**2. Preanesthetic assessment**

*Current Treatment of Cleft Lip and Palate*

whose incidence in Mexico.

age of interruption [8–10].

When attempting to identify patients with high risk, greater vulnerability was observed in those undergoing head and neck surgery that involves airway and specifically those of surgical correction of the cleft lip and palate [5–7]. The cleft lip and palate is the most common craniofacial anomaly nomination in Latin America

Cleft lip and palate (CLP) is the most common craniofacial anomaly in Latin America whose incidence in Mexico is 1 per 800–1000 live births registered with

It is defined as an elongated opening due to fusion failure between the lateral and medial nasal processes with the maxillary process during the fifth to eighth week of embryonic development, the severity of which is in relation to the percent-

There are multiple classifications of orofacial clefts; due to their location, they can be unilateral, bilateral, or midline, and by their description, they are complete, incomplete, or submucosal, and according to structures, they involved the tip of the nose, nasolabial groove, lips, gums, hard palate, soft palate, and uvula [9, 10]. The etiology is heterogeneous due to the interaction of genetic and environmental factors during the early stages of pregnancy such as exposure to tobacco, alcohol consumption, nutritional deficiencies, viral infections, and exposure to phenytoinlike teratogens, valproic acid, thalidomide, and herbicides [8, 11]. Prenatal diagnosis of cleft lip can be performed reliably in the 18–20 weeks of gestation, while the

Bibliographic reviews based on advances in medical technology agree that although surgical repair of cleft lip and palate is not an emergency, it should be done at an early age; the objective is to favor dentition and the development of hearing and language and reduce the incidence of respiratory infections by offering better esthetic and functional results that impact on the quality of life at an individual, family, and social level, with a low morbidity rate and zero mortality [7, 9, 12]. Primary repair of cleft lip and tip of the nose is performed around 3 months of age

**management**

Surgical technique

duration

**Anesthetic management**

Anesthetic technique

management

Endotracheal tube used

Extubation technique

**Postoperative management**

Airway edema

agitation

Nausea and vomiting postoperatively

Induction type Pain management

Maintenance Postoperative

Presence of bleeding

and that of cleft and maxillary palate at 9–12 months of life [13, 14].

**Comorbidities Surgical** 

Type of defect Heart disease Airway

*Factors to consider for the perioperative approach of patients with CLP.*

syndromes (Pierre Robin, Treacher, Goldenhar)

Weight Pneumopathies Procedure

great medical, psychological, and social repercussions [7].

cleft palate is difficult to identify before birth [10].

**52**

**Table 1.**

**Patient characteristics**

Recurrent respiratory tract infections

Mishandling of secretions

Anatomical predictors of difficult airway

Age Associated

Within the preanesthetic assessment of patients with CLP, it is mandatory to know:


The recommended age for surgical repair of cleft lip is 3–6 months, currently tends to be performed in the neonatal period with the implications of anesthetic management of this age group. Cleft palate repair is recommended at 9–12 months with reports up to 18 months [4, 10, 15]. There is evidence in the literature about a risk of complications 5 times greater during anesthetic management of children under 10 kg and under 10 weeks of age. A direct relationship between body weight at the time of surgery and the presence of complications has been observed; in patients weighing 4–6 kg, they occur in 54% and in patients weighing more than 8 kg in 26% [13, 16].

According to the characteristics of the defect, the surgical experience, and the management institutions' protocols, the surgeon will determine the age of repair and the need for a primary or sequential closure in stages with the objective of minimizing distortion in facial growth by very early repairs [10].

The male-female ratio is 2:1 in cases involving lip and 1:2 in cases involving only palate. As for laterality, the ratio is 2:1 left to right [14, 17]; greater risk of difficulty in airway management and secondary adverse events has been observed in patients with a cleft lip with bilateral defect, and in cases of cleft palate, the difficulty in laryngoscopy and intubation is related to age, at a younger age difficulty [3, 18].

Patients with CLP can present various malformations without integrating a specific craniofacial syndrome; approximately 70% of cases of CLP and 50% of isolated cleft palate are considered non-syndromatic. A higher ratio of malformations has been found in patients with CLP (32%) than 11% in isolated cleft lip or 22% in cleft palate [13, 19].

There are about 500 craniofacial syndromes related to the pathology that increase the probability of difficult airway (8.4%) and the risk of perioperative adverse events; the most frequent are Treacher Collins, Goldenhar, Pierre Robin sequence, and velocardiofacial syndrome [2, 13, 15].

As part of the comorbidities, the literature reports that 5–10% of patients have some congenital heart disease [7, 13]. The possibility of chronic respiratory symptoms such as rhinorrhea, chronic airway obstruction, and sleep apnea [3, 19] is also mentioned.

Given the history of upper airway infection, it is suggested that surgery be deferred for 2 weeks and in lower airway infections for 4 weeks with the objective of reducing risks of adverse events [3].
