51
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Babaji P, Manjunath BC, Mahesh M, Rani RMV. Hemifacial microsomia: an uncommon craniofacial anomaly—report of two cases from India with review of literature. Indian J Dent 2011. [DOI: 10.1016/s0975-962x(11)60024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Huang XS, Li X, Tan C, Xiao L, Jiang HO, Zhang SF, Wang DM, Zhang JX. Genome-wide scanning reveals complex etiology of oculo-auriculo-vertebral spectrum. TOHOKU J EXP MED 2011; 222:311-8. [PMID: 21150135 DOI: 10.1620/tjem.222.311] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Oculo-auriculo-vertebral spectrum (OAVS) is a common developmental disorder involving first and second pharyngeal arches. Although some family cases and such patients showing chromosomal aberrations suggest that OAVS have a genetic basis, no consistent genetic defects have been recorded at present time. Thus, we conducted genetic studies of a three-generation family with five OAVS patients to identify a causative variant for OAVS. Cytogenetic studies revealed those family members had a normal karyotype and no causative mutations were founded in SALL1 and TCOF1, which known to be responsible for two other syndromes that have clinical overlapping with OAVS. Genotyping with commercially available BeadChips was performed on 13 individuals in the same family, showing no significant difference between the affected and normal members in terms of copy number variations (CNVs) in either number or size and no definitive causative CNV. A total of 8,224 informative autosomal SNPs that are evenly distributed throughout the genome were selected for both parametric and non-parametric linkage analysis. Significant negative LOD scores were obtained for the reported OAVS locus, providing further evidence for genetic heterogeneity of this complex disorder. The highest LOD score of 1.60 was noted on chromosome 15q26.2-q26.3 showing a potential linkage to this locus. The variable phenotypes of the affected members and the failure to identify a causative variant indicate that a complex etiology may be present even in a consanguineous family, which makes it more challenging to ascertain the cause of OAVS in further analysis.
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Affiliation(s)
- Xue-shuang Huang
- Department of Medical Genetics, Huaihua School of Medicine, Huaihua, PR China
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53
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Lin L, Pan B, Jiang H, Zhuang H, Zhao Y, Guo D, Yu D. Mutational analysis of PACT gene in Chinese patients with microtia. Am J Med Genet A 2011; 155A:906-10. [DOI: 10.1002/ajmg.a.32821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Accepted: 02/08/2009] [Indexed: 11/07/2022]
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54
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Skeletal and Connective Tissue Disorders with Anterior Segment Manifestations. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00067-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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55
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Rooryck C, Souakri N, Cailley D, Bouron J, Goizet C, Delrue MA, Marlin S, Lacombe FD, Arveiler B. Array-CGH analysis of a cohort of 86 patients with oculoauriculovertebral spectrum. Am J Med Genet A 2010; 152A:1984-9. [PMID: 20635336 DOI: 10.1002/ajmg.a.33491] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Oculoauriculovertebral spectrum (OAVS) is a clinically and genetically heterogeneous congenital disorder. We performed high density oligonucleotide array-CGH on 86 OAVS patients and identified in 11 patients 12 novel genomic rearrangements (4 deletions and 8 duplications) ranging in size from 2.7 kb to 2.3 Mb. We discuss the potential pathogenic role of these chromosomal aberrations, and describe new candidate regions for OAVS.
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Affiliation(s)
- Caroline Rooryck
- Laboratoire de Génétique Humaine (EA4137), Université Victor Segalen Bordeaux 2, Bordeaux, France.
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Pericentric inversion, inv(14)(p11.2q22.3), in a 9-month old with features of Goldenhar syndrome. Clin Dysmorphol 2010; 19:185-189. [DOI: 10.1097/mcd.0b013e3283359386] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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57
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Vieux-Rochas M, Mantero S, Heude E, Barbieri O, Astigiano S, Couly G, Kurihara H, Levi G, Merlo GR. Spatio-temporal dynamics of gene expression of the Edn1-Dlx5/6 pathway during development of the lower jaw. Genesis 2010; 48:262-373. [PMID: 20333701 DOI: 10.1002/dvg.20625] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The morphogenesis of the vertebrate skull results from highly dynamic integrated processes involving the exchange of signals between the ectoderm, the endoderm, and cephalic neural crest cells (CNCCs). Before migration CNCCs are not committed to form any specific skull element, molecular signals exchanged in restricted regions of tissue interaction are crucial in providing positional identity to the CNCCs mesenchyme and activate the specific morphogenetic process of different skeletal components of the head. In particular, the endothelin-1 (Edn1)-dependent activation of Dlx5 and Dlx6 in CNCCs that colonize the first pharyngeal arch (PA1) is necessary and sufficient to specify maxillo-mandibular identity. Here, to better analyze the spatio-temporal dynamics of this process, we associate quantitative gene expression analysis with detailed examination of skeletal phenotypes resulting from combined allelic reduction of Edn1, Dlx5, and Dlx6. We show that Edn1-dependent and -independent regulatory pathways act at different developmental times in distinct regions of PA1. The Edn1-->Dlx5/6-->Hand2 pathway is already active at E9.5 during early stages of CNCCs colonization. At later stages (E10.5) the scenario is more complex: we propose a model in which PA1 is subdivided into four adjacent territories in which distinct regulations are taking place. This new developmental model may provide a conceptual framework to interpret the craniofacial malformations present in several mouse mutants and in human first arch syndromes. More in general, our findings emphasize the importance of quantitative gene expression in the fine control of morphogenetic events.
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Ongkosuwito EM, de Gijt P, Wattel E, Carels CEL, Kuijpers-Jagtman AM. Dental development in hemifacial microsomia. J Dent Res 2010; 89:1368-72. [PMID: 20739700 DOI: 10.1177/0022034510378425] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hemifacial microsomia (HFM) is a congenital disorder marked by facial asymmetry. Whether facial asymmetry accounts for asymmetrical dental development is unknown. There are few data on dental development relative to mandibular development or severity of HFM, or on development over time. We hypothesized that when mandibular development was severely disturbed, local dental development was also affected. We compared dental development scores between affected and non-affected mandibular sides in patients with HFM (n = 84) and compared these data with those collected from Dutch control children (n = 451). Logistic functions were constructed for dental age over time for all four Pruzansky/Kaban types. The results showed a tendency toward delayed dental development in Pruzansky/Kaban types IIb and III at younger ages. The temporary delay of tooth formation in patients with severe forms of HFM and the distribution of agenic teeth suggest an interaction between mandibular and dental development.
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Affiliation(s)
- E M Ongkosuwito
- Department of Orthodontics, Cleft Palate Team and Craniofacial Team, Erasmus MC-Sophia, University Medical Center, Room Sp 1408, Dr Molewaterplein 60, 3015 GJ Rotterdam, the Netherlands.
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Abstract
BACKGROUND Microtia can be defined as a malformation of the auricle; the varying severity that results can range from mild distortion of the anatomic landmarks to the complete absence of the ear. No specific study has been reported analyzing a family of several generations with bilateral congenital concha-type microtia so far. METHODS The authors obtained medical records and blood samples from a Chinese family with bilateral congenital concha-type microtia that involved 56 members of five generations. There were 20 patients with bilateral congenital concha-type microtia in this pedigree, and 14 patients were still alive. Pedigree analysis and genetic study were carried out to obtain the information in this family. RESULTS With regard to pedigree, 35.7 percent of the members of this family were affected by bilateral congenital concha-type microtia and showed the possibility of autosomal dominant inheritance model. Missense mutation A deletion on site 76234730 in goosecoid gene exon 3 occurred in eight cases in the family, which resulted in a frame shift mutation. CONCLUSIONS The goosecoid gene mutation in exon 3 may be involved in the malformation events in this family. The mutation can be accompanied by potential environmental risk factors, such as exposure to poison and hazardous materials, alcohol abuse, and disease during the mother's pregnancy. Further study is needed to clarify the relationship between the genetic and environmental factors associated with the congenital malformation.
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Huang XS, Xiao L, Li X, Xie Y, Jiang HO, Tan C, Wang L, Zhang JX. Two neighboring microdeletions of 5q13.2 in a child with oculo-auriculo-vertebral spectrum. Eur J Med Genet 2010; 53:153-8. [PMID: 20346424 DOI: 10.1016/j.ejmg.2010.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 03/15/2010] [Indexed: 11/15/2022]
Abstract
We describe a patient with multiple congenital anomalies, including hemifacial microsomia, asymmetric macrostomia, dysplastic mandible, multiple preauricular tags, atresia of the external auricular canal, and vertebral anomalies, which coincide with oculo-auriculo-vertebral spectrum. G-banding ( approximately 850 band level) showed a normal 46, XY karyotype. A genome-wide screen for copy number variations (CNVs) using single nucleotide polymorphism (SNP) arrays revealed a 1Mb and a 167 kb deletion both on chromosome 5q13.2, which were absent in the parents and in 27 controls. Sixteen genes were located in the deleted region, including BIR1C and OCLN, which are involved in apoptosis. Haploinsufficiency of these genes may be contributing to the phenotype in this patient. To our knowledge, there are no previous reports of this 5q13.2 deletion in a patient with oculo-auriculo-vertebral spectrum.
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Affiliation(s)
- Xue-shuang Huang
- Department of Histology and Embryology, School of Basic Medical Science, Central South University, Changsha, PR China.
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61
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Rooryck C, VuPhi Y, Souakri N, Burgelin I, Saura R, Lacombe D, Arveiler B, Taine L. Characterization of a de novo balanced translocation t(9;18)(p23;q12.2) in a patient with oculoauriculovertebral spectrum. Eur J Med Genet 2010; 53:104-7. [PMID: 20132917 DOI: 10.1016/j.ejmg.2010.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 01/20/2010] [Indexed: 10/19/2022]
Abstract
We report a patient presenting with oculoauriculovertebral spectrum and a de novo balanced reciprocal translocation t(9;18)(p23;q12.2). Physical mapping of the translocation breakpoints by fluorescent in situ hybridization showed that the breakpoints are located in two regions encompassing gene deserts. An additional paternally inherited duplication in 18p11.23p11.31 was identified by array-CGH. We discuss the possible involvement of these chromosomal abnormalities in OAVS.
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Affiliation(s)
- Caroline Rooryck
- Laboratoire de Génétique Humaine (EA4137), Université Victor Segalen Bordeaux 2, France.
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Zhang QG, Zhang J, Yu P, Shen H. Environmental and genetic factors associated with congenital microtia: a case-control study in Jiangsu, China, 2004 to 2007. Plast Reconstr Surg 2009; 124:1157-1164. [PMID: 19935299 DOI: 10.1097/prs.0b013e3181b454d8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The objectives of this study were to filter out the environmental and genetic risk factors in microtia patients and to demonstrate the relationship between environmental and inherited factors in congenital microtia. METHODS A case-control study was carried out in 121 congenital microtia patients and 152 controls. Epidemiologic data related to environmental exposure were gathered through personal interviews with the target group. Polymerase chain reaction and DNA sequence analysis were performed to analyze the Gsc gene and BMP5 gene mutation in the case and control groups. The logistic regression model was used to analyze environmental and genetic risk factors and their relationships to microtia. RESULTS The main risk factors were disease during pregnancy (odds ratio, 5.890; 95 percent CI, 2.358 to 14.715), toxicity exposure during pregnancy (odds ratio, 4.764; 95 percent CI, 1.659 to 13.680), and resident area (odds ratio, 5.114; 95 percent CI, 2.086 to 12.535). The synthetic attributable risks amount to 0.7185. As to the Gsc gene, six of these patients had a same-sense mutation C-->T on 197 bp in exon 2; a missense mutation on A-->G 125 bp in exon 3 occurred in two cases; and amino acid changes from glutamic acid to glutamine. A heterozygosity on 196 TTT-->ACA resulting in missense mutation was detected in four patients, causing the amino acid to change from phenylalanine to threonine in BMP5 maternal peptide gene. However, no mutations were detected in the control subjects. CONCLUSIONS The results suggested that both environmental and genetic factors contribute to congenital microtia. The Gsc gene and the BMP5 maternal peptide gene may act as the predisposing genes of microtia. Further research is needed to clarify the relationship between the risk factors and microtia.
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Affiliation(s)
- Qing-Guo Zhang
- Beijing, China From the Plastic Surgery Hospital, Chinese Academy of Medical Science
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63
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Passos-Bueno MR, Ornelas CC, Fanganiello RD. Syndromes of the first and second pharyngeal arches: A review. Am J Med Genet A 2009; 149A:1853-9. [PMID: 19610085 DOI: 10.1002/ajmg.a.32950] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Our aim in this review is to discuss currently known mechanisms associated with three important syndromes of the first and second pharyngeal arches: Treacher Collins syndrome (TCS), Oculo-auriculo-vertebral syndrome (AOVS) and Auriculo-Condylar syndrome (ACS) or question mark ear syndrome. TCS and ACS are autosomal dominant diseases, with nearly complete penetrance and wide spectrum of clinical variability. The phenotype of the latter has several overlapping features with OAVS, but OAVS may exist in both sporadic and autosomal dominant forms. Mutations in the TCOF1 gene are predicted to cause premature termination codons, leading to haploinsuficiency of the protein treacle and causing TCS. Low amount of treacle leads ultimately to a reduction in the number of cranial neural crest cells migrating to the first and second pharyngeal arches. Other than TCS, the genes associated with ACS and OAVS are still unknown. The first locus for ACS was mapped by our group to 1p21-23 but there is genetic heretogeneity. Genetic heterogeneity is also present in OAVS. Based on the molecular analysis of balanced translocation in an OAVS patient, it has been suggested that abnormal expression of BAPX1 possibly due to epigenetic disregulation might be involved with the etiology of OAVS. Involvement of environmental events has also been linked to the causation of OAVS. Identification of factors leading to these disorders are important for a comprehensive delineation of the molecular pathways underlying the craniofacial development from the first and the second pharyngeal arches, for genetic counseling and to open alternative strategies for patient treatment.
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Affiliation(s)
- Maria Rita Passos-Bueno
- Centro de Estudos do Genoma Humano, Departamento de Genética e Biologia Evolutiva, Instituto de Biociências, Universidade de São Paulo, Brazil.
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Goodin K, Prucka S, Woolley AL, Kohlhase J, Smith RJ, Grant J, Robin NH. Familial transmission of oculoauriculovertebral spectrum (Goldenhar syndrome) is not due to mutations in either EYA1 or SALL1. Am J Med Genet A 2009; 149A:535-8. [DOI: 10.1002/ajmg.a.32673] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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65
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Ou Z, Martin DM, Bedoyan JK, Cooper ML, Chinault AC, Stankiewicz P, Cheung SW. Branchiootorenal syndrome and oculoauriculovertebral spectrum features associated with duplication ofSIX1,SIX6, andOTX2resulting from a complex chromosomal rearrangement. Am J Med Genet A 2008; 146A:2480-9. [DOI: 10.1002/ajmg.a.32398] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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66
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Callier P, Faivre L, Thauvin-Robinet C, Marle N, Mosca AL, D'Athis P, Guy J, Masurel-Paulet A, Joly L, Guiraud S, Teyssier JR, Huet F, Mugneret F. Array-CGH in a series of 30 patients with mental retardation, dysmorphic features, and congenital malformations detected an interstitial 1p22.2-p31.1 deletion in a patient with features overlapping the Goldenhar syndrome. Am J Med Genet A 2008; 146A:2109-15. [PMID: 18629884 DOI: 10.1002/ajmg.a.32447] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Genosensor Array 300 (Abbott) is a multiplex platform for array-based comparative genomic hybridization that detects unbalanced genomic aberrations including whole chromosome gains/losses, microdeletions, duplications and unbalanced subtelomeric rearrangements. A series of 30 patients with unexplained mental retardation, dysmorphic features, congenital abnormalities and normal high resolution karyotype and FISH subtelomeric studies were analyzed using Genosensor Array 300 array-CGH. We identified a chromosomal aberration in one patient with an interstitial 1p31.1 deletion. FISH analysis with BACs specific probes of the 1p region confirmed the interstitial 1p22.2-p31.1 deletion. The patient was a 20-year-old man with short stature, facial dysmorphism including asymmetry, scoliosis, severe psychomotor delay and an epibulbar dermoid cyst. The phenotype was compatible with Goldenhar syndrome despite the absence of asymmetric ears. This observation is of interest since it could be a clue in the search for the genes responsible for Goldenhar syndrome. This study demonstrates the utility of the array-CGH technology in detecting interstitial deletions.
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Affiliation(s)
- P Callier
- Département de Génétique, Hôpital Le Bocage, Dijon, France.
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Strömland K, Miller M, Sjögreen L, Johansson M, Joelsson BME, Billstedt E, Gillberg C, Danielsson S, Jacobsson C, Andersson-Norinder J, Granström G. Oculo-auriculo-vertebral spectrum: associated anomalies, functional deficits and possible developmental risk factors. Am J Med Genet A 2008; 143A:1317-25. [PMID: 17506093 DOI: 10.1002/ajmg.a.31769] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Swedish patients with the oculo-auriculo-vertebral (OAV) spectrum participated in a prospective multidisciplinary investigation. The aims of the study were to describe their systemic and functional defects, especially autism spectrum disorders, and to search for possible etiologic risk factors. Available medical records were studied and the mothers answered a questionnaire on history of prenatal events. A clinical examination evaluating systemic findings, vision, hearing, speech, oral and swallowing function, and neuropsychiatric function, especially autism, was made. Eighteen patients, (11 males, 7 females) aged 8 months to 17 years with OAV were studied. Most frequent systemic malformations included, ear abnormalities (100%), ocular malformations (72%), vertebral deformities (67%), cerebral anomalies (50%), and congenital heart defects (33%). Functional defects consisted of hearing impairment (83%), visual impairment (28%), both visual and hearing impairment (28%), difficulties in feeding/eating (50%), speech (53%), mental retardation (39%), and severe autistic symptoms (11%). Three children were born following assisted fertilization (two intracytoplasmatic sperm injection, one in vitro fertilization), two mothers reported early bleedings, and six (33%) mothers had smoked during pregnancy.
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Affiliation(s)
- Kerstin Strömland
- Department of Ophthalmology, The Sahlgrenska Academy at Göteborg University, Göteborg, Sweden.
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68
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Auriculo-condylar syndrome: mapping of a first locus and evidence for genetic heterogeneity. Eur J Hum Genet 2007; 16:145-52. [DOI: 10.1038/sj.ejhg.5201955] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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69
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Klockars T, Suutarla S, Kentala E, Ala-Mello S, Rautio J. Inheritance of microtia in the Finnish population. Int J Pediatr Otorhinolaryngol 2007; 71:1783-8. [PMID: 17868909 DOI: 10.1016/j.ijporl.2007.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Revised: 07/31/2007] [Accepted: 08/04/2007] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To study the inheritance of microtia in the Finnish population, identify families for genetic linkage analyses and compare the phenotype between sporadic and familial patients. METHODS Retrospective case series and patient questionnaire of 109 microtia patients referred for reconstruction of the earlobe to the Helsinki University Central Hospital during the years 1980-2005. RESULTS 22 out of the 109 patients had a relative with microtia or preauricular tag. The familial and sporadic patients did not differ in microtia phenotype or sex distribution. Urinary system anomalies were statistically more prevalent in familial patients (p<0.01). The analyses of the birthplace of parents or grandparents of familial or sporadic microtia patients resulted in no evidence for founder effect. CONCLUSIONS The prevalence of familial microtia/OAVS in the Finnish population is higher than 20%. The sporadic and familial microtia/OAVS patients do not differ in the phenotype or sex distribution. The mode of inheritance seems to be autosomal dominant with incomplete penetrance.
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Affiliation(s)
- Tuomas Klockars
- Department of Otorhinolaryngology, Kymenlaakso Central Hospital, Kotkantie 41, 48210 Kotka, Finland.
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70
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Goldenhar-Syndrom mit Aplasie des rechten oberen und mittleren Lungenlappens. Monatsschr Kinderheilkd 2007. [DOI: 10.1007/s00112-007-1640-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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71
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Hartsfield JK. Review of the etiologic heterogeneity of the oculo-auriculo-vertebral spectrum (Hemifacial Microsomia). Orthod Craniofac Res 2007; 10:121-8. [PMID: 17651128 DOI: 10.1111/j.1601-6343.2007.00391.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hemifacial microsomia is a congenital asymmetry of the lower face that may be associated with other cranial and extracranial anomalies. The variability of its severity, and wide range of anomalies that have been reported with it in some cases has resulted in these composite manifestations being given a number of names, including oculo-auriculo-vertebral spectrum (OAVS). Etiology is often stated to be a perturbation of embryonic blood flow in the developing region, although other factors may also play a role in some cases. Depending on what is considered to be minimum criteria for affected classification, what is often to be presumed to be a sporadic event in a family may be the more severe manifestation of a familial condition. Etiological factors are clearly heterogeneous, the investigation of which is confounded by not only the lack of a refined affected phenotype, but also the apparent influence of genetic factors in some instances that directly influence phenotype perhaps through alteration of mesodermal development, or indirectly through increased susceptibility to vascular disruption. Future studies likely to advance knowledge in this area will need to incorporate an analysis of who may be minimally affected in families, so that advances in genotyping will have greater power to distinguish genetic factors that may influence OVAS through interaction with environmental factors in particular families. The same genetic-environmental factors and or etiological mechanisms may then be investigated in apparently sporadic cases.
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Affiliation(s)
- J K Hartsfield
- Department of Orthodontics and Oral Facial Genetics, Indiana University School of Dentistry, Indianapolis, IN, USA.
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72
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Abstract
A síndrome oculoauriculovertebral, mais comumente conhecida como síndrome de Goldenhar, pode ser diagnosticada pelo dermatologista. Achados como hipoplasia/aplasia de pavilhão auricular e alterações vertebrais, e a presença de trago acessório encontrados no paciente são elementos-chave para a suspeita da síndrome. Sua identificação é de suma importância dada a possibilidade de outras alterações sistêmicas, com impacto até no prognóstico do paciente. Após a confirmação diagnóstica, é interessante a abordagem multidisciplinar e integral em função da potencial pluralidade de manifestações que podem ocorrer na síndrome.
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Abstract
A patient with atypical Goldenhar syndrome is reported. The characteristic features similar to the other reported cases are facial asymmetry, multiple skin tags, limbal dermoids and posteriorly angulated ear. The atypical intraoral feature is unilateral presence of multiple complex odontomes. The hypotrophy of left hemisphere with localized calcification in the occipital and parietal regions of brain is also an additional finding in this patient.
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Affiliation(s)
- Ashok Kumar Jena
- Dept. of Orthodontics & Dentofacial Orthopedics, RAMA Dental College, Hospital & Research Centre, Lakhanpur, Kanpur-208024, India.
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Wieczorek D, Ludwig M, Boehringer S, Jongbloet PH, Gillessen-Kaesbach G, Horsthemke B. Reproduction abnormalities and twin pregnancies in parents of sporadic patients with oculo-auriculo-vertebral spectrum/Goldenhar syndrome. Hum Genet 2007; 121:369-76. [PMID: 17297623 DOI: 10.1007/s00439-007-0336-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2006] [Accepted: 01/18/2007] [Indexed: 01/16/2023]
Abstract
A great number of case reports on concordant and discordant twins with oculo-auriculo-vertebral spectrum (OAVS) suggest that there might be an association between reproductive abnormalities, twinning and OAVS. The etiology of OAVS is unknown, but may involve epigenetic dysregulation of the oocyte or early embryo. We collected data on fertility and pregnancy outcome of 72 parents of patients with sporadic OAVS. We also evaluated prospective follow-up data on 3.372 fetuses and children conceived by intracytoplasmatic sperm injection (ICSI). Parental age, duration of menstrual cycle and the incidence of spontaneous abortion was not different when compared to the German population. However, there is an excess of parents who have used assisted reproductive techniques (ART; retrospective P = 0.038, prospective P = 0.023) and an excess of twins among naturally conceived patients with OAVS (P = 0.0025). An excess of ART conceptions and monozygotic twinning in OAVS is compatible with the concept of overripeness ovopathy as proposed by Jongbloet (Maandschr Kindergeneeskd 36:352-367, 1968).
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Affiliation(s)
- Dagmar Wieczorek
- Institut für Humangenetik, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45122, Essen, Germany.
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Tasse C, Majewski F, Böhringer S, Fischer S, Lüdecke HJ, Gillessen-Kaesbach G, Wieczorek D. A family with autosomal dominant oculo-auriculo-vertebral spectrum. Clin Dysmorphol 2007; 16:1-7. [PMID: 17159507 DOI: 10.1097/mcd.0b013e328010d313] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Oculo-auriculo-vertebral spectrum (MIM 164210) is a term suggested by Gorlin to summarize the different phenotypic expressions of a continuum that has been known as hemifacial microsomia, Goldenhar syndrome, or first and second branchial arch anomalies. The different terms indicate the extremely variable clinical findings, including especially defects of aural, oral and mandibular development. Additionally, cardiac, renal, skeletal and other anomalies occur. The majority of oculo-auriculo-vertebral spectrum cases are sporadic; nevertheless, several families have been reported with proof of both autosomal dominant and autosomal recessive inheritance. We describe a family with transmission of oculo-auriculo-vertebral spectrum from a mother to her two daughters indicating an autosomal dominant mode of inheritance. Our literature review reveals that patients with autosomal dominant inheritance of oculo-auriculo-vertebral spectrum are more often bilaterally affected than patients with sporadic occurrence of oculo-auriculo-vertebral spectrum. In addition, hearing loss, absent or narrow external auditory canal, anomalies of the mouth and epibulbar dermoids seem to occur less frequently in patients with autosomal dominant oculo-auriculo-vertebral spectrum compared with sporadic oculo-auriculo-vertebral spectrum.
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Affiliation(s)
- Christiane Tasse
- Institute of Human Genetics, University Clinic Essen, Essen Institute of Human Genetics and Anthropology, University of Düsseldorf, Düsseldorf Institute of Human Genetics, University Clinic Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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76
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Richieri-Costa A, Ribeiro LA. Macrostomia, preauricular tags, and external ophthalmoplegia: a new autosomal dominant syndrome within the oculoauriculovertebral spectrum? Cleft Palate Craniofac J 2006; 43:429-34. [PMID: 16854200 DOI: 10.1597/05-060.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE First and second branchial arch involvement during early embryonic development results in a wide spectrum of anomalies that encompass diverse, superimposed, and heterogeneous phenotypes within the so-called oculoauriculovertebral spectrum. Nine members of a Brazilian family presenting typical branchial arch involvement in association with external opthalmoplegia are reported. CONCLUSION Macrostomia or abnormal mouth contour, preauricular tags, and uni- or bilateral ptosis were present in association in several patients. To our knowledge, this is the first report on this type of autosomal dominant condition. Clinical and genetic aspects are discussed.
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Affiliation(s)
- Antonio Richieri-Costa
- Speech-Hearing Genetics Department, Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Bauru, São Paulo, Brazil.
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Yang Y, Guo J, Liu Z, Tang S, Li N, Yang M, Pang Q, Fan F, Bu J, Yuan ST, Xiao X, Chen Y, Zhao K. A locus for autosomal dominant accessory auricular anomaly maps to 14q11.2–q12. Hum Genet 2006; 120:144-7. [PMID: 16775710 DOI: 10.1007/s00439-006-0206-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Accepted: 05/12/2006] [Indexed: 11/27/2022]
Abstract
Accessory auricular anomaly is a small excrescence of skin that contains elastic cartilage on different regions of the helix and the face. Previous work has shown that the genetic trait of some patients with the isolated symptom of accessory auricular anomaly is autosomal dominant. To map the gene for autosomal dominant accessory auricular anomaly (ADAAA), we investigated a Chinese family with 11 affected individuals. We performed linkage analysis with microsatellite markers spanning the whole human-genome in the family. The inheritance pattern of the ADAAA family was autosomal dominant with complete penetrance. Two-point linkage analysis revealed significant maximum LOD scores of 4.20(D14S990 and D14S264, sita = 0) in the family. Haplotype construction and multipoint linkage analysis also confirmed the locus and defined the isolated ADAAA locus to a 9.84 cM interval between the markers D14S283 and D14S297. Our study assigned an isolated ADAAA locus to 14q11.2-q12. This is the first ADAAA locus reported to date.
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Affiliation(s)
- Yongjia Yang
- Tianjin Eye Institute, Tianjin Eye Hospital, Tianjin Medical University, 300020 Tianjin, China
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78
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Fischer S, Lüdecke HJ, Wieczorek D, Böhringer S, Gillessen-Kaesbach G, Horsthemke B. Histone acetylation dependent allelic expression imbalance of BAPX1 in patients with the oculo-auriculo-vertebral spectrum. Hum Mol Genet 2006; 15:581-7. [PMID: 16407370 DOI: 10.1093/hmg/ddi474] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The oculo-auriculo-vertebral spectrum (OAVS) (OMIM % 164210) is a common developmental disorder characterized by hemifacial microsomia, epibulbar tumours, ear malformation and vertebral anomalies. Although rare familial cases suggest that OAVS has a genetic basis, no genetic defect has been identified so far. In a patient with OAVS and a chromosomal translocation t(4;8) we have found that the chromosome 4 breakpoint is 76.4 kb distal to the BAPX1 gene, which plays an essential role in craniofacial development. We did not detect any BAPX1 mutation in 105 patients, but observed a strong allelic expression imbalance (sAEI) in fibroblasts from five of 12 patients, but not in nine normal controls (Fisher's exact test, P=0.038). sAEI was de novo in one patient and inherited in two other patients. Prolonged cell culture or treatment with the histone deacetylase inhibitor Trichostatin A led to reactivation of the downregulated allele. We propose that epigenetic dysregulation of BAPX1 plays an important role in OAVS.
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Affiliation(s)
- Sven Fischer
- Institut für Humangenetik, Universitätsklinikum Essen, 45122 Essen, Germany
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79
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Shaw-Smith C. Oesophageal atresia, tracheo-oesophageal fistula, and the VACTERL association: review of genetics and epidemiology. J Med Genet 2005; 43:545-54. [PMID: 16299066 PMCID: PMC2564549 DOI: 10.1136/jmg.2005.038158] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Oesophageal atresia and/or tracheo-oesophageal fistula are relatively common malformations occurring in approximately 1 in 3500 births. In around half of the cases (syndromic oesophageal atresia), there are associated anomalies, with cardiac malformations being the most common. In the remainder (non-syndromic cases), oesophageal atresia/tracheo-oesophageal fistula occur in isolation. Data from twin and family studies suggest that genetic factors do not play a major role, and yet there are well-defined instances of this malformation where genetic factors clearly are important. This is highlighted by the recent identification of no fewer than three separate genes with a role in the aetiology of oesophageal atresia: those for Feingold syndrome (N-MYC), anophthalmia-oesophageal-genital (AEG) syndrome (SOX2), and CHARGE syndrome (CHD7). Additional support for genetic factors in this malformation comes from chromosomal studies and mouse models. This paper reviews current knowledge of the genetics and epidemiology of the different oesophageal atresia/tracheo-oesophageal fistula syndromes and associations.
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Affiliation(s)
- C Shaw-Smith
- Department of Medical Genetics, Box 134, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK.
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80
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Exclusion of TCOF1 mutations in a case of bilateral Goldenhar syndrome and one familial case of microtia with meatal atresia. Clin Dysmorphol 2005. [PMID: 15770127 DOI: 10.1097/00019605-200504000-00003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A number of different disorders involving first and second branchial arch anomalies have been described as distinct entities, including Treacher-Collins-Franceschetti syndrome, Goldenhar syndrome, Nager syndrome and Miller syndrome. The significant phenotypic overlap between these disorders raises the issue of a common developmental origin. After the identification of mutations in TCOF1 as a general cause of the Treacher-Collins-Franceschetti syndrome, TCOF1 mutations were excluded in patients with unilateral signs of the Goldenhar syndrome spectrum. We also present two rare cases of bilateral Goldenhar syndrome and familial microtia with meatal atresia, respectively, in whom we also excluded TCOF1 mutations. Thus, genetic heterogeneity in different disorders of the first and second branchial arch development is supported.
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81
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Tasse C, Böhringer S, Fischer S, Lüdecke HJ, Albrecht B, Horn D, Janecke A, Kling R, König R, Lorenz B, Majewski F, Maeyens E, Meinecke P, Mitulla B, Mohr C, Preischl M, Umstadt H, Kohlhase J, Gillessen-Kaesbach G, Wieczorek D. Oculo-auriculo-vertebral spectrum (OAVS): clinical evaluation and severity scoring of 53 patients and proposal for a new classification. Eur J Med Genet 2005; 48:397-411. [PMID: 16378924 DOI: 10.1016/j.ejmg.2005.04.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Accepted: 04/22/2005] [Indexed: 01/20/2023]
Abstract
Oculo-auriculo-vertebral spectrum (OMIM164210) is a phenotypically and probably also a genetically heterogeneous disorder, characterized by anomalies of the ear (mostly microtia), hemifacial microsomia, and defects of the vertebral column. Associated clinical findings include anomalies of the eye and brain, and developmental delay. We have evaluated the clinical data and photographs of 53 unrelated patients with OAVS, all presenting with either isolated microtia or preauricular tags in association with hemifacial microsomia as minimal diagnostic criteria; five had a positive family history for OAVS. Based on the main clinical findings and unilateral or bilateral involvement, we have developed a new classification system for OAVS, consisting of six subgroups. There is a statistically significant correlation between the subgroup and number of associated clinical findings, and a statistically significant difference regarding prognosis in uni- and bilaterally affected patients, suggesting that this classification is clinically relevant to the categorization of patients with OAVS. The newly developed scoring system (two points for each main clinical finding and one for each associated clinical finding) presented here, also aids prognosis, especially for delay of motor development and brain anomalies, and statistical analysis revealed significant clustering between different clinical findings of OAVS confirming the clinical impression previously published by several authors.
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Affiliation(s)
- Christiane Tasse
- Institut für Humangenetik, Universitätsklinikum Essen, Hufelandstr. 55, 45122 Essen, Germany
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82
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Hattori Y, Tanaka M, Matsumoto T, Uehara K, Ueno K, Miwegishi K, Ishimoto H, Miyakoshi K, Yoshimura Y. Prenatal diagnosis of hemifacial microsomia by magnetic resonance imaging. J Perinat Med 2005; 33:69-71. [PMID: 15841618 DOI: 10.1515/jpm.2005.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We present a case of hemifacial microsomia, first detected by prenatal sonography and confirmed by ultrafast magnetic resonance (MR) imaging. A 26-year-old patient was referred to our hospital at 20 weeks of gestation because of unilateral right-sided ventriculomegaly and of a possible ventriculoseptal defect (VSD). Our sonographic examination suggested a right orbital hypoplasia and a hemiatrophy of the nose. The ultrafast T2-weighted single-shot fast-spin echo MR imaging, demonstrated a right ear hypoplasia (microtia), a right orbital hypoplasia, and a right renal hypoplasia. Epibulbar dermoid or conjunctival lipodermoid were not recognized. The fetus was prenatally diagnosed as hemifacial microsomia. Termination of pregnancy was performed at 21 weeks gestation, and a male baby weighing 342g was stillborn. The baby showed facial asymmetry, including hemiatrophy of the right nose, and right ear hypoplasia. Autopsy revealed a 2mm area of VSD, agenesis of the right kidney and ureter, pancreatic and renal aberration into right adrenal gland, thymus hypoplasia and an unfixed ascending colon without intestinal malrotation. To the best of our knowledge, this is the first report of prenatal diagnosis for hemifacial microsomia using fetal MR imaging. In our case, fetal MR imaging has evolved into a powerful diagnostic tool, for the accurate prenatal diagnosis.
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Affiliation(s)
- Yoshihisa Hattori
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Japan.
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83
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Sigler MO, Stein J, Zuker R. A rare craniofacial cleft: numbers 7, 2, and 3 clefts accompanied by a single median lip pit. Cleft Palate Craniofac J 2004; 41:327-31. [PMID: 15151449 DOI: 10.1597/02-127.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE A unique case of a unilateral partial Tessier no. 7 cleft accompanied by no. 2 and 3 clefts along with a single median lip pit is presented. The history, genetics, epidemiology, classifications, embryology, pathogenesis, and correction techniques are briefly reviewed. After an extensive review of the literature, we conclude that this particular constellation of anomalies has not previously been described.
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Affiliation(s)
- Michael Orlin Sigler
- University of Sint Eustatius School of Medicine, Sint Eustatius, Netherlands-Antilles
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84
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Josifova DJ, Patton MA, Marks K. Oculoauriculovertebral spectrum phenotype caused by an unbalanced t(5;8)(p15.31;p23.1) rearrangement. Clin Dysmorphol 2004; 13:151-153. [PMID: 15194950 DOI: 10.1097/01.mcd.0000126138.37196.26] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present two siblings with oculoauriculovertebral spectrum phenotype (Goldenhar syndrome) and an unbalanced translocation t(5;8)(p15.31;p23.1) resulting in monosomy for the region 5p15.31 to 5pter and trisomy for 8p23.2 to 8pter region. The father was a carrier of the balanced rearrangement 46,XY,t(5;8)(p15.31;8p23.1). To our knowledge this is the first report of Goldenhar phenotype in association with an unbalanced (5p;8p) translocation.
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Affiliation(s)
- Dragana J Josifova
- Department of Clinical Genetics, St. George's Hospital Medical School, Cranmer Terrace, London, UK
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85
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Wan J, Meara JG, Kovanlikaya A, Nelson MD, Don D. Clinical, radiological, and audiological relationships in hemifacial microsomia. Ann Plast Surg 2003; 51:161-6. [PMID: 12897519 DOI: 10.1097/01.sap.0000058509.87198.ef] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hemifacial microsomia is a craniofacial disorder involving structures derived from the first and second brachial arches. Bony structures, soft tissue, and the facial nerve can all be hypoplastic or absent. In this retrospective study of 70 patients at the Children's Hospital Los Angeles, craniofacial dysmorphology, temporal bone computed tomography, and audiological evaluations were examined. The purpose of this study was to identify further relationships between clinical findings, temporal bone anatomy, and audiological findings in these patients. Significant relationships were identified between total radiographic score and overall clinical findings (p<0.001). Clinical measurements of mandibular hypoplasia were also predictive of temporal computed tomographic findings (p<0.001), whereas clinical ear findings were related specifically to specific temporal bone abnormalities such as hypoplasia of the middle ear (p=0.008) and fusion or absence of ossicles (p<0.001). Interestingly, neither clinical findings nor temporal bone computed tomographic findings were related to either hearing loss type or degree. Audiology should not be deferred on the basis of relatively mild clinical findings.
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86
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Pillay K, Matthews LS, Wainwright HC. Facio-auriculo-vertebral sequence in association with DiGeorge sequence, Rokitansky sequence, and Dandy-Walker malformation: case report. Pediatr Dev Pathol 2003; 6:355-60. [PMID: 14692650 DOI: 10.1007/s10024-003-1124-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Extreme variability of expression is characteristic of the facio-auriculo-vertebral sequence. Sporadic and familial cases have been reported with obvious etiologic heterogeneity. Most reports in the literature are of clinical cases. The purpose of this paper is to present a fetal autopsy case report of the facio-auriculo-vertebral sequence in association with DiGeorge sequence, Rokitansky sequence, and Dandy-Walker malformation. A standard neonatal autopsy was performed on a macerated female fetus, gestational age 29 wk. External examination of the fetus revealed hypoplastic right face, low-set microtic right ear, and macrostomia. Internal examination showed hypoplastic thymus and lungs, a type I truncus arteriosus, and ventricular septal defect. Both kidneys showed evidence of pelvi-ureteric junction obstruction. The ovaries and fallopian tubes were present with an absent uterus and vagina (Rokitansky sequence). In addition, Dandy-Walker malformation was identified. Microscopically, a single hypoplastic parathyroid gland was noted and there was cystic renal dysplasia. We report the sixth case of the facio-auriculo-vertebral sequence in association with Rokitansky sequence and the first case of this sequence in association with Dandy-Walker malformation. In addition, features of DiGeorge sequence were present.
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Affiliation(s)
- Komala Pillay
- Division of Anatomical Pathology, Department of Pathology, University of Cape Town Medical School/Groote Schuur Hospital, Anzio Road, Observatory, 7925 Cape Town, South Africa.
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87
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Abstract
We report a full-term male infant born to nonconsanguinous parents who had clinical features of Goldenhar syndrome and cri du chat syndrome. At birth, the infant was noted to have dysmorphic features with bilateral preauricular tags, rotated ears, bilateral epicanthic folds, a left epibulbar lipodermoid, and an accessory left nipple. After he was assessed for feeding difficulty and tachypnea, he was found to have esophageal atresia with tracheoesophageal fistula. In addition, he had a high-pitched, cat-like cry, characteristic of cri-du-chat syndrome. He also failed a hearing test. Chromosomal analysis and fluorescence in situ hybridisation studies showed an unbalanced karyotype with a terminal deletion of the segment p14 on the short arm of chromosome 5, which is consistent with the cri-du-chat locus. The association of Goldenhar syndrome and cri-du-chat syndrome in this patient suggests that the chromosome 5p14 locus may harbor a gene implicated with Goldenhar syndrome.
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Affiliation(s)
- Yee Fong Choong
- Department of Ophthalmology, University Hospital of Wales, Cardiff, UK
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