Massive lingual swelling following cleft palate repair
A 13-month-old female baby weighing 10 kg with no previous history of any significant medical problem was taken up for palatoplasty. She had an uneventful Cleft Lip procedure at the age of 3 months. Basline investigations showed hemoglobin as 12.5 g.dl/1. She was premedicated with Midazolam syrup (5 mg) along with 0.4 mg atropine orally 1 h before procedure. After sedation anesthesia was induced with sevofluarne in oxygen. Atracurium was used to facilitate tracheal intubation using 4.5 non cuffed (Ring, Adair, and Elwyn) tube. Anesthesia was maintained on O2, Nitrous Oxide and sevoflurane with atracurium as muscle relaxant. Electro CardioGram, non-invasive blood pressure, oxygen saturation, capnography, precordial stethoscope and airway pressure (attached to Fabius GS machine) were monitored. Palatoplasty was done by Bardach technique and the procedure lasted for 220 min. At the end of the procedure, after removing the mouth gag the concerned anesthesiologist noticed swelling in the tongue, which was still progressing. Tongue sutures were in situ which is a standard practice in our institution. There was no excessive bleeding. Hemodynamic status of the child was within acceptable limits, bilateral air entry was good. Dexamethazone 2 mg IV bolus was given, arterial oxygen saturation was satisfactory. Child was retained in Operation theatre and extubated with re-intubation and tracheotomy setup on the stand by. Gentle laryngoscopy was done before and after extubation to suction out secretions and asses airways. The decision for trial extubation was made after observing the child on spontaneous with endotracheal tube for 30 min when the child showed no evidence of respiratory distress and maintained adequate oxygen saturation. Child was kept in prone position with head turned to one side and oxygen was given by mask. After observing the child for another couple of hours in the operation theatre, she was shifted to post-operative ward and kept in propped up position for the next 48 h, where she was closely monitored clinically for any evidence of airway obstruction in addition to continuous pulse oxymetry. Steroids (Dexamethasone 1 mg IV once in 6 h) and oxygen mask were continued in post-operative ward. Child started taking glucose water after 6 h. Swelling reduced gradually in size and tongue regained near normal proportion by 3rd post-operative day.\nFollowing this we had another similar experience with an 18-month-old baby, which was managed along similar lines and had an uneventful recovery. Duration of procedure and anesthesia technique was similar to the previous case.