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Regional anaesthesia and multimodal analgesia in cleft palate repair Axel R. Sauter (*) Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway and Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland Cleft palate is one of the most common congenital birth defects, with an incidence rate of between one and 25 cases per 10,000 live births. 1 Repair of cleft palate is essential for improving both food intake and speech development. Effective postoperative pain management is crucial for enhancing recovery. Inadequate pain control may lead to agitation and crying, resulting in complications such as wound dehiscence and fistula formation. Conversely, children who receive adequate pain relief are more likely to resume normal feeding and drinking behaviours earlier in the postoperative period. To develop recommendations for the optimal management of postoperative pain following cleft palate repair, the PROcedure SPECific POSToperative Pain Management (PROSPECT) group reviewed the available literature and developed procedure specific recommendations.2 The analgesic regimen for cleft palate surgery should include intra-operative paracetamol and cyclo-oxygenase-2 (COX-2) specific inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs). The recommended interventions for improving postoperative pain included a suprazygomatic maxillary nerve block or a palatal nerve block if a maxillary nerve block cannot be performed. The use of dexmedetomidine as an adjuvant to local anaesthetic for suprazygomatic maxillary nerve block or, alternatively, as an intravenous perioperative administration is also recommended. Several studies have confirmed the efficacy of maxillary nerve blocks as part of a multimodal postoperative pain management regimen for children undergoing cleft palate surgery.3 4 The most commonly used technique for performing maxillary nerve blocks is the suprazygomatic approach, using a landmark-guided technique. Ultrasound guidance offers the theoretical advantage of real-time visualisation of both needle placement and local anaesthetic spread, which could increase block accuracy and safety. However, clinical studies have not yet demonstrated that ultrasound guidance achieves better results than landmark-based block techniques. A recent MRI study aimed to compare the effect of the guidance technique on the spread of local anaesthetic to the maxillary nerve in the pterygopalatine fossa.5 Similar results were found for both methods, with success rates ranging from 65% for landmark guidance to 70% for ultrasound guidance. Conclusion Effective postoperative pain treatment is crucial for recovery after cleft palate repair surgery. A maxillary nerve block using the suprazygomatic approach is an important component of a multimodal pain management regimen. Landmark-guided techniques for maxillary nerve blocks are a viable alternative to ultrasound-guided techniques.References Tanaka SA, Mahabir RC, Jupiter DC, Menezes JM. Updating the epidemiology of isolated cleft palate. Plast Reconstr Surg. 2013;131:650e-2e.Suleiman NN, Luedi MM, Joshi G, Dewinter G, Wu CL, Sauter AR. Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Reg Anesth Pain Med. 2024.Chiono J, Raux O, Bringuier S, et al. Bilateral suprazygomatic maxillary nerve block for cleft palate repair in children: a prospective, randomized, double-blind study versus placebo. Anesthesiology 2014;120:1362–9.Sola C, Raux O, Savath L, Macq C, Capdevila X, Dadure C. Ultrasound guidance characteristics and efficiency of suprazygomatic maxillary nerve blocks in infants: a descriptive prospective study. Paediatr Anaesth. 2012;22:841–6.Suleiman NN, Lien I, Akhavi MS, et al. Ultrasound guidance does not improve local anesthetic distribution in suprazygomatic maxillary nerve blocks in pediatric patients: a clinical, randomized, controlled, observer-blinded, crossover MRI trial. Reg Anesth Pain Med. 2025.