ORIGINAL ARTICLE Year : 2022  |  Volume : 55  |  Issue : 5  |  Page : 171-176

Evaluation of the association between nasopharyngeal depth and respiratory complications after cleft palate surgery in children between 9 and 18 months old

Sedighe Shahhosseini1, Amir Shafa1, Mohammadali Saadati2, Mohammad Omid3, Mehrdad Memarzadeh3, Mohammad Montasery1
1 Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Anesthesiology and Critical Care Research Center, Kashan University of Medical Sciences, Isfahan, Iran
3 Department of Surgery, Craniofacial and Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission13-May-2022Date of Decision18-Jun-2022Date of Acceptance21-Jun-2022Date of Web Publication26-Sep-2022

Correspondence Address:
Mohammad Montasery
Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan
Iran

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_115_22

Background: Considering the incidence of respiratory complications after cleft lip and palate surgery and its significance in the survival of children undergoing the mentioned surgery, the present study was performed to evaluate the association between the nasopharyngeal depth and the incidence of respiratory complications after cleft palate surgery.
Materials and Methods: The present cross-sectional study was performed on 222 children who aged 9–18 months and were the candidates for cleft palate surgery. After performing general anesthesia and implanting mouth gag and before surgery, the nasopharyngeal depth and the cleft palate width were measured with a calibrated ruler and an ophthalmic caliper, respectively. At the end of the surgery and after extubation, the incidence of respiratory complications such as respiratory distress, laryngospasm, bronchospasm, and need for intubation was recorded.
Results: The nasopharyngeal depth in children with respiratory complications with a mean of 7.57 ± 3.12 mm was significantly less than that of children without respiratory complications with a mean of 10.82 ± 2.14 mm (P < 0.001). The nasopharyngeal depth of ≤8 mm with a sensitivity of 80% and a specificity of 89.60% had a significant predictive value in the incidence of respiratory complications (P < 0.001).
Conclusion: According to the results of the present study, it seems that the nasopharyngeal depth of ≤8 mm can make the incidence of respiratory complications more likely. Therefore, considering the simplicity and convenience of measuring the nasopharyngeal depth and the cleft palate width, it is suggested to perform further studies to evaluate the anatomy of palate before this surgery using the employed method and address its association with respiratory complications.

Keywords: Bronchospasm, cleft lip and palate, laryngospasm, nasopharynx, respiratory complications, tracheal intubation

How to cite this article:
Shahhosseini S, Shafa A, Saadati M, Omid M, Memarzadeh M, Montasery M. Evaluation of the association between nasopharyngeal depth and respiratory complications after cleft palate surgery in children between 9 and 18 months old. Formos J Surg 2022;55:171-6
How to cite this URL:
Shahhosseini S, Shafa A, Saadati M, Omid M, Memarzadeh M, Montasery M. Evaluation of the association between nasopharyngeal depth and respiratory complications after cleft palate surgery in children between 9 and 18 months old. Formos J Surg [serial online] 2022 [cited 2022 Sep 27];55:171-6. Available from: https://www.e-fjs.org/text.asp?2022/55/5/171/356980   Introduction 

The prevalence of cleft palate is 1 in 700–1000 live births.[1] Speech and respiratory complications are common in this disease, which requires early reconstructive surgery during infancy. This disease is associated with various syndromes such as Pierre Robin, Crouzon, and Treacher Collins syndromes, in which the airway problems increase.[1],[2],[3]

However, complications after the cleft palate surgery are clinically unavoidable. Therefore, to reduce the complications of surgery, due attention should be devoted to children's etiological factors so that the incidence of mortality in these patients can be reduced by controlling the complications.[4]

The incidence of respiratory complications is higher in the cleft palate repair surgery compared with the cleft lip repair surgery,[5] and the need for the availability of a skilled specialist as well as continuous monitoring is essential to reduce morbidity.[6]

Immediately after surgery, the reduction of the velopharyngeal space, swelling of the tissue around the soft palate, hematoma inside the palate, and nasal obstruction due to clots and continued bleeding, even in small amounts, can cause airway obstruction and events.[7] These complications can be more severe and dangerous if the child receives sedation and the tongue moves to the floor of the throat.[7]

In this regard, airway control and management methods in high-risk patients with cleft palate include the use of tongue suture, distraction osteogenesis, and nasopharyngeal airway within 12–24 h after surgery.[8]

Conventional methods used to perform preoperative airway assessment include the distance between the lateral pharyngeal walls,[9] the adenoidal–nasopharyngeal ratio,[10] and the lateral cephalometric analysis of the neck,[11] which are not effective in patients with cleft palate repair.

In addition, performing standard lateral neck radiographs is problematic in infants before surgery and requires the cooperation of the infant and parents, which usually results in the parental dissatisfaction. Moreover, additional costs are imposed on the family, and the risk of the radiation exposure can be threatening at this particular age.[12] Therefore, direct measurement methods have been considered in previous studies for calculating the volume of cleft palate and nasopharyngeal space and their effect on velopharyngeal insufficiency.[13],[14],[15] However, so far, few studies have examined the association between the nasopharyngeal depth and the incidence of respiratory complications after cleft palate surgery and determined the cutoff point in predicting the possible incidence of these complications.

Therefore, the present study aimed at employing a direct, safe, noninvasive measurement method for infants who were the candidates for cleft palate surgery to evaluate the nasopharyngeal depth, with which the incidence of respiratory complications could be predicted after the surgery. Consequently, the results of this study can assist the cleft palate surgery team in making appropriate decisions on the surgery process, postoperative care, and alternative methods of surgery.

  Materials and Methods 

The present research was a diagnostic study. The study population included all children aged 9–18 months who were the candidates for cleft palate surgery and referred to Isfahan's Imam Hossein Hospital from November 22, 2020, to June 20, 2021. From the mentioned population, 222 patients were selected as the sample at 95% confidence level, 80% test power, and considering the estimate of the relative frequency of respiratory complications following the cleft palate repair surgery equal to 10% in a preliminary study for 30 patients.

Inclusion criteria consisted of children who were the candidates for cleft palate surgery for the first time, with American Society of Anesthesiologists equal to I or II, and within the age range of 9–18 months. In addition, the patients were not included in the study in case of failure to thrive, history of difficult intubation and tracheostomy, and history of airway events.

After obtaining the code of ethics from the Ethics Committee of Isfahan University of Medical Sciences (approval code: IR.MUI.MED.REC.1399.1154) and written consent from children's parents, their demographic information including sex, age, and weight was recorded. To reduce the anxiety of separation from parents, 0.01 mg/kg midazolam was administered intravenously. Then, the patient was transferred to the surgical bed and underwent standard anesthesia monitoring (noninvasive blood pressure, electrocardiogram, end tidal CO2, oxygen saturation [SpO2], and temperature [T]). After controlling patients' vital signs and confirming their clinical stability, anesthesia was induced using fentanyl (1–2 μg/kg), propofol (2–3 mg/kg), and cisatracurium (0.1–0.2 mg/kg). Three minutes after ventilation with a mask (FiO2 100%) and deepening of anesthesia, the child was intubated with a suitable endotracheal tube. The surgery team was allowed to perform the cleft palate surgery after fixing the endotracheal tube in the right position, ensuring adequate ventilation, and confirming hemodynamic stability.

At the beginning of surgery, after the implantation of Davis retractor or mouth gag and the suction of pharyngeal and nasopharyngeal secretions, before the injection of epinephrine by the surgeon, the distance between the highest point of the adenoid and the posterior edge of the soft palate was measured and recorded using a calibrated ruler with a vertical angle [Figure 1]. Then, at the same point, the transverse distance between the two free edges of the palate was measured and recorded using an ophthalmic caliper [Figure 2].[14],[15]

Figure 1: The axial view of the palate to measure the depth of the adenoid bulge to the edge of the cleft palate

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Figure 2: The axial view of the palate to measure the cleft palate width

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It should be noted that all patients underwent surgery following the Sommerlad's technique performed by a single professional surgery team.

At the end of surgery, reverse drug, atropine 0.02 mg/kg, and neostigmine (0.02–0.06 mg/kg) were injected after ensuring that the bleeding was controlled.

After reaching train of four ≥0.9, the patients were extubated. Then, patients' breathing pattern was monitored. In case of respiratory distress (suprasternal retraction and use of accessory muscles of respiratory, nasal flaring, and SpO2 <95%), the suction of secretions, correction of the patients' head and neck position (extension, jaw thrust, lateral position), and respiratory support with a mask were performed.

In addition, continuous positive airway pressure (CPAP) = 10–20 cmH2O was used in case of laryngospasm (spasm of the vocal cord muscles that leads to the airway obstruction and lack of ventilation) and bronchospasm (bronchial spasm characterized by wheezing, increased airway pressure, lack of ventilation, and decreased SpO2).

If no improvements were obtained following the correction of patient's position, mask ventilation, and CPAP, nasal airway was performed.

It should be noted that if the patient's distress was relieved with nasal airway, the nasal tube was fixed on the face and the patient was transferred to recovery. After ensuring adequate ventilation, the patient was transferred to the pediatric intensive care unit (PICU). If ventilation did not improve, reintubation was performed and the patient was transferred to the PICU.

Statistical analyses

Finally, the collected information was entered into SPSS software (version 25; SPSS Inc., Chicago, Ill., USA). Data were presented as means ± standard deviation or frequency (percentage). According to the results of Kolmogorov–Smirnov test indicating the normal data distribution, independent samples t-test and Chi-square test were used. In addition, receiver operating characteristic (ROC) curve analysis was also used to determine the cutoff point for the nasopharyngeal depth in predicting the possible incidence of respiratory complications. The significance level of <0.05 was considered in all analyses.

  Results 

Of 222 children with a mean age of 12.88 ± 2.40 months, 129 (58.1%) and 93 (41.9%) were boys and girls, respectively. The mean of the nasopharyngeal depth was 10.53 ± 2.43 mm. The incidence of respiratory complications including the need for nasal airway and bronchospasm occurred was 8.1% and 0.9%, respectively, and no cases of laryngospasm were reported. After surgery, 17.6% and 82.4% of children were hospitalized in the PICU and ward, respectively [Table 1].

Generally, 20 children had respiratory complications including the need for nasal airway and bronchospasm. The results of examining factors related to the incidence of respiratory complications revealed that sex, age, weight, and cleft palate width were not significantly associated with the incidence of respiratory complications (P > 0.05). However, the nasopharyngeal depth in children with respiratory complications with a mean of 7.57 ± 3.12 mm was significantly less than that of children without respiratory complications with a mean of 10.82 ± 2.14 mm (P < 0.001). In addition, hospitalization in the ward or PICU was significantly different with the incidence of respiratory complications (P < 0.001) [Table 2].

Table 2: Determining and comparing the basic and clinical characteristics of children in terms of the incidence of respiratory complications*

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The results of ROC analysis indicated that the nasopharyngeal depth with the cutoff point of ≤8 mm, with a sensitivity of 80% and specificity of 89.60%, had the positive and negative predictive value of 43.2% and 97.8%, respectively, in predicting the incidence of respiratory complications (P < 0.001) [Table 3] and [Figure 3].

Figure 3: Receiver operating characteristic analysis in determining the cutoff point of the nasopharyngeal depth in predicting respiratory complications

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Table 3: Receiver operating characteristic analysis in determining the appropriate cutoff point to predict the incidence of respiratory complications

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  Discussion 

According to the results of the present study, 9% of children undergoing cleft palate surgery had respiratory complications such as the need for nasal airway and bronchospasm. Although there was no difference in the age, sex, weight, and cleft palate width among children with and without respiratory complications, the mean nasopharyngeal depth in children with respiratory complications was significantly lower than that of the children without respiratory complications. Therefore, it seems that nasopharyngeal depth can be significant in predicting and preventing the possible respiratory complications in this surgery.

Regarding respiratory complications, Smith et al. reported five cases of respiratory distress and four cases requiring oxygen immediately after the cleft palate surgery.[4] Gilbert et al. also suggested careful monitoring of postoperative saturation for at least 24–48 h due to edema in the first few hours after palatoplasty.[13]

Kulkarni et al. showed that airway complications during and after cleft palate surgery were significantly higher than the complications occurred in the cleft lip surgery such that the incidence of respiratory complications was 7.4% and 1.7% after cleft lip and palate surgeries, respectively. Moreover, the incidence of upper respiratory tract infection and bronchopneumonia in cleft palate surgery was 0.7% and 0.4%, respectively.[5],[16]

Generally, the main causes of airway and respiratory complications in the cleft repair surgery include intubation, tube problems, laryngospasm, bronchospasm, desaturation, and aspiration.[16]

In addition, some studies have found a positive association between airway complications and the age of <6–7 years,[17],[18] which was contrary to the findings of the present study. The mentioned finding can be justified considering that our study was performed on infants under 9–18 months of age. In line with the findings of the present study, Desalu et al. did not report any association between these complications and patients' age.[16]

Fillies et al. reported a direct association between weight and complications during cleft palate surgery.[19] We examined weight as a factor; however, the weight of children was not significantly associated with the incidence of respiratory complications. In our study, the incidence of respiratory complications was more evident in the lower nasopharyngeal depths, while it was not significantly associated with the cleft palate width. Therefore, the current researchers believe that the anesthesia expertise and optimal monitoring facilities along with the accurate assessment of the patient in terms of age, weight, cleft palate, and nasopharyngeal depth before surgery can play an effective role in reducing the risk of respiratory complications. The results of ROC analysis in the present study showed that the nasopharyngeal depth with the cutoff point of ≤8 mm with a sensitivity of 80% and specificity of 89.60% can be a significant indicator in predicting the incidence of respiratory complications in these children. It is also noteworthy that two children with the nasopharyngeal depth of < 5–6 mm were not operated in our study due to the possibility of airway obstruction and the incidence of acute respiratory complications. Adenectomy was performed for the mentioned children. After a few months, in case of reexamination and the acceptable increase of nasopharyngeal depth, this surgery will be performed for these patients with more confidence.

In fact, infants born with cleft lip and palate can have difficulties in swallowing and breathing because of the connection between the nasopharynx, the nasal cavity, and the oral cavity as the nasopharynx is associated with important functions such as chewing, swallowing, breathing, smelling, and speaking.[20],[21] However, due to the limitations of existing methods for measuring the nasopharynx, little attention has been paid to this issue. Previous studies addressing cleft lip and palate have used two-dimensional (2D) lateral cephalometric methods, but these methods have significant limitations such as superimposition of structures, difficulty in identifying landmarks, and poor visualizations of 3D structures.[22],[23],[24]

Although none of the above-mentioned studies have evaluated the role of the nasopharyngeal depth in developing respiratory complications caused by cleft lip and palate surgery, these studies indicate that the nasopharynx has been considered as an important criterion by researchers. Therefore, considering that the nasopharyngeal depth was easily measured without advanced equipment and without the need for special skills in the current study, it can be regarded as the strength of this study.

Furthermore, the present researchers believe that the presence of preoperative cold symptoms can significantly increase the risk of postoperative respiratory complications. Therefore, the researcher made sure that all patients in the present study were asymptomatic, with normal white blood cell counts, and with no recent history of cold symptoms within 4–6 weeks before surgery. Moreover, all surgeries in this study were performed by a single skilled surgeon, as a result of which the role of the surgeon's expertise such as the skill of suturing that can be effective in the incidence of respiratory events was also controlled. Therefore, paying attention to these confounding factors can be considered as strength of this study. However, due to the small size of the study sample and the lack of other studies in this field, it is suggested to conduct further studies to achieve more reliable and generalizable results.

In addition, as the results of this study indicated, children are more likely to have respiratory complications at the nasopharyngeal depth of less than 8 mm. Therefore, from researchers' perspective, it is better to postpone cleft palate surgery in the first step and, if necessary, perform adenoidectomy or reach a more appropriate nasopharyngeal depth with the growth of child. Moreover, to obtain a successful surgery with fewer complications, it is recommended to fully prepare the anesthesia team to manage the patient's airway while regaining consciousness. All respiratory equipment including nasal airway, laryngoscope, endotracheal tube, mask, and CPAP should be available, and the PICU should be prebooked for these patients. Therefore, by conducting more studies enriched with the results of the present study, in addition to increasing the accuracy of the selected cutoff point, more successful solutions can be provided for preventing and offering timely treatment for respiratory complications.

  Conclusion 

According to the results of the present study, the incidence of respiratory complications was not significantly associated with age, sex, weight, and cleft palate width; however, its significant association with the nasopharyngeal depth of ≤8 mm can increase the chance of postoperative respiratory complications.

Acknowledgments

We express our thanks to Dr. Masoumeh Dousti, University of Isfahan, Iran, for proofreading the present manuscript.

Financial support and sponsorship

This work was supported by the Deputy Research and Technology of Isfahan University of Medical Sciences (Grant# 3991048).

Conflicts of interest

There are no conflicts of interest.

 

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  [Figure 1], [Figure 2], [Figure 3]
 
 
  [Table 1], [Table 2], [Table 3]