General Anesthesia Management Using Remimazolam and Dexmedetomidine in a Patient Undergoing Palatal Fistula Closure With a Tongue Flap

Palatal fistula closure with a tongue flap presents unique challenges in anesthetic management, particularly due to postoperative limitations in mouth opening, which complicate airway management. This report describes the anesthetic management of an 18-year-old male undergoing palatal fistula closure with a tongue flap. Anesthesia was induced and maintained with remimazolam and remifentanil, followed by the administration of dexmedetomidine toward the end of the surgery. After thorough oral suctioning, sugammadex was administered to reverse neuromuscular blockade, and flumazenil was used to counteract remimazolam-induced sedation. The patient regained consciousness smoothly, exhibiting a Ramsay Sedation Score of 2 and adequate spontaneous breathing. Mild postoperative bleeding was observed but was effectively managed with temporary re-sedation using sevoflurane. Extubation was successfully performed with a tube exchanger, and no postoperative respiratory complications ensued. Remimazolam, with its rapid metabolism and the availability of a specific antagonist (flumazenil), enabled controlled and timely recovery of cognitive function, minimizing the risk of postoperative agitation. Additionally, dexmedetomidine contributed to maintaining mild sedation and ensuring respiratory stability during emergence. This combination of remimazolam and dexmedetomidine offers an effective anesthetic strategy for safe emergence and extubation in patients undergoing palatal fistula closure with a tongue flap. It may also apply to other cases requiring cautious extubation and difficult airway management.