Anesthesia for Pediatric Craniofacial Surgery

Children with craniofacial abnormalities provide some of the most difficult challenges for anesthesiologists today. Whether the patient is scheduled for reconstructive surgery or a procedure unrelated to their anomaly, the care of these patients can be consuming and demanding. Since 1967 when the plastic surgeon Paul Tessier successfully demonstrated the correction of many deformities once thought to be uncorrectable, the field has continued to expand with new developments in both surgery and anesthesia. He found that the bones of the face and skull could survive as grafts when temporarily removed, remodeled and then replaced. It is important to understand the development and characteristics of the more common anomalies and their peculiar anesthetic challenges in order to construct a safe anesthetic plan. Craniofacial abnormalities begin early in development. Fertilization and cell division are the initial embryological stages of development that eventually lead to the three divisional layers, the ectoderm, mesoderm, and endoderm. The mesoderm is the most influential to further development and specialization. It is the forerunner of the skull and upper face. Facial prominences are formed from surface elevations of regional growth centers in the upper face. During the 30 th to 37 th gestational days, the bumps and valleys eventually form the nasal and oral cavity. The 50 th through 60 th gestational days consists of formation of the palatal shelves and eventually the hard and soft palate. Disturbances during the first phase give rise to facial clefts, while interruption in phase two results in cleft lips and palates. Mesodermal bulges below the oral cavity are called branchial or visceral arches. The ectodermal grooves lead to branchial clefts and the endoderm will form branchial pouches. There are six branchial arches that will develop into the pharynx and oral cavity. The first arch is " involved " with development of the face, cranial nerve V 1 and the muscles of mastication. Malformations here often involve hearing loss, abnormalities in mouth opening and the mandible. The second arch involves development of the ear, the 7 th cranial nerve and muscles of facial expression. The third arch involves the 9 th cranial nerve and upper pharyngeal muscles. Fusion of the 4 th and 6 th arches forms all the laryngeal cartilages except the epiglottis, the pharyngeal and laryngeal muscles and the thyroid. The first pouch forms the middle ear and eustachian tube, the 2 nd forms the palantine tonsil; the 3 rd …