Craniofacial surgery and specific airway problems

Abstract

Infants and children undergoing craniofacial surgery may present with a wide range of diseases and conditions posing an array of challenges to the anesthesiologist. Optimal perioperative care requires an understanding of these diseases and their impact on airway and anesthetic management. For those children with anomalies affecting airway anatomy, soft tissues of the head and neck, or skeletal mobility, advanced airway management techniques (ie, modalities other than direct laryngoscopy) may be required to secure the airway. Additionally, some craniofacial surgical procedures have direct implications on airway management, such as with Le Fort III midface advancement involving halo distractor application, where the distractor device precludes facemask ventilation. For all of these patients, the anesthetic and airway management plans must be tailored to the surgery being performed, the patient's specific conditions, and take into consideration all phases of perioperative care. In this review, we present some of the more commonly encountered craniofacial abnormalities affecting airway management.

An Approach to the Airway Management in Children with Craniofacial Anomalies

“…The airway management plan of the infants and children with difficult airway has many proposed algorithms but not unified as in the American Society of Anaesthesiologists (ASA) adult difficult airway algorithm [4][5][6][7]. The awake intubation is no more a popular option in pediatric intubations except for some emergency situations where the patient is in severe distress and obstruction, as it carries its own disadvantages (increase in intracranial pressure ICP and intracerebral hemorrhage ICH, gagging, uncooperative kid), hence induction of anesthesia with preservation of spontaneous breathing is the cornerstone for a safe airway management in patients with craniofacial syndromes with suspected difficult airway.…”

“…Airway and anesthetic implications: airway obstruction is common in children with Down's syndrome. A midface hypoplasia, narrow nasopharynx, choanal stenosis, high arched palate, pharyngeal muscle hypotonia, relative macroglossia, lingual tonsils, glossoptosis, adenotonsillar hypertrophy, micrognathia, short broad neck, and obesity, all these anatomical conditions combined together contribute to upper airway narrowing [6,10]. In addition, various other structural airway anomalies may be present and diminish further the airway volume.…”

“…Twenty five percent of these patients present with cervical spine fusion most commonly at the level of C2-C3. Syndactyly is considered much less severe as compared to Apert syndrome [6,7,17].…”

“…Occasional associations include laryngomalacia, tracheomalacia, and bronchomalacia, along with fused cervical spine at varying levels in 30% of Pfeiffer syndrome patients. Other less common associations include Arnold-Chiari malformation, imperforate anus, and congenital heart disease [6,7,17].…”

“…All these anomalies can disrupt several functions like breathing, swallowing, chewing, and speech. Systemic manifestations, namely cardiac, renal, and skeletal, especially cervical vertebral defects, may also be observed [1,4,6,7,17].…”