Midface distraction

Since the initial application of distraction osteogenesis to the human mandible by McCarthy, distraction osteogenesis has been used for gradual lengthening of the midface in children with syndromic craniosynostosis, cleft lip and palate, hemifacial microsomia, and midface hypoplasia from other causes. Both external and internal devices are available that permit midface distraction. The background of midface distraction and the development of a Modular Internal Distraction (MID) system that permits widespread use of easily customized, buried distraction devices throughout the craniofacial region are presented. The relative and potential clinical indications for distraction, treatment planning, patient preparation, and possible surgical orthodontic interactions during distraction, as well as a variety of case examples showing the MID system, are discussed.

Airway disorders in hemifacial microsomia

The anatomic components of hemifacial microsomia have been classified previously, but their relevance to functional abnormalities has not been stressed. In a recent review of the literature, we found that the frequency and severity of airway disorders, especially those leading to upper airway obstruction and/or obstructive sleep apnea, had not been reported. Accordingly, a retrospective study of 38 patients (21 male, 17 female), aged 6 months to 22 years (mean, 8 years 3 months) with hemifacial microsomia was undertaken to ascertain the frequency and severity of airway disorders in hemifacial microsomia. Upper airway disorders fell broadly within three categories: group I (n = 22, 58 percent) was asymptomatic for airway disturbances; group II (n = 7, 18 percent) had a medical history suspect for intermittent obstructive sleep apnea or had a perioperative apneic event; and group III (n = 9, 24 percent) had a definite history of obstructive sleep apnea or upper airway obstruction requiring tracheotomy or apnea surgery. Group III versus groups II and I had a higher incidence of bilateral involvement (33 percent versus 14 percent and none), a greater percentage of M2, M2a, M2b, and M3 mandibular deformities (88.9 percent versus 28.6 percent and 18.2 percent), more severe orbital involvement (33 percent O2 and O3 versus none in group II and 9 percent in group I), and more severe soft-tissue involvement (89 percent S2 and S3 versus 29 percent and 23 percent). Patients with more severe mandibular and orbital deformities, but not ear or vertebral abnormalities, appear at a greater risk for obstructive sleep apnea. The relationship of OMENS-Plus (extracraniofacial anomalies) to apnea was variable but was found more commonly in group II (86 percent) and group III (56 percent) than in group I (32 percent) patients. Group III patients had a higher frequency of cardiac anomalies (44 percent versus 29 percent in group II and 23 percent in group I). The incidence of obstructive sleep apnea in our population of patients with hemifacial microsomia approaches 24 percent. Patients with hemifacial microsomia should undergo routine screening for obstructive sleep apnea: a positive history warrants polysomnographic and anatomic workup.

Alternatives to tracheostomy in infants and children with obstructive sleep apnea

PURPOSE

Since 1989, 70 children have been treated surgically with varying degrees of obstructive sleep apnea (OSA). Of these, 29 patients had completely failed conventional medical and surgical treatment and were considered tracheostomy (T) candidates, whereas five had previously undergone T for severe OSA as infants and did not respond to standard decannulation protocols. The preoperative diagnoses were cerebral palsy (n = 5), Down's syndrome (n = 5), hemifacial microsomia (n = 4), Pierre Robin sequence (n = 6), and a mixed group of craniofacial disorders (n = 14). The patients ranged in age from 2.5 weeks to > or =18 months (mean, 7.32 years). Preoperatively, four patients were on ventilators and one suffered a cardiac arrest, attesting to the severity of OSA.

METHODS

To enlarge the caliber of the airway, each patient underwent an aggressive surgical treatment protocol. All sites of upper airway obstruction were treated simultaneously by a combination of craniofacial skeletal expansion and soft-tissue reduction.

RESULTS

Tracheostomy was avoided in 90.4% of patients. Temporary or "permanent T" were required in three patients (9.6%). One patient with cerebral palsy had recurrent OSA and died. A second patient with severe laryngotracheomalacia and retrognathia who did not respond to apnea surgery underwent a tracheostomy and ultimately died of pulmonary causes. Four patients (7.8%) required supplemental home oxygen or continuous positive airway pressure. The average preoperative respiratory disturbance index, defined as the average number of apneic and hypopneic events per hour of sleep, dropped from 25.9 to 4.4 after surgery. The average lowest recorded oxygen saturation during overnight polysomnography rose from 61% to 92% after surgery. Of the five patients with permanent T, four had thus far been decannulated. Complications occurred in 10 patients, 50% of which were related to minor problems with mandibular distraction devices.

CONCLUSION

Our results confirm the efficacy of an aggressive surgical approach to the treatment of OSA in children, avoiding the necessity for tracheostomy or permitting decannulation of permanent T in the majority of cases.

Pemphigus vegetans-Neumann variant associated with intranasal heroin abuse

Pemphigus vegetans is variant of pemphigus vulgaris accounting for 5% of all patients with pemphigus disorders. We describe a case of pemphigus vegetans-Neumann type associated with intranasal heroin abuse, restricted to the modified mucous membranes. The results of routine histology and direct and indirect immunofluorescence studies confirmed the diagnosis. The patient responded to oral prednisone of 40 mg daily for 1 month, followed by reduction to a maintenance dose of 15 mg daily. A complete remission was sustained for 6 months. The relationship between intranasal heroin use and the development of pemphigus vegetans remains uncertain but appears to be an intriguing possibility in this patient.

Skeletal expansion combined with soft-tissue reduction in the treatment of obstructive sleep apnea in children: physiologic results

Twenty consecutive children, ranging in age from 6 days to 18 years, were treated with skeletal expansion, in addition to soft-tissue reduction, for medically refractory obstructive sleep apnea. The underlying diagnoses were craniofacial microsomia (n = 6), Down syndrome (n = 3), Pierre Robin syndrome (n = 3), cerebral palsy (n = 3), Nager's syndrome (n = 1), Treacher Collins syndrome (n = 1), cri du chat syndrome (n = 1), juvenile rheumatoid arthritis (n = 1), and temporomandibular joint ankylosis (n = 1). Fourteen children had severe medically refractory sleep apnea and were tracheostomy candidates; in the remaining six, tracheostomies were placed shortly after birth and could not be decannulated. Overnight, 12-channel polysomnography was obtained before and after surgery. The mean apnea index improved from 7.42 to 1.26, the mean respiratory disturbance index improved from 25.24 to 1.72, and the mean lowest apnea-related oxygen saturation improved from 68% to 88%. Of the 14 children with medically refractory obstructive sleep apnea, two required tracheostomies. Of the six patients with tracheostomies, five have been decannulated at the time of this writing. Skeletal expansion in conjunction with soft-tissue reduction in the pediatric population permits substantial increases in the volume of both the nasopharynx and oropharynx. Creative use of conventional osteotomies and the application of distraction osteogenesis have enabled surgeons to apply maxillofacial and craniofacial techniques in treating children with obstructive sleep apnea.

Sleep apnea surgery versus tracheostomy in children: an exploratory study of the comparative effects on quality of life

Successful surgery for medically refractory obstructive sleep apnea in children has prevented tracheostomy in many cases. However, sleep apnea surgery requires postoperative ventilatory support and intensive care, and the magnitude of the surgery may be substantial. Tracheostomy, in contrast, is a simple procedure that is considered the standard of care for relief of upper airway obstruction. To determine their relative benefits, the posttreatment quality of life in children with airway obstruction who underwent either sleep apnea surgery or tracheostomy was evaluated and compared in this exploratory study. A 76-item questionnaire was developed to assess the quality of life in this population, including an investigation of physical symptoms, psychosocial function, and costs. Forty-four parent questionnaires were returned; 16 of these parents had children who had had clinically successful sleep apnea surgery and 6 had children who had had tracheostomies placed for obstructive sleep apnea. Results revealed that the parents of children in the tracheostomy group ranked 95 percent of all items on the questionnaire as worse than the parents of children in the surgery group. These rankings included statistically significant group differences (p < 0.05) on number of hospital, emergency room, and physician visits, and hours per day spent on their child's respiratory care. In addition, parents of the successful sleep apnea surgery group reported significant improvement (p < 0.05) in 100 percent of symptom variables (i.e., choking, snoring, and daytime sleepiness), 75 percent of parental care variables (i.e., assisting with their child's breathing, suctioning), 67 percent of medical visit items, and 75 percent of the stress and coping variables (i.e., perception of child's distress, worrying about their child's breathing, level of family stress), indicating substantial gains in quality of life. Despite initially higher costs, successful surgery for obstructive sleep apnea was associated with substantial benefits in quality of life, health, and psychosocial outcomes when compared with tracheostomy.

Applications of endoscopic surgery in pediatric patients

Although the advent of endoscopic technology is expanding the fields of reconstructive and aesthetic surgery in adults, there have been few reports of the use of this technology in the pediatric population. Because of their minimally invasive nature, yet wide range of exposure, endoscopic techniques have much appeal for this age group. Here we present our experience with endoscopic pediatric plastic surgery. From February of 1995 to August of 1997, 104 patients underwent 139 procedures utilizing 5- and 10-mm endoscopes. There were 58 male and 46 female patients. The mean age at surgery was 5.6 years (range, 3 weeks to 19 years). The most common type of procedures performed were insertion of tissue expanders (n = 34), excision of benign head and neck masses (n = 27), torticollis release (n = 20), excision of vascular lesions (n = 13), and miscellaneous procedures, (n = 10). There were 26 complications in 139 procedures (19 percent). Seventeen (65 percent) were in the tissue expander group. The rest were scattered among the groups with other diagnoses. Although there did not appear to be a specific type of complication associated with endoscopy, 77 percent occurred in the first 2 months of our study. This suggests a relatively steep technical learning curve. These results demonstrate that endoscopic techniques are eminently applicable in the pediatric population, providing the benefits of small and remote incisional wounds, with complication rates that are comparable with those of conventional open surgical treatment.

Two-piece occlusion rim for screw-retained implant prosthesis

The record base for a multiple, implant-supported, fixed prosthesis may be attached to the implants by screws. The screw attachment provides a stable record base for recording maxillomandibular relationships. Extraoral adjustment of the occlusion rim requires that it be unscrewed to allow removal from the mouth. The rim must be reattached with screws for the next intraoral evaluation. Although this cycle of removal and replacement provides stability, retention, and accuracy, it is time-consuming and inefficient. To resolve this problem, a two-piece record base/occlusion rim can be used. The screw-retained record base remains intraoral for the duration of the clinical appointment. The occlusion rim is designed to fit over the record base, with retention and stability, without screw retention. Use of the two-piece record base/occlusion rim facilitates convenient removal, adjustment, and replacement of the occlusion rim.

Periumbilical pseudoxanthoma elasticum associated with chronic renal failure and angioid streaks--apparent regression with hemodialysis

Pseudoxanthoma elasticum (PXE) is a heritable connective tissue disease involving progressive fragmentation and dystrophic calcification of elastic fibers. Periumbilical disease as the exclusive site of cutaneous involvement is most commonly seen in the rare entity termed periumbilical perforating pseudoxanthoma elasticum (PPPXE). Patients with this disorder are generally obese, middle aged, multiparous black women with hypertension. The cutaneous lesions are well-demarcated, hyperpigmented, periumbilical plaques with keratotic papules on the periphery. Extracutaneous manifestations have rarely been described. We describe a patient with periumbilical PXE associated with chronic renal failure and bilateral angioid streaks. Histopathologic examination demonstrated typical calcification of elastic fibers with additional amorphous calcium deposits in the superficial dermis. Transepidermal elimination was not present. Normalization of the serum calcium-phosphate product resulted in regression of the lesions--both clinically and histopathologically. The relation between PPPXE and hereditary PXE is discussed. The role of chronic renal failure in precipitating PPPXE is considered.

Activity of the soft gelatin formulation of saquinavir in combination therapy in antiretroviral-naive patients. NV15355 Study Team

OBJECTIVE

A Phase II, open-label, randomized, parallel-arm, multicentre trial to compare the antiviral activity and safety of two formulations of saquinavir (SQV), soft gelatin (SQV-SGC) and hard gelatin (SQV-HGC) capsules, in combination with two nucleoside reverse transcriptase inhibitors (NRTI), in antiretroviral-naive, HIV-1-infected individuals.

PARTICIPANTS

A total of 171 people of > or = 13 years, with plasma HIV-1 RNA levels > or = 5000 copies/ml, who had received no protease inhibitor therapy, < or = 4 weeks NRTI therapy and no antiretroviral treatment within 28 days of screening. Eighty-one people were randomized to the SQV-HGC group and 90 to the SQV-SGC group. A total of 148 patients completed 16 weeks of therapy.

INTERVENTION

Therapy for 16 weeks with either SQV-SGC 1200 mg or SQV-HGC 600 mg, both three times a day, in combination with two NRTI.

RESULTS

Using an on-treatment analysis, patients taking SQV-SGC had a larger reduction in plasma HIV-1 RNA than those taking SQV-HGC (-2.0 versus -1.6 log10 copies/ml). Eighty per cent of those on SQV-SGC had < 400 copies HIV RNA/ml, compared with 43% in the SQV-HGC group (P = 0.001). A statistically significant difference in the area under the curve (AUC) values between the SQV-SGC and SQV-HGC arms (-1.7 versus -1.5 log10 copies/ml, respectively; P = 0.0054) was observed when withdrawals prior to week 12, major protocol violators and patients with < 75% compliance were excluded from the analysis; however, the difference between the values for the intent-to-treat population was not significant (P = 0.1929). Adverse events (mostly mild) included diarrhoea and nausea.

CONCLUSIONS

SQV-SGC was generally well tolerated and gave significantly more potent suppression of plasma HIV-1 RNA in antiretroviral-naive patients than SQVHGC.

Intracranial pressure in single-suture craniosynostosis

In this paper, we review the incidence of increased intracranial pressure in children with single-suture craniosynostosis. The major studies in this area are presented, along with their limitations. A rational treatment plan including multidisciplinary team management is recommended. All patients with proven synostosis should be followed closely, whether or not surgery is chosen. Continued clinical and basic science research are necessary to further clarify the ramifications of asymptomatic elevations of intracranial pressure in these patients.

The differential diagnosis of abnormal head shapes: separating craniosynostosis from positional deformities and normal variants

The correct differential diagnosis of an abnormal head shape in an infant or a child is vital to the management of this common condition. Establishing the presence of craniosynostosis, which warrants surgical correction, versus non-synostotic causes of head deformity, which do not, is not always straightforward. This paper deals with three groups of abnormal head shape that may cause diagnostic confusion: the spectrum of metopic synostosis; the dolichocephaly of prematurity versus sagittal synostosis; and the differential diagnosis of plagiocephaly. Special emphasis has been placed on the problem of posterior plagiocephaly, in the light of recent evidence demonstrating that lambdoid synostosis has been overdiagnosed. Metopic synostosis presents as a wide spectrum of severity. Although only severe forms of the disorder are corrected surgically, all cases should be monitored for evidence of developmental problems. The dolichocephalic head shape of preterm infants is non-synostotic in origin and is managed nonsurgically. The scaphocephalic head shape resulting from sagittal synostosis requires surgical intervention for correction. Posterior plagiocephaly may be due to unilambdoid synostosis or positional molding, which have very different clinical and imaging features. True lambdoid synostosis is rare. Most cases of posterior plagiocephaly are due to positional molding, which can usually be managed nonsurgically. Regardless of the suture(s) involved, all children with confirmed craniosynostosis should be monitored for increased intracranial pressure and developmental problems.

Multiple suture synostosis and increased intracranial pressure following repair of single suture, nonsyndromal craniosynostosis

OBJECTIVE

Increased intracranial pressure, frequently associated with closure of multiple cranial sutures, has been reported to occur in 36% of cases following correction of syndromal craniosynostosis. Although much less common, multiple suture closure may occur following repair of single suture, nonsyndromal craniosynostosis and we present cases that concern two such children.

RESULTS

Two children with nonsyndromal craniosynostosis, one metopic and one left-coronal, underwent fronto-orbital advancement at age 3 months. At age 19 months and at age 5 years, respectively, both patients re-presented with headaches, decrease in head circumference percentile, and acceptable cosmetic outcome. Both had computerized tomographic evidence of multiple closed cranial sutures and increased intracranial pressure (ICP) (determined by monitoring). Both patients improved following a cranial expansion procedure.

CONCLUSION

Delayed closure of multiple sutures and resultant increased ICP may occur following correction of nonsyndromal, single suture craniosynostosis. This may be more likely when the initial suture is contiguous with the facial sutures. Children should be followed for many years following craniosynostosis repair with cranial, neurologic, and possibly funduscopic examinations as well as head circumference measurements to detect delayed closure of cranial sutures.

Mandibular distraction osteogenesis in the treatment of upper airway obstruction in children with craniofacial deformities

Over the past 3 years, 16 patients (12 males, 4 females) have undergone mandibular distraction osteogenesis in conjunction with soft-tissue procedures to treat medically refractory obstructive sleep apnea. Thirty distraction devices were placed for bilateral distraction in 14 children and unilateral distraction in 2. The mean age of treatment was 4 years and 8 months (range 14 weeks to 12 years and 8 months). Eight of the patients had failed conventional medical and surgical treatment of obstructive sleep apnea and were considered tracheostomy candidates, whereas the remaining eight had tracheostomies placed shortly after birth for upper airway obstruction. These eight children could not be decannulated by standard protocols. The average distraction distance was 25 mm (range 18 to 35 mm). To date, seven of the eight patients with tracheostomies have been decannulated, and one is still in progress. Clinical improvement in the signs and symptoms of sleep apnea and reduction or elimination of preoperative oxygen requirements occurred in seven of the eight children with medically refractory sleep apnea. Twelve-channel polysomnograms were obtained preoperatively and postoperatively in each of the eight patients without tracheostomies. Respiratory disturbance index decreased from a mean of 7.1 to 1.7 after surgery. Lowest oxygen saturation rose from a mean of 0.70 to 0.89 after surgery. Application of mandibular distraction osteogenesis is an important component in the treatment of obstructive sleep apnea and permits mandibular advancement in the younger child. As more experience is gained with distraction osteogenesis in the treatment of children with obstructive sleep apnea, the role of distraction will become better defined.

Endoscopic surgical treatment for congenital muscular torticollis

Muscular torticollis, if untreated, may result in significant permanent craniofacial deformities. Surgical release of the sternocleidomastoid muscle is recommended for patients who fail to respond to physical therapy. Current surgical techniques all leave noticeable scars, and provide limited exposure. These limitations make complete muscular release and visualization of the spinal accessory nerve difficult. We have applied a new technique of endoscopic release of the sternocleidomastoid muscle in 12 infants and children ages 4 to 18 months and one adolescent with muscular torticollis. Complete muscular release was achieved in all patients with one minor complication. The spinal accessory nerve was preserved in all cases. Our endoscopic approach allows precise division of the muscle fibers and preservation of neurovascular structures, leaving an inconspicuous scar in the scalp.

Well-being at the end of life: Part 2. A research agenda for the delivery of care from the patient's perspective

This article reviews the scientific literature in several areas important to the delivery of palliative care: multicultural issues, education, comprehensive outcome measures and ethics. Most of the research can be classified as fundamental rather than intervention research according to the Cancer Control Framework of the National Cancer Institute of Canada. Desired outcomes of interventions are most often defined from the health care professional's perspective but need to be defined from the patient's perspective. In areas such as multicultural issues and the effect of the volunteer on the patient, there is almost no research. The complexity of studying the best way to deliver palliative care would benefit from the input of colleagues who have experience addressing these issues in other patient populations.

Well-being at the end of life: Part 1. A research agenda for psychosocial and spiritual aspects of care from the patient's perspective

This article reviews the scientific literature concerning psychosocial and spiritual aspects of palliative care for the patient with cancer. It discusses 4 separate areas: the continuum of care, communication, spiritual and psychological issues, and psychotherapeutic and behavioural management of physical symptoms. Most of the research could be classified as fundamental according to the Cancer Control Framework of the National Cancer Institute of Canada. In some areas, even fundamental research was lacking. There is a need for clearer and more relevant definitions of the desired outcomes of interventions and also for the development of appropriate quantitative and qualitative methods. We must determine which interventions can be initiated earlier in the disease trajectory and can provide benefit at the palliative phase. Given the burden of suffering that palliative care aims to address, relatively little research in this area has been conducted.

The use of porous granular hydroxyapatite in secondary orbitocranial reconstruction

The search for the ideal bone-graft substitute has been the focus of many research and clinical studies. Hydroxyapatite is one such material that combines osseointegration with maintenance of implant volume and excellent durability. We present our experience in 29 patients ranging in age from 3 to 22 years (mean age 10.5 years) who underwent secondary orbitocranial reconstruction of large contour defects utilizing porous granular hydroxyapatite. Follow-up ranges from 6 to 72 months (mean 30 months). Indications for secondary surgery included residual bony contour defects of the frontal bone, temporal areas, and superior orbital rims that were present 12 months or more after initial surgery. There was one infection secondary to a chronic seroma necessitating removal of the porous hydroxyapatite, and one patient required revision for underfilling and another for overfilling. Excellent permanent contour improvement was obtained with a smooth skin surface in the remainder of our patients. The contour corrections have been long lasting, without evidence of porous hydroxyapatite resorption or migration.

A longitudinal, statistical study of reoperation rates in craniosynostosis

A prospective, statistical study of reoperation rates was done in the treatment of 167 consecutive children with nonsyndromic and syndromic craniosynostosis over a 6-year period at Scottish Rite Children's Medical Center in Atlanta, Georgia. Mean length of follow-up was 2.8 years, with a range of 3 months to 6 years. Reoperation equal to or exceeding the magnitude of the original procedure occurred in 7 percent of cases. Multiple regression analysis revealed several factors associated with reoperation: Females and children with syndromic synostoses were more likely to require reoperation. Total reoperation rates for syndromic and nonsyndromic synostoses were 27.3 and 5.9 percent, respectively. Age at initial surgery, length of operation, and estimated blood loss did not predict a higher reoperation rate.

Secondary management of congenital and acquired craniomaxillofacial deformities. Individualized treatment planning

Late treatment of craniofacial disorders with concomitant abnormalities of the jaw are the most challenging cases a craniofacial surgeon faces. This article details the principles of preoperative, individualized treatment planning using anthropometric guidelines in a simple but systematic scheme for facial analysis. Seventeen skeletally mature patients without cleft lip and palate or hemifacial microsomia, aged 15 to 65 years, underwent simultaneous orthognathic and craniofacial surgery for a variety of complex craniofacial disorders. The basic clinical approaches outlined in this article permit the surgeon to develop a flexible but accurate treatment plan and proceed with confidence in the management of patients with widespread craniomaxillofacial deformities.