Securing the airway in a child with cleft palate is a challenge. Various studies have mentioned the difficulties faced while establishing the airway with the conventional endotracheal tube (ETT) in such patients.1,2 The degree of difficult laryngoscopy is related to the type of deformity of the lip and palate.3,4 The overall incidence of difficult laryngoscopy in pediatric population has been reported to be around 1.35%.5 In patients with cleft lip and palate, the incidence of difficult laryngoscopy and intubation is around 4.77% and 0.91%, respectively, while the incidence of failed intubations is documented to be around 0.1025%. The incidence of difficult laryngoscopy in patients with simple cleft palate is reported to be 2.38%. Age ≤6 months old is considered to be an additional risk factor for difficult laryngoscopy.3
Laryngeal mask airway (LMA) has mostly been used as a conduit for ETT placement in patients with cleft palate.6 We successfully used AMBU® LMA® (Ambu Aura40, ALMA, Ballerup, Denmark) as a primary airway device in 2 children, 3 months and 6 years of age, with cleft palate undergoing ophthalmologic surgery.
Written informed consent for publication has been obtained from the parents of both the children.
A 3-month-old, 5-kg male child diagnosed with bilateral anterior segment dysgenesis was scheduled for optical photokeratoplasty under general anesthesia (GA). The rest of the physical examination was unremarkable. The child had a 2 × 2 cm defect involving both the soft and hard palate since birth (Figure A). After attaching the standard monitors, anesthesia was induced by inhalational route (sevoflurane in oxygen). A 22G intravenous catheter was secured, and fentanyl and atracurium were administered for analgesia and muscle relaxation, respectively. On the initial attempt, an appropriate-sized ALMA (1.5) was inserted by gently sliding the deflated cuff against the tongue in the midline of the oral cavity. The cuff was inflated, but chest expansion was poor and an audible leak was detected. A size 2 ALMA (Figure B) was introduced, controlled mechanical ventilation was satisfactory, and a tidal volume of 45 mL could be generated with airway pressures of 16 cm H2O (Figure C, D). Intraoperative course was uneventful. After completion of surgery, muscle relaxation was reversed with neostigmine and glycopyrrolate. The ALMA was removed in a deep plane of anesthesia, but the child desaturated rapidly and became cyanotic. Mask ventilation caused distention of the stomach, which inhibited further ventilation. A size 2 ALMA was reintroduced and ventilation improved, but the airway pressures were high. A nasogastric tube could not be passed beyond the ALMA to decompress the distended stomach. The ALMA was replaced with a size 2 ProSeal® LMA® (The Laryngeal Mask Company Limited, Westmeath, Ireland) A suction tube was introduced through the esophageal port and stomach decompression done, which led to normalization of airway pressures. The child breathed normally thereafter, and the ProSeal® LMA® was removed once the child was fully awake. The recovery was uneventful.
A 6-year-old male child, weighing 16 kg, with poor vision and excessive discharge from the right eye since birth was planned for Cutler Beard surgery of right upper eyelid under GA. The child had an asymmetrical face due to craniofacial deformity with telecanthus and a cleft palate of 1.5 × 2 cm.
He had undergone cleft lip repair at 2 years of age and cranioplasty at 5 years of age. There was no history of difficult airway management from the previous 2 surgeries performed under GA.
Anesthesia was induced with sevoflurane in oxygen and nitrous oxide. A 22G intravenous line was secured, and fentanyl and atracurium were administered. A size 2 ALMA was inserted with the cuff deflated and introduced in the midline, gently sliding the cuff against the tongue. The device was secured in place after confirming absence of leak. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide with atracurium boluses.
At the end of surgery, muscle relaxation was reversed with neostigmine and glycopyrrolate. ALMA was removed once the child was fully awake.
Airway management in children with cleft palate is tricky. Although ETT is considered to be the most definitive device for securing the airway in such patients, it may not always be easy.
Difficulties with laryngoscopy and endotracheal intubation range from the blade of the rigid laryngoscope getting entrapped in the palatal defect, to multiple attempts at intubation, airway bleeding, edema, bradycardia, and esophageal intubation.3,4
LMA has been observed to have lesser incidence of laryngospasm, postoperative sore throat, and cough as compared to ETT.7,8 Rise in intraocular pressure and hemodynamic changes are also reported to be less with the use of LMA than with the use of ETT.9 Hence LMA may be contemplated for airway management in surgical procedures where endotracheal intubation may not be mandatory.
The presence of a cleft palate, however, poses questions about the ease of insertion of a LMA and its stability thereafter. Therefore, rather than a primary airway device of choice, the LMA has so far served as a conduit for passage of a fiberoptic bronchoscope and subsequent placement of an ETT or as a rescue device for ventilation after a failed intubation attempt by direct laryngoscopy in patients with cleft palate.6,10,11
The reports of usage of ALMA in children with cleft palate are sparse. Apart from the following 2 case reports, we could not find any other literature on the use of ALMA in patients with cleft palate.12,13
ALMA has been used for cleft palate repair only when tracheal intubation has failed after repeated attempts.12 ALMA was used to secure the airway in a patient with Smith-Lemli-Opitz syndrome (SLOS) having partial cleft palate undergoing urethroplasty.13
Flexible LMA (FLMA) has been compared with ETT in cleft palate repair surgery. Insertion of the FLMA by the midline technique has been described to be difficult in children with large palatal defect; hence, lateral approach for insertion was opted. The cuff of the FLMA was partially inflated, because the soft tip tends to fold back on itself. The flexible shaft was stabilized with a mouth gag used for the surgery. Dislodgement of the FLMA from its original position has also been mentioned.8
In both our cases, we did not need to modify the technique of LMA insertion significantly. The ALMA was inserted by holding the rigid shaft in the midline of the oral cavity with the cuff deflated and gently sliding the mask against the tongue, as compared to the classical way of pressing the mask against the midline of the palate with the index finger and sliding it to the supraglottic area. It remained in position until the completion of the procedure.
We opted for muscle relaxation because its use has been shown to facilitate LMA insertion with reports of higher successful insertion rates, shorter duration for placement, lower leakage volume, and lower incidence of postoperative sore throat as compared to LMA placement without muscle relaxation.14,15
LMA has been included in the “difficult to ventilate” algorithm. However, no special mention has been made about LMA as a rescue device in patients with cleft palate. From our experience, we would like to emphasize that ALMA may be considered as a rescue airway device in “difficult to ventilate” situations involving cleft palate patients.
The advantage that we found with the ALMA is that its shaft is rigid and has a preformed curve, replicating the natural airway passage and hence having less chance of displacement. The reinforced tip prevents it folding back during insertion. The disadvantage of ALMA is the absence of a channel for gastric suction as found in a ProSeal® LMA®. When a LMA is properly used, a suction port is not mandatory, but in an emergent situation where the stomach is inadvertently insufflated during bag mask ventilation, the absence of a suction port becomes a limitation of the device.
We found ALMA to be an effective airway control device in patients with cleft palate for surgeries lasting for about an hour.
Airway management in children with cleft palate remains a challenge. Cuffed ETT is the most effective device for securing the airway in patients with cleft palate. However, alternative devices like AMBU® LMA® may be contemplated for short duration cases. In doing so, the possibility of a larger sized device affording a better seal should be kept in mind. Absence of a suction port is a limitation in this device especially in emergent situations.
Name: Devalina Goswami, MD.
Contribution: This author helped write, edit, and format the manuscript.
Name: Apala R. Chowdhury, MD.
Contribution: This author helped search the literature and edit the manuscript.
Name: Vineeta Venkateswaran, MD.
Contribution: This author helped write the manuscript.
Name: Sagar Gnana Sunkesula, MD.
Contribution: This author helped search the literature and write the manuscript.
Name: Riddhi Kundu, MD.
Contribution: This author helped write and format the manuscript.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
1. Hatch DJ. Airway management in cleft lip and palate surgery. Br J Anaesth. 1996;76:755–756.
2. Sen J, Sen B. Airway management: a comparative study in cleft lip and palate repair surgery in children. Anesth Essays Res. 2014;8:36–40.
3. Xue FS, Zhang GH, Li P, et al. The clinical observation of difficult laryngoscopy and difficult intubation in infants with cleft lip and palate. Paediatr Anaesth. 2006;16:283–289.
4. Gunawardana RH. Difficult laryngoscopy in cleft lip and palate surgery. Br J Anaesth. 1996;76:757–759.
5. Heinrich S, Birkholz T, Ihmsen H, Irouschek A, Ackermann A, Schmidt J. Incidence and predictors of difficult laryngoscopy in 11,219 pediatric anesthesia procedures. Paediatr Anaesth. 2012;22:729–736.
6. Hung KC, Shiau JM, Yang YL, Tseng CC. Fiberoptic tracheal intubation through a classical laryngeal mask airway under spontaneous ventilation in a child with Treacher Collins syndrome. Acta Anaesthesiol Taiwan. 2006;44:223–226.
7. Yu SH, Beirne OR. Laryngeal mask airways have a lower risk of airway complications compared with endotracheal intubation: a systematic review. J Oral Maxillofac Surg. 2010;68:2359–2376.
8. Kundra P, Supraja N, Agrawal K, Ravishankar M. Flexible laryngeal mask airway for cleft palate surgery in children: a randomized clinical trial on efficacy and safety. Cleft Palate Craniofac J. 2009;46:368–373.
9. Agrawal G, Agarwal M, Taneja S. A randomized comparative study of intraocular pressure and hemodynamic changes on insertion of ProSeal laryngeal mask airway and conventional tracheal intubation in pediatric patients. J Anaesthesiol Clin Pharmacol. 2012;28:326–329.
10. Bhat R, Mane RS, Patil MC, Suresh SN. Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel-Feil syndrome. Saudi J Anaesth. 2014;8:412–414.
11. Cain JM, Mason LJ, Martin RD. Airway management in two of newborns with Pierre Robin Sequence: the use of disposable vs multiple use LMA for fiberoptic intubation. Paediatr Anaesth. 2006;16:1274–1276.
12. Beveridge ME. Laryngeal mask anaesthesia for repair of cleft palate. Anaesthesia. 1989;44:656–657.
13. Govindarajan SR, Khanna P, Bhalla AP, Kumar A. Smith-Lemli-Opitz-syndrome: how different is the anesthetic technique? Saudi J Anaesth. 2014;8:440–442.
14. Nasseri K. Effect of low-dose atracurium on laryngeal mask airway insertion conditions: a randomized double-blind clinical trial. Adv Biomed Res. 2017;6:119.
15. Fujiwara A, Komasawa N, Nishihara I, et al. Muscle relaxant effects on insertion efficacy of the laryngeal mask ProSeal(®) in anesthetized patients: a prospective randomized controlled trial. J Anesth. 2015;29:580–584.