424 LETTERSTOTHEEDITOR IlkerOngucAycana,∗,HuseyinTurgutb,
AbdulmenapGuzela,ErdalDogana, GonulOlmezKavaka aDepartmentofAnaesthesiologyandReanimation,
MedicalFaculty,DicleUniversity,Diyarbakır,Turkey
bDepartmentofAnaesthesiologyandReanimation,Women
HealthandGynecologyHospital,Diyarbakır,Turkey
∗Correspondingauthor.
E-mail:ilkeraycan@gmail.com(I.O.Aycan). Availableonline11October2014
http://dx.doi.org/10.1016/j.bjane.2014.06.003
Is
it
a
matter
of
habit?
Será
uma
questão
de
hábito?
DearEditor,
Postoperative respiratory complications reportedly occur in 4.3% of surgical cases (1.7% and 7.4% of cleft lip and cleft palate repairs, respectively).1 Airway obstruction is themainearlypostoperativerespiratorycomplicationwith anoverallfrequencyof2.3%.2,3 Airwayobstructionusually occursfollowingclosureofawidecleftpalateorsyndromic cleftassociatedwithhypoplasiaofthemandible,the pres-enceofahematoma,orthepresenceofpacksaccidentally leftinthesurgicalsite.However,anairwayobstructiondue tosurgicalrepairofcleftasregardtoaclosureofthe habit-ualanatomicalairwayandthereasonforitspostoperative unexpectedrespiratorycomplicationshavenotbeen consid-eredincleftreportsuntilnow.
Patientswithcleftlipmaydevelopahabitualairway pre-operatively,basedontheirclefttypeandsize.Becausethey donothavesymptomsofbreathingdifficultyinthe preop-erativeperiod,theirmain airwayis notconsideredduring preoperative anestheticassessment; thus, the anesthetist maynotbereadyforanairwayprobleminthe postopera-tiveperiod.Wereviewedourrecentcaseserieswithrespect totheincidenceandpossiblecausesofpostoperativeairway obstruction.Postoperativedesaturationoccurredinonlyone caseinourseries;allotherreasons,suchasopiateanalgesic useandpostoperativeswellingoredemathatmaycause sim-ilarsymptoms,wereexcluded.Wepresenthereinourview ofairwayobstruction,withconsiderationofapatientwith unilaterallipcleftwhodevelopedpostoperative desatura-tion.
Patientswithcleftsbreathe mainlythroughone ofthe followingroutes:
Oralairway Nasalairway Cleftairway
Breathing throughthe nasal airwayis possible through the intactnostril in a patient witha unilateral complete cleft.Oralairwaypatencyismoreorlessdependentonthe positioning of the jaw and lower lip. However, the cleft airway will be occluded by the end of the operation. Therefore,duringthepreoperative period,infantpatients whobreathe predominantly throughthe cleft airway can manifest airway problems because of desaturation and
cyanosisrelatedtoclosureofthecleftuntiltheyareable tochange theirbreathinghabitintheearly postoperative period.Closingthecleftcanbeproblematic,anda transi-tionalperiodmaybenecessarytorelievetheagitationand symptoms,similartothoseobservedduringthe postopera-tiveperiod,inpatientswhohaveundergonenasalseptumor rhinoplastyoperations. Therefore,a relativelylongperiod ofairwayusemaybenecessaryuntilthesepatientslearnto breathethroughtheir‘‘new’’airway.
Werecentlyencountered a5-month-old patientwitha unilateral complete cleft lip in whom the oropharyngeal airwayhadtobemaintainedinthemouthfor24hours post-operatively. The baby tolerated the airway in his mouth even when fully awake without manifesting any signs of irritation, acting as if it were a pacifier (Fig. 1). Thus, cyanosis and desaturation were restored. Afterward, we taughthismotherhowtoinserttheairwayinto,andremove it,fromhismouthasneeded.Whenthebabyneededtobe fedand theairwayhad toberemoved,we observed that hehadlearnedtobreathethroughhisnewanatomical air-way and no longer required the artificial airway. Remote
Figure1 Awakebabywiththeairwayinhismouthwithout
LETTERSTOTHEEDITOR 425
Figure2 Pre-andpostoperativephotographsofthepatient.
monitoringofthepatientfor24hourspostoperativelywas adequatelysafe.
As we reviewed the preoperative photographs of the patient,we realizedthat his oral airway wasstructurally obliterated(Fig.2).Thelowerlipwasdisplacedand invad-ing the cleft area. As we retrospectively reviewed our seriesof postoperative cleft lip photographs, we realized that this was not a consistent problem present in every patient.
Inconclusion,surgicalrepairandcleftclosuremayresult indesaturationfollowingextubationinpatientswithclefts. Artificialoralairwayuseinthepostoperativeperiodcanhelp withrecoveryfromthe desaturation.Preoperative assess-mentofthethreeabove-mentionedairwaysinpatientswith cleftlipisimportantforanticipatingbeingreadyfor post-operativerespiratorycomplications.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.KulkarniKR,PatilMR,ShirkeAM,JadhavSB.Perioperative respi-ratory complications incleft lipand palate repairs: an audit of 1000 cases under ‘Smile Train Project’.Indian J Anaesth. 2013;57:562---8.
2.Hardcastle T.Anaesthesiafor repairof cleftlipand palate.J PerioperPract.2009;19:20---3.
3.MachottaA. Anestheticmanagementofpediatriccleftlipand cleftpalaterepair.Anaesthesist.2005;54:455---66.
MehmetYenidunyaa, MenekseOksarb,∗
aDepartmentofPlasticandReconstructiveSurgery,
UludagUniversityMedicalFaculty,Bursa,Turkey
bDepartmentofAnaesthesiologyandReanimation,
MustafaKemalUniversityMedicalFaculty,Hatay,Turkey
∗Correspondingauthor.
E-mail:menekseoksar@gmail.com(M.Oksar). Availableonline28October2014
