Subglottic Edema and Airway Compromise After Cleft Palate Repair
A report of two cases of Subglottic edema in the immediate post-operative period after furlow double opposing z-plasty in two patients without congenital anomalies or Pierre Robin sequence. The retrospective review of palate repairs by multiple surgeons using different techniques at Gillette Childrens Specialty Healthcare will examine variables in palatal repairs that may or may not contribute to a higher incidence of post-operative subglottic edema. Factors that correlate with the potentially life threatening complication of subglottic edema and airway compromise in cleft palate repair may direct to an etiology for the problem. Future areas of study will lead to control of cost, mortality and morbidity associated with repair of cleft palates. Methods
A retrospective chart review will be completed of the Gillette Specialty Healthcare system and the Craniofacial/plastic surgery database to include all cleft palate repairs from 2003 to 2013. In the “cyberdocs” system which reviews Gillette Childrens Specialty Healthcare electronic healthcare record only since its inception within the last two years Over 3000 documents exist including “cleft palate”, 42 for “palate repair,” 44 for “furlow,” 42 for “z plasty.” Paper and electronic charts as well as the craniofacial database will be reviewed extensively from 2003 to 2013. All data will be extracted as available and analyzed using chi square analysis. Research design
The research design involves retrospective study of all cleft palate repairs from a single institution’s multi-surgeon practice. The evaluation of different palatal repair techniques, in incidence of subglottic edema and airway compromise, intraoperative variable including operative time, time of dingman mouth retractor activity, severity of palatal cleft, difficulty of initial intubation, micrognathia, presence of congenital anomaly, concomitant release of tongue-lip adhesion. Sample
It is estimated that since the inception of the electronic health record at Gillette that there have been 42 palate repairs. It is estimated that in the last ten years there may be 210 to 315 palate repairs performed at Gillette Childrens Specialty Healthcare. The sample size is appropriate to provide a significant correlation the variability in surgeon and technique will be unique to the literature.
Results
The incidence of airway problems during and after the operations was 1.7 % The two reported cases of airway compromise were not associated with congenital anomoalies. The dingman mouth gag could not be shown to directly cause suglottic edema or airway compromises. Two of the reported incidents required prolonged or re-intubation in the post-operative setting. The overwhelming majority of the patients had furlow double opposing z-plasty. There were no cases of re-intubation after pharyngeal flap surgery. Dingman time was not recorded in the majority of cases.
Conclusions
Documentation of this complication in the literature is very rare. There has only been one retrospective study which reviewed 247 consecutive palatal operations (double opposing furlow z-plasty) by a single surgeon at a single institution, noting the incidence of airway problems before during and after the operations was 5.7 % Our study showed two cases which were not associated with syndromes whereas 93% were associated with syndromes in previous study. PRS was not found to have as many incidences as other articles. Etiologies to this complication have only been hypothesized due to the limited number of cases reported and variability within studies.
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