In the early postoperative period after the "pushback" and pharyngeal flap operation (pharyngoplasty), significant airway obstruction can occur, with sleeping pulse oximetry demonstrating hemoglobin desaturation in the first 48 to 72 hours. The degree of obstruction is related to the width of the flap. For subsequent procedures, knowledge of prior surgical interventions is essential. The pharyngoplasty makes nasotracheal intubation (and other transnasal procedures such as insertion of a nasogastric tube) more difficult (eg, for orthognathic or dental surgeries typically requiring a nasal ETT). Traumatic rupture of this flap secondary to attempted nasotracheal intubation could produce bleeding, aspiration, and laryngospasm. While it is generally avoided, methods such as fiberoptic assistance or a Seldinger technique over a well-lubricated red rubber catheter with direct visualization have been utilized. One should consider nasal endoscopy evaluation in the otolaryngoscopy clinic to assess the size, position, and shape of the velopharyngeal port in all patients who underwent a pharyngoplasty and are scheduled to have a nasotracheal intubation. This might be difficult in younger, uncooperative patients.

Traumatic rupture of soft palate can also occur from placement of a laryngeal mask airway, most likely during insertion or if a rotational technique is used.

References

• Cohen MD, Ahmed Z, Zestos M, Hildebrand J. A novel approach to nasotracheal intubation in pediatric patients with prior palate or pharyngeal surgery. Accessed March 26, 2025. https://www2.pedsanesthesia.org/meetings/2007winter/pdfs/CR68.pdf
• Dearlove O, Perkins RJ, Briggs G. Anaesthesia after cleft palate repair. Anaesthesia. 2004;59:1032.
• Somerville NS, Fenlon S, Boorman J, et al. Disruption of cleft palate repair following the use of the laryngeal mask airway. Anaesthesia. 2004;59:401-403.