacement to conventional DL. Although fiber-optic bronchoscope is also a good choice, it is still not available in many setups and demands a lot of maintenance.

Even though there are a lot of ongoing studies on airway techniques, dealing with airway in pediatric cleft defects, mainly when associated with syndromes, imposes a major challenge. Tracheostomy should be reserved for complicated cases associated with syndromic diagnosis, neurological impairment, and low birth weight

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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