NAP4 identified several factors associated with major airway complications.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"71585",title:"Smart Learning Environment: Paradigm Shift for Online Learning",doi:"10.5772/intechopen.85787",slug:"smart-learning-environment-paradigm-shift-for-online-learning",body:'Generally, a face-to-face classroom environment is a traditional way of learning. For this learning, the teacher or the instructor can explicitly observe real-time interaction and participation of the learners. The advantage is that the instructor can provide the appropriate intervention immediately. However, face-to-face learning frequently faces some difficulties in challenging successful learning. For example, the instructor may find it difficult to gain attention from a large class. The adaptation of the teaching method can be challenging to fit in the large class size, such as flipped classroom, problem-based learning, active learning, etc. Generally speaking, time and space always affect learning management.
With the limitation of time and space, teaching and learning process has been transformed into many different forms for promoting effective and convenient learning. Pieces of evidence show that innovations of a system supporting learning usually employ the technologies emerging at different points of time [1]. Computer aided instruction (CAI) and instruction tutoring system (ITS) demonstrate the excellent examples of the system supporting learning with the advance of computer technology. They can provide convenient learning without the instructor as traditional learning through a stand-alone computer program. Both CAI and ITS are generally used for supplementing traditional face-to-face learning [2, 3].
Online learning has become the solution of time and space constraint explicitly. After the introduction of computer communication, electronic learning (e-learning) has been developed based on the basic requirement of delivering content in the digital form to the massive learners conveniently anywhere and anytime [4, 5]. Without time and space constraint, e-learning can be used not only for supplementing the face-to-face class but also the main class as an online course nowadays [6]. E-learning even becomes more popular after the high-speed Internet becomes commonly available and low cost. It is also customarily called web-based learning (WEB) [7, 8]. As shown by its name, web technology has influenced the presentation of e-learning. For WEB, interactive learning is also one of the main purposes besides convenient learning [9]. Web 2.0 has demonstrated how effectively web technology can promote interactive learning [10]. Interactive environment helps the online classroom to be more interactive overcoming the limitation of space as in the traditional classroom environment.
With mobile technology, mobile learning (m-learning) has been widely offered. The mobile phone becomes the smartphone having high-performance computing ability within portable size devices. It is evitable that mobile phone or portable devices have become necessary for the learner’s daily life. M-learning explicitly promotes convenient learning which the learning process can happen anywhere and anytime, although the learning process on a small screen of the mobile phone might be easily distracted for some learners [11]. For m-learning, interactive learning is very challenging because of the small screen and the compatible ability of smartphone. However, it is easily integrated into the learner’s daily life.
Currently, there has been the introduction of ubiquitous learning (u-learning) [12, 13, 14, 15]. It employs the concept of ubiquitous computing [16] in which the computing can happen anywhere and anytime through the seamlessly connected small computing units. The users do not even realize about computations. For u-learning, learning can happen anywhere and anytime. Notably, the learning process of each learner happens unconsciously. The learners do not even realize those learning process. U-learning can be implemented as the physical learning environment [17]. For this environment, the contribution from different types of advanced technology such as sensors, sensor networks, embedded system, wireless communication, etc. is required. U-learning is commonly used for providing situation simulation for the learners. At the same time, u-learning is generally developed to guide the learners to achieve their learning goals or outcome individually with different learning paths and contents. It can be considered that u-learning has confirmed the concept of personalized learning, which the learning depends on individual context [18] such as needs, performances, goals, etc.
Online learning can also be considered with learning style points of view. Generally, online learning can promote both collaborative and individual learning. Collaborative learning believes that the learning process happens when the learners collaborate [19]. The learning outcome can be evaluated from the group product or even the consensus built within the group. Collaborative learning is important because this kind of skill is one of the marketable skills required in real-life situation. More specifically, collaborative learning aims to practice collaborative skills for the learners besides knowledge. It is essential for learners to learn how to encourage and engage team members to accomplish a common goal together.
On the other hand, individual learning aims to promote each learner individually. The assumption is made that all learners are unique and they require their learning path to achieve their individual learning goals. Personalized learning is one of the famous individual learning approaches. It can be implemented in many different forms and types of learners. It is popularly implemented as the curriculum for child learning [20] because of the expectation to enable the unique development of the child. Although, there are many different ways for the personalized learning pedagogy in child learning curriculum, the most critical processes are to assess an individual carefully and to provide the intervention appropriately. At the same time, personalized learning is widely found in online learning. Also, those two processes are essential for this environment. It has been claimed that personalized learning promotes flexibility and freedom for the learners as they are necessary not only for the twenty-first-century learning but also for lifelong learning.
Generally, online learning is also called a virtual learning environment (VLE) [21, 22, 23, 24]. After the emergence of the Internet in early 1990, VLE has been playing the leading role to support learning and teaching activities through Internet connection. Generally, VLE is used for distance learning as a complement to the traditional classroom. It provides convenient access to contents, tests, and virtual workspaces. It also provides communication tools and assessment for the instructor. Additionally, it is defined to cover the existing online learning environment including e-learning, m-learning, and u-learning.
In the recent past, VLE or online learning environment has successfully achieved a considerable interest from the learners worldwide. For example, massive open online course (MOOC) [6, 25], which is the largest online learning platform nowadays, provides massive online courses from all over the world for all learners. Although there are many provided online courses available, the learners are expected to be the active participants who know their own learning goal and can find their ways for achieving their goal. On the contrary, the concept of smart learning environment is that the learning system is smart enough to understand the learners individually both capability and personality so that it can provide the appropriate response or intervention appropriately. The learner may not even realize the happening learning process [14, 15].
As mentioned before, personalized learning is a significant characteristic of the smart learning environment, which expands the opportunities for lifelong learning and explores additional resources for individual according to personal interests [26]. Recently, personalized learning has become the most popular learning paradigm because it focuses on learners’ interests. It is also tailored to promote online learning as personalized online learning [27]. Generally, personalized online learning can be described as the teaching and learning paradigm applying intelligent technology for matching the learners with the content or learning activities accordingly to their proficiency level, learning styles, and interests through different types of learning environments. Currently, personalized learning is extensively popular because it results in the awareness of learners’ actual proficiency and needs. The instructors can design the course or give proper suggestions for the best results of learning.
In the early stage, the English instructional systems have been playing the primary role for personalized support for learners [28]. It makes the learners to be engaged with the learning system. The recommendation is given through the selection of lessons that can be matched with the learners’ skills and abilities [29, 30]. Nowadays, personalized learning can easily simulate the situation for engaging the learners in a lesson, discussion, and any learning activities [31, 32, 33]. It can also provide online learning experience that professionals will need for professional learning. At the same time, web-based learning becomes a flexible way to promote personalized learning recently [10]. Currently, there is an increasing demand for personalized online learning to serve huge demands of learners with all ages [34, 35]. It is thus challenging to provide personalized online learning that can satisfy all current and future demands.
As mentioned before, personalized learning aims to promote successful learning individually. Understanding different learners are challenging since the learners are different in many aspects such as age, goal, need, etc. Personalized online learning is widely adopted for all learners of different ages. Different ages of learners imply different characteristics and require different intervention or recommendation. For child learning, the learners are still immature. The child might not know exactly their performances and their goals. There is the necessity to have the professional to estimate the potential performance and predict the learners’ needs. For the teenager, some of them have explicitly shown their interests, goals, and demands. However, their goals can be changed dynamically due to many circumstances such as friends, family, school, etc. For professional learning, the learners know precisely about their goals. However, their different knowledge and backgrounds usually affect the ability to learn the same content. The content representation needs to be adjusted to fit different learners. For senior learning, their goals usually are clearly defined. However, the health condition may distract their ability to learn. Nowadays, implementing personalized online learning for learners of all ages is very challenging, as the learning environment is expected to cope with any differences dynamically. The environment needs to be smart enough to deal with and interpret any types of data. Consequently, smart learning environment is indeed required.
The concept of smart learning environment has been widely introduced [15, 36, 37] to satisfy the high demand for freedom in learning. Smart learning environment means that the learning environment can promote successful learning to the learners automatically. The concept of being smart can be implemented with both physical and online learning environments. The critical requirement is to make the environment to be smart. There have been many smart learning environments developed with a different degree of smart services or responses. For this chapter, smart learning environment focuses on only the online learning environment. More specifically, smart services or responses in an online learning environment mainly focus on promoting individual learning. It can be seen that smart learning environment in this context requires the implementation of personalized learning.
Generally, smart learning environment consists of two main components including learner classification and intervention feedback as shown in Figure 1.
Components of smart learning environment.
In Figure 1, the learner classification is also called as learner modeling or learner assessment. For this component, the primary objective is to understand the different learners. There are different types of information which can be called as the contexts involved, such as individual context and interaction context, to classify the learner. Individual context includes any information relating the learner individually such as profile, preference, performance, goal, need, clinical data, etc. On the other hand, the interaction context means the context is generated from the interaction of any entities such as interactions among learners, interactions between learner and learning object, interactions among learning objects, etc. The combination of different types of contexts is expected to provide a better understanding of the learners. The classification can be done in many different ways.
In this chapter, machine learning-based data classification is the main focus. Machine learning is widely used for data classification. For learner classification, all involved contexts are classified into different types of learners. The machine learning technique learns the data and makes a decision based on the data. It can employ both supervised and unsupervised learning to perform data classification. Supervised learning technique requires the given answer for the classification process. On the contrary, the unsupervised learning technique can perform data clustering without any given answer during the training process. Selecting the right technique is challenging; the comparison between different techniques is generally performed. The knowledge-based system is usually required for determining different types of learners. Human experts generally do this process. At the same time, the intervention feedback provides the appropriate intervention to each learner. This process is to map the types of learners with a set of appropriate intervention obtained from the experts. Sometimes, the predictive model may be involved. Predicting what the learner wants and what they want to be after learning may help to provide the intervention more appropriate. Additionally, the predictive model frequently employs machine learning-based technique for analyzing historical data and predicting the right output based on any relationship among data. Generally, the contribution from different areas may be involved in the learner classification component to increase higher classification accuracy such as behavioral science, physiology, cognitive science, etc.
Along with the evolution of technology, supporting learning mentioned before, the concept of context-aware computing [38] has already illustrated implicitly and explicitly into the modern online learning environment nowadays. Generally, context-aware applications can be found with different forms of online learning environment covering from stand-alone program and web-based, mobile, and ubiquitous learning environments. With the context-aware computing perspective, existing smart learning environments can be considered as a context-aware computing system. Any recommendation systems [39, 40, 41] frequently assess the learning’s ability and employ it as the main factor for providing the appropriate response. The learner’s ability can be considered as the primary context executing the smart intervention. The contexts used for smart learning environment can be any single context or the combination of many types of contexts [42]. It can be concluded that the vital element of context-aware computing is context awareness which is explicitly appropriate for smart learning environment so that all dynamic changes are observed, interpreted, and responded appropriately. It can be seen that developing a smart learning environment which can provide personalized learning for the learners requires the solution from multidisciplinary such as behavioral science, physiology, cognitive science, etc.
In conclusion, smart learning environment in this chapter mainly means the online learning environment with personalized learning implementation. This learning environment is expected to automatically respond to the learners appropriately for achieving their learning goal individually. For this instance, it is evitable to have advanced technology in many areas for satisfying smart ability of this learning environment. Machine learning-based techniques are the main aims of this chapter. Some techniques commonly used in the learning area are also briefly introduced in this chapter.
Machine learning is a method of data analysis for building analytical model autonomously. It is a subset of artificial intelligence. As humans learn from experience, machine learning learns from data. It is widely used for identifying and classifying the pattern as well as making a decision on behalf of the human. Machine learning is popularly used in classifying problems in many different areas, such as manufacturing, finance and banking, and medical diagnosis [43]. For the learning environment, machine learning is generally used for supporting the learning and teaching process on behalf of a human instructor. As mentioned before, smart learning environment requires not only an automatic response but also an individual response. Machine learning technique applied in smart learning environment requires specific knowledge from different points of view to understand each learner correctly such as pedagogy, behavioral science, psychology, etc. For example, from the pedagogical point of view, different teaching approaches can engage different learners. From the behavioral science point of view, the individual learner acts differently when they are in the learning process. From the psychology point of view, the learner can be classified into different learning styles representing individual ways of gathering information and absorbing the knowledge. Machine learning needs to be trained with this different knowledge so that the classification of learner and intervention will be performed and given correctly.
Many machine learning techniques have been widely applying K-nearest neighbor (KNN) for different purposes such as learning analytics supporting instructor decision [44], predicting successful learning for the learners [45, 46], classifying learning patterns [27, 47], predicting the learning outcomes from historical learning behavior of each learner [45], etc. Another popular method for pattern classification problem is an artificial neural network (ANN). It usually is one of the comparative alternative techniques for learner classification [48]. Lastly, decision tree has also gained much attention for grouping or matching different types of learners to particular recommendation or feedback [27, 49].
In this chapter, a brief introduction of these machine learning techniques is introduced. The examples are shown in the next section to demonstrate the principle concept of applying K-nearest neighbor, artificial neural network, and decision tree for simple learner classification.
K-nearest neighbor algorithm is a type of lazy learning in pattern recognition. It is used to classify and perform a regression of the dataset. It can define whether target data matches with the specific classes by investigating the number of K in the nearest condition. It will assign the weight for any contributing data along with the distance of neighbor to classify the target. Figure 2 shows the principle concept of KNN applied for classifying types of learners.
Principle concept of KNN for learner classification.
In Figure 2, KNN is applied for classifying two types of learners including learner requires assistant (learner with assistant) and learner does not require assistant (learner without assistant). The learning expert sets types of learners for the training process. The input of KNN can be any context relating to performance assessment of learners such as testing score, testing time duration, etc. It can be seen in Figure 2 that the classification result changes accordingly to different K values. For K = 3, the new learner is classified as the learner does not require the assistant. For this case, two nearest neighbors of the new learner are learners without an assistant, and only one nearest neighbor is the learner with the assistant. However, when the nearest neighbor number has increased to 5 (K = 5), the classification of the new learner is the learner requires assistant because three out of five nearest neighbors are learners who require an assistant. Therefore, different K may cause a different decision. Generally, there are many considerations, such as K value, size of input data, etc., for obtaining the highest classification accuracy.
Having the inspiration by biological neuron networks, artificial neural network is widely applied in many application domains. An ANN consists of many neurons linked together with specific network architecture and learning algorithm. Those neurons usually are highly interconnected among each other. It can have many layers between the input and output layer so-called hidden layer. For learning algorithms, ANN learns from the examples and presents some degree of generalization from the training data later. Also, ANNs adapt itself by using some examples of similar problems with and without the desired solution during the training period. After sufficient training, the trained ANN can provide a solution relating to inputs and outputs. Moreover, it can offer an alternative solution to the new problem. The conceptual diagram of applying ANN for learner classification is shown in Figure 3.
Conceptual diagram of ANN for learner classification.
Figure 3 shows that ANN is applied for classifying two types of learners including learner requires assistant (learner with assistant) and learner does not require assistant (learner without assistant). The learning expert sets types of learners. ANN learns from the examples or data during the process of the so-called training process. For the learning process, the corresponding type of learner together with its set of training data is required. The data can be any context, for example, the set of data representing the level of performance of the learners, time duration for content learning, etc. During the training process, the associated weights are adjusted so that the ANN can model two different types of learners correctly. The training process may require many times of iteration. Training parameters need to be set appropriately. Then, the trained ANN with updated weights is tested with testing data, which is the data from the new learner. ANN will finally classify the new learner into one of those two types. Selecting the type of ANN is challenging because different types of data fit with types of ANN differently. The comparison of classification accuracy among different types of ANN, different architecture, or even different configuration may need for achieving the highest classification accuracy.
The decision tree is another favorite machine learning technique for data classification. It is a predictive method having a tree structure which is built from a dataset for classifying data. More specifically, it has the leaf to represent a classification. The conjunction of features causing target classification is represented at each branch. The tree structure is constructed following the best attribute that can perform the best splitting set of data. The efficiency of this technique highly depends on the size of the training data. The conceptual diagram of the decision tree for learner classification is demonstrated in Figure 4.
Conceptual diagram of decision tree for learner classification.
In Figure 4, the decision tree is applied for learner classification problem which has two different target classes including learner requires assistant (learner with assistant) and learner does not require assistant (learner without assistant). The learning expert sets types of learners for training. As mentioned before, the training data can be any context representing the performance level of each learner. After having the set of training data, the root node representing the best attribute can split the training data the most. Classes of the associated attribute are represented at each branch. For splitting data, all internal nodes represent all attributes involved in data separation. Target class is represented at the leaf node whether the learner requires or do not require the assistant. At the end of the process, all relevant rules are constructed based on all relevant attributes. The size of the training data always influences the separation of data. More specifically, different data sizes may obtain a different tree structure.
This chapter presents the concept of smart learning environment as the online learning that can promote personalized learning. For this instance, the smart learning environment consists of two main components including learner classification and intervention feedback. The objective of smart learning environment is to understand the different learners individually and provide each learner with the appropriate support or intervention for successful learning. Therefore, it is necessary to have smart data analytic method so-called machine learning technique involved particularly in dealing with a vast of dynamic change and real-time intervention. For this chapter, KNN, ANN, and decision tree are chosen to demonstrate for solving a simple learner classification problem. Although machine learning has been playing a critical role in a smart learning environment, supporting learning and teaching still require the knowledge from the multidisciplinary area such as pedagogy, behavioral science, psychology, etc. so that the leaner classification and intervention feedback in the smart learning environment can be performed correctly.
The author would like to thank all Ph.D. students who work collaboratively to determine the new findings in the smart learning environment area. Special thanks go to all participants for their valuable data for all studies.
Head and neck (H&N) surgery encompasses an expanded spectrum of procedures varying greatly in complexity, duration, and complications. They range from simple surgeries such as dental procedure, adenotonsillectomy to precise and image-guided laryngologic, neurotologic, and skull-base surgery, complex obstructive sleep apnea (OSA) surgery, sophisticated transoral robotic surgery (TORS), transoral laser microsurgery (TLM), and major head and neck oncological surgery with extensive free-flap reconstruction.
\nHead and neck surgery presents unprecedented challenges for the anesthesiologists including shared airways, concurrent comorbidities, anesthesia techniques, and postoperative complications. A Shared Airway is the term commonly used in Head and Neck surgery which is characterized by “any procedure where the anesthesiologist needs to maintain a patient’s airway patency, oxygenation, and ventilation in a similar airway anatomical space in which the surgeon operates.” Both the anesthetists and surgeons must have a clear knowledge and understanding of their respective roles in managing the ‘shared airway’. The role of the anesthetist must be to provide safe general anesthesia for the patient, an uninterrupted airway during the perioperative period, and a clear field for the surgeon by applying various hypotensive anesthesia techniques. This chapter focuses on key aspects of anesthesia and airway management strategies for common Head and Neck surgical presentations, with relevance to the current evidence base and clinical guidelines. It is aimed to be a comprehensive review for residents and fellows training in the fields of anesthesia and head and neck surgery.
\nIt is estimated that the occurrence of difficult airway and complications are more frequent in H&N patients than in the general surgical population. In the Fourth National Audit Project (NAP4) from the Royal College of Anesthetists and the Difficult Airway Society in the United Kingdom (UK), data regarding major airway complications were collected prospectively in approximately three million anesthetized patients throughout the UK [1]. The incidence of airway-related complications was nearly 40% in H&N surgeries [2] and almost 75% of the cases required emergency surgical airway (ESA) for “cannot intubate/cannot oxygenate” (CICO) situations. Likewise, the incidence of the emergency surgical airway (ESA) was even higher in another retrospective study of 452,461 patients in the Danish Anesthesia Database [3]. In this study, the overall incidence of ESA in ear, nose, and throat surgery was reported as 1.6 events per thousand, which was 27 times higher than in the general surgical population (0.06 per thousand). The H&N oncological patients are at even higher risk of difficult airway management, predominantly males, with an incidence of over 12% experienced difficult direct laryngoscopy and tracheal intubation [4]. In NAP4, of the 21 cases of difficult airway observed on anesthesia induction, 13 cases occurred in patients with upper airway tumors [1]. Additionally, numerous studies have indicated that difficult tracheal intubation, defined as three or more attempts on direct laryngoscopy, may be observed in up to 7–9% of H&N cases [5, 6, 7], which is up to four folds higher than the general surgical population [8, 9, 10, 11]. In the NAP4 study, several factors have been associated with airway related complications (see \nTable 1\n). Furthermore, anesthesiologists experience greater challenges during extubation and post-anesthesia recovery period [1, 12].
\nFactors associated with airway management related complication | \nInadequate airway assessment | \n
Inadequate planning for airway management and for failure of intubation | \n|
Multiple intubation attempts | \n|
Inappropriate use of a supraglottic airway (SGA) device | \n|
Obesity | \n|
Failure to correctly interpret capnography and recognize esophageal intubation early | \n|
Anesthesia for head and neck surgery | \n|
Intubation in the emergency department or intensive care unit | \n
NAP4 identified several factors associated with major airway complications.
The preoperative Anesthesia assessment is imperative in reducing risk during shared airway procedure and must include a detailed general medical and surgical history, previous anesthetic exposure, and general physical examination as well as a focused airway assessment. It is paramount to have a multidisciplinary approach to an anticipated difficult airway in H&N surgery which requires a high degree of cooperation and communication with the surgeon, allowing for early identification of high-risk patients, and reciprocal anticipation of the potential problems and adequate preparation to face the challenges. Expertise in H&N anesthesia and complex airway management should be encouraged as it improves the outcome and reduces airway complications. The goal of preoperative assessment is to recognize patients with potentially difficult airways, stratify the risks, manage the co-morbidities, and optimize the patient’s condition before major H&N surgery (see \nTable 2\n).
\nPreanesthesia assessment invariably includes airway evaluation to identify and predict difficulty in airway management. The incidence of difficult airway is higher for patients who undergo H&N surgeries than for general surgical procedures. Therefore, the primary priority in airway assessment is to determine whether airway is compromised. A detailed history should be obtained before the surgery which incorporates reviewing previous anesthesia records with a particular focus on airway management, identifying risk factors of possible difficult mask ventilation and tracheal intubation. History of previous difficult tracheal intubation is one of the most important predictors of the anticipated difficult airway [9, 11]. It is worth mentioning that a history of prior easy intubation does not guarantee subsequent uneventful airway management in H&N procedures, due to the progression of the underlying pathological processes and their significant effect on the airway anatomy [13]. Anatomic anomaly relating to the face, mouth, nose, pharynx, or larynx must be thoroughly investigated. Hoarseness, drooling, dysphagia, orthopnea, stridor, cough, and recent onset of snoring may indicate airway compromise. Patients with vocal cord paralysis may be at increased risk for perioperative pulmonary aspiration. Prior H&N radiotherapy induces tissue fibrosis as well as long-standing epiglottic and glottic edema, leading to a non-compliant airway with limited mouth opening and restricted neck movement [9], which may make both mask ventilation and laryngoscopy potentially difficult [14]. Routine bedside airway assessment tools can be performed such as the American Society of Anesthesiologists (ASA) bedside airway assessment tool which includes Mallampati classification, thyromental distance, inter-incisor distance, neck mobility, and body mass index (BMI), etc. [15]. However, it is poorly predictive of difficult airway in Head and Neck surgery because it fails to assess the inside pathology and severity of the upper airway such as base of the tongue, glottic and vallecular lesions, etc. [8, 16]. Numerous risk factors associated with difficult airway management have been identified (see \nTable 3\n) [17].
\n\nAnesthesia considerations in Head and Neck Surgery | \nMultidisciplinary approach and close-in line communication | \n
Presence of expertise in H&N anesthesia and complex airway management | \n|
Anticipation of challenges during intubation and extubation | \n|
Shared Airway with the surgeon and related challenges | \n|
Different approach to airway management specific to surgery | \n|
Different Anesthesia technique and positioning challenges | \n|
Post Anesthesia recovery and Airway support | \n
Anesthesia considerations in head and neck surgery.
Risk factors for predicted difficult airway management | \nMallampati grade 3 or 4 | \n
Decreased thyromental distance | \n|
Male gender and Age > 57 years | \n|
Absence of teeth | \n|
Presence of beard | \n|
Obstructive sleep apnea or History of snoring | \n|
Dencreased Mandibular protrusion | \n|
Thick or short neck | \n|
Neck radiation changes or a neck mass | \n|
Obesity (BMI > 30) | \n
Risk factors associated with difficult airway management [17].
Head and Neck surgery may entail a wide range of patient populations from young and healthy to elderly, geriatric patients with significant cardiovascular, respiratory, endocrine, and renal diseases who are also at high risk for postoperative delirium and cognitive dysfunction. The perioperative risk related to major H&N surgery rises with advanced age and an increased number of comorbidities. As part of the multidisciplinary team, the anesthesiologist plays a crucial role in deciding the treatment plans, optimizing the patient’s condition pre-operatively, and weighing the risk to benefit ratio of the surgery. Patients with cardiovascular diseases such as uncontrolled hypertension, cerebrovascular, and coronary artery disease, chronic renal insufficiency, must be evaluated for cardiac risk prior to noncardiac surgery and if required must be referred to cardiologists. Cardiopulmonary exercise testing (CPET) can be a useful aid to decision making, particularly where more extensive or complex surgery is being performed. Also, poorly controlled heart failure (New York Heart Association Grade 3–4) is associated with poor prognosis. Brain natriuretic peptide (BNP) and N-terminal proBNP are useful biomarkers for perioperative screening of heart failure patients. Moreover, the hypotensive anesthesia technique should be avoided and intraoperative hyper or hypotension should be aggressively managed. Pulmonary comorbidities are common in H&N patients. Preoperative optimization of Chronic obstructive pulmonary disease (COPD) via treatment of acute infection and appropriate use of bronchodilators and steroids is crucial to prevent post-operative pulmonary complications. Furthermore, COPD patients may not tolerate intraoperative ventilation techniques such as spontaneous ventilation, one-lung ventilation, apneic intermittent, or jet ventilation. Likewise, patients with obstructive sleep apnea (OSA) are predisposed to difficult or challenging airways and are more sensitive to sedatives and opioids which should be used cautiously. H&N procedures involving the lower cranial nerves (Cranial nerves X, XI, and XII) may increase the risk of airway obstruction or aspiration in the post-operative period. H&N cancer patients are of particular concern as smoking and alcohol are the common cause of cancer, which also predispose them to post-operative malnutrition.
\nHead and Neck surgery patients must have baseline investigations which include complete blood count, biochemical profile with urea and electrolytes, coagulation profile, liver function test, blood sugar, and electrocardiography. Other investigations such as chest x-ray, pulmonary function tests, and arterial blood gases may be requested based on the risk factors and symptoms at presentation.
\nImaging studies with computed tomography (CT) or magnetic resonance imaging (MRI) and flexible nasal endoscopy aid to determine the extent of the pathology and its impact on the airway and the surrounding soft tissues. The preoperative endoscopic airway examination (PEAE) in particular is useful for examining the upper airway to assess the significance of the swelling and distortion, the location, size, the spread of the lesions, the degree of obstruction, and vocal cords’ mobility. Moreover, preoperative awake nasal endoscopy can be carried out by the anesthesiologist before induction which gives a real-time image of the upper airway and the larynx and is useful in formulating airway management strategies including awake intubation and surgical airway [18].
\nPremedication to reduce anxiety and secretions may be helpful in patients going for H&N surgery with minor airway lesions but should be avoided in patients with H&N masses compromising the airway. Antisialagogues may be administered in the preoperative phase to minimize oral and tracheobronchial secretions. The patient should be monitored closely when premedicated, preferably in the holding area of the OR. During the preoperative visit, anesthesiologist should attempt to reduce the patient’s fears and anxiety.
\nThe main intraoperative goal is the appropriate choice of airway technique and airway device tailored to the patient and surgical technique. Other goals are the provision of expert airway management, a continuous plane of anesthesia, clear and immobility of the surgical field, smooth and fast recovery from anesthesia. and surgery with the implementation of enhanced recovery after surgery (ERAS) protocol for fast-track discharge of patients [19].
\nStandard American Society of Anesthesiologists (ASA) monitors [20] such as Blood pressure, Electrocardiography, Pulse oximetry for O2 saturation, capnography, and temperature monitoring are usually applied during H&N surgery. Invasive blood pressure monitoring and advanced hemodynamic monitoring is usually considered in patients with significant cardiovascular disease or long procedures, and when excessive blood loss is expected. One study suggested that the use of goal-directed fluid therapy based on cardiac output monitoring helps guide fluid therapy and avoid fluid overload in free flap transfer [21]. Processed electroencephalogram (EEG) monitoring helps assess the depth of anesthesia and guide anesthetic drug dosing to provide a stable plane of anesthesia during surgery. Moreover, Neuromonitoring such as electromyography (EMG) monitoring of facial nerve in some head and neck surgery may guide to modify the anesthesia technique accordingly.
\nThe majority of head and neck surgeries are done in a supine position with a 15–20-degree head-up tilt to improve venous drainage. Anesthesiologists must pay meticulous attention to the patient’s positioning especially since the head of the operating table is usually turned 90–180 degrees away from the anesthesia machine, limiting immediate access to the airway. Thus, long ventilator tubing and vascular access lines are required and the endotracheal tube should be secured effectively to avoid accidental extubation and disconnection. The eyes should be protected with an occlusive dressing to keep the lid closed and to prevent skin preparation solution from entering the eyes. Goggles or eye pads may be used; all pressure points must be padded, and intermittent pneumatic calf compression is applied.
\nLarge-bore venous access is essential for major resections when significant blood loss is anticipated. Also, the need for invasive or advanced cardiac output monitoring is determined by the patient’s comorbidities as well as the nature and extent of the surgery. They are useful in assessing fluid response and guiding fluid therapy. Hypotensive anesthesia and hemodilution techniques may minimize blood loss, but must be practiced with care to maintain adequate blood flow to free flaps. Moreover, urine output should be monitored in prolonged surgeries.
\nGeneral anesthesia is the technique of choice as it provides airway protection, ensures adequate oxygenation, ventilation, immobility, and avoids distracting the surgeon. In some selected H&N surgeries, monitored anesthesia care can be provided to maintain spontaneous ventilation and a responsive patient with intact airway reflexes. The choice of induction technique for general anesthesia (intravenous versus inhalational agents) is based on patient factors, surgical needs, and potential for compromised ventilation. Preoperative assessment and consultation with the surgeon will determine the technique of endotracheal intubation (awake or asleep), selection of an intravenous versus inhalation induction technique, and whether to use a neuromuscular blocking agent (usually avoided if nerve monitoring to be used intraoperatively). The NAP4 report highlighted that inhalation induction may result in total airway obstruction in patients with H&N pathology, where patients do not exhale the anesthetic gases and rapid hypoxia ensues. The theoretical advantage of gas induction is that it is a slow induction that preserves spontaneous ventilation. Additionally, maintenance of anesthesia can be obtained either with total intravenous anesthesia (TIVA) or inhalation anesthetics or a combination of inhalation anesthetic with intravenous infusion of a short-acting anesthetic. Because many H&N surgeries are associated with high incidences of postoperative nausea and vomiting (PONV), propofol-based anesthesia may be a preferable technique of choice to prevent PONV [19, 22]. Many centers use total intravenous anesthesia (TIVA) with target-controlled infusion (TCI) of propofol and opioids (see \nTable 4\n). In TCI, pumps are programmed to deliver an induction bolus followed by a maintenance infusion based on patient’s demographics. TIVA is also useful to facilitate a clear surgical field by titrating the anesthetics to desired blood pressure [systolic blood pressure below 100 mmHg and mean arterial pressure of 60 to 70 mmHg [23]]. However, controlled hypotension should be avoided in patients with uncontrolled blood pressure, cerebrovascular or coronary artery disease, as well as chronic renal and hepatic insufficiency.
\nAdvantages of TIVA in Head and Neck surgery | \nRapid titration of anesthesia to the desired clinical effect | \n
Allows immobility and facilitates nerve monitoring | \n|
Allows rapid and smooth emergence after surgery | \n|
Reduction in Postoperative Nausea and vomiting | \n|
Induction of moderate hypotension may reduce blood loss and provide clear surgical field | \n|
Technique of choice in laryngologic surgery during jet ventilation or intermittent apnea ventilation | \n
Advantages of Total intravenous anesthesia in head and neck surgery.
Devising safe and optimal airway management depends on close in line communication between the anesthesiologist and surgeon, airway evaluation, reviewing imaging studies, type of surgery, location of the lesion, patient’s symptoms, and tolerance of the procedure and knowing the risk associated.
\nThe technique for airway management should be formulated with the surgeon preoperatively which includes reviewing preoperative imaging studies and endoscopy, choice of airway management device, route for tracheal intubation, awake versus sleep endotracheal intubation, use of jet ventilation, and backup strategies, including preparation for a surgical airway. The goal of a pre-planned and optimal airway approach is to achieve adequate ventilation, oxygenation, and airway protection against aspiration. The following general airway management strategies should be considered:
General anesthesia with endotracheal intubation
General anesthesia using a supraglottic device
General anesthesia using an Operative laryngoscopy in conjunction with jet ventilation
Use of intermittent apnea
General anesthesia using the patient’s natural airway or spontaneous ventilation
Local anesthesia in conjunction with intravenous sedation, with the patient breathing spontaneously
It is often prudent to opt for video-laryngoscopy (VL) as a primary tracheal intubation technique because most H&N patients have high incidences of anticipated difficult airway. Multiple attempts with direct laryngoscopy (DL) should be avoided as it will lead to bleeding, soiling, edema, and fragmentation of any friable tissue in the airway that may dramatically worsen the subsequent laryngoscopic view and facemask ventilation [1, 24]. Thus, VL could be considered as a primary intubation technique in H&N patients to maximize the likelihood of first-attempt success [25]. In one meta-analysis of randomized controlled trials that compared VL versus DL in patients with anticipated or simulated difficult airways, VL was associated with improved glottic view, more likely successful intubation, and a higher chance of first-attempt intubations [26]. The provider should nonetheless approach all anticipated difficulties with caution. In one study, there was an overlap in predictive factors such as previous radiotherapy, malignancy, and previous surgery that led to difficulty in both DL and VL [27].
\nIn conclusion, multiple attempts should be avoided as it leads to airway trauma and obstruction and alternative laryngoscopic or intubation techniques should be considered with caution (\nFigures 1\n and \n2\n).
\nA classification of video laryngoscopic devices. CTrach image courtesy of LMA North America. Pentax AWS image courtesy of Ambu USA. Airtraq image courtesy of Prodol Meditec S.A. Bonfils and C-MACA ˆ VC 2012 Photo Courtesy of KARL STORZ Endoscopy-America, Inc. GlideScope image courtesy of Verathon, USA. The McGrath series 5 image courtesy of Aircraft Medical, UK. VC 2012 Healy et al.; licensee BioMed Central Ltd. Reproduced under the terms of its Creative Commons Attribution License (2.0).
4th generation Video Laryngoscope.jpg” by KARL STORZ Endoscope is licensed with CC BY-SA 4.0. To view a copy of this license, visit https://creativecommons.org/licenses/by-sa/4.0.
There is a common perception that awake fiberoptic intubation (AFOI) is the safest approach to difficult airway management [28]. Certainly, advantages of maintenance of airway patency, gas exchange, and protection against aspiration during the intubation process are offered by awake intubation. AFOI is helpful in patients with supraglottic obstruction, e.g. epiglottic or tongue base obstruction, but it is not the preferred technique in patients with a critically narrowed laryngeal inlet where there are copious secretions, difficulty in maintenance of spontaneous ventilation, and small laryngeal aperture. Adequate topicalization is key to the patient’s comfort and successful airway management. Asleep fiberoptic intubation has certain benefits such as patient comfort, avoidance of anxiety, and smooth transformation to other airway devices if necessary. However, asleep fiber optic intubation may lead to a difficult airway due to airway collapse and hypoxia from depressed respiratory function. The possibility of a successful exit strategy must be evaluated when considering asleep fiber optic intubation. In NAP4, both awake and asleep flexible fiberoptic intubation have relatively high failure rates in patients with H&N pathology, with a frequency up to 60 percent [1, 29]. The most common causes for failure of flexible scope intubation include the inability to identify the glottis, difficulty passing the scope, bleeding, and airway obstruction. In conclusion, awake fiberoptic intubation should be considered first in patients with head and neck pathology with an understanding of the pre-existing limitations to flexible scope intubation.
\nRescue endotracheal intubation using operative laryngoscopy such as anterior commissure scope or rigid bronchoscope (\nFigure 3\n) has been effective and shown to be successful in difficult airway scenarios or when direct laryngoscopy fails [31, 32, 33]. Hillel and colleagues have shown that the use of surgical laryngoscopes helped secure over 35% of difficult airways and reduced the number of emergent cricothyroidotomies to nearly half [34]. After an operative laryngoscope or rigid bronchoscope is placed, manual ventilation can be provided safely through the lumen of the scope and subsequently, endotracheal intubation can be performed with the aid of an airway exchange catheter or a gum elastic bougie [35]. Thus, operative laryngoscopy and rigid bronchoscopy can rescue failed tracheal intubation and cannot intubate/cannot oxygenate (CICO) situations.
\nENT endoscope examples. (a) Dedo scope with external channel for light source; (b) Venturi jet for insertion into rigid scope; and (c) anterior commissure scope with narrower lumen. Reprinted from [30] Published by Elsevier Ltd.
Optical intubation stylets (such as Bonfils, Clarus video System, Sensascope, Levitan optical stylets, etc.) may be helpful and offer an advantage over flexible scopes. These rigid optical stylets can help bypass mobile supraglottic and glottic masses, and once the glottis is entered, the endotracheal tube will follow the trajectory of the stylet in the patient’s trachea. However, studies reported a wide range of success rates with the use of optical stylet [36, 37]. Success rates are higher with experienced users with the mean time to intubation at 23 seconds [38].
\nLaryngeal mask airway (LMA) devices (\nFigure 4\n) offer many advantages in H&N surgery. They may be used:
as primary ventilator devices and to provide smooth emergence from anesthesia in many elective H&N surgeries, such as ear, nasal and intranasal surgery, and facial cosmetic surgery.
as conduits for endotracheal intubation (intubating LMA).
as rescue devices in patients who are difficult to intubate or mask ventilate.
Supraglottic airway devices (single use). (a) Classic LMA (Ambu AuraStraight disposable laryngeal mask). (b) Flexible LMA (Ambu AuraFlex disposable laryngeal mask). (c) Second Generation LMA (Ambu AuraGain disposable laryngeal mask). (d) i-gel supraglottic airway. (e) Intubating LMA (LMA Fastrach). Reprinted from [39]. Crown Copyright © 2018 Published by Elsevier Ltd. All rights reserved.
If LMAs are deemed necessary, the anesthetist should opt for the second generation whose seal design have been shown with less leakage and reduced risk of aspiration.
\nHowever, there are limitations to the supraglottic airway devices in H&N pathology. They may be difficult to place in patients with history of neck irradiation; limited mouth opening; and glottic, hypopharyngeal, or subglottic lesions.
\nThe combination of VL and flexible scope or optical stylet is gaining popularity in complex airway management [40, 41, 42]. Video laryngoscopy provides an enlarged view of the glottis and facilitates manipulation of the flexible scope or optical stylet in patients with distorted anatomy or airway tumors. The combined technique allows continuous visualization and reduced trauma to friable tumors or masses.
\nSurgical airway is considered when endotracheal intubation fails or when traditional endotracheal intubation is not a feasible option due to the nature and unique requirements of the surgery. Awake tracheostomy under local anesthesia should be strongly considered as a primary plan in patients with significant airway obstruction. It may also be planned as the primary intubation strategy in patients who are expected to have significant airway compromise postoperatively possibly due to extensive reconstructive surgery. An alternative is awake cricothyroidotomy (CTM) which can be safely performed for any patients with difficult airways [43]. In case of emergency airway management, surgical cricothyroidotomy is strongly preferred over the percutaneous cricothyroidotomy as the chance of failure of emergency transcutaneous CTM is nearly 60% in H&N patients according to NAP4 report.
\nThe type and size of tubes depending on the type of surgeries, location, invasiveness of the surgery, and the patient’s factors (\nFigure 5\n). The size and type of ETT should be determined with the surgeon. Endotracheal tubes must be appropriately sized and adequately secured to prevent accidental extubation or displacement during surgery.
A reinforced, flexible ETT is an excellent choice for shared airway procedures. They are commonly utilized for intraoral surgery.
Nasal endotracheal intubation (e.g. Nasal RAE tube) is commonly preferred for procedures such as transoral robotic surgery, orthognathic and maxillomandibular surgery, base of tongue surgery, and some dental procedures as it provides better visualization of the oral cavity.
A small-sized micro laryngeal tube (5-mm internal diameter tube but are longer than standard tube) is commonly used for micro laryngeal surgery to facilitate surgical access.
A specialized laser-resistant endotracheal tube is used for airway laser surgery.
Nerve integrity monitor endotracheal tube may be used for specific H&N procedures closely approximating the laryngeal nerves.
Tracheal Tubes. (a) Armored flexible (Mallinckrodt Lo-Contour Reinforced TT). (b) Micro laryngeal (Mallinckrodt Microlaryngeal TT Cuffed). (c) Standard (Mallinckrodt Hi-Contour Cuffed TT). (d) Standard Profile Cuff (Portex Profile Soft Seal Cuff). (e) Preformed Polar North Facing Nasal (Portex Ivory PVC, North Facing, Nasal, Profile Soft Seal Cuff, Polar Preformed). (f) Preformed RAE South Facing Oral (Mallinckrodt Oral RAE TT Cuffed). (g) Laser (Mallinckrodt Laser TT Dual Cuffed). Reprinted from [39]. Crown Copyright © 2018 Published by Elsevier Ltd. All rights reserved.
Maintenance of oxygenation and ventilation is the cornerstone of shared airway management in H&N surgery as these patients are at high risk of failed tracheal intubation and a “cannot intubate, cannot ventilate” situation. Traditional methods of increasing the apneic window during induction involve spontaneous facemask ventilation with 100 percent oxygen. Transnasal high-flow rapid insufflation ventilator exchange or THRIVE delivered through a nasal high-flow oxygen delivery system has been shown to increase the apnea time in a patient with difficult airway to an average of 14 minutes (\nFigure 6\n) [44]. THRIVE provides apneic oxygenation, continuous positive airway pressure to avoid atelectasis, as well as flow-dependent dead space and carbon dioxide flushing, and its role in difficult airway management is presently being studied. Alternatively, a pre-operative transtracheal jet ventilation (TTJV) cannula or an Arndt cricothyroidotomy catheter can be used for tracheal oxygen insufflation [45] to facilitate ventilation. For patients at risk of rapid desaturation or anticipated difficult airway, the provider may use the head-up position, then noninvasive ventilation (NIV) for preoxygenation followed by apneic oxygenation after induction of anesthesia.
\nThe OptiFlow high-flow humidified oxygen delivery system. The oxygen humidification unit (a) receives oxygen from a standard oxygen regulator and delivers humidified oxygen to a custom-built transnasal oxygen cannula (b and c) like a standard nasal oxygen cannula (d). Reprinted from [44]. © 2014 The Authors Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.
Various ventilatory techniques are applied to meet the demands of H&N surgery such as the type of surgery and the access required to the operative site. Following are the ventilator mode techniques used during laryngologic surgery
\nSpontaneous ventilation with local anesthesia or sedation: this mode of ventilation allows patients to maintain their airways, but few tolerate procedures with such mode of ventilation.
\nSpontaneous respiration with general anesthesia: common in pediatric; oxygenation and ventilation are provided via Stroz bronchoscopy for upper airway endoscopic procedures.
\nIntermittent, Positive-pressure ventilation: this is usually carried out using a micro laryngoscopy tube (MLT), and allows for the use of standard anesthetic equipment in a normal operating setup. However, it provides a mobile operative field that moves with respiration and sometimes surgical access is reduced or obscured especially in surgery involving the posterior third of the glottis.
\nIntermittent apnea without endotracheal intubation: this has the advantage of providing an unobstructed surgical view but poor airway protection and inadequate control of anesthesia depth. The patient’s airway is intubated in cases of desaturation and but may be extubated prior to surgery resumption.
\nJet ventilation: consists of rapid insufflation of gas (oxygen) at high velocity via a narrow nozzle into an open airway. It can be done at either low or high-frequencys. Jet ventilation can be delivered via supraglottic, infraglottic, or transtracheal routes and it provides the optimal surgical view with reduced stimulation (\nTable 5\n). Paralysis and TIVA are usually required for this technique.
\nLow-frequency jet ventilation (LFJV) is delivered using a high-pressure gas source via a narrow cannula attached to a suspension laryngoscope or bronchoscope. Ventilatory frequency is usually around 10–30 cycles per minute. The stream of high-velocity gas entrains air and increases the tidal volume but reduces the oxygen concentration of the inspired gas. It is easy to perform, requiring uncomplicated anesthetic equipment and allows a clear surgical view. Inhalational anesthesia may not be delivered easily, so total intravenous anesthesia is preferred. However, there are certain disadvantages such as mobility of the operative field, difficulty monitoring airway pressure, risk of gas entrainment, and barotrauma
\nHigh-frequency jet ventilation is more commonly used especially for infraglottic and transtracheal routes. HFJV is usually set at 150 cycles per minute, delivering tidal volumes as small as 1 to 3 ml/kg. HFJV provides a motionless and still surgical field. TIVA is the anesthesia of choice. However, there are possible risks of gastric insufflation, carbon dioxide retention, and barotrauma
Type by technique | \nType by location | \n
---|---|
• Conventional jet ventilation or LFJV (manual via high pressure manual jet) | \n• Supraglottic (via rigid ENT laryngoscope) | \n
• High Frequency jet ventilation via machine with low tidal volumes and high frequencies | \n• Subglottic (via special catheter) | \n
\n | • Trantracheal (via cannula) | \n
Classification of jet ventilation.
A multimodal approach in the form of acetaminophen, non-steroidal anti-inflammatory drugs, gabapentin, opioids, and local as well as regional anesthesia can be given perioperatively. Post-operative patient-controlled analgesia can be considered with step down to oral opioids as required.
\nPatients who undergo H&N surgery are at high risk of postoperative nausea and vomiting and should be managed aggressively as it can result in increased morbidity. A multimodal approach to prophylaxis is essential, encompassing TIVA with intraoperative dexamethasone (8 mg Intravenous), 5-HT3 antagonist (e.g. ondansetron 4 to 8 mg intravenous), and utilization of multimodal analgesia to minimize opioid requirement.
\nClasses of antiemetics are
5-HT3 receptor antagonists (e.g. ondansetron)
Nk-1 receptor antagonists (e.g. aprepitant)
Corticosteroids (e.g. dexamethasone)
Butyrophenones (e.g. haloperidol)
Antihistamines (e.g. meclizine)
Anticholinergics (e.g. scopolamine)
Phenothiazines (e.g., metoclopramide)
The goals of safe emergence from anesthesia include smooth, rapid emergence and extubation, avoidance of straining, bucking, and coughing, and a complete, pain-free awakening. Extubation plan should be formulated thoroughly with the surgeons in the preoperative period. One may consider the extubation guidelines as outlined by the Difficult Airway Society of the United Kingdom or American Society of Anesthesiologists Practice Guidelines for the management of the difficult airway [46, 47]. In cases of anticipated post-operative airway complications, extubation may be delayed and patient should be transported to the intensive care unit. Extubation considerations should include the following options:
Fully awaken the patient and extubate immediately postoperatively
If anticipating airway compromise, admit to the intensive care unit for a delayed tracheal extubation
Conduct tracheostomy.
Enhanced recovery after surgery protocol should be applied to facilitate fast-track discharge as most of the H&N surgeries are done on an ambulatory basis [19]. Those patients who require post-operative airway management should be cared for in intensive care unit. Varadarajan and colleagues [48] proposed that any of the following could be indications for postoperative ICU admission:
Patients requiring post-op assisted ventilation
Patients requiring diagnostic or therapeutic bronchoscopy
Patients requiring invasive hemodynamic or cardiac monitoring such as in the setting of hemodynamic instability
Patients with multiorgan failure requiring critical care management.
Transoral robotic surgery is a minimally invasive surgical technique most widely used for radical tonsillectomy, oropharyngeal cancer resection, localization of occult primary head and neck tumors, supraglottic partial laryngectomy, and treatment of snoring and obstructive sleep apnea [49]. TORS allows exceptional surgical treatment of head and neck pathology while minimizing morbidity and improving functional outcomes as compared with open surgical approaches. Anesthetic challenges include shared airway with a robot and limited access to the patient intraoperatively. Airway management includes nasal RAE or wire-reinforced endotracheal intubation and the use of TIVA with a combination of TCI propofol and remifentanil as the choice of anesthetic. Possible complications include pressure point injury and deep vein thrombosis due to prolonged surgery, risk of airway fire, aspiration, and post-operative bleeding. As TORS expands, local guidelines must be produced that support high standards of perioperative care [49, 50].
\nLaser surgery is employed to treat laryngeal pathoses such as papilloma, laryngomalacia, vocal cord cysts, vocal cord polyps and granulomas, and post-operative scar tissues. Laser micro laryngoscopy enables precise management of a wide range of upper airway conditions. The type of airway management required for laser surgery is determined by whether access is needed to the hypopharynx, supraglottis, larynx, or subglottis. Ventilatory techniques that may be used include continuous endotracheal intubation with specialized laser tubes, spontaneous ventilation with insufflation techniques, intermittent apneic technique, or jet ventilation (supraglottic or subglottic) and with TIVA. TIVA using propofol and remifentanil titrated to maintain spontaneous ventilation is an alternative technique. Laser-resistant endotracheal tubes are used as airway fire poses a major risk. For a fire to occur, the triad of fuel (e.g., ETT, drapes, sponges), oxygen, and ignition source is needed. The American Society of Anesthesiologists (ASA) published an operating room fire algorithm that guides managing airway fires [51]:
Declare a fire and alert the team
Halt the procedure and the laser beam
Irrigate the surgical field with saline
Immediately cease airway gases/ventilation and remove ETT
Remove sponge and other flammable materials from the airway
Resume bag-mask ventilation and prepare for reintubation once the airway fire is extinguished
Examine the airway for evidence of debris, thermal injury, or foreign bodies and consider bronchoscopy
Functional endoscopic sinus surgery is an effective, low-risk procedure for chronic rhinosinusitis, nasal polyposis, epistaxis control, tumor excision, foreign body removal, treatment of sinus mucoceles, and more. Anesthetic considerations include local versus general anesthesia, supraglottic airway devices versus endotracheal intubation, inhaled anesthesia versus TIVA, and the preferences of the surgical team while taking the patient’s comorbidities into account. The main goals are to provide a bloodless surgical field, patient immobility, stable hemodynamic conditions, and smooth emergence. Different techniques are utilized to induce “controlled hypotension” which reduces bleeding and improves the surgical visual field. However, this procedure has potential major complications which include orbital hematoma resulting in blindness or reduced vision, cerebrospinal fluid leaks, renal or arterial injury, severe hemorrhage, and death.
\nBecause oral cancers are associated with smoking and alcohol excess, cardiopulmonary compromise and malnutrition are more common comorbidities. Moreover, airway difficulty can arise due to distortion of the airway by the tumor or as a consequence of radiotherapy. Surgery is typically performed using general anesthesia with tracheal intubation (preferably nasal ETT) and invasive hemodynamic monitors depending on the extent of the surgery and the patient’s comorbidities. Hypotensive anesthesia is encouraged to reduce blood loss. Long-acting paralytics should be avoided when electromyography is employed, TIVA is often a preferred anesthetic choice. The application of ERAS to major head and neck cancer surgery has led to other guidelines for perioperative management.
\nTissue transfer in the form of a pedicled or microvascular free flap is commonly employed to reconstruct defects following H&N cancer resection [52]. The graft may consist of soft tissues, bone, or both. Anesthetic management aims to maintain a full, hyperdynamic circulation with increased cardiac output, liberal fluid resuscitation, peripheral vasodilation, and normothermia to maximize flap perfusion. Hematocrit should be maintained at 30–35% to improve oxygen transfer and red cell velocity within the microcirculation. Vasoconstrictors are usually discouraged as they can contribute to graft ischemia. Intraoperative and postoperative flap monitoring is achieved clinically (by bedside examination of the flap color, temperature, turgor, edema, and capillary refill), and by using technical means such as Doppler ultrasound or near-infrared spectroscopy.
\nCraniofacial surgery addresses congenital or acquired deformities through cleft lip and palate repair, temporomandibular joint surgery, and orthognathic procedures. Obstructive sleep apnea and congenital airway deformormities is common in these patients. In general, nasal intubation is frequently preferred in orthognathic surgery. Submental intubation may be required if the nasal route is difficult or if the surgeon requires access to the upper portion of the face. In submental intubation, an incision is first made through the submental skin into the floor of the mouth. After routine oral intubation, the proximal end of the endotracheal tube is passed through the floor of the mouth out to the submental skin. The process is reversed at the end of the surgery and the patient is extubated orally. Bleeding is a potential risk that can be controlled by positioning the patient head up, ensuring free venous drainage, utilizing local anesthesia containing adrenaline, and utilizing controlled hypotension. Antibiotic prophylaxis, multi-modal analgesia, PONV prophylaxis, and steroids to reduce swelling are also important components of perioperative management.
\nPreemptive imaging of the airway is a valuable aide to traditional clinical airway evaluation for strategizing airway management. The NAP4 highlighted that 40% of the patients with head and neck pathology developed airway related complications. These failures were attributed to shortcomings in airway evaluation, planning, and adaptations of airway and anesthetic techniques according to the patient’s pathology. Virtual endoscopy (VE) has been utilized by radiologists for many years to assess, identify, and stage the various lesions. VE utilizes multidimensional CT images to construct 3D endoscopic images at various sites from the nasopharynx to a tracheobronchial tree [53]. VE enables computer-generated 3-dimensional portrayal of the airway cavity (\nFigures 7\n–\n9\n). Virtual endoscopy is a valuable and safe tool as it provides a complete, non-invasive, and anatomically accurate portrayal of the patient’s airway, starting from nasopharynx or oro-pharynx to the tracheobronchial tree. The virtual airway can be reconstructed from the patient’s pre-existing diagnostic CT images using the OsiriX software [54, 55, 56]. VE can contribute significantly to preemptive strategies against the NAP4 highlighted shortcomings and help improve overall patient outcome.
\nSupraglottic virtual endoscopy reconstruction showing the epiglottis [54]. Reprinted with permission from Dr. Imran Ahmad FRCA, Consultant Anaesthetist, Clinical Lead for Airway Management, Service Clinical Lead for Anaesthesia & Theatres, Guy’s Hospital, Guy’s & St Thomas’ NHS Foundation Trust, London, UK & Honorary Senior Lecturer, King’s College London, UK.
Virtual endoscopy reconstruction showing the glottic opening [54]. Reprinted with permission from Dr. Imran Ahmad FRCA, Consultant Anaesthetist, Clinical Lead for Airway.
Subglottic virtual endoscopy reconstruction showing the trachea [54]. Reprinted with permission from Dr. Imran Ahmad FRCA, Consultant Anaesthetist, Clinical Lead for Airway Management, Service Clinical Lead for Anaesthesia & Theatres, Guy’s Hospital, Guy’s & St Thomas’ NHS Foundation Trust, London, UK & Honorary Senior Lecturer, King’s College London, UK.
The novel coronavirus disease 2019 (COVID-19) has become a pandemic exposing many unprecedented challenges to health care systems. In head and neck procedures, health care staff are at a higher risk of contracting the virus as most examinations and procedures within the respiratory tract. Understanding how to mitigate the risks is critical. The British Otolaryngology Society and the American Society of Gastrointestinal Endoscopy recommended mandatory personal protective equipment (PPE) use, procedures performed in negative-pressure rooms, and thorough decontamination of endoscopes, equipment, and rooms. All non-urgent surgery should be deferred to prevent consumption of emergency equipment and avoid outpatients spread. Airway management strategies should include designating experienced providers, closing circuits, intubating in negative pressure rooms, applying rapid sequence induction techniques, and minimizing bag-mask ventilation. All standard airway equipments should be available including bag-masks with High-Efficiency Particular Air (HEPA) filters, video laryngoscopes with disposable blades, ventilators, and tubes with inline adapter, HEPA filter, and clamp for ETT for application during tube disconnection to avoid aerosolization [57]. On the other hand, awake intubation should be avoided as coughing and bucking may promote aerosolization. THRIVE, jet ventilation, or open-circuit positive pressure ventilation are discouraged. Laser surgery or endonasal and otologic drilling should be avoided as viral particles can spread through plumes [58].
\nHead and neck surgery involves a wide range of procedures from the simple to the complex. Thus, it poses greater challenges to the anesthesiologist; he/she must optimize the patient’s comorbidities preoperatively, share the airway, implement different anesthesia and airway techniques specific to each surgery, and manage postoperative airway complications. Head and neck surgery patients often present with difficult airways due to the pathologies which impede the airway anatomy. Therefore, preoperative planning necessitates thorough history and physical examination with particular attention to the airway evaluation. High-risk patients should be identified preoperatively and medically optimized before surgery. A multidisciplinary approach and expertise in H&N anesthesia and advanced airway management should be encouraged as it decreases airway complications and improves surgical outcomes. The preoperative endoscopic airway examination is a useful aide in providing a real-time image of the upper airway and allows adequate preparation. General anesthesia with total intravenous anesthesia (TIVA) is the anesthesia of choice as it offers quick titration of anesthesia, allows immobility, prevents postoperative nausea and vomiting, reduces blood loss by inducing controlled hypotension, and facilitates smooth and rapid emergence. Airway management planning also requires close communication and cooperation with the surgical team. Endotracheal intubation is a general considered in H&N surgery because it offers optimal airway control with adequate oxygenation, ventilation, and protection against aspiration. Video laryngoscopy is recommended in H&N surgery. Different ventilator techniques including jet ventilation should be considered in H&N surgery. Furthermore, multimodal analgesia, PONV prophylaxis, use of steroids to reduce airway edema, and antibiotic prophylaxis are essential components of intraoperative management. Enhanced recovery after surgery (ERAS) guidelines in H&N surgery should be applied. The decision to admit a patient in the critical care unit postoperatively is based on the patient’s comorbidities, intraoperative events, complexities of the surgery, and requirements for airway support. Recent advances in airway management techniques (such as virtual endoscopy) and surgical techniques have been shown to improve the outcome.
\nThe authors declare no conflict of interest.
\nAs an Open Access publisher, IntechOpen is dedicated to maintaining the highest ethical standards and principles in publishing. In addition, IntechOpen promotes the highest standards of integrity and ethical behavior in scientific research and peer-review. To maintain these principles IntechOpen has developed basic guidelines to facilitate the avoidance of Conflicts of Interest.
",metaTitle:"Conflicts of Interest Policy",metaDescription:"As an Open Access publisher, IntechOpen is dedicated to maintaining the highest ethical standards and principles in publishing. In addition, IntechOpen promotes the highest standards of integrity and ethical behavior in scientific research and peer-review.",metaKeywords:null,canonicalURL:"/page/conflicts-of-interest-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"In each instance of a possible Conflict of Interest, IntechOpen aims to disclose the situation in as transparent a way as possible in order to allow readers to judge whether a particular potential Conflict of Interest has influenced the Work of any individual Author, Editor, or Reviewer. IntechOpen takes all possible Conflicts of Interest into account during the review process and ensures maximum transparency in implementing its policies.
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\\n\\nAuthors are required to declare all potentially relevant non-financial, financial and material Conflicts of Interest that may have had an influence on their scientific work.
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\\n"}]'},components:[{type:"htmlEditorComponent",content:"In each instance of a possible Conflict of Interest, IntechOpen aims to disclose the situation in as transparent a way as possible in order to allow readers to judge whether a particular potential Conflict of Interest has influenced the Work of any individual Author, Editor, or Reviewer. IntechOpen takes all possible Conflicts of Interest into account during the review process and ensures maximum transparency in implementing its policies.
\n\nA Conflict of Interest is a situation in which a person's professional judgment may be influenced by a range of factors, including financial gain, material interest, or some other personal or professional interest. For IntechOpen as a publisher, it is essential that all possible Conflicts of Interest are avoided. Each contributor, whether an Author, Editor, or Reviewer, who suspects they may have a Conflict of Interest, is obliged to declare that concern in order to make the publisher and the readership aware of any potential influence on the work being undertaken.
\n\nA Conflict of Interest can be identified at different phases of the publishing process.
\n\nIntechOpen requires:
\n\nCONFLICT OF INTEREST - AUTHOR
\n\nAll Authors are obliged to declare every existing or potential Conflict of Interest, including financial or personal factors, as well as any relationship which could influence their scientific work. Authors must declare Conflicts of Interest at the time of manuscript submission, although they may exceptionally do so at any point during manuscript review. For jointly prepared manuscripts, the corresponding Author is obliged to declare potential Conflicts of Interest of any other Authors who have contributed to the manuscript.
\n\nCONFLICT OF INTEREST – ACADEMIC EDITOR
\n\nEditors can also have Conflicts of Interest. Editors are expected to maintain the highest standards of conduct, which are outlined in our Best Practice Guidelines (templates for Best Practice Guidelines). Among other obligations, it is essential that Editors make transparent declarations of any possible Conflicts of Interest that they might have.
\n\nAvoidance Measures for Academic Editors of Conflicts of Interest:
\n\nFor manuscripts submitted by the Academic Editor (or a scientific advisor), an appropriate person will be appointed to handle and evaluate the manuscript. The appointed handling Editor's identity will not be disclosed to the Author in order to maintain impartiality and anonymity of the review.
\n\nIf a manuscript is submitted by an Author who is a member of an Academic Editor's family or is personally or professionally related to the Academic Editor in any way, either as a friend, colleague, student or mentor, the work will be handled by a different Academic Editor who is not in any way connected to the Author.
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\n\nAll Reviewers are required to declare possible Conflicts of Interest at the beginning of the evaluation process. If a Reviewer feels he or she might have any material, financial or any other conflict of interest with regards to the manuscript being reviewed, he or she is required to declare such concern and, if necessary, request exclusion from any further involvement in the evaluation process. A Reviewer's potential Conflicts of Interest are declared in the review report and presented to the Academic Editor, who then assesses whether or not the declared potential or actual Conflicts of Interest had, or could be perceived to have had, any significant impact on the review itself.
\n\nEXAMPLES OF CONFLICTS OF INTEREST:
\n\nFINANCIAL AND MATERIAL
\n\nNON-FINANCIAL
\n\nAuthors are required to declare all potentially relevant non-financial, financial and material Conflicts of Interest that may have had an influence on their scientific work.
\n\nAcademic Editors and Reviewers are required to declare any non-financial, financial and material Conflicts of Interest that could influence their fair and balanced evaluation of manuscripts. If such conflict exists with regards to a submitted manuscript, Academic Editors and Reviewers should exclude themselves from handling it.
\n\nAll Authors, Academic Editors, and Reviewers are required to declare all possible financial and material Conflicts of Interest in the last five years, although it is advisable to declare less recent Conflicts of Interest as well.
\n\nEXAMPLES:
\n\nAuthors should declare if they were or they still are Academic Editors of the publications in which they wish to publish their work.
\n\nAuthors should declare if they are board members of an organization that could benefit financially or materially from the publication of their work.
\n\nAcademic Editors should declare if they were coauthors or they have worked on the research project with the Author who has submitted a manuscript.
\n\nAcademic Editors should declare if the Author of a submitted manuscript is affiliated with the same department, faculty, institute, or company as they are.
\n\nPolicy last updated: 2016-06-09
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