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Rada",authors:[{id:"114650",title:"Dr",name:"Eugen",middleName:null,surname:"Culea",fullName:"Eugen Culea",slug:"eugen-culea"},{id:"114653",title:"Dr.",name:"Simona",middleName:null,surname:"Rada",fullName:"Simona Rada",slug:"simona-rada"}]},{id:"36169",title:"Water in Rocks and Minerals - Species, Distributions, and Temperature Dependences",slug:"water-in-rocks-and-minerals-species-distributions-and-temperature-dependences",signatures:"Jun-ichi Fukuda",authors:[{id:"105384",title:"Dr.",name:"Jun-Ichi",middleName:null,surname:"Fukuda",fullName:"Jun-Ichi Fukuda",slug:"jun-ichi-fukuda"}]},{id:"36170",title:"Attenuated Total Reflection - Infrared Spectroscopy Applied to the Study of Mineral - Aqueous Electrolyte Solution Interfaces: A General Overview and a Case Study",slug:"attenuated-total-reflection-infrared-spectroscopy-applied-to-the-study-of-mineral-aqueous-el",signatures:"Grégory Lefèvre, Tajana Preočanin and Johannes Lützenkirchen",authors:[{id:"108416",title:"Dr.",name:"Johannes",middleName:null,surname:"Lützenkirchen",fullName:"Johannes Lützenkirchen",slug:"johannes-lutzenkirchen"},{id:"111675",title:"Dr.",name:"Gregory",middleName:null,surname:"Lefevre",fullName:"Gregory Lefevre",slug:"gregory-lefevre"},{id:"111676",title:"Prof.",name:"Tajana",middleName:null,surname:"Preocanin",fullName:"Tajana Preocanin",slug:"tajana-preocanin"}]},{id:"36171",title:"Research of Calcium Phosphates Using Fourier Transform Infrared Spectroscopy",slug:"research-of-calcium-phosphates-using-fourier-transformation-infrared-spectroscopy",signatures:"Liga Berzina-Cimdina and Natalija Borodajenko",authors:[{id:"110522",title:"Prof.",name:"Liga",middleName:null,surname:"Berzina-Cimdina",fullName:"Liga Berzina-Cimdina",slug:"liga-berzina-cimdina"},{id:"112181",title:"MSc.",name:"Natalija",middleName:null,surname:"Borodajenko",fullName:"Natalija Borodajenko",slug:"natalija-borodajenko"}]},{id:"36172",title:"FTIR Spectroscopy of Adsorbed Probe Molecules for Analyzing the Surface Properties of Supported Pt (Pd) Catalysts",slug:"ftir-spectroscopy-of-adsorbed-probe-molecules-for-analyzing-the-surface-properties-of-supported-pt-p",signatures:"Olga B. 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Escobar Barrios, José R. Rangel Méndez, Nancy V. Pérez Aguilar, Guillermo Andrade Espinosa and José L. 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Cabanelas",slug:"juan-c.-cabanelas"}]},{id:"36179",title:"Use of FTIR Analysis to Control the Self-Healing Functionality of Epoxy Resins",slug:"use-of-ft-ir-analysis-to-control-the-self-healing-functionality-of-epoxy-resins",signatures:"Liberata Guadagno and Marialuigia Raimondo",authors:[{id:"106836",title:"Prof.",name:"Liberata",middleName:null,surname:"Guadagno",fullName:"Liberata Guadagno",slug:"liberata-guadagno"}]},{id:"36180",title:"Infrared Analysis of Electrostatic Layer-By-Layer Polymer Membranes Having Characteristics of Heavy Metal Ion Desalination",slug:"infrared-analysis-of-electrostatic-layer-by-layer-polymer-membranes-having-characteristics-of-heavy",signatures:"Weimin Zhou, Huitan Fu and Takaomi Kobayashi",authors:[{id:"110384",title:"Dr.",name:"Takaomi",middleName:null,surname:"Kobayashi",fullName:"Takaomi Kobayashi",slug:"takaomi-kobayashi"}]},{id:"36181",title:"Infrared Spectroscopy as a Tool to Monitor Radiation Curing",slug:"infrared-spectroscopy-as-a-tool-to-monitor-radiation-curing",signatures:"Marco Sangermano, Patrick Meier and Spiros Tzavalas",authors:[{id:"112286",title:"Dr.",name:"Spiros",middleName:null,surname:"Tzavalas",fullName:"Spiros Tzavalas",slug:"spiros-tzavalas"},{id:"114382",title:"Prof.",name:"Marco",middleName:null,surname:"Sangermano",fullName:"Marco Sangermano",slug:"marco-sangermano"},{id:"114384",title:"Dr",name:"Patrick",middleName:null,surname:"Meier",fullName:"Patrick Meier",slug:"patrick-meier"}]},{id:"36182",title:"Characterization of Compositional Gradient Structure of Polymeric Materials by FTIR Technology",slug:"characterization-of-compositional-gradient-structure-of-polymeric-materials-by-ft-ir-technology",signatures:"Alata Hexig and Bayar Hexig",authors:[{id:"20867",title:"Dr.",name:"Bayar",middleName:null,surname:"Hexig",fullName:"Bayar Hexig",slug:"bayar-hexig"},{id:"111986",title:"Dr.",name:"Alata",middleName:null,surname:"Hexig",fullName:"Alata Hexig",slug:"alata-hexig"}]},{id:"36183",title:"Fourier Transform Infrared Spectroscopy - Useful Analytical Tool for Non-Destructive Analysis",slug:"fourier-trasform-infrared-spectroscopy-useful-analytical-tool-for-non-destructive-analysis",signatures:"Simona-Carmen Litescu, Eugenia D. Teodor, Georgiana-Ileana Truica, Andreia Tache and Gabriel-Lucian Radu",authors:[{id:"24425",title:"Dr.",name:"Simona Carmen",middleName:null,surname:"Litescu",fullName:"Simona Carmen Litescu",slug:"simona-carmen-litescu"},{id:"24429",title:"Prof.",name:"Gabriel-Lucian",middleName:null,surname:"Radu",fullName:"Gabriel-Lucian Radu",slug:"gabriel-lucian-radu"},{id:"108318",title:"Dr.",name:"Eugenia D.",middleName:null,surname:"Teodor",fullName:"Eugenia D. Teodor",slug:"eugenia-d.-teodor"},{id:"108323",title:"Dr.",name:"Georgiana-Ileana",middleName:null,surname:"Badea",fullName:"Georgiana-Ileana Badea",slug:"georgiana-ileana-badea"},{id:"136337",title:"Ms.",name:"Andreia",middleName:null,surname:"Tache",fullName:"Andreia Tache",slug:"andreia-tache"}]},{id:"36184",title:"Infrared Spectroscopy in the Analysis of Building and Construction Materials",slug:"infrared-spectroscopy-of-cementitious-materials",signatures:"Lucia Fernández-Carrasco, D. Torrens-Martín, L.M. Morales and Sagrario Martínez-Ramírez",authors:[{id:"107401",title:"Dr.",name:"Lucia J",middleName:null,surname:"Fernández",fullName:"Lucia J Fernández",slug:"lucia-j-fernandez"}]},{id:"36185",title:"Infrared Spectroscopy Techniques in the Characterization of SOFC Functional Ceramics",slug:"infrared-spectroscopy-techniques-in-the-characterization-of-sofc-functional-ceramics",signatures:"Daniel A. Macedo, Moisés R. Cesário, Graziele L. Souza, Beatriz Cela, Carlos A. Paskocimas, Antonio E. Martinelli, Dulce M. A. Melo and Rubens M. Nascimento",authors:[{id:"102015",title:"MSc.",name:"Daniel",middleName:null,surname:"Macedo",fullName:"Daniel Macedo",slug:"daniel-macedo"},{id:"112309",title:"MSc",name:"Moisés",middleName:"Romolos",surname:"Cesário",fullName:"Moisés Cesário",slug:"moises-cesario"},{id:"112310",title:"Ms.",name:"Graziele",middleName:null,surname:"Souza",fullName:"Graziele Souza",slug:"graziele-souza"},{id:"112311",title:"MSc.",name:"Beatriz",middleName:null,surname:"Cela",fullName:"Beatriz Cela",slug:"beatriz-cela"},{id:"112312",title:"Prof.",name:"Carlos",middleName:null,surname:"Paskocimas",fullName:"Carlos Paskocimas",slug:"carlos-paskocimas"},{id:"112314",title:"Prof.",name:"Antonio",middleName:null,surname:"Martinelli",fullName:"Antonio Martinelli",slug:"antonio-martinelli"},{id:"112315",title:"Prof.",name:"Dulce",middleName:null,surname:"Melo",fullName:"Dulce Melo",slug:"dulce-melo"},{id:"112316",title:"Dr.",name:"Rubens",middleName:"Maribondo Do",surname:"Nascimento",fullName:"Rubens Nascimento",slug:"rubens-nascimento"}]},{id:"36186",title:"Infrared Spectroscopy of Functionalized Magnetic Nanoparticles",slug:"infrared-spectroscopy-of-functionalized-magnetic-nanoparticles",signatures:"Perla E. García Casillas, Claudia A. Rodriguez Gonzalez and Carlos A. Martínez Pérez",authors:[{id:"104636",title:"Dr.",name:"Perla E.",middleName:null,surname:"García Casillas",fullName:"Perla E. García Casillas",slug:"perla-e.-garcia-casillas"},{id:"112440",title:"Dr.",name:"Carlos A.",middleName:null,surname:"Martínez Pérez",fullName:"Carlos A. Martínez Pérez",slug:"carlos-a.-martinez-perez"},{id:"112441",title:"Dr.",name:"Claudia A.",middleName:null,surname:"Rodriguez Gonzalez",fullName:"Claudia A. 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Particularly, cancer of the larynx, which is the second most frequent neoplasm of the aerodigestive tract, represents a real challenge for the anesthesiologist, since he deals with patients with tumors at any stage and in elective or emergency situations.
Of head and neck tumors, laryngeal cancer accounts for 50% with a higher incidence in men than woman with a 4:1 ratio. The three major locations for laryngeal cancer are glottis (59%), followed by the supraglottic area (40%) and the subglottic area (1%) [1]. Laryngeal stenosis, fistula formation, local recurrence, and adjacent lymph node metastasis are some of the complications that the patient can develop in long term [2].
Laryngectomy is an effective cancer procedure and is associated with good functional outcomes. The current UK standard of care for locally advanced malignancy is aimed at organ preservation. This is for patients with T3 tumors on the tumor-nodes-metastases (TNM) scale. For patients with T4 disease invading the laryngeal cartilages, total laryngectomy is recommended. Although laryngeal preservation may seem preferable, these cases require careful discussion at a regional head and neck cancer multidisciplinary team meeting, as evidence is emerging that patients who undergo primary surgery have improved survival rates. Long-term complications of oncological treatments may ultimately result in a “frozen larynx,” where the patient requires a tracheostomy and gastrostomy, or even ultimately a laryngectomy to prevent aspiration. National guidelines recommend that laryngectomy is performed in specialist centers, as complication rates are lower in departments that perform this procedure frequently [3].
Organ preservation is recommended in patients with T3 tumors on TNM classification (tumor, nodule, metastasis), and total laryngectomy is indicated in T4 patients with invasive disease to laryngeal cartilages. Although preserving surgery may seem better, all cases require careful analysis to perform the procedure that improves survival rates. We can see complications of oncological treatments; for example, “frozen larynx,” in these cases the patient requires tracheostomy and gastrostomy, or even a laryngectomy to prevent aspiration. National guidelines recommend that laryngectomy is performed in specialist centers, as complication rates are lower in departments that perform this procedure frequently [3].
The context in which the anesthesiologist can find the patient is in elective or emergency situations, as well as in early or advanced stages. The most challenging aspect would be the intubation of the post-radiotherapy patient. It is important to understand the disease process and the management of these cancers, because a proper anesthetic management plan will be decisive. There must be open lines of communication with surgeon and wider team for better results [3].
Based on the knowledge of the possible occurrence of difficult ventilation, all the associated necessary equipment should be ready for an instant application, and also, additional measures such as preparation of emergent tracheostomy, cardiopulmonary resuscitation, and airway management following ASA guideline may be implemented [2].
Difficult airway is defined as the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with facemask ventilation, difficulty with tracheal intubation, or both. Situations of “cannot intubate and cannot ventilate (CICV)” may occur in 0.01–0.07% of patients undergoing surgery. This is a true emergency situation. This situation must be resolved as soon as possible, so that a harmful outcome does not occur like permanent brain damage or death. Spontaneous breathing must be restored, if is not possible then the surgical access of the airway must be done [4].
The anatomical modifications due to the disease as well as morphological changes by previous treatments (radiotherapy and chemotherapy in the head and neck cancer patients) are responsible for the difficulties in the airway. The incidence of difficult intubation ranges from 0.5 to 2% in the general population, from 8 to 10% in patients having ears, nose, and throat surgery, and rises to 28% in patients with tumors of the airway [1, 5]. Glottic cancers are the commonest (50–60%). These patients present difficulties due to the presence of mass, a receding jaw, restricted mouth opening, and neck movement or due to associated comorbidities. The size and location of tumor are the crucial factors in determining the appropriate approach to the airway [1].
The characteristics that are most often observed in the patient who has head and neck cancer are the following: elderly, chronic consumer of ethanol, and/or a smoker. broncho-pneumopathie chronique obstructive, pulmonary emphysema, ischemic coronary heart disease, high blood pressure, chronic hepatopathy with toxic etiology, coagulopathies are associated with the oncological status [6].
Some patients have nutritional disorders due to the difficulty in swallowing due to the presence of the tumor, which leads to weight loss, anemia, and dyselectrolytemia. All these alterations should be corrected as far as possible before undergoing surgery [6].
Preoperative evaluation should include full blood count, clotting screen, biochemical profile with urea and electrolytes, liver function test, blood sugar, and electrocardiography. Other studies that should be considered in some patients are chest X-ray, pulmonary function tests, arterial blood gases, and echocardiogram, because some may have chronic obstructive pulmonary disease or some cardiopathy associated with their risk factors [7].
It is common to find chronic obstructive pulmonary disease (COPD) in head and neck cancer patients so modification of bronchodilator therapy, steroids, and treatment of acute infection can optimize patient conditions [7].
Laryngeal cancer treatment includes surgery, chemotherapy, and radiotherapy, and these treatments may worsen airway management. Radiation therapy after the primary surgery may lead to immobility of the mandible and neck. A careful examination of the área between the hyoid bone and submentum is required, because we can detect risk factors for difficult airway. For some patients, even with normal mentohyoid distance, the larynx might be located much more anterior than normal, due to radiotherapy-induced fibrosis in the submandibular área, and this factor makes intubation difficult. Some side effects of radiation therapy, for example, dermatitis and oral mucositis, can make the tissue more susceptible to infection, and bleeding may occur during airway management. The patient may present local edema due to damage to the lymphatic ducts after radiotherapy. Preoperative tracheostomy sometimes becomes indicated when a difficult airway is evident before surgery or after previously performed laryngeal surgery [2].
We should evaluate the mouth opening, mallampati score, laryngoscopic view at previous operations, neck movement, and prominent teeth, and look for masses in neck, scarring from previous surgery, and immobility of the larynx from previous radiotherapy.
Cross-sectional imaging techniques are the most useful in confirming intrinsic compression of the airways, a feature that may not be appreciated on endoscopic analysis alone [8]. It is indicated to identify the extension of the tumor and the potential obstruction through imaging studies, radiological imaging with computed tomography or magnetic resonance imaging can help. In experienced hands, ultrasonography is useful in identifying the cricothyroid membrane before induction of anesthesia to have identified the surgical access in case of emergency (Figure 1) [7].
A. Computed tomography with axial section showing maximum glottic narrowing caused by tumor. B. Subglottic region, with less compromise in the tracheal diameter.
Awake nasal endoscopy can be carried out before induction of anesthesia and is especially useful when no other radiological investigations are available. It gives a real-time view of the upper airway and the larynx [7].
Preoperative nasoendoscopy can determine the airway diameter, detailed evaluation of the airway, location, size, nature and mobility of tumor (e.g., pedunculated), bleeding and edema, the epiglottis and glottis, vocal cord movement, pooling of secretions, it does not require more than a simple preparation of the nose with a local anesthetic and a vasoconstrictor, and it is very important to identify a potential airway obstruction [8] and is useful in identifying patients in whom an awake technique or conscious fibroscopic-assisted intubation is more appropriate [2, 7]. In short, it allows us to examine the condition of larynx and pharynx.
Before starting surgery, the following points should be defined:
Ventilation with a face mask will be possible?
Laryngoscopy is going to be difficult?
Intubation (passing the tube through the glottis) is going to be difficult?
An awake technique is more appropriate?
It is possible to make a surgical airway and front of neck access (FONA) is feasible?
When you should consider awake intubation? When difficulty in tracheal intubation and bag-mask ventilation is predicted or has been experienced previously. When performing a technique with an awake patient, you have an advantage because you maintain the permeable airway, gas exchange, and protection against aspiration during the intubation process. General anesthesia makes the airway more difficult with more obstruction, making identification of landmarks difficult on endoscopy [7].
It is essential for the anesthesiologist to prevent an emergency situation and make the right decision for the safety of the patient; therefore, a plan must be formulated.
Procedures performed on patients with laryngeal cancer ranges from panendoscopy and biopsy to laryngectomy and occasionally emergency tracheostomy [3]. And the planning of airway management should be performed for elective patient and elective surgery and for those who may present in extremis with stridor.
Evaluation of the airway includes history and bedside examination, review of imaging and nasendocopy findings as well as discussion with the surgical team.
It is essential to bear in mind other rescue oxygenation techniques, in case the primary plan fails. The rescue plans may include ventilation with face mask or supraglottic devices, and also a surgical airway. The team must consider that insertion and placement of supraglottic airway devices are difficult in patients with reduced opening of the jaw, oropharyngeal lesions, and after radiotherapy. In these cases, intubation using a supraglottic airway as a conduit is difficult or even impossible so we must consider these risk factors before performing the anesthetic induction.
Because of the high incidence of anticipated difficult airways in head and neck patients, it is prudent to seek video-assisted laryngoscopy as the primary technique, video laryngoscopes have emerged as a common first-line option for laryngoscopy, and the Difficult Airway Society (DAS) highlights its role in difficult intubation. A 93–96% first-attempt intubation success rate can be achieved with acute-angle video laryngoscopes such as the Glidescope or CMAC Storz systems, reducing the number of patients at risk of intubation failure.
Direct laryngoscopy (DL) exposes the laryngeal inlet under direct vision and requires a direct line of sight to align airway axes (oral-pharyngeal-laryngeal) for optimal glottic visualization. Oftentimes, manipulations to align these axes include head extension, neck flexion, laryngeal manipulation, and other stressful movements [9]. Videolaryngoscopy (VL) optimizes first-attempt success when compared to direct laryngoscopy, and utilizes indirect laryngoscopy
Evidence has made it clearer that videolaryngoscopy eases intubation difficulty and increases first-attempt success rates in the airway predicted to be difficult to intubate by direct laryngscopy.
Awake fiber-optic intubation is the safest approach to managing difficult airways, and it can be extremely helpful in patients with supraglottic obstruction (e.g., epiglottis, tongue, basal obstructions, intraoral masses), but it is not the first-line option in patients with a narrow laryngeal inlet or with tumors that cause obstruction at the laryngeal level, which may fail due to the inability to displace the tumor or simply because the tube cannot be advanced and thus precipitates a total obstruction [7].
Active oxygenation strategies must be present throughout the difficult airway management process. One of them is apneic oxygenation.
Trans-nasal high-flow rapid insufflation ventilatory exchange or THRIVE is an oxygenation technique that provides heated and humidified oxygen using high-flow nasal cannula. This system has recently been shown to increase the apnea time in head and neck patients including those with stridor. Trans-nasal high-flow rapid insufflation ventilatory exchange combines apneic oxygenation, continuous positive airway pressure and flow-dependent dead space flushing, which overcomes airway obstruction and increases safety margin during sedation. THRIVE provides up to 70 L/min of oxygen and is well tolerated because of humidification. It changes the nature of difficult intubations from a hurried process to a more controlled event, with an extended apneic window and reduced iatrogenic trauma [3].
The mainstay method of increasing the apneic window is through pre-oxygenation, which entails spontaneous facemask ventilation with 100% oxygen [10]. Pre-oxygenation denitrogenises the lungs and creates an alveolar oxygen reservoir. The physiological phenomenon that occurs is called aventilatory mass flow (AVMF) or apneic oxygenation. A patent air passageway exists between the lungs and the exterior, and the difference between the alveolar rates of oxygen removal and carbon dioxide excretion generates a negative pressure gradient of up to 20 cmH2O that drives oxygen into the lungs. This could extend safe apnea time during prolonged laryngoscopy and intubation.
Inspiratory stridor suggests a reduction in airway diameter at the supraglottic, periglottic, or glottic level of at least 50%. Expiratory stridor originates at or below the glottis level, which is characteristic of tracheal or tracheobronchial narrowing, while inspiratory-expiratory (biphasic) stridor generally points to obstructive subglottic disease [11].
We have to define the group of patients who are being considered with stridor at rest. In this group, the stridor is due to a reduction in airway diameter of at least 50%. Patients with slow-growing tumors often present late. So when we meet patients classified in this small group, we know that we will face a tumor of important measure.
Perilaryngeal tumors include supraglottic, pharyngeal, pyriform fossa, epiglottic, vocal cord, and subglottic lesions.
The patient should be asked whether, in addition to having noisy breathing, he has actually experienced difficulty in breathing; in particular, has he woken at night in a panic. The presence of nocturnal symptoms usually indicates that there is more advanced obstruction [11].
Patients with significant stridor at rest can be divided broadly into two groups: (1) those in whom intubation is considered possible and (2) those definitely requiring preliminary local anesthetic tracheosomy [11].
The patient, who comes to hospital for the first time as an emergency, is usually the one who will needs a local anesthetic tracheostomy. Severe disease will generally manifest with nocturnal respiratory difficulties and panic attacks [11]. The patient with less severe obstruction is referred to an outpatient clinic (Figures 2 and 3).
A. Videolaryngoscopy images show a narrowing at the level of the glottis. B. decreased diameter, and inability to pass a #5.5 DI orotracheal tube. C. Friable and bleeding tumor.
Total laryngectomy in laryngeal cancer.
It is required to identify patient at risk of airway obstruction because intravenous or inhalational induction may precipitate airway obstruction due to tumor bulk. Even local anesthesia is not without risk because severe airway obstruction precipitated by laryngospasm has occurred [12].
Is polemical the use of muscle relaxant drugs sometimes facilitates laryngoscopy but in other cases is controversial because of the greater risk of airway obstruction. Current practice has also been influenced by new intubation devices such as video laryngoscopes [12].
If tracheal intubation is considered possible, the main options are an inhalational induction with direct laryngoscopy and tracheal intubation, or an awake fiber-optic intubation. Supraglottic tumors may cause obstruction when intravenous induction and muscle relaxation are used. Intravenous induction of anesthesia and the use of a muscle relaxant are not recommended in this situation [8].
The objective of an inhalational induction is to preserve spontaneous ventilation until adequate depth of anesthesia is obtained and direct laryngoscopy and visualization of the glottis is allowed [8]. Sevoflurane is used and allows rapid, smooth induction of anesthesia, and has the benefit of lack of airway irritation and low blood gas solubility. The disadvantages that can be presented are coughing and laryngospasm upon instrumentation, and sometimes respiratory obstruction when the patient loses consciousness to the beginning of the anesthesia.
When anesthetic depth is adequate, laryngoscopy is undertaken and a rapid decision is made as to whether intubation is possible. If a laryngoscope does not provide an adequate view of the glottis, a second attempt may be made with a different instrument or a different approach, for example, video-laryngoscope. A rigid bronchoscope may be used by an experienced person.
If after laryngoscopy and under direct vision, the anatomy is difficult to visualize or the glottic opening is very small, which is prudent to let the surgeon perform the tracheostomy without haste; but if it is decided to intubate, it must be made a maximum of two attempts. Repeated laryngoscopies have a risk of generating bleeding in necrotic and friable tumors, and this may lead to a total obstruction of the airway, and lead to a situation of “I cannot intubate” “I cannot oxygenate.” If the laryngoscopy fails, the team must be informed and continue with the planned plan [7].
The prolonged manipulation of the upper respiratory tract can cause cardiovascular responses: bradycardia, tachycardia, hypertension, cardiac arrhythmias, and is important to consider.
The way to ensure the airway in the postoperative of head and neck cancer surgery is with a tracheostomy. When orotracheal or nasotracheal intubation is not possible or a major surgical intervention for oral cancer with reconstructive tissue transfer is planned, the better option is an elective tracheostomy in a conscious patient [6].
Tracheostomy as an approach method of the airways is obligated in patients with tumors located in the larynx or below the glottis with obstructive effect, and also in cases of laryngeal stenosis or significant supraglottic edema. Tracheostomy should not be made in pediatric patients because the trachea is small with a soft cartilage and difficult to palpate [6].
A careful strategy should be planned for the extubation of those patients who do not require postoperative tracheostomy.
After prolonged surgery, we can find some issues, for example, swelling, bleeding, and airway debris. If tracheal intubation was difficult in the first place, reintubation is likely to be more. Other strategies may also be used: trans-tracheal catheters and airway exchange catheters. An airway exchange catheter is a long, small internal diameter, hollow, semi-rigid catheter that is inserted through an
It is essential that anesthetists are aware of human factors, maintain situational awareness, avoid task fixation, and do not resort to unfamiliar techniques. A coordinated team approach with clear communication is essential [6].
Difficult airway can lead to serious complications in head and neck cancer surgical patients, specifically in cancer of the larynx.
The anesthesiologist should need a careful planning for intubation and extubation of difficult airway depending on surgery and conditions of the patient.
The use of appropriate airway equipment, oxygenation techniques, surgical airway access, all options must be available to rescue a difficult airway.
Intubation of the patient with laryngeal cancer is a challenge that must be addressed through a team approach. Management will depend on clinical presentation, individual experience, and equipment availability.
I thank the “Instituto Nacional de Cancerología” in México, the institution where I did the Onco-Anesthesia care Fellowship, and to all the doctors who taught me with their experience with patients with difficult airways.
The authors declare no conflict of interest.
The Internet has irrevocably changed the dynamics of scholarly communication and publishing. Consequently, we find it necessary to indicate, unambiguously, our definition of what we consider to be a published scientific work.
",metaTitle:"Prior Publication Policy",metaDescription:"Prior Publication Policy",metaKeywords:null,canonicalURL:"/page/prior-publication-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"A significant number of working papers, early drafts, and similar work in progress are openly shared online between members of the scientific community. It has become common to announce one’s own research on a personal website or a blog to gather comments and suggestions from other researchers. Such works and online postings are, indeed, published in the sense that they are made publicly available. However, this does not mean that if submitted for publication by IntechOpen they are not original works. We differentiate between reviewed and non-reviewed works when determining whether a work is original and has been published in a scholarly sense or not.
\\n\\nThe significance of Peer Review cannot be overstated when it comes to defining, in our terms, what constitutes a published scientific work. Peer Review is widely considered to be the cornerstone of modern publishing processes and the key value-adding contribution to a scholarly manuscript that a publisher can make.
\\n\\nOther than the issue of originality, research misconduct is another major issue that all publishers have to address. IntechOpen’s Retraction & Correction Policy and various publication ethics guidelines identify both redundant publication and (self)plagiarism to fall within the definition of research misconduct, thus constituting grounds for rejection or the issue of a Retraction if the work has already been published.
\\n\\nIn order to facilitate the tracking of a manuscript’s publishing history and its development from its earliest draft to the manuscript submitted, we encourage Authors to disclose any instances of a manuscript’s prior publication, whether it be through a conference presentation, a newspaper article, a working paper publicly available in a repository or a blog post.
\\n\\nA note to the Academic Editor containing detailed information about a submitted manuscript’s previous public availability is the preferred means of reporting prior publication. This helps us determine if there are any earlier versions of a manuscript that should be disclosed to our readers or if any of those earlier versions should be cited and listed in a manuscript’s references.
\\n\\nSome basic information about the editorial treatment of different varieties of prior publication is laid out below:
\\n\\n1. CONFERENCE PAPERS & PRESENTATIONS
\\n\\nGiven that conference papers and presentations generally pass through some sort of peer or editorial review, we consider them to be published in the accepted scholarly sense, particularly if they are published as a part of conference proceedings.
\\n\\nAll submitted manuscripts originating from a previously published conference paper must contain at least 50% of new original content to be accepted for review and considered for publication.
\\n\\nAuthors are required to report any links their manuscript might have with their earlier conference papers and presentations in a note to the Academic Editor, as well as in the manuscript itself. Additionally, Authors should obtain any necessary permissions from the publisher of their conference paper if copyright transfer occurred during the publishing process. Failure to do so may prevent Us from publishing an otherwise worthy work.
\\n\\n2. NEWSPAPER & MAGAZINE ARTICLES
\\n\\nNewspaper and magazine articles usually do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense. Articles appearing in newspapers and magazines rarely possess the depth and structure characteristic of scholarly articles.
\\n\\nSubmitted manuscripts stemming from a previous newspaper or magazine article will be accepted for review and considered for publication. However, Authors are strongly advised to report any such publication in an accompanying note to the External Editor.
\\n\\nAs with the conference papers and presentations, Authors should obtain any necessary permissions from the newspaper or magazine that published the work, and indicate that they have done so in a note to the External Editor.
\\n\\n3. GREY LITERATURE
\\n\\nWhite papers, working papers, technical reports and all other forms of papers which fall within the scope of the ‘Luxembourg definition’ of grey literature do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense.
\\n\\nAlthough such papers are regularly made publicly available via personal websites and institutional repositories, their general purpose is to gather comments and feedback from Authors’ colleagues in order to further improve a manuscript intended for future publication.
\\n\\nWhen submitting their work, Authors are required to disclose the existence of any publicly available earlier drafts in a note to the Academic Editor. In cases where earlier drafts of the submitted version of the manuscript are publicly available, any overlap between the versions will generally not be considered an instance of self-plagiarism.
\\n\\n4. SOCIAL MEDIA, BLOG & MESSAGE BOARD POSTINGS
\\n\\nWe feel that social media, blogs and message boards are generally used with the same intention as grey literature, to formulate ideas for a manuscript and gather early feedback from like-minded researchers in order to improve a particular piece of work before submitting it for publication. Therefore, we do not consider such internet postings to be publication in the scholarly sense.
\\n\\nNevertheless, Authors are encouraged to disclose the existence of any internet postings in which they outline and describe their research or posted passages of their manuscripts in a note to the Academic Editor. Please note that we will not strictly enforce this request in the same way that we would instructions we consider to be part of our conditions of acceptance for publication. We understand that it may be difficult to keep track of all one’s internet postings in which the researcher´s current work might be mentioned.
\\n\\nIn cases where there is any overlap between the Author´s submitted manuscript and related internet postings, we will generally not consider it to be an instance of self-plagiarism. This also holds true for any co-Author as well.
\\n\\nFor more information on this policy please contact permissions@intechopen.com.
\\n\\nPolicy last updated: 2017-03-20
\\n"}]'},components:[{type:"htmlEditorComponent",content:'A significant number of working papers, early drafts, and similar work in progress are openly shared online between members of the scientific community. It has become common to announce one’s own research on a personal website or a blog to gather comments and suggestions from other researchers. Such works and online postings are, indeed, published in the sense that they are made publicly available. However, this does not mean that if submitted for publication by IntechOpen they are not original works. We differentiate between reviewed and non-reviewed works when determining whether a work is original and has been published in a scholarly sense or not.
\n\nThe significance of Peer Review cannot be overstated when it comes to defining, in our terms, what constitutes a published scientific work. Peer Review is widely considered to be the cornerstone of modern publishing processes and the key value-adding contribution to a scholarly manuscript that a publisher can make.
\n\nOther than the issue of originality, research misconduct is another major issue that all publishers have to address. IntechOpen’s Retraction & Correction Policy and various publication ethics guidelines identify both redundant publication and (self)plagiarism to fall within the definition of research misconduct, thus constituting grounds for rejection or the issue of a Retraction if the work has already been published.
\n\nIn order to facilitate the tracking of a manuscript’s publishing history and its development from its earliest draft to the manuscript submitted, we encourage Authors to disclose any instances of a manuscript’s prior publication, whether it be through a conference presentation, a newspaper article, a working paper publicly available in a repository or a blog post.
\n\nA note to the Academic Editor containing detailed information about a submitted manuscript’s previous public availability is the preferred means of reporting prior publication. This helps us determine if there are any earlier versions of a manuscript that should be disclosed to our readers or if any of those earlier versions should be cited and listed in a manuscript’s references.
\n\nSome basic information about the editorial treatment of different varieties of prior publication is laid out below:
\n\n1. CONFERENCE PAPERS & PRESENTATIONS
\n\nGiven that conference papers and presentations generally pass through some sort of peer or editorial review, we consider them to be published in the accepted scholarly sense, particularly if they are published as a part of conference proceedings.
\n\nAll submitted manuscripts originating from a previously published conference paper must contain at least 50% of new original content to be accepted for review and considered for publication.
\n\nAuthors are required to report any links their manuscript might have with their earlier conference papers and presentations in a note to the Academic Editor, as well as in the manuscript itself. Additionally, Authors should obtain any necessary permissions from the publisher of their conference paper if copyright transfer occurred during the publishing process. Failure to do so may prevent Us from publishing an otherwise worthy work.
\n\n2. NEWSPAPER & MAGAZINE ARTICLES
\n\nNewspaper and magazine articles usually do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense. Articles appearing in newspapers and magazines rarely possess the depth and structure characteristic of scholarly articles.
\n\nSubmitted manuscripts stemming from a previous newspaper or magazine article will be accepted for review and considered for publication. However, Authors are strongly advised to report any such publication in an accompanying note to the External Editor.
\n\nAs with the conference papers and presentations, Authors should obtain any necessary permissions from the newspaper or magazine that published the work, and indicate that they have done so in a note to the External Editor.
\n\n3. GREY LITERATURE
\n\nWhite papers, working papers, technical reports and all other forms of papers which fall within the scope of the ‘Luxembourg definition’ of grey literature do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense.
\n\nAlthough such papers are regularly made publicly available via personal websites and institutional repositories, their general purpose is to gather comments and feedback from Authors’ colleagues in order to further improve a manuscript intended for future publication.
\n\nWhen submitting their work, Authors are required to disclose the existence of any publicly available earlier drafts in a note to the Academic Editor. In cases where earlier drafts of the submitted version of the manuscript are publicly available, any overlap between the versions will generally not be considered an instance of self-plagiarism.
\n\n4. SOCIAL MEDIA, BLOG & MESSAGE BOARD POSTINGS
\n\nWe feel that social media, blogs and message boards are generally used with the same intention as grey literature, to formulate ideas for a manuscript and gather early feedback from like-minded researchers in order to improve a particular piece of work before submitting it for publication. Therefore, we do not consider such internet postings to be publication in the scholarly sense.
\n\nNevertheless, Authors are encouraged to disclose the existence of any internet postings in which they outline and describe their research or posted passages of their manuscripts in a note to the Academic Editor. Please note that we will not strictly enforce this request in the same way that we would instructions we consider to be part of our conditions of acceptance for publication. We understand that it may be difficult to keep track of all one’s internet postings in which the researcher´s current work might be mentioned.
\n\nIn cases where there is any overlap between the Author´s submitted manuscript and related internet postings, we will generally not consider it to be an instance of self-plagiarism. This also holds true for any co-Author as well.
\n\nFor more information on this policy please contact permissions@intechopen.com.
\n\nPolicy last updated: 2017-03-20
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr.",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Rheinmetall (Germany)",country:{name:"Germany"}}},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. His current research interests are in the fields of intelligent control and robotics.",institutionString:null,institution:{name:"Technical University of Sofia",country:{name:"Bulgaria"}}},{id:"585",title:"Prof.",name:"Munir",middleName:null,surname:"Merdan",slug:"munir-merdan",fullName:"Munir Merdan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/585/images/system/585.jpg",biography:"Munir Merdan received the M.Sc. degree in mechanical engineering from the Technical University of Sarajevo, Bosnia and Herzegovina, in 2001, and the Ph.D. degree in electrical engineering from the Vienna University of Technology, Vienna, Austria, in 2009.Since 2005, he has been at the Automation and Control Institute, Vienna University of Technology, where he is currently a Senior Researcher. His research interests include the application of agent technology for achieving agile control in the manufacturing environment.",institutionString:null,institution:null},{id:"605",title:"Prof",name:"Dil",middleName:null,surname:"Hussain",slug:"dil-hussain",fullName:"Dil Hussain",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/605/images/system/605.jpg",biography:"Dr. Dil Muhammad Akbar Hussain is a professor of Electronics Engineering & Computer Science at the Department of Energy Technology, Aalborg University Denmark. Professor Akbar has a Master degree in Digital Electronics from Govt. College University, Lahore Pakistan and a P-hD degree in Control Engineering from the School of Engineering and Applied Sciences, University of Sussex United Kingdom. Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. He has contributed in stochastic estimation of control area especially, in the Multiple Target Tracking and Interactive Multiple Model (IMM) research, Ball & Beam Control Problem, Robotics, Levitation Control. He has contributed in developing Algorithms for Fingerprint Matching, Computer Vision and Face Recognition. He has been supervising Pattern Recognition, Formal Languages and Distributed Processing projects for several years. He has reviewed many books on Management, Computer Science. Currently, he is an active and permanent reviewer for many international conferences and symposia and the program committee member for many international conferences.\nIn teaching he has taught the core computer science subjects like, Digital Design, Real Time Embedded System Programming, Operating Systems, Software Engineering, Data Structures, Databases, Compiler Construction. In the Engineering side, Digital Signal Processing, Computer Architecture, Electronics Devices, Digital Filtering and Engineering Management.\nApart from his Academic Interest and activities he loves sport especially, Cricket, Football, Snooker and Squash. He plays cricket for Esbjerg city in the second division team as an opener wicket keeper batsman. 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In all cases, cyclical ups and downs depend not only on internal system cyclical processes and their factors in countries but also on the consequences of intercountry interaction. The ability to measure and predict business cycles, taking into account their mutual influence, is a prerequisite for the development of an adequate business policy of countries and their associations.",book:{id:"6703",slug:"statistics-growing-data-sets-and-growing-demand-for-statistics",title:"Statistics",fullTitle:"Statistics - Growing Data Sets and Growing Demand for Statistics"},signatures:"Elena Zarova",authors:null},{id:"60246",title:"Statistical Research of Investment Appeal of Russian Regions",slug:"statistical-research-of-investment-appeal-of-russian-regions",totalDownloads:1014,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"In this chapter, the methodological results directed on realization statistical research of investment appeal of Russian regions are offered. 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He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. 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His passion for teaching then led him to join the faculty of dentistry at University Malaya and he has since became a valuable lecturer and clinical specialist in the Department of Restorative Dentistry. He is currently the removable prosthodontic undergraduate year 3 coordinator, head of the undergraduate module on occlusion and a member of the multidisciplinary team for the TMD clinic. He has previous membership in the British Society for Restorative Dentistry, the Malaysian Association of Aesthetic Dentistry and he is currently a lifetime member of the Malaysian Association for Prosthodontics. Currently, he is also the examiner for the Restorative Specialty Membership Examinations, Royal College of Surgeons, England. He has authored and co-authored handful of both local and international journal articles. 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Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. 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Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. 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