Perioperative pain management for cleft palate repair: can we determine what is optimal?
Lynne G. Maxwell, MD, Alan Jay Schwartz, MD, MSEd
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Like many colleagues in the pediatric anesthesia community, we have cared for infants undergoing cleft palate surgery in both well-resourced children’s hospitals in the US as well as in the low resource, austere environments of surgical missions. As stated by the authors of today’s PAAD, “Cleft palate surgery is associated with significant postoperative pain. Effective pain control can decrease stress and agitation in children undergoing cleft palate surgery and improve surgical outcomes.”1 It was always distressing to observe the pain and distress with associated delayed oral intake in infants in whom local anesthetic infiltration of the palate provided insufficient analgesia in settings in which postoperative opioids are not available and even if available, may be ill-advised.
Several years ago, a CHOP plastic surgeon, Jordan Swanson, who had long participated in cleft missions in low resource environments and is the author of a text on the subject,2 taught us the landmark-based suprazygomatic maxillary nerve block (SZMNB). Implementation of this block for cleft palate surgery (anecdotally) yielded infants who had less pain and earlier oral intake than patients who previously had had only local anesthetic infiltration of the palate. Subsequent publications of ERAS (enhanced recovery after surgery) protocols which incorporated SZMNB or alternatively palatal nerve block reported earlier oral intake, lower postoperative opioid utilization, and reduced length of stay, but did not reduce the need for intraoperative opioid.3,4 This block was discussed in the context of tonsillectomy in a prior PAAD (PAAD 06/11/2024 Suprazygomatic Maxillary Nerve Blocks for pediatric T&A https://ronlitman.substack.com/p/suprazygomatic-maxillary-nerve-blocks), which provided a video and images of the nerve block technique.
Although individual institutional anecdotal experience, small single institution ERAS initiatives, and cleft mission experience in environments in which postoperative opioids are unavailable may indicate that the SZMNB is a game-changer, more wide-ranging evidence is needed to firmly establish this conclusion. In today’s PAAD, Suleiman et al. aimed to “evaluate the available evidence and to develop recommendations for optimal pain management after cleft palate surgery using procedure-specific postoperative pain management (PROSPECT) methodology.” 1 Did they achieve their objective?
Original article
Suleiman NN, Luedi MM, Joshi G, Dewinter G, Wu CL, Sauter AR; PROSPECT Working Group. Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Reg Anesth Pain Med. 2024 Sep 2;49(9):635-641. doi: 10.1136/rapm-2023-105024. PMID: 38124208; PMCID: PMC11420763.
Suleiman et al reviewed randomized controlled trials (RCT) and systematic reviews of pain in children undergoing cleft palate repair that included information about analgesic interventions and measurement of postoperative pain intensity. Two independent reviewers examined 19 RCTs and 4 systematic reviews, deriving recommendations utilizing PROSPECT (PROcedure-SPECific postoperative pain managemenT) methodology.5
The authors’ recommendations are:
· Basic analgesic regimen should include acetaminophen and nonsteroidal anti-inflammatory drugs or cyclooxygenase-2-specifc inhibitors administered preoperatively or intraoperatively and continued postoperatively administered as scheduled (round-the-clock) dosing.
· Pre-incisional SZMNB is recommended, and if that cannot be performed, pre-incisional palatal nerve block should be administered.
· Dexmedetomidine is recommended as an additive to local anesthetic for SZMNB. Alternatively, intravenous dexmedetomidine may be administered if not used as an additive for the block.
· Opioids should be reserved as rescue analgesia in the postoperative period.
Although Suleiman et al recommended the above-described “basic analgesic regimen”, many of the studies they reviewed used only acetaminophen (IV, rectal, or oral) and/or ibuprofen for perioperative analgesia, and none included all components on a scheduled basis. Although NSAIDS are mentioned, it should be stated that many plastic surgeons do not want their cleft palate patients to receive ketorolac perioperatively, although a recent small quality improvement study by the same investigators as Moffitt3 at Children’s Memorial Hermann Hospital in Houston reported the that the addition of IV ketorolac beginning at the conclusion of surgery and continued q8 hours for 24 hours postoperatively to a previously established ERAS protocol of palatal blocks and postoperative acetaminophen and ibuprofen resulted in decreased postoperative opioid administration and significantly decreased length of stay with no incidence, with no incidence of bleeding or reoperation.6 The conclusion of the latter study is limited by the small number of patients (28 consecutive patients who received ketorolac compared to 57 previous patients who received the pre-established ERAS regimen).
The authors’ preference for SZMNB over palatal block seems to derive principally from the conclusion of the systematic review of Oberhofer et al who concluded that SZMNB was superior to greater palatine nerve block based on reduction of postoperative pain scores and opioid consumption.7 However, the systematic review of Morzycki et al8 concluded that palatal nerve block was preferred because it provided the greatest latency to first analgesia, but no decrease in total opioid administered. Of the RCTs evaluated, Abu Elyazed and Mostafa found that ultrasound guided maxillary nerve blocks showed a clinically significant decrease in postoperative pain in the first 12 hours, reduced cumulative opioid (Demerol) consumption for 24 hours, and decreased time until oral intake. Palatal nerve block patients had similar pain scores, but opioid consumption was higher.9
It is important to note that although most studies of SZMNB reviewed by Suleiman et al found decreased postoperative opioid consumption when compared to placebo injections, opioids were still administered intraoperatively (morphine or fentanyl). This has also been the case in recently reported ERAS initiatives for cleft palate.3,4
With regard to ultrasound guidance vs. landmark based technique for SZMNB, Suleiman et al state “since the block can be performed as a landmark-guided technique, it is also suitable for low-resource settings. Ultrasound guidance has been used with the aim of improving the technique. However, visualization of the pterygopalatine fossa which contains the maxillary nerve is not described in most reports. Instead, a visualization of the more superficially situated infratemporal fossa and local anesthetic spread within this region are described. At present, there are no studies comparing landmark-based with ultrasound-guided (SZMNB). Therefore, no specific recommendation on needle guidance can be given.”1 Those who have used the landmark based technique use a dose of 0.15ml/kg of 0.2% plain ropivacaine or 0.25% bupivacaine per side with good efficacy, using a 25g, 1 ½ inch needle. Esfahanian et al used a larger volume of a lower concentration of ropivacaine (1mg/kg diluted to 5ml per side) in an effort to fill the space visualized on ultrasound [personal communication], but there is no evidence that a larger volume is necessary to achieve good analgesia. Reported adverse effects are minimal, most commonly slight bleeding at the injection site. The landmark-based technique we have used is derived from that reported by Mesnil et al.10
A recent study of SZMNB implementation for palate surgery in the UK found no systemic or local adverse events. There was no decrease in postoperative opioid administration and the authors commented “it may be difficult to demonstrate a change in opioid use in clinical settings where enhanced recovery techniques are established, and opioid use is already low.”11 The authors provided the figure below.
What do you think? What block, if any, do you use for cleft palate repair in your practice at home or on surgical missions? Do you administer ketorolac? Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Suleiman NN, Luedi MM, Joshi G, Dewinter G, Wu CL, Sauter AR; PROSPECT Working Group. Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Reg Anesth Pain Med. 2024 Sep 2;49(9):635-641. doi: 10.1136/rapm-2023-105024. PMID: 38124208; PMCID: PMC11420763.
2. Swanson JW, Low DW. Global Cleft Care in Low-Resource Settings. Springer, 2021.
3. Moffitt JK, Cepeda A Jr, Ekeoduru RA, Teichgraeber JF, Nguyen PD, Greives MR. Enhanced Recovery After Surgery Protocol for Primary Cleft Palate Repair: Improving Transition of Care. J Craniofac Surg. 2021 Jan-Feb 01;32(1):e72-e76. doi: 10.1097/SCS.0000000000006985. PMID: 32897976.
4. Esfahanian M, Marcott SC, Hopkins E, Burkart B, Khosla RK, Lorenz HP, Wang E, De Souza E, Algaze-Yojay C, Caruso TJ. Enhanced recovery after cleft palate repair: A quality improvement project. Paediatr Anaesth. 2022 Oct;32(10):1104-1112. doi: 10.1111/pan.14541. Epub 2022 Aug 11. PMID: 35929340.
5. Joshi GP, Van de Velde M, Kehlet H; PROSPECT Working Group Collaborators. Development of evidence-based recommendations for procedure-specific pain management: PROSPECT methodology. Anaesthesia. 2019 Oct;74(10):1298-1304. doi: 10.1111/anae.14776. Epub 2019 Jul 11. PMID: 31292953; PMCID: PMC6916581.
6. Cepeda A Jr, Johnson ML, Kelagere K, Obinero CG, Nguyen PD, Greives MR. The Limit Is Zero: A Prospective Evaluation of Ketorolac in Patients Undergoing Primary Palatoplasty to Reduce Narcotic Utilization. J Craniofac Surg. 2023 Sep 1;34(6):1713-1716. doi: 10.1097/SCS.0000000000009503. Epub 2023 Jun 29. PMID: 37381130.
7. Oberhofer HM, Breslin N, Heindel H, Ching J. Analgesic Efficacy of Intraoperative Nerve Blocks for Primary Palatoplasty. J Craniofac Surg. 2021 Mar-Apr 01;32(2):594-596. doi: 10.1097/SCS.0000000000006829. PMID: 33704988.
8. Morzycki A, Nickel K, Newton D, Ng MC, Guilfoyle R. In search of the optimal pain management strategy for children undergoing cleft lip and palate repair: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2022 Nov;75(11):4221-4232. doi: 10.1016/j.bjps.2022.06.104. Epub 2022 Jun 29. PMID: 36171173.
9. Abu Elyazed MM, Mostafa SF. Bilateral suprazygomatic maxillary nerve block versus palatal block for cleft palate repair in children: A randomized controlled trial. Egypt J Anaesth 2018; 34: 83-88. https://doi.org/10.1016/j.egja.2018.05.003.
10. Mesnil M, Dadure C, Captier G, Raux O, Rochette A, Canaud N, Sauter M, Capdevila X. A new approach for peri-operative analgesia of cleft palate repair in infants: the bilateral suprazygomatic maxillary nerve block. Paediatr Anaesth. 2010 Apr;20(4):343-9. doi: 10.1111/j.1460-9592.2010.03262.x. Epub 2010 Feb 23. PMID: 20199610.
11. Fell M, Fenner L, Fallico N. Demystifying the Suprazygomatic Maxillary Nerve Block in Paediatric Cleft Palate Surgery. Cleft Palate Craniofac J. 2024 Sep 10:10556656241284514. doi: 10.1177/10556656241284514. Epub ahead of print. PMID: 39257219.