Anatomical malformations related to difficult airway in craniofacial syndromes.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"273",leadTitle:null,fullTitle:"Research on Melanoma - A Glimpse into Current Directions and Future Trends",title:"Research on Melanoma",subtitle:"A Glimpse into Current Directions and Future Trends",reviewType:"peer-reviewed",abstract:"The book Research on Melanoma: A Glimpse into Current Directions and Future Trends, is divided into sections to represent the most cutting-edge topics in melanoma from around the world. The emerging epigenetics of disease, novel therapeutics under development and the molecular signaling aberrations are explained in detail. Since there are a number of areas in which unknowns exist surrounding the complex development of melanoma and its response to therapy, this book illuminates and comprehensively discusses such aspects. It is relevant for teaching the novice researcher who wants to initiate projects in melanoma and the more senior researcher seeking to polish their existing knowledge in this area. Many chapters include visuals and illustrations designed to easily guide the reader through the ideas presented.",isbn:null,printIsbn:"978-953-307-293-7",pdfIsbn:"978-953-51-6481-4",doi:"10.5772/797",price:139,priceEur:155,priceUsd:179,slug:"research-on-melanoma-a-glimpse-into-current-directions-and-future-trends",numberOfPages:428,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"03dcadf8ca228b0a39a14c7614a712f2",bookSignature:"Mandi Murph",publishedDate:"September 12th 2011",coverURL:"https://cdn.intechopen.com/books/images_new/273.jpg",numberOfDownloads:44367,numberOfWosCitations:51,numberOfCrossrefCitations:13,numberOfCrossrefCitationsByBook:2,numberOfDimensionsCitations:46,numberOfDimensionsCitationsByBook:2,hasAltmetrics:0,numberOfTotalCitations:110,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 28th 2010",dateEndSecondStepPublish:"November 25th 2010",dateEndThirdStepPublish:"April 1st 2011",dateEndFourthStepPublish:"May 1st 2011",dateEndFifthStepPublish:"June 30th 2011",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"32293",title:"Prof.",name:"Mandi",middleName:null,surname:"Murph",slug:"mandi-murph",fullName:"Mandi Murph",profilePictureURL:"https://mts.intechopen.com/storage/users/32293/images/163_n.jpg",biography:"Mandi Murph is a Georgia Cancer Coalition Scholar and an Assistant Professor in the College of Pharmacy at the University of Georgia in Athens, Georgia. Before coming to Georgia, Murph was a postdoctoral fellow in Systems Biology at the University of Texas M.D. Anderson Cancer Center in Houston. She won a young investigator award from the Biochemical Journal. She is an author on publications in Cancer Cell, Molecular Cancer, Journal of the National Cancer Institute, Molecular Cancer Research, PLoS ONE, Clinical Cancer Research and the Journal of Biological Chemistry. She has received grant funding from the Georgia Cancer Coalition and the National Cancer Institute, which is part of the National Institutes of Health.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"University of Georgia",institutionURL:null,country:{name:"United States of America"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1077",title:"Dermatological Oncology",slug:"dermatological-oncology"}],chapters:[{id:"19089",title:"Predictive Capacity and Functional Significance of MicroRNA in Human Melanoma",doi:"10.5772/18686",slug:"predictive-capacity-and-functional-significance-of-microrna-in-human-melanoma",totalDownloads:2047,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:null,signatures:"Xiaobo Li and Yaguang Xi",downloadPdfUrl:"/chapter/pdf-download/19089",previewPdfUrl:"/chapter/pdf-preview/19089",authors:[{id:"32242",title:"Dr.",name:"Yaguang",surname:"Xi",slug:"yaguang-xi",fullName:"Yaguang Xi"},{id:"51393",title:"Dr.",name:"Xiaobo",surname:"Li",slug:"xiaobo-li",fullName:"Xiaobo Li"}],corrections:null},{id:"19090",title:"Epigenetic Changes in Melanoma and the Development of Epigenetic Therapy for Melanoma",doi:"10.5772/19088",slug:"epigenetic-changes-in-melanoma-and-the-development-of-epigenetic-therapy-for-melanoma",totalDownloads:1670,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:null,signatures:"Duc P. 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The incidence of difficult airway is higher in children with craniofacial syndromes than normal children, hence a thorough airway evaluation is crucial in order to anticipate difficult airway and to formulate a safe plan. Common challenges encountered upon examination of a child’s airway include an uncooperative child and the unreliability of the Mallampati scoring for prediction of the difficult airway in children [1]. Airway assessment must focus on the general clinical systematic evaluation as well as the more specific airway issues of each syndrome and other associated organs involvement. The approach should include history taking, physical examination, and diagnostic tests.
General clinical history should focus on the presence of any problem affecting the airway or the respiratory system including history of snoring or apneas, upper respiratory tract infection (URTI), croup, stridor, voice hoarseness, recurrent aspirations, asthma, parental smoking, and most importantly a history of previous difficult airway management [2].
The general airway examination must include: a baseline oxygen saturation on room air, respiratory rate, preferred body position (prone position must be red-flagged as upper airway obstruction), mouth breathing, existence of any obstruction manifested by intercostal/suprasternal retractions, oral examination of the mouth opening, teeth, tongue size and Mallampati score, shape and position of the mandible, hyo-mental distance, and neck length/mobility.
Nevertheless, the airway examination in children may be difficult to perform in detail especially with an uncooperative child, thus it may be restricted to the general observation of the face, mandible, and breathing pattern in such situations.
The most critical step in airway examination of children pertains at taking a lateral “profile” look of the mandible which could spot a micrognathia or a retracted mandible that might be masked with the frontal look.
General diagnostic tests: they are seldom required especially when further details of the airway are needed. An X-ray of the head and neck can show the place and the level of upper airway obstruction; however, a CT scan/MRI can provide further details (especially in tumors and vascular malformations of the airway). CT virtual endoscopy (VE) is an excellent tool used to obtain an anatomically similar representation of the intraluminal geography of the airway, including supraglottic, glottic, and subglottic structures without the risk of exposure to ionizing radiation. Compared to conventional 3-D reconstructions, the images obtained through virtual endoscopy create the impression of a true endoscopic image allowing for a tailored approach toward the airway management. A flexible fiberoptic endoscopy maybe required in children with airway pathology especially children with an unexplained hoarse voice, suprasternal/intercostal retractions, and chronic aspirations.
The clinical evaluation should focus on risk factors which may potentially contribute to difficult airway management including (Table 1) [3]:
An extremely short thyro-mental distance with an overbite, with micro/retrognathia such as seen in Pierre Robin sequence and Treacher-Collins syndrome;
A fixed neck such as in Klippel-Feil syndrome;
A small oral opening and large tongue such as seen in Beckwith-Wiedemann syndrome;
Obstructive sleep apnea +/− secondary pulmonary hypertension;
Stiff subcutaneous tissues as seen in Mucopolysaccharidosis (high risk of difficult ventilation);
Midface hypoplasia as seen in Apert and Crouzon syndromes;
Obstruction of the airway when in supine position and the need to continuously maintain in prone positioning;
History of a previous failed airway;
Soft tissue tumors and vascular malformations with significant obstruction of the airway.
Anatomical malformation | Syndrome |
---|---|
Overbite | Pierre Robin-Treacher Collins-Goldenhar |
Mandibular prognathism | Apert |
Small mouth | Pierre-Robin, Treacher-Collins, Goldenhar, Down’s syndrome |
Large mouth | Mucopolysaccharidosis, Beckwith-Wiedemann |
Palate (high arched) | Down, Crouzon, Apert, Pierre Robin, Treacher Collins, Mucopolysaccharidosis |
Cleft Palate | Pierre Robin, Treacher Collins, Goldenhar, Down’s, Apert, Crouzon |
Tongue abnormality (Large or Glossoptosis) | Beckwith-Wiedemann, Mucopolysaccharidosis, Pierre Robin. |
Short thyromental distance (less than 3 finger breadths used by the own child’s fingers) | Pierre Robin, Treacher Collins, Goldenhar, |
Subglottic narrowing | Down’s syndrome |
Tracheal abnormality (tortuosity) | Mucopolysaccharidosis |
Cervical spine abnormalities | Down’s syndrome, Klippel-Feil, Mucopolysaccharidosis, Goldenhar |
Anatomical malformations related to difficult airway in craniofacial syndromes.
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.
The airway provider should set a structured strategy for the management of the airway. Common practice is to have a “Plan A” as an initial approach with subsequent plan B and C in case of failure of the former.
An otolaryngologist attendance for emergency backup surgical access (Bronchoscopy/Tracheostomy) is recommended during the management of the potential difficult airway.
A secured peripheral IV line prior to induction is recommended in patients with cranio-facial anomalies.
Presence of two airway experts (pediatric anesthesiologists) during induction is advisable.
Induction using IV sedative medication: propofol infusion or boluses (also dexmedetomidine, ketamine)
Or
Inhalation induction with Sevoflurane
While patient is spontaneously breathing, a careful insertion of the laryngoscope blade may be attempted provided that the patient tolerates without bucking norcoughing.
A wide range of airway tools and techniques have been described for the intubation. However, it is crucial that the airway operator sticks with the tool that he is mostly familiar with. It is noteworthy to keep in mind that an airway tool is not a plan.
Techniques used for intubation of syndromic children with difficult airway include:
The paraglossal approach with a straight blade is a well-described technique for intubation in children with difficult airway where conventional laryngoscopy technique fails. Using this technique may allow the operator to avoid the large tongue commonly encountered in cranio-facial syndromes via inserting the laryngoscope’s straight blade through the trench between the tonsils and the base of the tongue. This technique allows a better exposure of an anterior larynx; however, it does not provide an adequate space for tube manipulation, hence it requires a high level of skills by the operator.
Intubation with direct laryngoscopy may be facilitated with gum elastic bougie or a stylet.
It is also challenging to perform F.O.B intubation in neonates who have a small airway as the field of vision in the distal lens is very narrow and might get easily obstructed whenever touching any obstacle, hence it requires a high-level skill set and expertise.
However, the removal of the LMA might get complicated with accidental ETT extubation, thus many techniques have been described for the removal; however, the safest strategy remains keeping both the LMA and the ETT in place after intubation and removing them together at extubation.
If “Cannot ventilate” through LMA, then the operator should immediately move to plan C.
If all the previous attempts fail, then an emergency surgical airway must imminently be resorted to by the otolaryngologist with either an emergent rigid bronchoscopy placement or an emergency tracheostomy.
An atraumatic intubation with minimal airway edema
A minor short surgery not involving the airway (excluding adeno-tonsillectomies)
Absence of a history of severe obstructive apnea
The extubation should be performed when the patient is fully awake with vigorous spontaneous breathing and resumption of airway reflexes. The anesthesiologist must be ready for a re-intubation with all the airway tools set up should the extubation trial fail.
Patients at risk of post-operative airway obstruction such as obstructive sleep apnea must be monitored overnight in a high dependency unit (Apnea monitoring).
Patients with significant obstructive apneas undergoing major airway surgeries (such as mandibular distraction osteogenesis surgery) in which intubation might have been difficult or traumatic should not be extubated at the end of the procedure as they are at high risk of obstruction post-op which may necessitate an intubation that would likely be extremely difficult as exacerbated by the airway edema. Such patients should be kept intubated, properly sedated, and transferred to the ICU for post-monitoring. Intravenous steroids regimen should be given to minimize airway edema.
In 1866, Dr. John Langdon Down, with few simple words, well described the main craniofacial features related to this disorder: a flat and broad face, narrow palpebral fissures, small nose, and long and thick tongue. These anomalies include a microcephaly, brachycephaly, a flattened occiput, a sloping forehead, midfacial hypoplasia, depressed nasal bridge, slanting eyes with epicanthic folds, hypotelorism, strabismus, and small ears with flat or absent helix. A cleft lip and/or palate may be present.
Collecting a detailed and accurate history from the parents is the first step in assessing the airways. Symptoms related to obstructive sleep apnea (snoring, choking, mouth breathing, sleep disturbances/restless sleep, diurnal drowsiness or fatigue) and a recent episode of upper respiratory tract infection should be noted. Any recent or active upper respiratory infection should prompt the physician to postpone any non-urgent surgery because of the high rate of postoperative respiratory complications. Examination of the oropharynx and head-neck is of utmost importance looking for any predictor of a difficult airway. A careful pulmonary examination is a must, and preoperative chest X-ray is not routinely required. An echocardiography is sometimes indicated to rule out any congenital heart defect or pulmonary hypertension [12].
The risk of upper airway obstruction at the induction of anesthesia for children with Down’s syndrome is always present, hence a difficult airway management scenario must be anticipated. A difficult mask ventilation may necessitate insertion of an oropharyngeal or a nasopharyngeal airway. Tracheal intubation in children with Down’s syndrome deserves special attention. The trachea is narrow and smaller than in healthy children, not only at the subglottic area but over its entire length and may be the site of numerous anatomical anomalies. When endotracheal intubation is indicated, a tracheal tube of 0.5 or 1 mm smaller than the expected one may be required due to the high risk of post-extubation stridor. It is recommended to monitor the ETT cuff pressure and keep it below 18 cm H2O in order to lower the risk of post-extubation stridor, whereas a smooth and non-traumatic tracheal intubation should be the rule with cuffed ETT [1].
Craniocervical instability is reported to be common in children with DS with an incidence of about 15% of the cases, mostly secondary to a hyperlaxity of the transverse ligament. Nonetheless, a malformation of the craniovertebral junction bones may be associated. Atlanto-occipital and atlanto-axial joints are at high risk of subluxation during airway manipulation which may result in compression of the underlying spinal cord [13]. Thus, a gentle and cautious manipulation of the neck and the head is required during the airway management of children with DS especially those with potential risk of cervical spine instability causing neurological deficit or at risk of worsening while under anesthesia. A cervical spine manual in-line immobilization approach must always be provided by an assistant during mask ventilation and intubation.
After surgery, a “no touch technique” awake extubation with the child kept in lateral position is preferred. Down’s syndrome children with a history of obstructive sleep apnea are hypersensitive to opioid effects and need to be admitted for post-operative apnea monitoring (with continuous SPO2 monitoring and a dedicated nurse) due to the high incidence of postoperative airway obstruction and hypoventilation. The use of non-invasive positive pressure support may be required for DS patients with severe OSA.
Pierre Robin sequence frontal (A) and lateral (B) facial [
Infants may present with airway obstruction (stridor) and respiratory distress and may require multiple surgeries (tongue adhesion, mandibular distraction osteogenesis, or tracheostomy).
The major challenge to the anesthesiologist is managing the airway of such patients who are infamous to be difficult to bag-mask-ventilate and extremely difficult to intubate.
The preoperative evaluation should focus on risk factors which may contribute to difficult airway management including:
An extremely short hyo-mental distance of less than 1 cm (or a maxillary to mandibular discrepancy of more than 1 cm)
Obstruction of the airway when in supine position and the need to continuously maintain in prone positioning
Frequent desaturations and the need to provide supplementary oxygenation
Presence of OSA (may indicate severe airway obstruction)
Presence of pulmonary hypertension
History of a previous failed airway
Co-existing pulmonary disease (secondary to reflux/recurrent aspirations, laryngo-tracheo-broncho malacia, chronic lung disease…)
Presence of reflux and feeding difficulties (nasogastric-tube dependent) [17]
The airway examination must focus on taking a lateral “profile” look of the mandible, assessing for the mandibulo-maxillary discrepancy and the degree of micrognathia. As well as examining the oral cavity for the degree of glossoptosis (size and position of the tongue) and for the presence of a co-existing “cleft palate.”
The presence of any associated syndrome (Stickler, Velocardial, Treacher-Collins) or any heart murmur upon physical exam should prompt a request of a preoperative echocardiography as congenital heart anomalies are not uncommon in such patients.
The glossoptosis and the micrognathia make the glottic opening more angled and further anteriorly displaced leading to a more anterior view with the laryngoscope. Also, the nearly absent submental space makes it impossible to accommodate the tongue during laryngoscopy which renders the view obstructed by the tongue as well as the difficulty to align the oro-pharyngo-laryngeal axes. The presence of a cleft palate may prevent proper position of the laryngoscope blade in the oro-pharynx hence further complicating the view.
Despite the subglottic anatomy is usually being normal in PRS, it should be remembered that the cricothyroid space is extremely small in infants which makes emergency crico-thyroitomy an impractical option in case of the need of an emergency airway access, thus the presence of an ENT surgeon as a backup for emergency tracheotomy is recommended as an integral part of the airway management in children with PRS.
The main aim during anesthetic induction is to preserve spontaneous ventilation by avoiding muscle relaxants as not to “burn your bridges.” This could be achieved via a careful titration of IV propofol (infusion/boluses) or through inhalation induction.
Should the scenario of “Cannot Ventilate” occur at any moment of the airway management in children with PRS, a backup plan of alternative ventilation/oxygenation techniques must be imminently applied which includes first a two-handed ventilation technique with oropharyngeal/nasopharyngeal airway, and if failed, an immediate insertion of an LMA.
In case of failure of the above techniques, a laryngoscopy attempt may be tried once as to relief the obstruction done by the tongue and resumption of spontaneous breathing, or to possibly intubate. Should it fail, a prompt decision to establish an emergent surgical airway access (tracheostomy) by the otolaryngologist must be taken immediately.
If intubation was difficult and traumatic, then extubation should not be attempted at the end of the procedure, but rather the patient should be appropriately sedated/paralyzed and transferred to the ICU for post-operative care where extubation should be delayed until the patient is fully awake and has a positive leak test, along with the appropriate set up for a re-intubation in case of airway obstruction/respiratory distress.
Apert syndrome: prominent forehead, hypertelorism, proptosis, low set ears, open mouth, and feet with extensive syndactyly [
Images of children with type 1,2,3 Pfeiffer syndrome [
Treacher Collins syndrome with characteristic facial features including downward and laterally slanting palpebral fissures, paucity of lashes and lack of naso-frontal angle, bird like appearance, micrognathia, microtia (deformed pinna), macrostomia, and large tongue [
A rigorous and warily planned algorithm is the success key in the management of the airways in children with Treacher Collins syndrome. Consultation of previous anesthesia records is of valuable aid, and a meticulous airway reassessment is required. A preoperative 3D tomographic images help assess anatomical features of the upper airway and guide the choice of the best airway management plan.
A laryngeal mask airway (LMA) is indicated for short and superficial procedures. But, whenever tracheal intubation is required, the spontaneous ventilation during anesthetic induction must be maintained until securing the airways. Fiberoptic intubation represents the preferred technique. It is facilitated by application of traction on the tongue, and a jaw thrust with a backward-upward-rightward pressure (“BURP”) maneuver. Awake fiberoptic intubation is challenging in the pediatric population owing to the lack of cooperation. Other several techniques have been successfully used for tracheal intubation, namely fiberoptic intubation through LMA, fiberoptic-assisted laryngoscopy, blind nasal intubation, retrograde intubation, Shikani Optical Stylet (SOS), indirect videolaryngoscopy with GlideScope Ranger, Airtraq optical laryngoscope, Airway Scope or C-MAC videolaryngoscope with D-Blade, and tracheostomy as the last option. The use of TruView EVO2 laryngoscope for reintubation after accidental extubation in a neonate with TCS was also reported [26, 31].
TCS patients undergoing major surgical procedures involving the airway should be kept intubated and sedated in the intensive care unit (PICU) until subsidization of the edema. For short surgical superficial procedures not involving the airway, extubation may be attempted based on the clinical judgment of the anesthesiologist and the hospital set up. Before extubation, a nasopharyngeal airway must be inserted and maintained during the postoperative period in order to prevent upper airway obstruction.
Goldenhar’s syndrome before and after surgical procedure for lip and palatoplasty, correction of macrostomia and nasal septum deformity, excision of pre-auricular tags: (A) preoperative; (B) postoperative [
The anesthetic management is risky because of the difficult airway. The degree of difficulties depends directly on the severity of craniofacial anomalies and associated vertebral defects and tends to worsen progressively with increasing age. Detecting patients at risk in the preoperative setting may anticipate challenging airway situations. Consultation of previous anesthesia records is of a valuable help; however, the airway must be reassessed before any new airway manipulation. The degree of severity of mandibular hypoplasia correlates with difficult tracheal intubation. Virtual imaging using 3D CT or cone-beam computed tomography may be indicated for selected patients to assess the airway anatomy looking for anomalies [34].
Facemask ventilation is challenging in children with Goldenhar’s syndrome due to a poor mask seal, often requiring the use of a gauze with self-adhesive tape to provide an adequate seal. The reason for this poor mask fit is the facial asymmetry and the presence of a soft tissue slit extended from the side of the mouth to the middle of the cheek on the abnormal hemi-face.
Tracheal intubation is usually more difficult to achieve than maintaining airway patency, especially in the case right-sided hemifacial microsomia. Several combined conditions may contribute to difficult intubation, including retrognathia, micrognathia, asymmetrical hypoplasia of the mandible, limited mouth opening, palatal anomalies, potentially associated vertebral defects, and limited neck motion. The hypoplastic mandible reduces the retromandibular space. The relatively bulky tongue is displaced posteriorly overhanging the larynx, thus making visualization of the vocal inlets difficult, even nearly impossible during conventional laryngoscopy.
Although fiberoptic intubation (FOB) technique is one of the popular options for securing difficult airways of patients with GS, various strategies can be adopted successfully to perform tracheal intubation; however, it is recommended that the airway operator sticks with the tool and technique that is the most familiar to his practice. These include: FOB through LMA (video-assisted fiberoptic intubation (VAFI)), GlideScope, Air-Q, Airtraq, C-MAC D-blade or C-MAC Miller-blade videolaryngoscopy, Pentax-AWS Airwayscope with tracheal introducer, Laryngeal Mask Airway helped by Pediatric Boussignac Bougie or retrograde tracheal intubation. The Truview PCD® laryngoscopy has proven its effectiveness and offers the advantage of continuously supplying oxygen via its oxygenation side port during the procedure. When the intubation is not required, LMA or nasopharyngeal airway constitutes a possible alternative [1, 35, 36].
Child with Klippel-Feil syndrome and anomaly of the Occipito-cervical junction. The images show an elevated left shoulder due to a Sprengel anomaly, a short, webbed neck, and a low hairline (scar on the thorax after surgical repair of nonrestrictive atrial septal defect) [
KPS may be related to other anomalies such as cranio-facial deformities including craniosynostosis, cleft lip, micrognathia, and laryngeal defects. Thoracic deformities such as scoliosis may be present in addition to other skeletal deformities like scapular elevation (Sprengel’s). Uro-genital malformations are commonly present as well as congenital heart defects most commonly the VSD.
Neurological deficits with hyperlaxed cervical spines and neuro-degeneration with fused spines are commonly associated with KPS [17].
Screening patients at risk for cervical spine instability is a crucial step before airway management in order to avoid spinal injury, especially those with hyperlaxed spines who may require C-spine precautions with in-line-stabilization during intubation. This is performed via a lateral neck X-ray in flexion and extension positions [1, 4, 5, 6, 7].
Obstructive sleep apnea (OSA) is not uncommonly encountered in patients with KFS, hence a preoperative sleep study may be indicated along with postoperative apnea monitor. A preoperative echocardiography must be considered especially in patients with pulmonary hypertension secondary to OSA and scoliosis.
A history of previous smooth intubation in KPS patient does not implicate a future favorable outcome due to the progressive nature of the disease. Hence, a careful preoperative assessment and planning is critical for safe airway management.
Bag-mask ventilation is likely difficult in those patients as well as direct laryngoscopy owing to the fixed neck or the in-line neck stabilization.
Should the older child be cooperative enough to sustain an awake fiberoptic intubation (with light sedation) that would be the approach of choice avoiding both the risks of difficult ventilation and neck injury secondary to airway manipulation.
Otherwise, a plan to preserve spontaneous ventilation during anesthetic induction should be performed with either total intravenous anesthesia (TIVA) or inhaled Sevoflurane (IV Dexmedetomidine and IV Ketamine can be used as well) avoiding the use of neuro-muscular blockers.
A trial of manual bag-mask to assess for ventilation is used by some practitioners before airway manipulation. The various arrays of airway tools including videoscopes (Glidescope/C-MAC etc.) as well as the fiberoptic bronchoscope have been used successfully for intubation in patients with KFS. They are preferred as first line intubation technique due to the lower incidence of cervical spine mobilization when used.
It is important to keep in mind that the option of an emergency surgical airway such as cricothyrotomy/tracheostomy is very limited in patients with KFS due to the extremely short neck, thus the airway approach must be very carefully planned.
Extubation must only be attempted when the patient is fully awake and in the presence of protective airway reflexes. An opioid-sparing anesthetic technique is recommended (regional anesthesia whenever possible) as the presence of OSA may increase narcotic-sensitivity. KFS patients should preferably be monitored in the post-operative setting in a high dependency unit or an intensive care unit according to the severity of their cardio-pulmonary and airway pathology.
If the patient is on a home BIPAP, it will be required after extubation.
Macroglossia in the patient with Beckwith-Wiedemann syndrome after intubation [
These children are associated with exomphalos, macroglossia, gigantism, macrosomia, visceromegaly, horizontal earlobe creases, renal medullary dysplasia, cardiac malformations, hypoglycemia, hypothyroidism, hyperlipidemia, polycythemia, hypercalciuria, and embryonal tumors. The presence of three features out of the above will confirm the clinical diagnosis of BWS after ruling out the clinical features of overgrowth syndromes. The risk for embryonal tumor development especially hepatoblastoma, neuroblastoma, rhabdomyosarcoma, gonadoblastoma, and adrenal carcinoma has been observed [6, 7, 17].
Preoperative assessment should include a careful evaluation of the airway focusing on the mouth opening, tongue size, and preoperative head and neck imaging if required. It should focus also on other systems involvement such as the heart, hence an echocardiography is recommended. The genito-urinary system and the liver must be evaluated in addition to the preoperative glucose homeostasis.
The major challenge during airway management of a patient with Beckwith-Wiedemann syndrome pertains to the huge tongue which might completely obstruct the airway with anesthetic induction rendering the bag-mask ventilation and intubation difficult to perform [39, 40].
Hence a careful plan A, with a backup plan B and a plan C must be organized beforehand. An intravenous line is recommended to be secured before induction. Keeping spontaneous ventilation is considered to be the safest approach to the airway that can be achieved with intravenous anesthetics or inhalational Sevoflurane and by avoiding non-depolarizing neuro-muscular blockers. Some practices may use muscle relaxants after making sure of the ability to ventilate by a trial of ventilation after induction. Sugammadex muscle (rocuronium antidote) has allowed more confidence for anesthesiologists to give muscle relaxants in order to facilitate intubation.
A variety of tools can be used for intubation ranging from the direct laryngoscopes aided by a Gum elastic Bougie or a stylet, to the Videoscopes including the C-MAC and the Glidescope, to the fiberoptic bronchoscope.
A plan B consists of inserting a laryngeal mask airway should ventilation become problematic, and in case of the latter’s failure, a plan C with a surgical airway must be immediately implemented.
Extubation must only occur when patient is fully awake and may be helped with a nasopharyngeal airway “in-situ” to help overcoming the tongue’s obstruction in the immediate post-operative period. Patients with BWS must have a post-operative monitoring after surgery in the high dependency area or the intensive care unit.
Some types of MPS (Type1: Hurler, Type 4: Morquio, and Type 6: Maroteaux-Lamy) may be associated with atlantoaxial subluxation and odontoid hypoplasia which may lead to spinal cord compression with subsequent neurological deficit. Accumulation in the cervical spines may lead to a short and fixed neck. The temporo-mandibular joint may get affected with restricted mobility. Deposition of mucopolysaccharides in the heart and vascular tissues may lead to cardiomyopathies, arrhythmias, and pulmonary hypertension [5].
A narrow/distorted trachea may prevent an appropriately sized endotracheal tube from passing throughout the vocal cords.
Fortunately, the enzymatic replacement therapy may hinder the progression of the disease, hence an adequately treated mucopolysaccharidosis patient may have a lesser risk of difficult airway than the untreated patient.
Preoperatively, the MPS patient must be well assessed for the extent of the disease as well as a focused airway assessment including the mouth opening, tongue and tonsillar size, presence of obstructive sleep apnea (which is very common in MPS), and pulmonary hypertension. A preoperative echocardiography is essential to rule out any associated cardiomyopathy. Patients with MPS type 1 (Hurler), 4 (Morquio), and 6 must be checked for any cervical spine or atlanto-axial instability [42].
Intravenous cannulation in MPS patients may be challenging due to the thick infiltrated skin, hence a preoperatively inserted intravenous line before anesthetic induction is preferable.
Spontaneous ventilation must be maintained during induction of anesthesia due to the high risk of difficult ventilation in case of apnea. This could be achieved with either intravenous or inhalational induction agents and by avoiding neuro-muscular blockers.
An LMA must be used as a second plan whenever encountering difficulties in ventilation; it can also be used to facilitate fiberoptic intubation.
Video-laryngoscopies are other favorable options for intubation in MPS patients especially those with unstable cervical spine owing to the lesser risk of neck mobilization when used. Establishment of a surgical airway access such as tracheostomy may be difficult due to the thick tissues and the associated tracheal deformities.
Vascular anomalies are disorders of abnormal vasculogenesis or lymphogenesis. They can involve any part of body and can present in any phase of development. They include different types according to histopathology and anatomical site.
VMs may be with other syndromic malformations such as Parkes-Weber, Sturge-Weber, Klippel-Trenaunay Servelle-Martorell, PHACE and LUMBAR syndromes.
Huge movable mass is found out on the left neck [
Arterio-venous malformations (AVM) involving the face and the airway are rare to occur. The main issue with airway management is the risk of massive bleeding that can occur if the AVM has been traumatized when managing the airway.
General anesthesia with an inhaled agent such as Sevoflurane or an intravenous agent (such as propofol, ketamine or dexmedetomidine) while maintaining spontaneous ventilation is the technique of choice. Video laryngoscopy, FOB-guided endotracheal intubation, and endotracheal intubation through an LMA are the most popular strategies for intubation.
A pre-procedure tracheostomy inserted under local anesthesia may be indicated for high risk malformations with severe airway obstruction [48].
The airway management of children with craniofacial abnormalities imposes great challenges owing to the difficulties in ventilation and intubation potentially encountered in most of the syndromes as well as the other systems involvement. A careful anticipation, preparation, and planning are key elements for a safe and successful airway management. The approach to each patient should be tailored according to the extent of the relevant abnormalities following a strategy of a simple clear plan A with a backup plan B and C. Preserving spontaneous breathing is one of the safe practices when patients are at risk of difficult ventilation. The use of the most familiar airway tools is pivotal in achieving favorable results. Extubation is an integral part of the airway management and should only be performed when the child meets its criteria and in a controlled environment. Post-extubation monitoring in a critical care or an observation area must be carried out for patients at risk of airway obstruction.
Special thanks for Dr. Habib El Bechouti, senior anesthesia consultant in Sidra Medicine, Qatar and Dr. Yasser Hammad, senior anesthesia consultant in Hamad Medical Corporation, Qatar for their valuable comments, chapter editing, and reviewing.
The authors declare no conflict of interest.
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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. 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. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. 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. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. 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Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. 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After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. 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