Pediatric Airway: An Interdisciplinary Approach, Charles M. Myer, III, Robin T. Cotton, and Sally R. Shott, eds. Philadelphia: JB Lippincott, 1995, ISBN 0-397-51415-8, 374 pp, $69.50.
This book addresses a topic that has received less than its deserved attention in text form: the pediatric airway. The book is edited by three members of the Department of Otolaryngology-Head and Neck Surgery from the Children's Hospital Medical Center in Cincinnati, with 20 additional contributors primarily from the fields of otolaryngology and pediatrics. The book has minor contribution from anesthesiologists (chapters on inflammatory diseases of the airway and anesthetic techniques with laser endoscopy).
Pediatric Airway: An Interdisciplinary Approach is intended primarily for the otolaryngologist, not for the anesthesiologist; emphasis is on surgical technique and not anesthetic management. The text comprises 19 chapters devoted to pathology causing airway obstruction in the pediatric population. The first two chapters are concise, well written, descriptions of developmental anatomy and physiology of the airway. Chapter 3, titled "Evaluation of the Airway," pertains to airway evaluation by rigid and flexible fiberoptic endoscopy and flow-volume loops, not airway evaluation as an attempt to predict ease of glottic visualization on direct laryngoscopy.
There are several quality chapters on subjects of subglottic stenosis, vocal cord paralysis, gastroesophageal reflux, and pediatric laryngeal trauma accompanied by clear illustrations. The chapter titled "Inflammatory Diseases of the Airway" is dedicated to croup, epiglottitis, and bacterial tracheitis, although it mentions other disease states in passing. The three diseases are discussed in excellent detail and clarity and are well referenced.
The anesthesiologist, however, will find this book is not the answer to their concerns when managing the pediatric airway. "Anesthetic Techniques with Laser Endoscopy" is a well written chapter, but it does not guide the anesthesiologist in how to proceed if airway obstruction is encountered during administration of general anesthesia. The chapter on epiglottitis lacks details of how the child is anesthetized and tracheally intubated. The discussion on mediastinal masses fails to emphasize certain aspects of the disease that are important in its anesthetic management: e.g., the option of awake tracheal intubation, the importance of the lateral (or prone) position for both induction of anesthesia and treatment of airway obstruction, the importance of flow-volume loop studies, and the significance of superior vena cava syndrome. The chapter on craniofacial anomalies lacks description of methods and instruments available in securing the airway, and does not discuss all the associated airway problems (e.g., potential for cervical spine fusion in patients with Apert and Crouzon syndromes).
For certain pathology, the anesthetic management options are oversimplified. For example, in the discussion of airway and esophageal foreign body aspiration, the issues of full stomach and waiting as opposed to proceeding promptly with anesthesia, rapid sequence induction, and application of cricoid pressure are not addressed. The chapter "Anesthetic Adaptations for the Child with a Critical Airway" provides good general guidelines for anesthetic management in children with airway obstruction, but it does not discuss the various instruments available for emergency ventilation and oxygenation (laryngeal mask airway, Combitube Trademark, etc.).
There are also chapter topics (e.g., "Home Care of the Child with Tracheostomy," "Sleep Studies in Evaluating the Pediatric Airway") that are not of special interest to the anesthesiologist, while certain pathologies, obstructive and nonobstructive, of importance are not included in any appreciable detail (e.g., tongue pathology, lymphatic malformations of the neck, the unstable cervical spine). The text does not discuss the ASA's difficult airway algorithm.
From the anesthesiologist's perspective, this book does not satisfy the need for a source that details the range of pediatric airway lesions with methods of evaluation, ventilation; and tracheal intubation. However, there is much useful physiologic and clinical information contained within the text that will be of great value to the anesthesiologist who performs anesthesia for ENT procedures or who has an interest in pediatric anesthesia. The interested anesthesiologist will benefit from this well priced book by getting an in-depth description of many airway pathologies and achieve a better understanding of the surgeon's perspective of pediatric airway problems.
Jalil Riazi, MD
Department of Anesthesiology,
University of California, Irvine Medical Center, Orange, CA 92668