Nerve block may reduce opioid use in infants undergoing cleft palate surgery: Study

For infants undergoing cleft palate surgery, local anesthetic injection targeting the maxillary nerve of the face may reduce or eliminate the need for opioid medications to control postoperative pain, reports a study in The Journal of Craniofacial Surgery. The journal is published in the Lippincott portfolio by Wolters Kluwer.

"Our study presents preliminary but promising results suggesting that suprazygomatic maxillary nerve block [SMNB] may reduce perioperative opioid consumption in pediatric primary clefts particularly cleft palate closure," comments senior author Rutger M. Schols, MD, PhD, of MosaKids Children’s Hospital, Maastricht, the Netherlands.

Nerve block for cleft palate surgery: Technique and outcomes

Cleft palate is a common congenital condition, occurring in 0.3% to 0.4% of infants. Early surgery – typically performed at age six to 12 months – is essential for normal speech, swallowing, and breathing function.

Postoperative pain control remains a significant challenge in infants undergoing cleft palate surgery. While opioid medications such as morphine are effective, they pose substantial risks including nausea and vomiting, constipation, and depressed breathing. Regional anesthesia techniques have been evaluated to help control postoperative pain, potentially reducing the need for opioids.

Dr. Schols and colleagues evaluate their experience with SMNB in in ten infants, average age seven months, undergoing cleft palate surgery. After induction of general anesthesia, a small dose of local anesthetic is injected to block transmission of pain signals from the maxillary nerve, which provides sensation to the middle of the face, including the upper jaw (maxilla) and upper lip.

The article includes a detailed, illustrated explanation of the injection technique, including the use of ultrasound guidance to ensure precise injection of local anesthetic around the maxillary nerve. The authors' SMNB technique includes the use of a mild sedative (dexmedetomidine), which may help to prolong the effects of nerve block.

Focusing on the need for opioid medications, the researchers compared postoperative pain control for infants undergoing SMNB versus ten patients undergoing prior cleft palate surgery without nerve block. Use of other pain control measures, including non-opioid pain relievers, was similar between groups.

Overall, infants receiving SMNB had significantly lower opioid use after cleft palate surgery. Median total morphine dose was 0.1 milligrams in the SMNB group, compared to 0.75 mg in infants who did not undergo nerve block. Seven out of ten children in the SMNB group did not need any morphine for pain control, compared to just two of ten without SMNB.

Use of other pain medications, including a weaker opioid called tramadol, was similar between groups. Infants receiving SMNB spent less time in the hospital after surgery: 2.0 days, compared to 2.5 days in those not receiving nerve block. However, this difference was not statistically significant.

The researchers note some limitations of their small, exploratory study, including the fact that patients were not randomly assigned to SMNB or standard pain control alone. The authors emphasize the need for larger, controlled trials to confirm their findings.

While the SMNB technique is not new, previous studies of its use for cleft palate surgery have varied significantly, particularly in the injection techniques used. Dr. Schols and coauthors highlight the use of real-time ultrasound guidance to ensure proper local anesthetic injection. They conclude: "By assessing this targeted approach, we aim to contribute to the development of standardized perioperative pain management protocols, ultimately optimizing recovery and reducing hospital length of stay in this vulnerable patient population."

Reference:

Wijnants, Nina MD*; Hanot, Jan MD†; Ramaut, Lisa E. MD, PhD‡; van Kuijk, Sander M.J. PhD§; Booi, Darren I. MD, PhD*; van der Hulst, René R.W.J. MD, PhD*; Schols, Rutger M. MD, PhD*,‡. Preoperative Suprazygomatic Maxillary Nerve Block to Reduce Perioperative Opioid Use in Pediatric Primary Cleft Palate Repair: Preliminary Clinical Experience. The Journal of Craniofacial Surgery ():10.1097/SCS.0000000000012101, December 6, 2025. | DOI: 10.1097/SCS.0000000000012101