• Gaston Echaniz, Marcos De Miguel, Glenn Merritt, Plinio Sierra, Pranjal Bora, Nabamallika Borah, Christopher Ciarallo, Miriam de Nadal, Richard J Ing, and Adrian Bosenberg.
• From the Department of Anesthesiology, Vall d'Hebron Hospital, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain (GE, MDM, MdN), Department of Anesthesiology, Children's Hospital Colorado, Denver, Colorado, USA (GM, CC, RJI), Department of Pediatric Anesthesia, King Abdullah Hospital, Riyadh, Saudi Arabia (PS), Department of Anesthesiology, Guwahati Comprehensive Cleft Care Center, Guwahati, India (PB, NB) and Department Anesthesiology and Pain Management, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA (AB).
• Eur J Anaesthesiol. 2019 Jan 1; 36 (1): 40-47.

BackgroundCleft defects are common craniofacial malformations which require early surgical repair. These patients are at high risk of postoperative airway obstruction and respiratory failure. Cleft surgery may require high doses of opioids which may contribute to these complications.ObjectivesTo compare the effectiveness of proximal and distal approaches to blocking the maxillary nerve in patients undergoing cleft lip or cleft palate surgery.DesignRandomised, controlled and double-blind study.SettingThe current study was carried out in Guwahati (Assam, India) between April 2014 and June 2014.PatientsA total of 114 patients older than 6 months who underwent cleft lip or cleft palate surgery were included. Exclusion criteria included coagulation disorders, peripheral neuropathy or chronic pain syndrome, infection in the puncture site, allergy to local anaesthetics, lack of consent and language problems or other barriers that could impede the assessment of postoperative pain.InterventionsPatients were randomly assigned to one of two groups: proximal group (bilateral suprazygomatic maxillary nerve blocks) and distal group (bilateral infraorbital nerve blocks for cleft lip repair and bilateral greater and lesser palatine nerve blocks and nasopalatine nerve block for cleft palate surgery).Main Outcome MeasureThe primary endpoint was the percentage of patients requiring extra doses of opioids. Secondary endpoints included pain scores, respiratory and nerve block-related complications during the first 24 h.ResultsIn the intra-operative period, there was a significant reduction of nalbuphine consumption in the proximal group (9.1 vs. 25.4%, P = 0.02). The percentage of patients requiring intra-operative fentanyl was lower in the proximal group (16.4 vs. 30.5%, P = 0.07). There were no differences in either postoperative pain scores or in postoperative complications. No technical failure or block-related complications were reported.ConclusionBilateral suprazygomatic maxillary nerve block is an effective and safe alternative to the traditional peripheral nerve blocks for cleft lip and cleft palate surgery, in a mixed paediatric and adult population.

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