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Adelaide Pinto Coelho1, Gil Alexandre2, António Moniz3, Teresa Rocha4

1 - Interno de Anestesiologia, Hospital Divino Espírito Santo, Ponta Delgada
2 - Interno de Anestesiologia, Hospital Prof. Doutor Fernando Fonseca
3 - Assistente Hospitalar, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central
4 - Chefe de Serviço, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central

- Reunião Nacional – XXIII Congresso Anual do CAR/ESRA Portugal 2015

Introduction: Cleft lip and cleft palate are birth defects, with a prevalence of 1,5/10.000 births. They occur when lip and/or palate (smooth and/or hard) do not fuse properly between the fourth and tenth week of gestation. With different clinical presentations (unilateral, bilateral, complete, incomplete, atypical) it may affect the suction-swallowing in newborns so the surgical repair should not be delayed. Its surgical repair is a commom procedure, although painful. It´s associated with a significant risk of airway obstruction and postoperative respiratory complications. This risk seems to be exacerbated by the administration of intravenous opioids in intra and/or postoperative period. The bilateral suprazygomatic maxillary nerve block, with injection of local anesthetic in the pterygomaxillary fossa, might be an effective and safe analgesic alternative. It appears to reduce dramatically the consumption of intra and postoperative opioids, with the obvious associted advantages1,2
Case report: 8 months, male, 7 kg, ASA I, diagnosis of cleft palate and unilateral incomplete cleft lip, proposed for cleft palate correction and cleft lip repair.
Inhalational anesthetic induction with Sevoflurane, Sufentanyl (0,3 mcg/kg), Propofol and Cisatracurium administration and orotracheal intubation with wire-reinforced tube no 3,5. Mechanical ventilation – controlled by volume and bilateral suprazygomatic maxillary nerve block, by anatomical landmarks, with the administration of 2 ml of 0,1% ropivacaine (2 mg). No additional infiltration with local anesthetic by the surgeon. Cardiovascular and respiratory stability during the 200 minutes of the surgery , no additional analgesic requirements. Post-anesthesia care unit (PACU) for 1 hour, without complications
Discussion and conclusion: The maxillary nerve, the second division of the trigeminal nerve, supplies sensory innervation of the lower eyelid, the upper lip, the skin between them, the roof of the mouth and the palate. Injection of local anesthetic in pterygomaxillary fossa blocks the maxillary nerve and the majority of its branches, which provides adequate analgesia for this surgery. This aproach provides greater analgesic efficiency and has less risk of complications than the isolated block of its branches, namely the bilateral infra-orbital nerve block (acidental puncture of the maxillary artery) and the palatine nerve block (alter surgical field). The suprazigomatic approach emerges as the most secure, simple and effective route to access the pterygomaxillary fossa. The bilateral suprazygomatic maxillary nerve block seems to provide greater patient confort and better control of intra and postoperative pain. There is a consequent reduction in opioid consumption and an early resumption of feeding per os,  with the advantage of early intake of milk1,2

Palavras Chave: Bilateral suprazygomatic maxillary nerve block