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Wright M, Knowles RL, Cortina-Borja M, Javadpour S, Mehendale FV, Urquhart DS. Airway management in infants with Robin sequence in the United Kingdom and Ireland: A prospective population-based study. Pediatr Pulmonol 2024. [PMID: 39031808 DOI: 10.1002/ppul.27140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 05/06/2024] [Accepted: 06/07/2024] [Indexed: 07/22/2024]
Abstract
OBJECTIVE There is currently no consensus about managing upper airway obstruction (UAO) in infants with Robin sequence (RS), in terms of treatment efficacy or clinical outcomes. This study describes UAO management in UK/Ireland, and explores relationships between patient characteristics, UAO management, and clinical outcomes in the first 2 years of life. METHODS Active surveillance of RS throughout UK/Ireland via the British Paediatric Surveillance Unit and nationally commissioned cleft services. Clinical data were collected at initial notification and 12-month follow-up. RESULTS 173 infants with RS were identified, of which 47% had additional congenital anomalies or an underlying syndrome (non-isolated RS). Two-thirds (n = 119) required an airway intervention other than prone positioning: non-surgical in 84% and surgical (tracheostomy) in 16%. Nasopharyngeal airway (NPA) was the most common intervention, used in 83% (n = 99) for median 90 days (IQR 136). Surgical UAO management was associated with prolonged hospital admission, higher prevalence of neurodevelopmental delay (NDD), lower weight-for-age z-scores, and delayed oral feeding. These findings were not attributable to a higher prevalence of non-isolated RS in this group. Although more commonly associated with non-isolated RS, growth faltering was also identified in 48%, and NDD in 18%, of cases of isolated RS. CONCLUSIONS In UK/Ireland, most infants with RS are managed with NPA, and tracheostomy is reserved for refractory severe UAO. Clinical outcomes and duration of use indicate that NPA is a safe and feasible first-line approach to UAO. Longitudinal assessment of neurodevelopment and growth is imperative, including in children with isolated RS. Current variations in practice reinforce the need for evidence-based treatment guidelines.
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Affiliation(s)
- Marie Wright
- Division of Paediatric Respiratory Medicine, BC Children's Hospital, Vancouver, Canada
- Department of Paediatrics, University of British Columbia, Vancouver, Canada
- Department of Population, Policy and Practice Research and Teaching, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Rachel L Knowles
- Department of Population, Policy and Practice Research and Teaching, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Mario Cortina-Borja
- Department of Population, Policy and Practice Research and Teaching, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Sheila Javadpour
- Division of Paediatric Respiratory Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Felicity V Mehendale
- Global Cleft Lip and Palate Research Programme, Global Health Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Don S Urquhart
- Division of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Children and Young People, Edinburgh, UK
- Department of Child Life and Health, University of Edinburgh, Edinburgh, UK
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Wiechers C, Sowula J, Kreutzer K, Schwarz CE, Weismann C, Krimmel M, Poets CF, Koos B. Prospective cohort study on facial profile changes in infants with Robin sequence and healthy controls. World J Pediatr 2024; 20:581-589. [PMID: 38578561 PMCID: PMC11239728 DOI: 10.1007/s12519-024-00797-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/04/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Various conservative and surgical approaches exist to treat Robin sequence (RS), but their effects on facial profile and mandibular catch-up growth are unclear. A functional treatment concept, used in our centre for 25 years, includes an individualized palatal plate with a velo-pharyngeal extension and intensive feeding training. METHODS We performed a prospective study to objectively describe facial profiles in infants with RS treated with the above concept. Infants with isolated RS were admitted to our tertiary perinatal and national referral centre for craniofacial malformations between May 2018 and Nov 2019. Infants with RS received 3D-photographs during clinically indicated visits. Healthy controls were recruited from Dec 2018 to Sep 2019 and received 3D-photographs every 3 months. The digitally measured jaw index (JI), defined as alveolar overjet (O) x maxillary arch (U)/mandibular arch (L), and the soft tissue reference points A'-point, Nasion', B'-point angle (ANB'), describing the relative position of maxilla to mandible, were evaluated. Linear mixed models were used to examine time trajectories in JI and ANB'. RESULTS A total of 207 3D images, obtained in 19 infants with RS and 32 controls, were analysed. JI and ANB' decreased over time in both groups [for JI - 0.18 (95% CI - 0.25 to - 0.10); for ANB': - 0.40° per month [(95% CI - 0.48 to - 0.32)]] but remained lower in controls [for JI - 2.5 (95% CI - 3.2 to - 1.8); for ANB'-1.7° (95% CI - 2.4 to - 1.0)]. Also, the ANB' model showed a significant effect of the interaction term diagnosis x age. CONCLUSIONS Based on longitudinal 3D images, we describe changes in objective parameters of facial profile in infants with and without RS during the first year of life. Our findings indicate catch-up growth in infants treated for RS. Video Abstract.
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Affiliation(s)
- Cornelia Wiechers
- Department of Neonatology, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany
- Center for Cleft Lip, Palate and Craniofacial Malformations, Tuebingen University Hospital, Tuebingen, Germany
| | - Julian Sowula
- Department of Neonatology, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany
| | - Karen Kreutzer
- Department of Neonatology, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany
- Center for Cleft Lip, Palate and Craniofacial Malformations, Tuebingen University Hospital, Tuebingen, Germany
| | - Christoph E Schwarz
- Department of Neonatology, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany
| | - Christina Weismann
- Center for Cleft Lip, Palate and Craniofacial Malformations, Tuebingen University Hospital, Tuebingen, Germany
- Department of Orthodontics, Tuebingen University Hospital, Tuebingen, Germany
| | - Michael Krimmel
- Center for Cleft Lip, Palate and Craniofacial Malformations, Tuebingen University Hospital, Tuebingen, Germany
- Department of Oral and Maxillofacial Surgery, Tuebingen University Hospital, Tuebingen, Germany
| | - Christian F Poets
- Department of Neonatology, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany.
- Center for Cleft Lip, Palate and Craniofacial Malformations, Tuebingen University Hospital, Tuebingen, Germany.
| | - Bernd Koos
- Center for Cleft Lip, Palate and Craniofacial Malformations, Tuebingen University Hospital, Tuebingen, Germany
- Department of Orthodontics, Tuebingen University Hospital, Tuebingen, Germany
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Baek SH, Hong H, Yang IH. Growth Patterns of the Maxillomandibular Complex in Preadolescent Patients With Pierre-Robin Sequence Using Cluster Analysis and Longitudinal Follow-Up Cephalometric Data. J Craniofac Surg 2024:00001665-990000000-01612. [PMID: 38771200 DOI: 10.1097/scs.0000000000010187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 03/05/2024] [Indexed: 05/22/2024] Open
Abstract
OBJECTIVE To investigate the growth patterns of the maxillomandibular complex in preadolescent patients with Pierre-Robin sequence (PRS). METHODS The samples consisted of 20 preadolescent PRS patients who had cleft palate and did not undergo growth-modification therapy or surgical intervention [6 boys and 14 girls; mean age of lateral cephalograms taken, 8.8 y (T1) and 13.7 y (T2)]. According to k-means cluster analysis, four clusters were defined over 3 major groups at T1: (1) Both very retrusive maxilla and mandible group: Cluster-4 [n=4, very large gonial angle, very low facial height ratio (FHR)] and Cluster-1 (n=5, small gonial angle, normal FHR); (2) Retrusive maxilla and very retrusive mandible group (Cluster-3, n=7, normal gonial angle, very low FHR); and (3) Both normal maxilla and mandible group (Cluster-2, n=4, very large gonial angle, low FHR). Seven angular and ratio variables [sella-nasion-A point (SNA), sella-nasion-B point (SNB), A point-nasion-B point (ANB), saddle angle, gonial angle, mandibular-body-length/anterior-cranial-base-length (MBL/ACBL), and FHR] at T1 and T2 and growth change from T1 to T2 were investigated. RESULTS At T1, SNA, SNB, saddle angle, gonial angle (all P<0.05), and FHR (P<0.01) showed significant difference among 4 clusters. At T2, SNA, SNB and gonial angle (all P<0.05) still showed significant difference among 4 clusters. During T1 to T2, there was no significant change in variables at each cluster except an increase in MBL/ACBL in Cluster-1 and FHR in Cluster-3 (all P<0.05). CONCLUSIONS Preadolescent PRS patients exhibited diverse skeletal phenotypes at T1, which did not change significantly from their original skeletal patterns by growth during T1 to T2.
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Affiliation(s)
- Seung-Hak Baek
- Dental Research Institute and Department of Orthodontics, School of Dentistry, Seoul National University
| | - Hyunseung Hong
- Department of Orthodontics, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Il-Hyung Yang
- Dental Research Institute and Department of Orthodontics, School of Dentistry, Seoul National University
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Sullivan NAT, Lachkar N, Don Griot JPW, Kruisinga FH, Leeuwenburgh-Pronk WG, Broers CJM, Breugem CC. Respiratory outcomes after cleft palate closure in Robin sequence: a retrospective study. Clin Oral Investig 2024; 28:247. [PMID: 38602599 PMCID: PMC11008067 DOI: 10.1007/s00784-024-05647-w] [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: 06/12/2023] [Accepted: 04/01/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVES There is a paucity of information about the possible risk factors that could identify patients with Robin sequence (RS) who are more prone to developing obstructive airway complications after palate closure. This study aimed to compare the respiratory complication rates in patients with RS and isolated cleft palate (ICP). MATERIALS AND METHODS In this retrospective study, we reviewed the medical records of 243 consecutive patients with RS and ICP who were treated at Amsterdam University Medical Centers over the past 25 years. We collected preoperative data on previous treatment, diagnostic findings, surgical technique, weight, and presence of congenital anomalies. RESULTS During cleft palate closure, patients with RS were older (11.9 versus 10.1 months; p = 0.001) and had a lower gestational age than those with ICP (37.7 versus 38.5 weeks; p = 0.002). Patients with RS had more respiratory complications (17 versus 5%; p = 0.005), were more often non-electively admitted to the pediatric intensive care unit (PICU) (13 versus 4.1%; p = 0.022), and had a longer hospital stay duration (3.7 versus 2.7 days; p = 0.011) than those with ICP. The identified risk factors for respiratory problems were a history of tongue-lip-adhesion (TLA) (p = 0.007) and a preoperative weight of < 8 kg (p = 0.015). Similar risk factors were identified for PICU admission (p = 0.015 and 0.004, respectively). CONCLUSIONS The possible risk factors for these outcomes were a low preoperative weight and history of TLA. Closer postoperative surveillance should be considered for patients with these risk factors. CLINICAL RELEVANCE Identifying risk factors for respiratory complications could provide clinicians better insight into their patients and allows them to provide optimal care for their patients.
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Affiliation(s)
- Nathaniel A T Sullivan
- Amsterdam UMC, Department of Plastic Surgery, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands.
| | - Nadia Lachkar
- Amsterdam UMC, Department of Plastic Surgery, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - J Peter W Don Griot
- Amsterdam UMC, Department of Plastic Surgery, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Frea H Kruisinga
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
| | - Wendela G Leeuwenburgh-Pronk
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
| | - Chantal J M Broers
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
| | - Corstiaan C Breugem
- Amsterdam UMC, Department of Plastic Surgery, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, The Netherlands
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Knechtel P, Weismann C, Poets CF. Caring for Infants with Robin Sequence Treated with the Tübingen Palatal Plate: A Review of Personal Practice. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1628. [PMID: 37892291 PMCID: PMC10605622 DOI: 10.3390/children10101628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023]
Abstract
The Tübingen Palatal Plate (TPP) is a minimally invasive yet highly effective functional orthodontic treatment for upper airway obstruction in infants with Robin Sequence (RS). It consists of a palatal plate to cover the cleft and a velar extension that shifts the root of the tongue forward. We review our practical experience with this approach. First, upon admission, our local orthodontists perform an (3-D) intraoral scan of the maxilla. Based on the scan data, the TPP is manufactured in a semi-digital workflow. The length and angulation of its extension is checked via awake laryngoscopy and the effectiveness confirmed by a sleep study. Plates are kept in place by adhesive cream. When inserting the TPP, the tip of the tongue must be visible. Next, metal fixation bows should be secured to the forehead using tape and elastic bands. Plates are removed daily for cleaning, and the oral mucosa is then checked for pressure marks. Feeding training (initially only via finger feeding) may even start before plate insertion. Breathing often normalizes immediately once the plate is inserted. For isolated RS, we have never had to perform a tracheostomy. This has largely been possible through our highly dedicated and competent team, particularly the nursing staff, and the early involvement of parents.
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Affiliation(s)
- Petra Knechtel
- Department of Neonatology, Tübingen University Hospital, 72076 Tübingen, Germany
| | - Christina Weismann
- Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, 72076 Tübingen, Germany
- Department of Orthodontics, Tübingen University Hospital, 72076 Tübingen, Germany
| | - Christian F. Poets
- Department of Neonatology, Tübingen University Hospital, 72076 Tübingen, Germany
- Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, 72076 Tübingen, Germany
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6
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The management of upper airway obstruction in Pierre Robin Sequence. Paediatr Respir Rev 2023; 45:11-15. [PMID: 35987882 DOI: 10.1016/j.prrv.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/24/2022]
Abstract
Pierre Robin Sequence (PRS) is defined by a constellation of characteristics including micrognathia, glossoptosis and airway obstruction. PRS can occur in isolation or can be associated with syndromes and another anomalies. Airway obstruction and feeding difficulties are the major presenting issues, and the severity of the condition ranges from mild, with minimal to no symptoms, to severe, with overt obstruction resulting in apnoeas, severe respiratory distress and cyanosis. The presence of airway obstruction can result in obstructive sleep apnoea and abnormalities in gas exchange, as well as exacerbation of already present feeding difficulties and failure to thrive, secondary to mismatch of caloric intake to energy usage associated with increased effort of breathing. Management of airway obstruction for infants with PRS varies between centres. This paper explores the surgical and non-surgical management options available, their effectiveness and pitfalls in children with PRS. Despite the pros and cons of each management option, it is evident that resource availability and multidisciplinary clinical support are key factors to successful management.
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7
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Sullivan NAT, Smit JA, Lachkar N, Logjes RJH, Kruisinga FH, Reinert S, Persson M, Davies G, Breugem CC. Differences in analysis and treatment of upper airway obstruction in Robin sequence across different countries in Europe. Eur J Pediatr 2023; 182:1271-1280. [PMID: 36633656 DOI: 10.1007/s00431-022-04781-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 01/13/2023]
Abstract
The goal of this study was to explore the availability of diagnostic and treatment options for managing upper airway obstruction (UAO) in infants with Robin Sequence (RS) in Europe. Countries were divided in lower- (LHECs, i.e., PPP per capita < $4000) and higher-health expenditure countries (HHECs, i.e., PPP per capita ≥ $4000). An online survey was sent to European healthcare professionals who treat RS. The survey was designed to determine the availability of diagnostic tools such as arterial blood gas analysis (ABG), pulse oximetry, CO2 analysis, polysomnography (PSG), and sleep questionnaires, as well as to identify the used treatment options in a specific center. Responses were received from professionals of 85 centers, originating from 31 different countries. It was equally challenging to provide care for infants with RS in both LHECs and HHECs (3.67/10 versus 2.65/10, p = 0.45). Furthermore, in the LHECs, there was less access to ABG (85% versus 98%, p = 0.03), CO2 analysis (45% versus 70%, p = 0.03), and PSG (54% versus 93%, p < 0.01). There were no significant differences in the accessibility concerning pulse oximetry, sleep questionnaires, home saturation monitoring, nasopharyngeal tubes, Tuebingen plates, and mandibular distraction. Conclusion: This study demonstrates a large difference in available care for infants with RS throughout Europe. LHECs have less access to diagnostic tools in RS when compared to HHECs. There is, however, no difference in the availability of treatment modalities between LHECs and HHECs. What is Known: • Patients with Robin sequence (RS) require complex and multidisciplinary care. They can present with moderate to severe upper airway obstruction (UAO). There exists a large variety in the use of diagnostics for both UAO treatment indications and evaluations. In most cases, conservative management of UAO in RS is sufficient. Patients with UAO that persist despite conservative management ultimately need surgical intervention. To determine which intervention is best suitable for the individual RS patient, the level of UAO needs to be determined through diagnostic testing. • There is a substantial variation among institutions across Europe for both diagnostics and treatment options in UAO. A standardized, internationally accepted protocol for the assessment and management of UAO in RS could guide healthcare professionals in the timing of assessment and indications to prevent escalation of UAO. Creating such a protocol might be a challenge, as there are large financial differences between countries in Europe (e.g., health expenditure per capita in purchasing power parity in international dollars ranges from $600 to over $8500). What is New: • There is a substantial variation in the availability of objective diagnostic tools between European countries. Arterial blood gas analysis, CO2 analysis and polysomnography are not equally accessible for lower-healthcare expenditure countries (LHECs) compared to higher-healthcare expenditure countries (HHECs). These differences are not only limited to availability; there is also a difference in quality of these diagnostic tools. Surprisingly, there is no difference in access to treatment tools between LHECs and HHECs. • There is national heterogeneity in access to tools for diagnosis and treatment of RS, which suggests centralization of health care, showing that specialized care is only available in tertiary centers. By centralization of care for RS infants, diagnostics and treatment can be optimized in the best possible way to create a uniform European protocol and ultimately equal care across Europe. Learning what is necessary for adequate monitoring could lead to better allocation of resources, which is especially important in a low-resource setting.
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Affiliation(s)
- Nathaniel A T Sullivan
- Department of Plastic Surgery, Amsterdam UMC, Location University of Amsterdam, Emma Childrens Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Johannes A Smit
- Department of Plastic Surgery, Amsterdam UMC, Location University of Amsterdam, Emma Childrens Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Nadia Lachkar
- Department of Plastic Surgery, Amsterdam UMC, Location University of Amsterdam, Emma Childrens Hospital, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Robrecht J H Logjes
- Department of Plastic Surgery, Amsterdam UMC, Location University of Amsterdam, Emma Childrens Hospital, Meibergdreef 9, Amsterdam, The Netherlands
| | - Frea H Kruisinga
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Emma Childrens Hospital, Meibergdreef 9, Amsterdam, The Netherlands
| | - Siegmar Reinert
- Department of Oral and Maxillofacial Surgery, Tuebingen University Hospital, Osianderstrasse 2-8, Tuebingen, 72076, Germany
| | - Martin Persson
- Faculty of Health Science, Kristianstad University, Elmetorpsvägen 15, Kristianstad, 291 39, Sweden
| | - Gareth Davies
- European Cleft Organisation, Verrijn Stuartlaan 28, Rijswijk, ZH, 2288 EL, The Netherlands
| | - Corstiaan C Breugem
- Department of Plastic Surgery, Amsterdam UMC, Location University of Amsterdam, Emma Childrens Hospital, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands.
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Emma Childrens Hospital, Meibergdreef 9, Amsterdam, The Netherlands.
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Long-term speech outcome in patients with Robin sequence after cleft palate repair and tongue-lip adhesion: A 21-year retrospective analysis. J Craniomaxillofac Surg 2023:S1010-5182(23)00012-4. [PMID: 37117117 DOI: 10.1016/j.jcms.2023.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/21/2022] [Accepted: 01/22/2023] [Indexed: 02/05/2023] Open
Abstract
The purpose of this study was to assess the effect of tongue-lip adhesion (TLA) on the long-term speech and articulation outcomes of patients with Robin sequence (RS) after cleft palate repair. Outcomes were compared to those in patients with RS who required positioning alone and to patients with isolated cleft palate (ICP). All consecutive patients with RS (with or without TLA) versus isolated cleft palate (ICP) who underwent cleft palate repair were retrospectively reviewed. Speech and articulation included all assessments between the age of 3-6 years. Secondary speech operations, velopharyngeal insufficiency (VPI), hypernasality, and articulation errors by cleft-type characteristics (CTC), including 4 categories (passive), non-oral, anterior-oral, and posterior-oral. A total of 41 RS patients and 61 ICP patients underwent repair with sufficient follow-up. Of them, 23 patients underwent a TLA at median age of 12 days. Rates of hypernasality (p = 0.004), secondary speech operations (p = 0.004), and posterior oral CTC (p = 0.042) were higher in RS compared to ICP. Isolated RS had speech outcomes similar to those of ICP; however, syndromic RS patients needed more secondary speech operations compared to isolated RS (p = 0.043). TLA-RS patients did not demonstrate differences in speech outcomes or any CTCs (all p > 0.05) compared to non-TLA-RS patients, except for the anterior oral CTC (74% TLA-RS vs 28% non-TLA-RS, p = 0.005). Within the limitations of the study, it seem that TLA does not affect long-term velopharyngeal function in patients with RS. However, TLA-RS patients demonstrated higher rates of anterior-oral CTC, which might be related to a different positioning of the tongue after TLA. Every effort should be taken to treat patients with RS conservatively instead of with TLA because of this demonstrated a negative effect on one type of articulation error. However, if conservative therapy fails, a TLA is still a valuable adjunct in the treatment of RS, and cleft speech pathologists who treat such patients should be more aware of this phenomenon in order to improve long-term articulation outcomes.
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9
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Effert J, Uhlig S, Wiechers C, Quante M, Poets CF, Schulz MC, Reinert S, Krimmel M, Koos B, Weise C. Prospective Evaluation of Children with Robin Sequence following Tübingen Palatal Plate Therapy. J Clin Med 2023; 12:jcm12020448. [PMID: 36675376 PMCID: PMC9864988 DOI: 10.3390/jcm12020448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/19/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND To assess the long-term functional orthodontic outcome of the Tübingen palatal plate (TPP) in children with Robin sequence (RS) in comparison to age- and sex-matched healthy controls. METHODS Between 09/2019 and 10/2020, we performed orthodontic assessments in 41 children at our Department of Orthodontics. Included were patients with RS (17 non-syndromic; four syndromic) and healthy controls (n = 22, average age in both groups 9.9 y). Facial analyses of 2D images, digital study casts and cephalometric measurements were made. RESULTS The orthodontic examinations showed no statistically significant group differences regarding functional extraoral, intraoral and pharyngeal parameters, or in skeletal patterns. The relationship between the upper and lower incisors was significantly increased (overjet 4 (2-10) vs. 3 (0-9) mm; p = 0.01) with a significant deficit in the lower face proportions (Jaw Index 4.15 (1.9-9.6) vs. 2.98 (0-9); p = 0.02; Facial convexity angle 157 (149-173) vs. 159 (149-170); p = 0.01). CONCLUSION Children with RS treated with the TPP showed normal long-term functional orthodontic outcomes, thanks to the functional adaption of the stomatognathic system. However, soft tissue growth did not completely match skeletal growth, resulting in a more convex facial profile.
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Affiliation(s)
- Josephine Effert
- Department of Orthodontics, University Hospital Tuebingen, Osianderstr. 2-8, 72076 Tuebingen, Germany
| | - Simone Uhlig
- Department of Neonatology, University Hospital Tuebingen, Calwerstr. 7, 72076 Tuebingen, Germany
| | - Cornelia Wiechers
- Department of Neonatology, University Hospital Tuebingen, Calwerstr. 7, 72076 Tuebingen, Germany
| | - Mirja Quante
- Department of Neonatology, University Hospital Tuebingen, Calwerstr. 7, 72076 Tuebingen, Germany
| | - Christian F. Poets
- Department of Neonatology, University Hospital Tuebingen, Calwerstr. 7, 72076 Tuebingen, Germany
| | - Matthias C. Schulz
- Department of Oral and Maxillofacial Surgery, University Hospital Tuebingen, Osianderstr. 2-8, 72076 Tuebingen, Germany
| | - Siegmar Reinert
- Department of Oral and Maxillofacial Surgery, University Hospital Tuebingen, Osianderstr. 2-8, 72076 Tuebingen, Germany
| | - Michael Krimmel
- Department of Oral and Maxillofacial Surgery, University Hospital Tuebingen, Osianderstr. 2-8, 72076 Tuebingen, Germany
| | - Bernd Koos
- Department of Orthodontics, University Hospital Tuebingen, Osianderstr. 2-8, 72076 Tuebingen, Germany
| | - Christina Weise
- Department of Orthodontics, University Hospital Tuebingen, Osianderstr. 2-8, 72076 Tuebingen, Germany
- Correspondence: ; Tel.: +49-7071-29-62581
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Poets CF, Wiechers C, Koos B, Muzaffar AR, Gozal D. Pierre Robin and breathing: What to do and when? Pediatr Pulmonol 2022; 57:1887-1896. [PMID: 33580741 DOI: 10.1002/ppul.25317] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/06/2021] [Accepted: 02/09/2021] [Indexed: 01/09/2023]
Abstract
Robin sequence is characterized by mandibular retrognathia, airway obstruction, and glossoptosis; 80%-90% also have a cleft palate. Various treatment approaches exist, and although controlled studies are rare, objective assessment of treatment outcomes that address the leading clinical issues, namely obstructive sleep apnea and failure to thrive, are essential. Sleep-disordered breathing may be detected using cardiorespiratory polygraphy or polysomnography. Pulse oximetry alone may miss infants with frequent obstructive apneas, yet no intermittent hypoxia. Among conservative treatment options, the Tubingen Palatal Plate with a velar extension shifting the tongue base forward is the only approach that corrects the underlying anatomy and that has undergone appropriate evaluation. Of the surgical treatment options, which are not necessarily the first line of therapy, mandibular distraction osteogenesis (MDO) is effective and has been most extensively adopted. Notwithstanding, it is puzzling that MDO is frequently used in some countries, yet hardly ever in others, despite similar tracheostomy rates. Thus, prospective multicenter studies with side-by-side comparisons aimed at identifying an optimal treatment paradigm for this potentially life-threatening condition are urgently needed.
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Affiliation(s)
- Christian F Poets
- Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Neonatology, Tübingen University Hospital, Tübingen, Germany
| | - Cornelia Wiechers
- Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Neonatology, Tübingen University Hospital, Tübingen, Germany
| | - Bernd Koos
- Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Orthodontics, Tübingen University Hospital, Tübingen, Germany
| | - Arshad R Muzaffar
- Division of Plastic Surgery, University of Missouri, Columbia, Missouri, USA
| | - David Gozal
- Department of Child Health, University of Missouri, Columbia, Missouri, USA
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11
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Stefanovski D, Tapia IE, Lioy J, Sengupta S, Mukhopadhyay S, Corcoran A, Cornaglia MA, Cielo CM. Respiratory indices during sleep in healthy infants: A prospective longitudinal study and meta-analysis. Sleep Med 2022; 99:49-57. [DOI: 10.1016/j.sleep.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022]
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12
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Ahn HW. READER'S FORUM. Korean J Orthod 2022; 52:163-164. [PMID: 35580872 PMCID: PMC9117791 DOI: 10.4041/kjod21.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Hyo-Won Ahn
- Department of Orthodontics, School of Dentistry, Kyung Hee University, Seoul, Korea
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13
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van der Plas PPJM, Joosten KFM, Wolvius EB, Koudstaal MJ, Mathijssen IMJ, van Dooren MF, Pullens B. Mandibular distraction to correct severe non-isolated mandibular hypoplasia: The role of drug-induced sleep endoscopy (DISE) in decision making. Int J Pediatr Otorhinolaryngol 2022; 152:110968. [PMID: 34861552 DOI: 10.1016/j.ijporl.2021.110968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/17/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In patients with mandibular hypoplasia, mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction. Drug-induced sleep endoscopy (DISE) provides a dynamic assessment of the upper airway and visualizes anatomical site and cause of airway obstruction. The aim of this study was to evaluate the effect of MDO on tongue-based airway obstruction found by DISE within a non-isolated patient population with severe upper airway obstruction (UAO). Furthermore, we aimed to assess the additional value of DISE in clinical decision making by correlating DISE findings to functional airway outcomes after MDO. METHODS Findings on DISE in children who underwent MDO were retrospectively gathered and evaluated. According to DISE findings, severity of tongue-based obstruction was scored using a 4-step classification similar to the one that is used by Bravo et al.. Intubation conditions were scored according to the Cormack Lehane score (CLS). Pre-and postoperative DISE findings were compared and correlated with functional airway outcomes following MDO. RESULTS In 19 out of 28 MDO procedures, both a pre-and postoperative DISE was available. Tongue-based obstruction scores improved in 13 procedures, which correlated to a functional improvement in seven. Postoperative tongue-based obstruction differed significantly between patients with successful MDO and patients treated unsuccessfully (2.00 ((Interquartile range (IQR) 1.00-2.00) vs. 3.00 (IQR 2.00-4.00), p = 0.028), whereas this difference was not significant for the CLS (1.00 (IQR 1.00-1.50) vs. 2.00 (IQR 1.00-4.00), p = 0.066). If no improvement of tongue-based obstruction was seen, MDO is very unlikely to be successful on the functional airway. CONCLUSIONS DISE provides information on the site and nature of airway obstruction and can visualize the effect of MDO on the severity of tongue-based airway obstruction. Therefore, it can be of additional value in understanding the differences in functional airway outcomes after MDO and aids in deciding appropriate and targeted treatment. Hence, standardized use of DISE, in addition to the clinical assessment of mandibular position and a polysomnography, during MDO management is highly recommended.
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Affiliation(s)
- Pleun P J M van der Plas
- Department of Oral and Maxillofacial Surgery, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Koen F M Joosten
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Eppo B Wolvius
- Department of Oral and Maxillofacial Surgery, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Maarten J Koudstaal
- Department of Oral and Maxillofacial Surgery, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Irene M J Mathijssen
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Marieke F van Dooren
- Department of Clinical Genetics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Bas Pullens
- Department of Otorhinolaryngology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
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14
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Waters KA. Positioning as a conservative treatment option in infants with micrognathia and/or cleft. Semin Fetal Neonatal Med 2021; 26:101282. [PMID: 34742665 DOI: 10.1016/j.siny.2021.101282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Evaluation and management of airway obstruction in prone position were reviewed from studies in infants with micrognathia and/or cleft palate, using polysomnography (PSG) or similar measures, and comparing prone against other positions. Most studies identified were case series from specialist referral centres. Airway obstruction appears more severe on PSG than clinical assessment, but there is no consensus for PSG definitions of mild, moderate or severe airway obstruction. Infants show individual variability in responses to positioning; sleep quality tends to improve when prone, but 22-25% have better respiratory outcomes when supine. Most centres recommend home monitoring if advising that an infant be placed prone to manage their airway obstruction. In conclusion, in case series, success rates for managing infant airway obstruction by prone positioning vary from 12 to 76%. PSG studies comparing prone with other sleep positions can help differentiate which infants show improved airway obstruction and/or sleep quality when positioned prone.
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Affiliation(s)
- Karen A Waters
- The Children's Hospital at Westmead, Sydney, 2145, NSW, Australia; Department of Child and Adolescent Health, Faculty of Medicine, University of Sydney, NSW, 2050, Australia.
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15
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Long Term Speech and Feeding Outcomes in Patients With Pierre Robin Sequence. J Craniofac Surg 2021; 33:475-479. [PMID: 34608009 DOI: 10.1097/scs.0000000000008232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Airway obstruction in newborns with Pierre Robin sequence (PRS) may be managed with tongue-lip adhesion (TLA), mandibular distraction osteogenesis (MDO), or tracheostomy to prevent airway compromise when conservative airway interventions fail or are contraindicated based on the type of obstruction present. Unfortunately, some of these procedures have the potential to affect a child's speech and feeding development. METHOD The authors retrospectively reviewed the records of all children with PRS treated at our institution in the last 25 years. Our primary outcomes of interests were: (1) consonant production errors; (2) achievement of full oral feeds; (3) need for prolonged gastrostomy tube feeds; and (4) avoidance of tracheostomy. RESULTS Seven (7/73, 10%) children required intubation at birth for respiratory failure. Forty-two children were treated with TLA (42/73, 58%), 2 with MDO (2/73, 3%), and 1 (1/73, 1%) with tracheostomy. Twenty-one (21/73, 29%) were treated with conservative airway interventions. Of the 7 children requiring intubation, 1 required tracheostomy, and 6 required TLA. Five children who received TLA initially proceeded to tracheostomy. Of the 3 children who underwent MDO, 2 required tracheostomy. Of the 2 patients who underwent MDO, 2 failed, requiring tracheostomy. One child required tracheostomy as the first airway intervention. Among all children with PRS, /s,z/ speech errors were the most common. Children treated with conservative airway interventions had significantly fewer /sh/ errors at age 3 (X = 6.604, P < 0.05) relative to those treated with TLA, MDO, and/or tracheostomy. Consonant production errors extinguished over time, with significantly less /s,z/ errors produced at age 8 compared to at ages 3 (Z = -2.263, P < 0.01), 4 (Z = -2.449, P < 0.05), 5 (Z = -2.775, P < 0.01), and 6 (Z = -2.049, P < 0.05). Among all children, 70% (51/70) were able to achieve full oral feeds. CONCLUSIONS This study describes speech-production and feeding outcomes in children with PRS. Tongue-tip sound errors, including /s,z/, are prominent early in speech development but later extinguish, a pattern of speech maturation that follows that of typically-developing children.Most children were able to achieve full oral feeds, with few requiring prolonged g-tube placement. We hope these results serve as a useful tool in managing speech and feeding in children with TLA, and when counselling patients with PRS requiring definitive airway surgery.
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16
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Affiliation(s)
- Christian F Poets
- Department of Neonatology and Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, University of Tuebingen, Tuebingen, Germany
| | - Cornelia Wiechers
- Department of Neonatology and Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, University of Tuebingen, Tuebingen, Germany
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17
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Yang IH, Chung JH, Lee HJ, Cho IS, Choi JY, Lee JH, Kim S, Baek SH. Characterization of phenotypes and predominant skeletodental patterns in pre-adolescent patients with Pierre-Robin sequence. Korean J Orthod 2021; 51:337-345. [PMID: 34556588 PMCID: PMC8461384 DOI: 10.4041/kjod.2021.51.5.337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/07/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate the phenotypes and predominant skeletodental pattern in pre-adolescent patients with Pierre–Robin sequence (PRS). Methods The samples consisted of 26 Korean pre-adolescent PRS patients (11 boys and 15 girls; mean age at the investigation, 9.20 years) treated at the Department of Orthodontics, Seoul National University Dental Hospital between 1998 and 2019. Dental phenotypes, oral manifestation, cephalometric variables, and associated anomalies were investigated and statistically analyzed. Results Congenitally missing teeth (CMT) were found in 34.6% of the patients (n = 9/26, 20 teeth, 2.22 teeth per patient) with 55.5% (n = 5/9) exhibiting bilaterally symmetric missing pattern. The mandibular incisors were the most common CMT (n = 11/20). Predominant skeletodental patterns included Class II relationship (57.7%), posteriorly positioned maxilla (76.9%) and mandible (92.3%), hyper-divergent pattern (92.3%), high gonial angle (65.4%), small mandibular body length to anterior cranial base ratio (65.4%), linguoversion of the maxillary incisors (76.9%), and linguoversion of the mandibular incisors (80.8%). Incomplete cleft palate (CP) of hard palate with complete CP of soft palate (61.5%) was the most frequently observed, followed by complete CP of hard and soft palate (19.2%) and CP of soft palate (19.2%) (p < 0.05). However, CP severity did not show a significant correlation with any cephalometric variables except incisor mandibular plane angle (p < 0.05). Five craniofacial and 15 extra-craniofacial anomalies were observed (53.8% patients); this implicated the need of routine screening. Conclusions The results might provide primary data for individualized diagnosis and treatment planning for pre-adolescent PRS patients despite a single institution-based data.
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Affiliation(s)
- Il-Hyung Yang
- Department of Orthodontics, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | - Jee Hyeok Chung
- Department of Plastic and Reconstructive Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyeok Joon Lee
- Department of Orthodontics, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | | | - Jin-Young Choi
- Departement of Oral and Maxillofacial Surgery, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | - Jong-Ho Lee
- Departement of Oral and Maxillofacial Surgery, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | - Sukwha Kim
- Departmentof Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul, Korea
| | - Seung-Hak Baek
- Department of Orthodontics, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
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18
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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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19
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Choo H, Khosla RK, Meister KD, Wan DC, Lin HFC, Feczko R, Bruckman K, Hopkins E, Truong MT, Lorenz HP. Nonsurgical Orthodontic Airway Plate Treatment for Newborns With Robin Sequence. Cleft Palate Craniofac J 2021; 59:403-410. [PMID: 33845627 DOI: 10.1177/10556656211007689] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite promising outcomes for >50 years, nonsurgical orthodontic airway plates (OAP) are only infrequently offered for babies with Robin sequence in a few parts of the world. This article demonstrates possibility of providing functional improvement using an OAP to help these babies overcome their functional and structural difficulties on their own. Two consecutively treated cases are presented exemplifying that OAP treatment that had originated from Europe is reproducible and effective in an institution in the United States.
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Affiliation(s)
- HyeRan Choo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.,Craniofacial and Airway Orthodontic Clinic, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Rohit K Khosla
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Kara D Meister
- Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.,Division of Head and Neck Surgery, Department of Otolaryngology, 10624Stanford University School of Medicine, Palo Alto, CA, USA
| | - Derrick C Wan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Hung-Fu C Lin
- Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Robert Feczko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Karl Bruckman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Elena Hopkins
- Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Mai Thy Truong
- Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.,Division of Head and Neck Surgery, Department of Otolaryngology, 10624Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hermann P Lorenz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
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20
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Remy F, Godio-Raboutet Y, Captier G, Bonnaure P, Burgart P, Guyot L, Thollon L. The Hypoplasic Mandible: What Makes it Different From the Healthy Child? Cleft Palate Craniofac J 2020; 58:966-973. [PMID: 33167677 DOI: 10.1177/1055665620972301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE This study aimed to analyze the morphology of the hypoplasic mandible and its evolution during the growth period to better understand how it differs from the pediatric healthy mandible. METHOD Three-dimensional mandibular models of hypoplasic and healthy children aged from 39 gestational weeks to 7 years old were analyzed with a morphometric method including data clustering. Morphological distinctions between pathological and healthy mandibles were highlighted. Bilateral and unilateral mandibular hypoplasia were distinguished. RESULTS The study sample was composed of 31 hypoplasic children and as many sex- and age-matched healthy children. Morphological distinctions between pathological and healthy mandibles were highlighted only from the first year of life. In bilateral hypoplasia, the overall mandibular dimensions were reduced while there was only a ramus asymmetry in unilateral mandibular hypoplasia (mean ± SD of the difference between the Grp03c and Grp03b subgroups: 6.80 ± 6.37 - P value = 1.64e-3 for the height of the left ramus versus 0.18 ± 4.18 - P value = .82 for the height of the right ramus). Supervised classification trees were built to identify the pathology and discriminate unilateral from bilateral mandibular hypoplasia (prediction rates = 81% and 84%, respectively). CONCLUSIONS Based on a morphometric analysis, we demonstrated that mandibular hypoplasia significantly impacts the mandibular morphology only from the first year of life, with a distinction between bilateral and unilateral hypoplasia.
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Affiliation(s)
- Floriane Remy
- Aix-Marseille Univ, yUniv Gustave Eiffel, LBA, Marseille, France.,YooMed, Montpellier, France
| | | | - Guillaume Captier
- Department of Plastic and Craniofacial Pediatric Surgery, Lapeyronie University Hospital, Montpellier, France
| | | | | | - Laurent Guyot
- Department of Oral-Maxillofacial, Plastic and Reconstructive Surgery, A.P.-H.M., North University Hospital, Marseille, France.,Aix-Marseille Univ, CNRS, EFS, ADES, Marseille, France
| | - Lionel Thollon
- Aix-Marseille Univ, yUniv Gustave Eiffel, LBA, Marseille, France
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21
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Sleep Outcomes in Neonates with Pierre Robin Sequence Undergoing External Mandibular Distraction: A Longitudinal Analysis. Plast Reconstr Surg 2020; 146:1103-1115. [DOI: 10.1097/prs.0000000000007289] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Treatment approaches to syndromes affecting craniofacial and dental structures. J World Fed Orthod 2019. [DOI: 10.1016/j.ejwf.2019.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Galluccio G, Mazzoli V, Vernucci R, Silvestri A, Barbato E. Neonatal Functional Treatment for Pierre Robin Sequence. Turk J Orthod 2019; 32:151-159. [PMID: 31565690 DOI: 10.5152/turkjorthod.2019.18057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/25/2018] [Indexed: 12/22/2022]
Abstract
Objective Pierre Robin Sequence (PRS) is a heterogeneous pathological condition characterized by the coexistence of micrognathia, glossoptosis, and cleft palate, resulting in upper airway tract obstruction. Among the treatment modalities, the orthodontic approach is one part of the comprehensive care of those patients and will be present in the treatment modalities during all the growth period of the child. Methods All patients with PRS observed in the period 2013-2017 were treated with a definite functional approach. The results were retrospectively analyzed with regard to functional outcome, total treatment time, and number of plates provided for a single patient. Results In all the patients, the indicated treatment protocol has been applied as early impression and plate supply, stimulation of bottle feeding with the use of the plate, eventual substitution of the plate if no more adequate to the transverse and sagittal growth of the palate, and continuing the use until the surgical closure of the cleft. All the patients showed a positive outcome to the proposed treatment approach, evaluated with regard to the incidence of feeding improvement and weight gain, to the limit for the surgical phase, in the absence of adverse effects. Conclusion The use of a functional obturator plate, removing functional alterations to mandibular growth, reduces and, in some cases, eliminates the need for surgical intervention. As also stated in the literature, if despite the presence of the plate nutritional problems persist, immediate different surgical approaches, mainly mandibular osteodistraction, become necessary.
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Affiliation(s)
- Gabriella Galluccio
- Department of Orthodontics and Maxillofacial Surgery, Sapienza University of Rome School of Dentistry, Rome, Italy
| | - Valentina Mazzoli
- Department of Orthodontics and Maxillofacial Surgery, Sapienza University of Rome School of Dentistry, Rome, Italy
| | - Roberto Vernucci
- Department of Orthodontics and Maxillofacial Surgery, Sapienza University of Rome School of Dentistry, Rome, Italy
| | - Alessandro Silvestri
- Department of Orthodontics and Maxillofacial Surgery, Sapienza University of Rome School of Dentistry, Rome, Italy
| | - Ersilia Barbato
- Department of Orthodontics and Maxillofacial Surgery, Sapienza University of Rome School of Dentistry, Rome, Italy
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24
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Poets CF, Koos B, Reinert S, Wiechers C. The Tübingen palatal plate approach to Robin sequence: Summary of current evidence. J Craniomaxillofac Surg 2019; 47:1699-1705. [PMID: 31477439 DOI: 10.1016/j.jcms.2019.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/05/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022] Open
Abstract
Various treatments, many of them considerably invasive, are currently applied to infants with Robin sequence (RS) and accompanying upper airway obstruction (UAO). We present a narrative review of our data on the Tübingen palatal plate (TPP) which show the following: a) in a randomized trial, the TPP was superior to a sham procedure in alleviating UAO; b) children treated with the TPP in infancy showed an intellectual development within the reference range; c) prone positioning is no alternative, as it is ineffective and associated with an increased risk of sudden death; d) the TPP reduces the mixed-obstructive apnea index to near-normal values, both in isolated and most (83%) syndromic RS, e) of 443 infants (129 syndromic) treated with the TPP in our center, 23 (5%) ultimately received a tracheostomy (all with syndromic RS), f) recent data suggest that the TPP may induce mandibular catch-up growth, g) the TPP may also help to reduce respiratory complications following cleft closure in RS, and h) TPP treatment is applied by various centers around the world, although it is unclear if its effectiveness is invariably controlled by endoscopy and sleep studies, although both are necessary. Given these data from peer-reviewed studies, it may be questioned whether the "First do no harm" principle is always adhered to when subjecting RS infants to more invasive procedures such as mandibular distraction osteogenesis or tongue-lip adhesion.
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Affiliation(s)
- Christian F Poets
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Germany; Department of Neonatology and Pediatric Sleep Lab, Tübingen University Hospital, Germany.
| | - Bernd Koos
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Germany; Department of Orthodontics, Tübingen University Hospital, Germany
| | - Siegmar Reinert
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Germany; Department of Craniomaxillofacial Surgery, Tübingen University Hospital, Germany
| | - Cornelia Wiechers
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Germany; Department of Neonatology and Pediatric Sleep Lab, Tübingen University Hospital, Germany
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Hong H, Wee CP, Haynes K, Urata M, Hammoudeh J, Ward SLD. Evaluation of Obstructive Sleep Apnea in Prone Versus Nonprone Body Positioning With Polysomnography in Infants With Robin Sequence. Cleft Palate Craniofac J 2019; 57:141-147. [DOI: 10.1177/1055665619867228] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: Management of obstructive sleep apnea in infants with Robin sequence (RS) includes prone positioning during sleep, which conflicts with safe infant sleep data. We examined changes in polysomnography (PSG) parameters for prone versus nonprone body positions in these infants. Design: Pre–post interventional, nonblinded study. Participants: Infants with RS referred for PSG were recruited from craniofacial clinic and inpatient units at Children’s Hospital Los Angeles, a tertiary pediatric center. Fourteen infants were recruited, and 12 studies were completed on both body positions; 11 studies were used in the analysis. Interventions: The PSG was divided into nonprone and prone sleep, moving from their usual sleep position to the other position midway in the study. Main Outcome Measures: Data was collected in each position for obstructive apnea–hypopnea index (oAHI), central apnea index (CAI), sleep efficiency (SE), and arousal index (AI). Signed rank test was used to evaluate the change in body position. Results: All infants were term except 1, age 7 to 218 days (mean: 55 days; standard deviation: 58 days), and 8 (57%) of 14 were female. From nonprone to prone sleep position, the median oAHI (16.0-14.0), CAI (2.9-1.0), and AI (28.0-19.9) decreased ( P = .065); SE increased (67.4-85.2; P = .227). Conclusions: Prone positioning may benefit some infants with RS. However, even those with significant improvement in obstructive sleep apnea did not completely resolve their obstruction. The decision to use prone positioning as a therapy should be objectively evaluated in individual infants.
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Affiliation(s)
- Hanna Hong
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Choo Phei Wee
- The Saban Research Institute Biostatistics Core, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Karla Haynes
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Mark Urata
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Jeffrey Hammoudeh
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Sally L. Davidson Ward
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
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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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Wiechers C, Buchenau W, Arand J, Oertel AF, Peters K, Müller-Hagedorn S, Koos B, Poets CF. Mandibular growth in infants with Robin sequence treated with the Tübingen palatal plate. Head Face Med 2019; 15:17. [PMID: 31228944 PMCID: PMC6588871 DOI: 10.1186/s13005-019-0200-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 06/06/2019] [Indexed: 12/28/2022] Open
Abstract
Background Robin sequence (RS) is characterized by mandibular retrognathia, glossoptosis and upper airway obstruction. Whether mandibular catch-up growth may occur in RS is yet controversial. Our functional and less invasive treatment including the Tübingen Palatal Plate (TPP), early oral feeding and orofacial stimulation may promote mandibular catch-up growth. We evaluated the effect of the Tübingen Palatal Plate on mandibular growth, expressed by the Jaw index, sleep study results and weight gain in infants admitted with isolated and syndromic RS, born at or referred to our center between 6/2015 and 5/2018. Methods Retrospective analysis of our electronic patient database that included data on jaw index measurements, sleep study results and standard deviation (Z-)scores for weight. Results Of 31 patients referred for RS treatment (22 isolated, 9 syndromic), we had data on the above parameters, determined at admission, discharge and 3 months after discharge, in 20. Jaw index at admission and 3-month follow-up was 8.8 (6.3–11.3) and 2.1 (2.0–4.0), respectively (median (IQR); p < 0.0001). Mixed-obstructive apnea index (MOAI) decreased from 9.7 (4.8–24.2) to 0.0 (0–1.3; p < 0.002). No significant correlation was observed between MOAI and Jaw Index, but MOAI correlated with the Maxillary/Mandibular arch ratio (r = 0.58; p < 0.001). Z-scores for weight were similar at both time points at − 1.34 (− 1.76 – − 0.57) and − 1.50 (− 1.89 – − 0.54), while the proportion of infants requiring nasogastric tube feeding decreased from 84 to 8%. No infant had craniofacial surgery; one with syndromic RS required tracheostomy. Conclusion These longitudinal cohort data suggest that the Tübingen Palatal Plate as used here may alleviate upper airway obstruction by promoting mandibular growth. Trial registration N.A.
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Affiliation(s)
- Cornelia Wiechers
- Department of Neonatology, Tübingen University Hospital, Calwerstr. 7, D-72076, Tübingen, Germany.,Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany
| | - Wolfgang Buchenau
- Department of Neonatology, Tübingen University Hospital, Calwerstr. 7, D-72076, Tübingen, Germany.,Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany
| | - Jörg Arand
- Department of Neonatology, Tübingen University Hospital, Calwerstr. 7, D-72076, Tübingen, Germany.,Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany
| | - Anne-Friederike Oertel
- Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Orthodontics, Tübingen University Hospital, Tübingen, Germany
| | - Katharina Peters
- Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Orthodontics, Tübingen University Hospital, Tübingen, Germany
| | - Silvia Müller-Hagedorn
- Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Orthodontics, Tübingen University Hospital, Tübingen, Germany.,Department of Orthodontics, Rostock University Hospital, Rostock, Germany
| | - Bernd Koos
- Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Orthodontics, Tübingen University Hospital, Tübingen, Germany
| | - Christian F Poets
- Department of Neonatology, Tübingen University Hospital, Calwerstr. 7, D-72076, Tübingen, Germany. .,Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.
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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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Heffernan CB, Calabrese CE, Resnick CM. Does Mandibular Distraction Change the Laryngoscopy Grade in Infants With Robin Sequence? J Oral Maxillofac Surg 2019; 77:371-379. [DOI: 10.1016/j.joms.2018.05.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/18/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
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Surgical Management and Outcomes of Pierre Robin Sequence: A Comparison of Mandibular Distraction Osteogenesis and Tongue-Lip Adhesion. Plast Reconstr Surg 2019; 142:480-509. [PMID: 29870511 DOI: 10.1097/prs.0000000000004581] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is a paucity of literature directly comparing tongue-lip adhesion versus mandibular distraction osteogenesis in surgical treatment of patients with Pierre Robin sequence. This study comprehensively reviews the literature for evaluating airway and feeding outcomes following mandibular distraction osteogenesis and tongue-lip adhesion. A search was performed using the MEDLINE and Embase databases for publications between 1960 and June of 2017. English-language, original studies subjects were included. Extracted data included prevention of tracheostomy (primary airway outcome) and ability to feed exclusively by mouth (primary feeding outcome). A total of 67 studies were included. Ninety-five percent of subjects (657 of 693) treated with mandibular distraction osteogenesis avoided tracheostomy, compared to 89% of subjects (289 of 323) treated with tongue-lip adhesion. Eighty-seven percent of subjects (323 of 370) treated with mandibular distraction osteogenesis achieved full oral feeds at latest follow-up. Seventy percent of subjects (110 of 157) treated with tongue-lip adhesion achieved full oral feeds at latest follow-up. The incidence of second intervention for recurrent obstruction ranged from 4 to 6 percent in mandibular distraction osteogenesis studies, compared to a range of 22 to 45 percent in tongue-lip adhesion studies. Variability of patient selection, surgical techniques, outcomes measurement methods, and follow-up length across studies precluded meta-analysis of the data. Both mandibular distraction osteogenesis and tongue-lip adhesion are effective alternatives to tracheostomy for patients who fail conservative management and improve feeding. Mandibular distraction osteogenesis may be superior to tongue-lip adhesion in long-term resolution of airway obstruction and avoidance of gastrostomy, but is associated with notable complications.
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Resnick CM, LeVine J, Calabrese CE, Padwa BL, Hansen A, Katwa U. Early Management of Infants With Robin Sequence: An International Survey and Algorithm. J Oral Maxillofac Surg 2019; 77:136-156. [DOI: 10.1016/j.joms.2018.05.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/17/2018] [Accepted: 05/21/2018] [Indexed: 10/14/2022]
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Tongue Lip Adhesion in the Treatment of Robin Sequence: Respiratory, Feeding, and Surgical Outcomes. J Craniofac Surg 2018; 29:2327-2333. [PMID: 30339599 DOI: 10.1097/scs.0000000000004975] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Objective evaluation of the efficacy of tongue lip adhesion (TLA) in the management of Robin sequence (RS). STUDY DESIGN Retrospective cohort study. SETTING Tertiary referral hospital. PATIENTS, PARTICIPANTS The craniofacial database of Amsterdam UMC, Vrije Universiteit Amsterdam was searched to identify infants with RS who underwent tong lip adhesion (TLA). Forty-one RS infants who underwent TLA from 1993 to 2016 were identified. INTERVENTIONS TLA. MAIN OUTCOME MEASURE The outcome measures were pre- and postoperative polysomnography results, nutritional status, weight gain, age at operation, hospital stay length, extubation time after TLA, and complications. RESULTS Forty-one RS patients were included who had TLA at an average age of 26.6 days. In 16 cases a pre- and postoperative polysomnography was performed. In 13 of these cases (81.3%) improvement was observed, in 2 (12.5%) the results were inconclusive, and in 1 (6.3%) no improvement was seen. Patients were extubated after a mean of 2.2 days.The mean hospital stay was 40.2 days. Reintervention was needed in 7 patients because of a wound dehiscence. The mean age of TLA release was 9.7 months. At discharge, 9 (22%) children still needed total nutritional support for persistent feeding difficulties. The average growth from birth to adhesion release was 4.6 kg. CONCLUSION This cohort demonstrates that TLA is a successful procedure in children with RS in terms of respiratory, feeding, and growth outcome. Only minor complications were seen in our cohort.
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Wright M, Mehendale F, Urquhart DS. Epidemiology of Robin sequence with cleft palate in the East of Scotland between 2004 and 2013. Pediatr Pulmonol 2018; 53:1040-1045. [PMID: 29736909 DOI: 10.1002/ppul.24038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/13/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND Robin sequence (RS) is a congenital disorder characterized by cleft palate, micrognathia, and glossoptosis which can result in clinically significant upper airway obstruction (UAO). Historically, incidence of RS in the UK has been estimated as 1 in 8500 live births. Our study describes birth prevalence, clinical characteristics, and management of RS in the East of Scotland (EoS) region. METHODS Retrospective case note review of infants born in EoS from 2004 to 2013 with a clinical diagnosis of RS. Cases were identified by searching the regional cleft service patient database and review of Hospital Activity Statistics data. Regional live birth rate provided the denominator for incidence calculations. RESULTS A total of 105 cases of RS were identified, giving a birth prevalence of 1:2685 live births. No trends in annual incidence were observed over the 10-year period. Intrauterine exposure to potentially teratogenic agents was identified in 17% cases, including Methadone in 8% cases. Signs of UAO were present in 93% of infants, 63% of whom required active airway management. Nasopharyngeal airway (NPA) was the most commonly used intervention (53% cases), whilst only 7% required surgical management. Infants with an underlying syndrome or additional anomalies (RS+) were significantly more likely to be admitted to a tertiary center and require surgical airway or feeding support compared to those with isolated RS. CONCLUSIONS RS incidence in EoS is substantially higher than that reported within other populations, and than previously reported in the UK. A possible association with intrauterine Methadone exposure warrants further investigation.
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Affiliation(s)
- Marie Wright
- Department of Pediatric Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, United Kingdom.,Department of Pediatric Respiratory Medicine, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Felicity Mehendale
- Department of Cleft Surgery, Royal Hospital for Sick Children, Edinburgh, United Kingdom.,Department of Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Don S Urquhart
- Department of Pediatric Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, United Kingdom.,Department of Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom
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MacLean JE. Sleep frequently asked questions: Question 1: What abnormalities do babies with cleft lip and/or palate have on polysomnography? Paediatr Respir Rev 2018; 27:44-47. [PMID: 29937141 DOI: 10.1016/j.prrv.2018.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Joanna E MacLean
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Women and Children's Health Research Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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Müller-Hagedorn S, Buchenau W, Arand J, Bacher M, Poets CF. Treatment of infants with Syndromic Robin sequence with modified palatal plates: a minimally invasive treatment option. Head Face Med 2017; 13:4. [PMID: 28356131 PMCID: PMC5372279 DOI: 10.1186/s13005-017-0137-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/26/2017] [Indexed: 11/21/2022] Open
Abstract
Background Infants with Robin sequence (RS) suffer from upper airway obstruction (UAO) and feeding problems. We developed an oral appliance with a velar extension in combination with functional treatment and appropriate feeding techniques, which was proven effective in isolated RS. As the above problems are particularly challenging in syndromic RS, we set out to evaluate our treatment concept also in these patients. Methods We searched our electronic departmental database to identify all children admitted to our department between 01/01/2003 and 31/12/2009 because of syndromic RS. UAO was quantified by cardiorespiratory sleep studies performed before and during treatment with a modified palatal plate. This appliance consists of a palatal part, covering the hard palate as well as the alveolar ridges and the potential cleft, and a velar extension shifting the tongue in a more anterior position, thereby opening the pharyngeal airway. It is adjusted by fiberoptic nasopharyngoscopy and controlled by cardiorespiratory sleep studies. Obstructive sleep apnea was defined as a mixed obstructive sleep apnea index (MOAI) >3/h. Feeding modalities before and after treatment and weight gain, determined as standard deviation score, were also evaluated. Results Of 68 children meeting inclusion criteria, 56 completed treatment (46 of these being infants). Underlying diagnoses included craniofacial dysostosis (N = 13) and synostosis syndromes (N = 5), unspecified dysmorphic syndromes (N = 23) and miscellaneous rare conditions (N = 27). Median MOAI decreased from 8.5 (range 0.3–76.0) at admission to 1.1 (0.0–5.2) at discharge (p < 0.001). 51 children received only a TPP and 5 additionally continuous positive airway pressure (CPAP) or high-flow nasal cannula during sleep for mild residual OSA. Three children ultimately required tracheostomy. The number of exclusively gavage fed infants was reduced from 23 to 7. Conversely, the number of children fed exclusively by mouth increased from 18 to 30. Median SDS for weight decreased from −1.6 (−3.5–1.7) to −1.3 (−4.1-2.5). Twelve children had their treatment prematurely discontinued, e.g. due to laryngeal collapse/laryngomalacia. No patient died during treatment. Conclusion Treatment of UAO and feeding problems in these children with syndromic RS by a modified palatal plate with a velar extension was shown to be effective and safe. If confirmed in prospective studies, it may help to avoid more invasive interventions.
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Affiliation(s)
- Silvia Müller-Hagedorn
- Interdisciplinary Centre for Craniofacial Malformations, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany.,Department of Neonatology, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany.,Department of Orthodontics, Tuebingen University Hospital, Osianderstrasse 2-8, 72076, Tuebingen, Germany
| | - Wolfgang Buchenau
- Interdisciplinary Centre for Craniofacial Malformations, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany.,Department of Neonatology, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany
| | - Jörg Arand
- Department of Neonatology, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany
| | - Margit Bacher
- BIP - Orthodontic Practice, Schweickhardtstrasse 11, 72072, Tübingen, Germany
| | - Christian F Poets
- Interdisciplinary Centre for Craniofacial Malformations, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany. .,Department of Neonatology, Tuebingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany.
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The role of flexible fiberoptic laryngoscopy in Robin Sequence: A systematic review. J Craniomaxillofac Surg 2017; 45:210-215. [DOI: 10.1016/j.jcms.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/29/2016] [Accepted: 11/10/2016] [Indexed: 11/17/2022] Open
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Abstract
Glossoptosis causes varying degrees of airway obstruction and feeding difficulties. It can occur as a consequence of micrognathia in Robin Sequence, but can also occur in children with hypotonia. Despite several attempts to classify severity in Robin Sequence patients, taking into account symptoms, presence of concomitant syndromes or malformations, and even endoscopic findings, there is still no general consensus. Furthermore, several management recommendations have been reported without an agreement about indications, efficacy, or risks of each treatment option. The present article provides an overview of clinical presentation, diagnosis, management, and prognosis of patients with glossoptosis.
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Affiliation(s)
- Cláudia Schweiger
- Otolaryngology and Head and Neck Surgery Department, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, CEP 90035-903, Porto Alegre, Brazil.
| | - Denise Manica
- Otolaryngology and Head and Neck Surgery Department, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, CEP 90035-903, Porto Alegre, Brazil
| | - Gabriel Kuhl
- Otolaryngology and Head and Neck Surgery Department, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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