Airway Compromise Following Cleft Palate Repair in Robin Sequence: Improving Safety and Predictability

Background:

Prior studies report a high incidence of airway complications with rates of 23 to 44% in patients with Robin sequence (RS) following palate repair.  None of these studies directly measure the severity of airway obstruction preoperatively.  Our institution utilizes polysomnography (PSG) to assess risk of airway compromise prior to palatoplasty in these patients.  The purpose of this study is to compare airway complications in Robin sequence to cleft palate only (CPO) using this screening airway protocol.  In addition, we identify risk factors for airway complications after palatoplasty.

Methods:

A 12-year retrospective review of patients with Robin sequence undergoing palatoplasty was performed.  Robin sequence patients were divided into non-operative management (RS-Nonop) or mandibular distraction osteogenesis (RS-MDO) subgroups.  Patients with Veau I and II CPO served as matched controls.  Preoperative variables, including comorbidities and apnea hypopnea index (AHI), were recorded.  The primary outcome was postoperative airway complication, defined as reintubation, emergency room visit, or hospital admission within 3 months of palatoplasty.  Significant variables for postoperative airway complications were identified via univariate analysis. 

Results:

113 patients met inclusion criteria: 39 (34.5%) CPO, 74 (65.5%) RS, and 34 (30.1%) RS-MDO.  The total airway complication rate was 7.1%; this was similar between RS (5.8%) and CPO (7.7%).  In isolated Robin sequence, the reintubation rate was 0%.  Significant variables for reintubation for all patients were cardiac anomalies (p=0.046), gastrointestinal anomalies (p=0.04), lower airway anomalies (p=0.02) and syndromic diagnosis/genetic anomaly (p=0.052).

Conclusions:

These data suggest that the incidence of airway complications after palatoplasty is not affected by the presence of Robin sequence when using screening PSG.  This study, which is the most extensive of its kind, demonstrates that PSG is a critical tool when determining the timing of palatoplasty for patients with Robin sequence.  Cardiac, gastrointestinal, lower airway anomalies, and syndromic diagnosis/genetic anomalies are associated with postoperative reintubation.  Close postoperative surveillance may be considered in patients with these risk factors.