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Hu KG, Aral A, Rancu A, Alperovich M. Computerized Surgical Planning for Mandibular Distraction Osteogenesis. Semin Plast Surg 2024; 38:234-241. [PMID: 39118864 PMCID: PMC11305829 DOI: 10.1055/s-0044-1786757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Mandibular distraction osteogenesis is a technically challenging procedure due to complex mandibular anatomy, especially in the treatment of Pierre-Robin Sequence due to variable bone thickness in the infant mandible and the presence of tooth buds. Computerized surgical planning (CSP) simplifies the procedure by preoperatively visualizing critical structures, producing cutting guides, and planning distractor placement. This paper describes the process of using CSP to plan mandibular distraction osteogenesis, including discussion of recent advances in the use of custom distractors.
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Affiliation(s)
- Kevin G. Hu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Ali Aral
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Albert Rancu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michael Alperovich
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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2
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Gyapay R, Ioan I, Thieux M, Guyon A, Ayari S, Hullo E, Franco P, Coutier L. Gas exchange parameters for the prediction of obstructive sleep apnea in infants. J Clin Sleep Med 2024; 20:1059-1067. [PMID: 38372169 PMCID: PMC11217622 DOI: 10.5664/jcsm.11064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 02/20/2024]
Abstract
STUDY OBJECTIVES Sleep laboratory polysomnography is the gold standard for obstructive sleep apnea (OSA) diagnosis in infants, but its access remains limited. Oximetry-capnography is another simple and widely used tool that can provide information on the presence of desaturations and alveolar hypoventilation. However, its reliability is debated. This study aimed at examining its use in determining OSA severity in infants. METHODS This retrospective study was conducted in a sleep unit in a tertiary hospital in infants < 4 months old with clinical signs of OSA or Pierre Robin sequence who underwent a 1-night polysomnography coupled with oximetry-capnography. RESULTS Among the 78 infants included (median [interquartile range] age: 61 [45-89] days at polysomnography), 44 presented with Pierre Robin sequence and 34 presented with isolated airway obstruction. The clinical, sleep, and respiratory characteristics were not significantly different between the 2 subgroups. In the entire cohort, 63.5% had severe OSA. The median obstructive apnea-hypopnea index was 14.5 (7.4-5.9) events/h, peripheral oxygen saturation (SpO2) was 97.4% (96.5-98.1%), and transcutaneous carbon dioxide pressure (PtcCO2) was 41.1 mmHg (38.3-44.9). The optimal threshold to predict an obstructive apnea-hypopnea index > 10 events/h was 6 events/h for an oxygen desaturation index ≥ 3% (sensitivity, 95.7%; specificity, 51.9%) and 2 events/h for an oxygen desaturation index ≥ 4% (sensitivity, 95.7%; specificity, 48.1%). CONCLUSIONS Whereas transcutaneous capnography does not appear to be sufficient in predicting severe OSA in infants < 4 months old with Pierre Robin sequence or clinical signs of OSA, oximetry may be a useful alternative for the screening of severe OSA in infants in the absence of polysomnography. CITATION Gyapay R, Ioan I, Thieux M, et al. Gas exchange parameters for the prediction of obstructive sleep apnea in infants. J Clin Sleep Med. 2024;20(7):1059-1067.
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Affiliation(s)
- Romane Gyapay
- Service de Pneumologie Infantile, Allergologie et Centre De Référence En Mucoviscidose, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Iulia Ioan
- Service d’Explorations Fonctionnelles Pédiatriques, Hôpital d’Enfants, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Marine Thieux
- Service Epilepsie, Sommeil, Explorations Fonctionnelles Neurologiques Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- U1028, Centre de Recherche en Neurosciences de Lyon, Université de Lyon 1, Lyon, France
| | - Aurore Guyon
- Service Epilepsie, Sommeil, Explorations Fonctionnelles Neurologiques Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- U1028, Centre de Recherche en Neurosciences de Lyon, Université de Lyon 1, Lyon, France
| | - Sonia Ayari
- Service de Chirurgie Oto-Rhino-Laryngologie, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Eglantine Hullo
- Service de Pneumologie Infantile, Hôpital Couple-Enfant, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Patricia Franco
- Service Epilepsie, Sommeil, Explorations Fonctionnelles Neurologiques Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- U1028, Centre de Recherche en Neurosciences de Lyon, Université de Lyon 1, Lyon, France
| | - Laurianne Coutier
- Service de Pneumologie Infantile, Allergologie et Centre De Référence En Mucoviscidose, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- Service Epilepsie, Sommeil, Explorations Fonctionnelles Neurologiques Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- U1028, Centre de Recherche en Neurosciences de Lyon, Université de Lyon 1, Lyon, France
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3
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Nino G, Aziz J, Weiss M, Allen M, Lew J, Manrique M, Mantilla-Rivas E, McGrath JL, Rogers GF, Oh AK. Defining Age-related OSA Features in Robin Sequence Using Polysomnographic-based Analyses of Respiratory Arousal Responses and Gas-exchange Parameters. Cleft Palate Craniofac J 2023; 60:142-150. [PMID: 34787016 DOI: 10.1177/10556656211055017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Robin sequence (RS) is a leading cause of obstructive sleep apnea (OSA) in newborns. Most studies have focused on understanding anatomic factors leading to OSA and changes in apnea-hypopnea index (AHI) on polysomnography (PSG) beyond the neonatal period. This study aims to define age-related OSA features between patients with RS, without RS and healthy controls using PSG-based analyses of respiratory arousal responses and gas-exchange parameters. DESIGN Retrospective comparison of PSG features in a total of 48 children encompassing three groups: (a) infants with RS (n = 24, <1-year old), (b) non-RS older children (1-2 years old) with severe OSA (obstructive AHI (OAHI) of ≥10 events; n = 12), and (c) control infants and children (0-2 years old) without sleep apnea (OAHI ≤1.5/h, n = 12). We examined OSA sleep-stage specific and position-specific indexes, and the relationship between OSA severity and respiratory arousal indexes (OAHI/respiratory arousal indexes). RESULTS OSA sleep-stage specific indexes (rapid eye movement [REM] vs non-REM[NREM]) as well as position-specific indexes (supine vs nonsupine) were similar in individuals with and without RS. Relative to the non-RS groups, infants with RS have more sustained hypoxemia (time with SpO2 < 90%) and reduced arousal responses to OSA demonstrated by higher OAHI/respiratory arousal indexes. OAHI/respiratory arousal indexes significantly correlated with the severity of hypoxemia in infants with RS. CONCLUSION Infants with RS and OSA show reduced arousal responses to apneic events, which correlates with higher hypoxemia severity. OAHI/respiratory arousal indexes in RS may identify high-risk individuals with upper airway obstruction and reduced arousal protective responses.
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Affiliation(s)
- Gustavo Nino
- Division of Pulmonary and Sleep Medicine, 8404Children's National Hospital, Washington, DC, USA
| | - Julia Aziz
- Division of Pulmonary and Sleep Medicine, 8404Children's National Hospital, Washington, DC, USA
| | - Miriam Weiss
- Division of Pulmonary and Sleep Medicine, 8404Children's National Hospital, Washington, DC, USA
| | - Michelle Allen
- Division of Pulmonary and Sleep Medicine, 8404Children's National Hospital, Washington, DC, USA
| | - Jenny Lew
- Division of Pulmonary and Sleep Medicine, 8404Children's National Hospital, Washington, DC, USA
| | - Monica Manrique
- Division of Plastic and Reconstructive Surgery, 8404Children's National Hospital, Washington, DC, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, 8404Children's National Hospital, Washington, DC, USA
| | - Jennifer L McGrath
- Division of Plastic and Reconstructive Surgery, 8404Children's National Hospital, Washington, DC, USA
| | - Gary F Rogers
- Division of Plastic and Reconstructive Surgery, 8404Children's National Hospital, Washington, DC, USA
| | - Albert K Oh
- Division of Plastic and Reconstructive Surgery, 8404Children's National Hospital, Washington, DC, USA
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Ratanakorn W, Brockbank J, Ishman S, Tadesse DG, Hossain MM, Simakajornboon N. The maturation changes of sleep-related respiratory abnormalities in infants with laryngomalacia. J Clin Sleep Med 2021; 17:767-777. [PMID: 33295276 DOI: 10.5664/jcsm.9046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) and central sleep apnea (CSA) are common in infants with laryngomalacia. The purpose of this study was to evaluate developmental changes in sleep-related breathing disorders over time in infants with laryngomalacia and understand the effect of supraglottoplasty (SGP) and nonsurgical treatment. METHODS This is a retrospective review of infants with laryngomalacia who had at least 2 diagnostic polysomnography studies performed from January 2000 and May 2015. We included infants who had either OSA or CSA. Comparison of sleep and respiratory parameters by age group (0-6, 6-12, and >12 months old) was performed in both SGP and non-SGP groups using a mixed-effect regression model. A log-normal mixed model was used to explore the changes in sleep and respiratory parameters with age. The time to resolution of CSA and OSA was analyzed using nonparametric survival analysis. RESULTS A total of 102 infants were included; 57 had only OSA and 45 had both CSA and OSA. There were significant decreases in apnea-hypopnea index, obstructive index, central apnea index, and arousal index with increasing age in both SGP and non-SGP groups. The mean age at resolution of CSA (central apnea index < 5) was 7.60 months old for SGP and 12.57 months old for non-SGP (P < .05). There were no significant differences in the mean age at resolution of OSA (obstructive index < 1; 35.18 [SGP] vs 41.55 months [non-SGP]; P = .60) between SGP and non-SGP groups. Infants with neurologic disease, congenital anomalies, or genetic syndromes required significantly more time to resolve OSA (28.12 [normal] vs 53.13 [neurological] vs 59.53 months [congenital anomalies and genetic]; P < .01). CONCLUSIONS Both OSA and CSA improve in infants with laryngomalacia with increasing age regardless of SGP. The mechanism underlying these changes may involve airway growth and maturation of respiratory control. Time to resolution of OSA is affected by the presence of neurologic diseases, congenital anomalies, and genetic syndromes. Further studies are needed to confirm these findings and to evaluate long-term outcomes in this population.
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Affiliation(s)
- Woranart Ratanakorn
- Sleep Center, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, Chonburi Hospital, Chonburi, Thailand
| | - Justin Brockbank
- Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Stacey Ishman
- Sleep Center, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dawit G Tadesse
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Md Monir Hossain
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Narong Simakajornboon
- Sleep Center, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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5
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Abbas DB, Lavin C, Fahy EJ, Choo H, Truong MT, Bruckman KC, Khosla RK, Lorenz HP, Momeni A, Wan DC. A Systematic Review of Mandibular Distraction Osteogenesis Versus Orthodontic Airway Plate for Airway Obstruction Treatment in Pierre Robin Sequence. Cleft Palate Craniofac J 2021; 59:365-376. [PMID: 34075816 DOI: 10.1177/10556656211011886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Mandibular distraction osteogenesis (MDO) is frequently performed to address airway obstruction in patients with Pierre Robin sequence (PRS), though more recently the technique of orthodontic airway plating (OAP) has gained traction. We aimed to evaluate OAP compared to MDO for airway obstruction in PRS. DESIGN A systematic literature search across PubMed, Embase, and Google Scholar identified all studies published in English, which involved MDO or any form of OAP as treatments for PRS. All relevant articles were reviewed in detail and reported on, adhering to PRISMA guidelines. MAIN OUTCOME MEASURES Airway (tracheostomy avoidance, decannulation rate), feeding (full oral feeding tolerance). RESULTS Literature search identified 970 articles, of which 42 MDO studies and 9 OAP studies met criteria for review. A total of 1159 individuals were treated with MDO, and 322 individuals were treated with OAP. Primary outcomes appear similar for MDO and OAP at face value; however, this must be interpreted with different pretreatment contexts in mind. CONCLUSIONS Orthodontic airway plating may be considered for airway obstruction in PRS, as some airway-related and feeding-related outcomes appear similar with MDO, per existing evidence in the literature. However, since PRS severity differed between studies, OAP cannot be uniformly considered a replacement for MDO. Further research is required to more comprehensively assess these treatment modalities inclusive of metrics that allow for direct comparison.
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Affiliation(s)
- Darren B Abbas
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Christopher Lavin
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Evan J Fahy
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - HyeRan Choo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Mai Thy Truong
- Division of Pediatric Otolaryngology, Department of Otolaryngology, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Karl C Bruckman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Rohit K Khosla
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - H Peter Lorenz
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Arash Momeni
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Derrick C Wan
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
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6
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Abstract
Pierre Robin sequence is defined by the clinical triad: mandibular hypoplasia, glossoptosis, and airway obstruction. Mandibular distraction osteogenesis (MDO) is a standard treatment of Robin sequence associated with severe airway obstruction and is the only intervention that directly corrects the underlying anatomic pathologic condition. Compared with tongue-lip adhesion, MDO has demonstrated more success in treating airway obstruction in infants with Pierre Robin sequence, including patients with syndromic diagnoses and concomitant anomalies. This article provides a current, comprehensive review of neonatal mandibular distraction and offers treatment guidelines based on a combined surgical experience of more than 400 patients.
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Affiliation(s)
- Kerry A Morrison
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Medical Center, 222 East 41st Street, New York, NY, 10017, USA
| | - Marcus V Collares
- Rio Grande do Sul Federal University Medical School, Hospital de Clinicas de Porto Alegre, Rio Grande do Sul Federal University, Rua Hilário Ribeiro 202, cj 406, Porto Alegre, Brazil
| | - Roberto L Flores
- Hansjörg Wyss Department of Plastic Surgery, Cleft and Craniofacial Surgery, NYU Langone Health, 222 East 41st Street, 22nd floor, New York, NY, 10017, USA.
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7
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Logjes RJH, MacLean JE, de Cort NW, Poets CF, Abadie V, Joosten KFM, Resnick CM, Trindade-Suedam IK, Zdanski CJ, Forrest CR, Kruisinga FH, Flores RL, Evans KN, Breugem CC. Objective measurements for upper airway obstruction in infants with Robin sequence: what are we measuring? A systematic review. J Clin Sleep Med 2021; 17:1717-1729. [PMID: 33960296 DOI: 10.5664/jcsm.9394] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Identifying optimal treatment for infants with Robin sequence (RS) is challenging due to substantial variability in the presentation of upper airway obstruction (UAO) in this population. Objective assessments of UAO and treatments are not standardized. A systematic review of objective measures of UAO was conducted as step towards evidence based clinical decision making for RS. METHODS A literature search was performed in Pubmed and Embase databases (1990-2020) following PRISMA-guidelines. Articles reporting on RS and UAO-treatment were included if the following objective measures were studied: oximetry, polysomnography and blood gas. Quality was appraised by methodological index for non-randomized studies (MINORS, range:0-24). RESULTS A total of 91 articles met inclusion criteria. Mean MINORS-score was 7.1 (range:3-14). Polysomnography was most frequently used (76%) followed by oximetry (20%) and blood gas (11%). Sleep position of the infant was reported in 35% of studies, with supine position most frequently, and monitoring time in 42%, including overnight recordings in more than half. Of 71 studies that evaluated UAO-interventions, the majority used polysomnography (90%), of which 61% did not specify the polysomnography technique. Reported polysomnography metrics included oxygen saturation (61%), apnea-hypopnea index (52%), carbon dioxide levels (31%), obstructive-apnea-hypopnea index (27%), and oxygen-desaturation-index (16%). Only 42 studies reported indications for UAO-intervention, with oximetry and polysomnography thresholds used equally (both 40%). In total, 34 distinct indications for treatment were identified. CONCLUSIONS This systematic review demonstrates a lack of standardization, interpretation and reporting of assessment and treatment indications for UAO in RS. An international, multidisciplinary consensus protocol is needed to guide clinicians on optimal UAO assessment in RS.
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Affiliation(s)
- Robrecht J H Logjes
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Department of Plastic and Reconstructive Surgery, Amsterdam University Medical Centre, location AMC & VU, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Joanna E MacLean
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Alberta, Canada
| | - Noor W de Cort
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Christian F Poets
- Department of Neonatology, Tuebingen University Hospital, Tuebingen, Germany
| | - Véronique Abadie
- Department of General Pediatrics, Necker University Hospital, Paris, France
| | - Koen F M Joosten
- Department Pediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Cory M Resnick
- Department of Plastic and Oral Surgery, Harvard Medical School Boston, Boston Children's Hospital, USA
| | - Ivy K Trindade-Suedam
- Sleep Unit, Laboratory of Physiology, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Brazil
| | - Carlton J Zdanski
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina, Chapel Hill, USA
| | - Christopher R Forrest
- Division Plastic and Reconstructive Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Frea H Kruisinga
- Department of Pediatrics, Amsterdam University Medical Centre, location AMC, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Roberto L Flores
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, USA
| | - Kelly N Evans
- Department of Pediatrics, University of Washington, Seattle Children's Craniofacial Center, Seattle, USA
| | - Corstiaan C Breugem
- Department of Plastic and Reconstructive Surgery, Amsterdam University Medical Centre, location AMC & VU, Emma Children's Hospital, Amsterdam, The Netherlands
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8
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Varadarajan S, Balaji TM, Raj AT, Gupta AA, Patil S, Alhazmi TH, Alaqi HAA, Al Omar NEM, Almutaher SABA, Jafer AA, Hedad IA. Genetic Mutations Associated with Pierre Robin Syndrome/Sequence: A Systematic Review. Mol Syndromol 2021; 12:69-86. [PMID: 34012376 DOI: 10.1159/000513217] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/20/2020] [Indexed: 01/16/2023] Open
Abstract
Pierre Robin syndrome/sequence (PRS) is associated with a triad of symptoms that includes micrognathia, cleft palate, and glossoptosis that may lead to respiratory obstruction. The syndrome occurs in 2 forms: nonsyndromic PRS (nsPRS), and PRS associated with other syndromes (sPRS). Studies have shown varying genetic mutations associated with both nsPRS and sPRS. The present systematic review aims to provide a comprehensive collection of published literature reporting genetic mutations in PRS. Web of Science, PubMed, and Scopus were searched using the keywords: "Pierre Robin syndrome/sequence AND gene mutation." The search resulted in 208 articles, of which 93 were excluded as they were duplicates/irrelevant. The full-text assessment led to the further exclusion of 76 articles. From the remaining 39 articles included in the review, details of 324 cases were extracted. 56% of the cases were sPRS, and 22% of the cases were associated with other malformations and the remaining were nsPRS. Genetic mutations were noted in 30.9% of the 300 cases. Based on the review, SOX9 was found to be the most common gene associated with both nsPRS and sPRS. The gene mutation in sPRS was specific to the associated syndrome. Due to the lack of original studies, a quantitative analysis was not possible. Thus, future studies must focus on conducting large-scale cohort studies. Along with generating data on genetic mutation, future studies must also conduct pedigree analysis to assess potential familial inheritance, which in turn could provide valuable insights into the etiopathogenesis of PRS.
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Affiliation(s)
- Saranya Varadarajan
- Department of Oral Pathology and Microbiology, Sri Venkateswara Dental College and Hospital, Chennai, India
| | | | - A Thirumal Raj
- Department of Oral Pathology and Microbiology, Sri Venkateswara Dental College and Hospital, Chennai, India
| | - Archana A Gupta
- Department of Oral Pathology and Microbiology, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth, Pune, India
| | - Shankargouda Patil
- Division of Oral Pathology, Department of Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, Jazan University, Jazan, Saudi Arabia
| | - Tariq Hassan Alhazmi
- Community Dental Unit, College of Dentistry, Jazan University, Jazan, Saudi Arabia
| | | | - Neda Essa M Al Omar
- Community Dental Unit, College of Dentistry, Jazan University, Jazan, Saudi Arabia
| | | | | | - Ismaeel Abker Hedad
- Community Dental Unit, College of Dentistry, Jazan University, Jazan, Saudi Arabia
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9
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Sleep-Disordered Breathing and Airway Assessment Using Polysomnography in Pediatric Patients With Craniofacial Disorders. J Craniofac Surg 2020; 31:720-726. [PMID: 32049904 DOI: 10.1097/scs.0000000000006249] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Children with cleft and craniofacial conditions commonly present with concurrent airway anomalies, which often manifest as sleep disordered breathing. Craniofacial surgeons and members of the multidisciplinary team involved in the care of these patients should appreciate and understand the scope of airway pathology as well as the proper means of airway assessment. This review article details the prevalence and assessment of sleep disordered breathing in patients with craniofacial anomalies, with emphasis on indications, limitations, and interpretation of polysomnography.
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10
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Kurian C, Ehsan Z. Sleep and respiratory outcomes in neonates with Pierre Robin sequence: a concise review. Sleep Breath 2019; 24:1-5. [DOI: 10.1007/s11325-019-01876-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/15/2019] [Accepted: 06/11/2019] [Indexed: 11/28/2022]
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11
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Ehsan Z, Kurian C, Weaver KN, Pan BS, Huang G, Hossain MM, Simakajornboon N. Longitudinal Sleep Outcomes in Neonates With Pierre Robin Sequence Treated Conservatively. J Clin Sleep Med 2019; 15:477-482. [PMID: 30853035 DOI: 10.5664/jcsm.7680] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/03/2019] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Although Pierre Robin sequence (PRS) is a major cause of neonatal obstructive sleep apnea (OSA), longitudinal studies reporting evolution with age are lacking. This study aimed to describe changes in sleep-related respiratory parameters and sleep architecture in neonates with PRS treated conservatively (defined for this paper as treatment without tracheostomy or mandibular distraction). METHODS A retrospective, 14-year, single-institution study of neonates with PRS who underwent diagnostic polysomnography (PSG) and at least one follow-up PSG. Those treated with surgery were excluded. Data were analyzed using a mixed-effects model with subject-specific random effect. RESULTS In a cohort of 21 infants, baseline PSG (mean age 0.9 ± 0.7 months) showed a total apnea-hypopnea index (AHI) of 24.3 ± 3.6 events/h, obstructive apnea-hypopnea index (OAHI) of 13.4 ± 1.6 events/h, central apnea index of 10.2 ± 3.2 events/h, and an arousal index of 28.3 ± 1.3 events/h (variables reported as least square means ± standard error of the mean). There was a significant reduction in AHI, OAHI, arousal index, and percentage of REM sleep with advancing age. Although 71% of infants achieved full oral feeds by one month of age, some infants remained underweight during infancy. CONCLUSIONS These neonates with PRS and OSA, treated conservatively, had an improvement in OAHI with advancing age with the median age of OSA resolution at 15 months. Factors potentially responsible include craniofacial growth and maturational changes of respiratory control. Further studies are necessary to determine the long-term effects of conservative management on growth and neurodevelopmental outcomes in these infants.
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Affiliation(s)
- Zarmina Ehsan
- Division of Pulmonary and Sleep Medicine, Children's Mercy-Kansas City, Kansas City, Missouri
| | - Christopher Kurian
- University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - K Nicole Weaver
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brian S Pan
- Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Guixia Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Md M Hossain
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Narong Simakajornboon
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Pierre Robin sequence: A comprehensive narrative review of the literature over time. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2018; 119:419-428. [DOI: 10.1016/j.jormas.2018.05.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/11/2018] [Indexed: 12/12/2022]
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Zaffanello M, Antoniazzi F, Tenero L, Nosetti L, Piazza M, Piacentini G. Sleep-disordered breathing in paediatric setting: existing and upcoming of the genetic disorders. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:343. [PMID: 30306082 PMCID: PMC6174189 DOI: 10.21037/atm.2018.07.13] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/16/2018] [Indexed: 12/11/2022]
Abstract
Childhood obstructive sleep apnea syndrome (OSAS) is characterized by anatomical and functional upper airway abnormalities as pathophysiological determinants, and clinical symptoms are frequently clear. OSAS is widely described in rare genetic disorders, such as achondroplasia, Down syndrome, Prader-Willi syndrome, Pierre Robin sequence, and mucopolysaccharidosis. Craniofacial and upper airway involvement is frequently morbid conditions. In children with genetic diseases, the clinical symptoms of OSAS are often slight or absent, and related morbidities are usually more severe and can be observed at any age. The present review is aimed to updating the discoveries regarding OSAS on Achondroplasia, Down syndrome, Prader-Willi syndrome, Pierre Robin sequence, Sickle cell disease, or encountered in our clinical practice (Ehlers-Danlos syndrome, Ellis-van Creveld syndrome, Noonan syndrome). Two additional groups of genetic disorders will be focused (mucopolysaccharidoses and osteogenesis imperfecta). The flowing items are covered for each disease: (I) what is the pathophysiology of OSAS? (II) What is the incidence/prevalence of OSAS? (III) What result from the management and prognosis? (IV) What are the recommendations? Considering the worries of OSAS, such as inattention and behavioural problems, daytime sleepiness, failure to thrive, cardiological and metabolic complications, the benefit of a widespread screening and the treatment in children with genetic diseases is undoubtful. The goals of the further efforts can be the inclusion of various genetic diseases into guidelines for the screening of OSAS, updating the shreds of evidence based on the research progression.
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Affiliation(s)
- Marco Zaffanello
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Franco Antoniazzi
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Laura Tenero
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Luana Nosetti
- Department of Pediatrics, University of Insubria, Varese, Italy
| | - Michele Piazza
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Giorgio Piacentini
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
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Mandibular advancement for pediatric obstructive sleep apnea: A systematic review and meta-analysis. J Craniomaxillofac Surg 2018; 46:1296-1302. [DOI: 10.1016/j.jcms.2018.04.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 04/25/2018] [Accepted: 04/26/2018] [Indexed: 11/23/2022] Open
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Association of polysomnographic parameters with clinical symptoms severity grading in Robin sequence patients: a cohort nested cross-sectional study. Sleep Med 2018; 43:96-99. [PMID: 29482821 DOI: 10.1016/j.sleep.2017.11.1136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 10/06/2017] [Accepted: 11/05/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the association of polysomnographic parameters with clinical symptom severity in Robin sequence (RS) patients. METHODS All patients diagnosed as presenting with RS at Hospital de Clínicas de Porto Alegre from October 2012 to June 2016 were enrolled. They were classified as isolated RS, RS-plus, and syndromic RS. Polysomnography (PSG) was performed, except for those patients in need of respiratory support. Symptom severity was evaluated as defined by the Cole et al. CLASSIFICATION Ordinal OR (for the chance of increase in one grade on the clinical severity scale) and R2 (determination coefficient from ordinal logistic regression) were computed from data analysis. RESULTS A total of 80 participants were enrolled in the study. Fifty-five of these were able to undergo polysomnography. Worsening of the studied PSG parameters was associated with increase in clinical severity grading, as follows: desaturation index (OR 1.27; 95% CI; 1.07-1.51; R2 = 19.8%; p = 0.006); apnea/hypopnea Index (OR 1.13; 95% CI; 1.01-1.26; R2 = 12.5%; p = 0.02); sleep mean oxygen saturation (OR 0.16; 95% CI; 0.05-0.52; R2 = 22.6%; p = 0.002); oxygen saturation nadir (OR 0.73; 95% CI; 0.56-0.96; R2 = 10.0%; p = 0.02); percentage of time with oxygen saturation <90% (OR 9.49; 95% CI; 1.63-55.31, R2 = 37.6%; p = 0.012); and percentage of time presenting with obstruction (OR 2.5; 95% CI; 1.31-4.76; R2 = 25.1%; p = 0.006). CONCLUSIONS Polysomnography parameters were associated with severity of clinical manifestations in patients with RS. Oxyhemoglobin saturation-based parameters had surprisingly significant R2 values. Therefore, those parameters, which have traditionally been undervalued in other clinical settings, should also be assessed in the polysomnographic evaluation of RS patients.
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Aaronson NL, Jabbour N. Can telemetry data obviate the need for sleep studies in Pierre Robin Sequence? Int J Pediatr Otorhinolaryngol 2017; 100:238-241. [PMID: 28802380 DOI: 10.1016/j.ijporl.2017.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/09/2017] [Accepted: 07/12/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study looks to correlate telemetry data gathered on patients with Pierre Robin Sequence (PRS) with sleep study data. Strong correlation might allow obstructive sleep apnea (OSA) to be reasonably predicted without the need for sleep study. METHODS Charts from forty-six infants with PRS who presented to our children's hospital between 2005 and 2015 and received a polysomnogram (PSG) prior to surgical intervention were retrospectively reviewed. Correlations and scatterplots were used to compare average daily oxygen nadir, overall oxygen nadir, and average number of daily desaturations from telemetry data with apnea-hypopnea index (AHI) and oxygen nadir on sleep study. Results were also categorized into groups of AHI ≥ or <10 and oxygen nadir ≥ or <80% for chi-squared analysis. RESULTS Our data did not show significant correlations between telemetry data and sleep study data. Patients with O2 nadir below 80% on telemetry were not more likely to have an O2 nadir below 80% on sleep study. Patients with an average O2 nadir below 80% did show some correlation with having an AHI greater than 10 on sleep study but this relationship did not reach significance. Of 22 patients who did not have any desaturations on telemetry below 80%, 16 (73%) had an AHI >10 on sleep study. CONCLUSIONS In the workup of infants with PRS, the index of suspicion is high for OSA. In our series, telemetry data was not useful in ruling out severe OSA. Thus our data do not support forgoing sleep study in patients with PRS and concern for OSA despite normal telemetry patterns.
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Affiliation(s)
- Nicole Leigh Aaronson
- Children's Hospital of Pittsburgh of UPMC, Department of Otolaryngology, University of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 7th Floor, Pittsburgh, PA 15224, United States.
| | - Noel Jabbour
- Children's Hospital of Pittsburgh of UPMC, Department of Otolaryngology, University of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 7th Floor, Pittsburgh, PA 15224, United States
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Almajed A, Viezel-Mathieu A, Gilardino MS, Flores RL, Tholpady SS, Côté A. Outcome following Surgical Interventions for Micrognathia in Infants with Pierre Robin Sequence: A Systematic Review of the Literature. Cleft Palate Craniofac J 2017; 54:32-42. [DOI: 10.1597/15-282] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Tongue-lip adhesion (TLA), mandibular distraction osteogenesis (MDO), and subperiosteal release of the floor of the mouth (SPRFM) are the most commonly performed surgical procedures to treat severe airway obstruction in infants born with Pierre Robin sequence (PRS). Objectives To determine the rate of failure of each type of procedure, in terms of mortality and the need for tracheostomy, and to determine what proportion of infants have significant airway obstruction postoperatively as determined by polysomnography (PSG) and compare the data by procedure type. Method A comprehensive literature search (1981 through June 2015) was done of the National Library of Medicine database using PubMed. Extracted data included diagnosis, type of surgery, and outcome including mortality, need for postoperative tracheostomy and details of PSG. Persistence of significant airway obstruction was defined as an apnea-hypopnea index > 15 events/h on PSG. Results Both mortality rate and need for tracheostomy were low for all procedures. Many studies lacked sufficient detail to identify significant airway obstruction postoperatively. In studies with sufficient data, MDO was associated with the lowest percentage of significant airway obstruction postprocedure (3.6%) compared to 50% for infants who underwent TLA. Insufficient PSG data was available for patients who were treated with SPRFM. Conclusions There is a paucity of objective PSG data to definitively assess postoperative airway outcomes for PRS. MDO appears to be the most effective technique based on the available PSG data. Standardized use of PSG may lead to better identification and treatment of patients at risk for suboptimal airway outcomes postoperatively.
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Affiliation(s)
- Athari Almajed
- Pediatric Pulmonology Division, Mubarak Al Kabeer Hospital, Kuwait
| | | | - Mirko S. Gilardino
- McGill University, Plastic Surgeon, Division of Plastic and Reconstructive Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Canada
| | - Roberto L. Flores
- New York University, Plastic Surgeon, Department of Plastic Surgery, NYU Langone Medical Center, New York, New York
| | - Sunil S. Tholpady
- Indiana University School of Medicine, Plastic Surgeon, Division of Plastic Surgery, Indiana University Medical Center, Indianapolis, Indiana
| | - Aurore Côté
- McGill University, Pediatric Pulmonologist, Division of Respiratory Medicine, The Montreal Children's Hospital, Montreal, Canada
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Management and outcomes of obstructive sleep apnea in children with Robin sequence, a cross-sectional study. Clin Oral Investig 2016; 21:1971-1978. [PMID: 27889866 PMCID: PMC5487824 DOI: 10.1007/s00784-016-1985-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 10/20/2016] [Indexed: 11/23/2022]
Abstract
Objective The objective of this cross-sectional study is to assess the prevalence, course, and management of obstructive sleep apnea (OSA) in children with Robin sequence (RS) aged 1–18 years. Materials and methods A cross-sectional study was conducted in 63 children aged 1 to18 years with RS. Patient data were collected on baseline characteristics and management. OSA was evaluated by polysomnography. Results Sixty-three children with RS were included (median age 8.0 years) and divided into two groups based on the initial treatment: prone positioning or respiratory support. Respiratory support was more often indicated in children with a non-isolated RS (p < 0.05). At cross section, in the prone positioning group (n = 32), one child was diagnosed with OSA. In the respiratory support group (n = 31), 13 children (42 %) had respiratory problems of whom 10 needed respiratory support. Conclusions Between the age of 1 and 18 years, almost one out of four children with RS still has respiratory problems. Children with RS, who can be treated with prone positioning only as an infant, are not likely to develop obstructive airway problems at a later age. In contrast, children who need respiratory support early after birth are at risk of continuing or re-developing OSA after the age of 1 year. Clinical relevance This study shows that those who need respiratory support at an early age need careful monitoring until adulthood.
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Bangiyev JN, Traboulsi H, Abdulhamid I, Rozzelle A, Thottam PJ. Sleep architecture in Pierre-Robin sequence: The effect of mandibular distraction osteogenesis. Int J Pediatr Otorhinolaryngol 2016; 89:72-5. [PMID: 27619032 DOI: 10.1016/j.ijporl.2016.07.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/13/2016] [Accepted: 07/14/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Pierre-Robin Sequence (PRS), a triad of micro/retrognathia, glossoptosis, and upper airway obstruction, usually in conjunction with a cleft palate is frequently associated with significant morbidity. Mandibular distraction osteogenesis (MDO) is an effective treatment modality to address retroglossal upper airway obstruction by increasing the anterior-posterior diameter of the infant airway. Although MDO has been shown to improve the apnea-hypopnea index (AHI) in children with PRS, the consequences of MDO on other aspects of infant sleep, including hypercapnea, hypoxia, the REM to Non-REM ratio, as well as its effect on central and mixed apneas has not been investigated with an adequate sample size. OBJECTIVE To characterize the effect of MDO on key components of sleep architecture in infants with PRS. METHODS Charts from 32 infants with PRS that were addressed with MDO at our tertiary-care children's hospital were retrospectively reviewed. Of these, 26 infants (57.7% male; mean age = 4.1 weeks, SD = 5.0) had pre- and post-operative polysomnograms (PSG). Paired samples t-tests were used to compare pre- and post- MDO sleep architecture mean score differences. RESULTS Among the 26 infants, 73.1% demonstrated severe pre-MDO sleep apnea (AHI > 10). Several aspects of sleep architecture were found to improve post-operatively. Significant improvements were found in AHI (30.3 vs. 8.7; t = 4.1, p < 0.001), obstructive apneas (79.3 vs. 5.8; t = 4.0, p < 0.001), hypopneas (48.1 vs. 22.1; t = 2.2, p = 0.040), time spent below 90% SpO2 (3.9% vs. 0.7%; t = 3.3, p = 0.003), and lowest SpO2 nadir (75.4% vs. 82.9%; 3.4, p = 0.002). In addition, a marginally significant improvement was found for mixed apnea (6.3 vs. 1.6; t = 1.99, p = 0.058). CONCLUSION MDO improves several sleep architecture parameters in this sample of infants with PRS. Statistically significant improvement was seen in obstructive apneas, hypopneas, AHI, obstructive AHI, and several indicators of hypoxia during sleep.
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Affiliation(s)
- J N Bangiyev
- Detroit Medical Center Department of Otolaryngology-HNS, Detroit, MI, USA; Children's Hospital of Michigan, Department of Pediatric Otolaryngology, Detroit, MI, USA.
| | - H Traboulsi
- Children's Hospital of Michigan, Department of Pediatric Otolaryngology, Detroit, MI, USA
| | - I Abdulhamid
- Children's Hospital of Michigan, Department of Pediatric Pulmonology and Sleep Medicine, Detroit, MI, USA
| | - A Rozzelle
- Children's Hospital of Michigan, Department of Plastic Reconstructive Surgery, Detroit, MI, USA
| | - P J Thottam
- Children's Hospital of Michigan, Department of Pediatric Otolaryngology, Detroit, MI, USA; MPENTA, Michigan Pediatric ENT Associates, Detroit, MI, USA; Department of Pediatric Otolaryngology, Beaumont Children's Hospital, Detroit, MI, USA
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Cielo CM, Montalva FM, Taylor JA. Craniofacial disorders associated with airway obstruction in the neonate. Semin Fetal Neonatal Med 2016; 21:254-62. [PMID: 26997148 PMCID: PMC4967408 DOI: 10.1016/j.siny.2016.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In infants with craniofacial disorders, upper airway obstruction is one of the primary causes for morbidity and mortality in the neonatal period. Infants with craniofacial disorders, including Pierre Robin sequence, are at high risk for obstructive sleep apnea syndrome. Because of the complexity of their care, these neonates are usually followed by a multidisciplinary team to ensure timely evaluation and optimal treatment. In addition to history and physical examination, clinical evaluation may include genetic testing, imaging, endoscopy, and polysomnography. There are various treatment options, both surgical and non-surgical, that may be used depending on clinical assessment, underlying condition, and severity of disease. Recent advances have led to better assessment and treatment of these patients, but many questions remain. This review outlines the available literature pertaining to the evaluation and management of upper airway obstruction in the neonate with craniofacial conditions, with a particular focus on Pierre Robin sequence.
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Affiliation(s)
- Christopher M. Cielo
- Perelman School of Medicine at the University of Pennsylvania, Division of Pulmonary Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Corresponding author. Address: 9NW50, Main Hospital, The Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA. Tel.: +1 267-426-5842; fax: +1 267-426-9234. (C.M. Cielo)
| | | | - Jesse A. Taylor
- Perelman School of Medicine at the University of Pennsylvania, Division of Plastic and Reconstructive Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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