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McGrath JL, Mantilla-Rivas E, Aivaz M, Manrique M, Rana MS, Crowder HR, Oh NS, Rogers GF, Oh AK. Predicting Failure of Conservative Airway Management in Infants with Robin Sequence: The EARN Factors. Cleft Palate Craniofac J 2024:10556656231224194. [PMID: 38166451 DOI: 10.1177/10556656231224194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024] Open
Abstract
OBJECTIVE Evaluate infants with Robin Sequence (RS) who were successfully treated with conservative airway measures alone vs. those who failed and eventually underwent surgical airway intervention after a protracted course of conservative management. DESIGN Retrospective review of prospectively gathered database. SETTING Large tertiary care institution. PATIENTS Infants diagnosed with RS (n = 122) who underwent primary airway management at a single institution from 1994-2020. MAIN OUTCOME MEASURE Patient demographics, nutritional and respiratory status, laboratory values, and polysomnographic results were compared between patients who were discharged after successful conservative airway management (Group 1, n = 61) and patients that underwent surgical airway intervention after failing a prolonged course of conservative management (Group 2, n = 61). Receiver operating characteristic (ROC) curve analysis was done to assess continuous variables that may predict failure of conservative airway management. RESULTS 122 infants with RS were investigated. While several variables were significantly different between groups, the following polysomnographic EARN factors, with cut points, were identified as most predictive of failed conservative airway management: ETCO2 (max) > 49 mmHg, AHI > 16.9 events/hour, OAHI REM >25.9 events/hour, OAHI Non-REM > 23.6 events/hour. CONCLUSIONS We identified factors in infants with RS that were associated with severe UAO that failed to improve despite weeks of conservative airway management. Our results may expedite earlier definitive treatment of these critical patients and reduce risks for known complications of prolonged UAO.
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Affiliation(s)
- Jennifer L McGrath
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Esperanza Mantilla-Rivas
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Marudeen Aivaz
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Monica Manrique
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Md Sohel Rana
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Hannah R Crowder
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Nathanael S Oh
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Gary F Rogers
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Albert K Oh
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
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2
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van der Plas PPJM, van Heesch GGM, Koudstaal MJ, Pullens B, Mathijssen IMJ, Bernard SE, Wolvius EB, Joosten KFM. Non-Surgical Respiratory Management in Relation to Feeding and Growth in Patients with Robin Sequence; a Prospective Longitudinal Study. Cleft Palate Craniofac J 2023:10556656231199840. [PMID: 37728101 DOI: 10.1177/10556656231199840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVE To reflect upon our non-surgical respiratory management by evaluating clinical outcomes regarding airway, feeding, and growth during the first year of life in patients with Robin Sequence. DESIGN Prospective study. SETTING Sophia Children's Hospital, Rotterdam, the Netherlands. PATIENTS/ PARTICIPANTS 36 patients with Robin Sequence who were treated between 2011 and 2021. INTERVENTIONS Positional therapy and respiratory support. MAIN OUTCOME MEASURE(S) Data on respiratory outcomes included polysomnography characteristics and capillary blood gas values. Feeding outcomes were based on the requirement of additional tube feeding. Outcomes on growth were expressed as standard-deviation-scores (SDS) for weight-for-age (WFA) and height-for-age (HFA). RESULTS Twenty patients were treated with positional therapy (PT), whilst the other 16 patients required respiratory support. Twenty-two patients presented with non-isolated Robin Sequence (RS). During the first year of life, obstructive apnea hypopnea index decreased, oxygen levels enhanced, and capillary blood gas values improved. Eighty-six percent (31/36) experienced feeding difficulties, which completely resolved in 71% (22/31) during their first year of life. From start treatment, to stop treatment, to the age of 1 year, the SDS WFA worsened from -0.40 to -0.33 to -1.03, respectively. CONCLUSIONS Non-surgical respiratory treatment resulted in an improvement of respiratory outcomes to near normal during the first year of life in patients with RS. These patients often experience feeding difficulties and endure impaired weight gain up to 1 year of age, despite near normalization of breathing. The high prevalence of feeding difficulties and impaired weight for age indicate the urgency for early recognition and adequate treatment to support optimal growth.
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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
| | - Gwen G M van Heesch
- Department of Pediatric Intensive Care, 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
| | - Bas Pullens
- Department of Otorhinolaryngology, Sophia Children's Hospital - Erasmus Medical Center, Rotterdam, The Netherlands
| | - Irene M J Mathijssen
- Department of Plastic and Reconstructive Hand Surgery, Sophia Children's Hospital - Erasmus Medical Center, Rotterdam, The Netherlands
| | - Simone E Bernard
- Department of Otorhinolaryngology, 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
| | - Koen F M Joosten
- Department of Pediatric Intensive Care, Sophia Children's Hospital - Erasmus Medical Center, Rotterdam, The Netherlands
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3
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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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4
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Poets CF, Abadie V, Breugem C, Wallis C, Abel F, Chalouhi C, Kruisinga F, Sorg AL, Wiechers C. Managing infants with craniofacial malformations - Where to go next? Semin Fetal Neonatal Med 2021; 26:101289. [PMID: 34548245 DOI: 10.1016/j.siny.2021.101289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Treatment of infants with craniofacial malformations, e.g. Robin sequence, is characterized by considerable heterogeneity and a lack of randomized trials to identify an optimal approach. We propose to establish an international register using a common minimal dataset that will better allow for a comparison between key determinants and outcomes in these patients. In infants, this should include an assessment of mandibular micrognathia, glossoptosis, upper airway obstruction, weight gain and mode of feeding. Later on, neurocognition, speech development, hearing and quality of life should also be included. Together, these data will help better to advice parents on which treatment to choose for their baby with a craniofacial malformation.
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Affiliation(s)
- Christian F Poets
- Interdisciplinary Center for Cleft Palate & Craniofacial Malformations and Department of Neonatology, Tübingen University Hospital, Tübingen, Germany.
| | - Veronique Abadie
- Department of General Pediatrics, Reference Center for Rare Diseases "Pierre Robin Sequences and Congenital Sucking-swallowing Troubles", Necker University Hospital, Paris University, France
| | - Corstiaan Breugem
- Department of Plastic Reconstructive and Hand Surgery, Amsterdam UMC, Emma Children's Hospital - Location AMC, University of Amsterdam, the Netherlands
| | - Colin Wallis
- Department of Paediatric Respiratory Medicine, Great Ormond Street Hospital, London, UK
| | - Francois Abel
- Department of Paediatric Respiratory Medicine, Great Ormond Street Hospital, London, UK
| | - Christel Chalouhi
- Department of Plastic Reconstructive and Hand Surgery, Amsterdam UMC, Emma Children's Hospital - Location AMC, University of Amsterdam, the Netherlands
| | - Frea Kruisinga
- Department of Plastic Reconstructive and Hand Surgery, Amsterdam UMC, Emma Children's Hospital - Location AMC, University of Amsterdam, the Netherlands
| | - Anna-Lisa Sorg
- Interdisciplinary Center for Cleft Palate & Craniofacial Malformations and Department of Neonatology, Tübingen University Hospital, Tübingen, Germany
| | - Cornelia Wiechers
- Interdisciplinary Center for Cleft Palate & Craniofacial Malformations and Department of Neonatology, Tübingen University Hospital, Tübingen, Germany
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5
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van Nunen DPF, Griot JPWD, Kruisinga F, Broers CJM, Breugem CC. A Comparison of Weight Gain Following Mandibular Distraction Osteogenesis and Tongue-Lip Adhesion in the Treatment of Robin Sequence. J Craniofac Surg 2021; 32:e578-e582. [PMID: 34054095 DOI: 10.1097/scs.0000000000007741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Obstructive respiratory stress and feeding difficulties in infants with Robin sequence (RS) may result in poor weight gain or loss. Following failure of conservative treatment, surgical options include mandibular distraction osteogenesis (MDO) and tongue-lip adhesion (TLA). Whilst both techniques have demonstrated to improve airway patency and feeding behavior, an advantage of either in restoring weight growth remains unknown. This study aimed to improve procedural selection by examining weight gain following MDO and TLA. A retrospective chart review was performed for 17 RS patients that had undergone MDO and 25 that had received TLA. The mean body weight in both groups was below the 50th population percentile at birth and fell further in the period before surgery. A mixed model analysis demonstrated that postoperative weight gain depended on the progression of time and preoperative weight. Conversely, biological sex, congenital comorbidities, method of feeding, the respective cleft team, and the type of surgery did not significantly influence the evolution of postoperative body weight. In conclusion, both MDO and TLA were able to restore weight growth in infants affected by RS, though a clear superiority of either technique could not be established.
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Affiliation(s)
- Daan P F van Nunen
- Cleft Center Amsterdam, Amsterdam UMC, Division of Plastic and Reconstructive Surgery, Location AMC, Meibergdreef
| | - J Peter W Don Griot
- Cleft Center Amsterdam, Amsterdam UMC, Division of Plastic and Reconstructive Surgery, Location VUmc, Ziekenhuisgebouw, De Boelelaan
| | - Frea Kruisinga
- Department of Pediatrics, Amsterdam UMC, Location AMC, Meibergdreef
| | - Chantal J M Broers
- Department of Pediatrics, Amsterdam UMC, Location VUmc, Ziekenhuisgebouw, De Boelelaan, Amsterdam, The Netherlands
| | - Corstiaan C Breugem
- Cleft Center Amsterdam, Amsterdam UMC, Division of Plastic and Reconstructive Surgery, Location AMC, Meibergdreef
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Resnick CM, Calabrese CE, Sahdev R, Padwa BL. Is Tongue-Lip Adhesion or Mandibular Distraction More Effective in Relieving Obstructive Apnea in Infants With Robin Sequence? J Oral Maxillofac Surg 2019; 77:591-600. [DOI: 10.1016/j.joms.2018.09.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/07/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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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: 61] [Impact Index Per Article: 12.2] [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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8
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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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9
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The Effect of Mandibular Distraction Osteogenesis on Weight Velocity in Infants With Severe Pierre Robin Syndrome. J Craniofac Surg 2018; 29:1851-1854. [DOI: 10.1097/scs.0000000000004650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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10
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Randall RS, Kian A, Chin K, French B. Resolution of obstructive sleep apnea after mandibular distraction osteogenesis in setting of delayed tongue-lip adhesion takedown: A case report. Medicine (Baltimore) 2018; 97:e12853. [PMID: 30334989 PMCID: PMC6211851 DOI: 10.1097/md.0000000000012853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE There is a high prevalence of obstructive sleep apnea (OSA) in patients with Pierre Robin sequence (PRS), and treatment approaches are highly variable. One approach is a temporary tongue-lip adhesion (TLA) that acts as a temporizing measure while the mandible continues to grow and is usually taken down at 1 year of age. PATIENT CONCERNS Side effects of prolonged tongue-lip adhesion and optimal workup and treatment of persistent OSA in the setting of a tongue-lip adhesion. DIAGNOSES Pierre Robin sequence (PRS), persistent obstructive sleep apnea (OSA), and tongue-lip adhesion (TLA). INTERVENTIONS Mandibular distraction osteogenesis (MDO), adenotonsillectomy, and tongue-lip adhesion takedown. OUTCOMES Resolution of OSA. LESSONS This case puts into question the efficacy of isolated TLA in infants with Pierre Robin sequence and OSA, and places emphasis on the importance of considering an earlier workup of other potential causes of obstruction and the potential need for MDO as a primary or adjunctive approach to treatment.
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Affiliation(s)
| | - Aaron Kian
- University of Colorado School of Medicine
| | | | - Brooke French
- Department of Plastic Surgery, Children's Hospital Colorado, Aurora, CO
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11
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Evaluation of the efficacy of tongue-lip adhesion in Pierre Robin sequence. Eur Ann Otorhinolaryngol Head Neck Dis 2018; 135:155-158. [DOI: 10.1016/j.anorl.2017.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Caillot A, Ambroise B, Bénateau H, Veyssiere A. Impact of early intravelar veloplasty at six months on mandibular growth in patients with Pierre Robin Sequence. J Craniomaxillofac Surg 2018; 46:1059-1064. [PMID: 29793779 DOI: 10.1016/j.jcms.2018.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 03/12/2018] [Accepted: 05/03/2018] [Indexed: 10/16/2022] Open
Abstract
Pierre Robin Sequence (PRS) combines mandible microretrognathia, asynchronism of the pharynx and tongue, glossoptosis and, in some cases, cleft palate. Its principal functional consequences are respiratory and feeding problems during the neonatal period. In this study, we focused on the impact of early closure of the cleft at six months on mandibular growth in patients with PRS. We performed a retrospective study of 15 patients followed for PRS and undergoing surgery performed by the same senior surgeon (HB) at our cleft center between 2005 and 2012. These patients underwent early closure of the cleft (at a mean age of 5.87 months) by intravelar veloplasty, as described by Sommerlad. Only one article with exploitable data analyzing facial and mandibular growth in a cephalometric study of children with PRS has been published. The children in this series, constituting the control group for our study, underwent veloplasty between the ages of 12 and 18 months, often accompanied by labioglossoplasty, and the cephalometric study was carried out between the ages of four and seven years. We compared this control group in which surgery was performed at 12-18 months with our series of children undergoing surgery at six months, in a cephalometric study based on teleradiographic profile measurements performed between the ages of four and seven years. We found that early closure of the cleft soft palate yielded results identical to those for the control group in terms of mandibular growth, without the need for labioglossopexy. Finally, early intravelar veloplasty led to early functional improvement in terms of speech and phonation.
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Affiliation(s)
- Aude Caillot
- Department of Maxillofacial and Plastic Surgery, Caen University Hospital, 14000, Caen, France; Medecine Faculty of Caen, University of Caen Basse Normandie, 14032, Caen Cedex 5, France
| | - Béatrice Ambroise
- Department of Maxillofacial and Plastic Surgery, Caen University Hospital, 14000, Caen, France; Medecine Faculty of Caen, University of Caen Basse Normandie, 14032, Caen Cedex 5, France
| | - Hervé Bénateau
- Department of Maxillofacial and Plastic Surgery, Caen University Hospital, 14000, Caen, France; UNICAEN, EA7451 Equipe BioConnecT, Avenue de la Côte de Nacre, 14000, Caen, France; Medecine Faculty of Caen, University of Caen Basse Normandie, 14032, Caen Cedex 5, France
| | - Alexis Veyssiere
- Department of Maxillofacial and Plastic Surgery, Caen University Hospital, 14000, Caen, France; UNICAEN, EA7451 Equipe BioConnecT, Avenue de la Côte de Nacre, 14000, Caen, France; Medecine Faculty of Caen, University of Caen Basse Normandie, 14032, Caen Cedex 5, France.
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Airway and Feeding Outcomes of Mandibular Distraction, Tongue-Lip Adhesion, and Conservative Management in Pierre Robin Sequence: A Prospective Study. Plast Reconstr Surg 2017; 139:975e-983e. [PMID: 28350680 DOI: 10.1097/prs.0000000000003167] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pierre Robin sequence is characterized by mandibular retrognathia and glossoptosis resulting in airway obstruction and feeding difficulties. When conservative management fails, mandibular distraction osteogenesis or tongue-lip adhesion may be required to avoid tracheostomy. The authors' goal was to prospectively evaluate the airway and feeding outcomes of their comprehensive approach to Pierre Robin sequence, which includes conservative management, mandibular distraction osteogenesis, and tongue-lip adhesion. METHODS A longitudinal study of newborns with Pierre Robin sequence treated at a pediatric academic medical center between 2010 and 2015 was performed. Baseline feeding and respiratory data were collected. Patients underwent conservative management if they demonstrated sustainable weight gain without tube feeds, and if their airway was stable with positioning alone. Patients who required surgery underwent tongue-lip adhesion or mandibular distraction osteogenesis based on family and surgeon preference. Postoperative airway and feeding data were collected. RESULTS Twenty-eight patients with Pierre Robin sequence were followed prospectively. Thirty-two percent had a syndrome. Ten underwent mandibular distraction osteogenesis, eight underwent tongue-lip adhesion, and 10 were treated conservatively. There were no differences in days to extubation or discharge, change in weight percentile, requirement for gastrostomy tube, or residual obstructive sleep apnea between the three groups. No patients required tracheostomy. The greatest reduction in apnea-hypopnea index occurred with mandibular distraction osteogenesis, followed by tongue-lip adhesion and conservative management. CONCLUSIONS Careful selection of which patients with Pierre Robin sequence need surgery, and of the most appropriate surgical procedure for each patient, can minimize the need for postprocedure tracheostomy. A comprehensive approach to Pierre Robin sequence that includes conservative management, mandibular distraction osteogenesis, and tongue-lip adhesion can result in excellent airway and feeding outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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14
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Almajed A, Viezel-Mathieu A, Gilardino MS, Flores RL, Tholpady SS, Côté A. Outcome following Surgical Interventions for Micrognathia in Infants with Pierre Robin Sequence: A Systematic Review of the Literature. Cleft Palate Craniofac J 2017; 54:32-42. [DOI: 10.1597/15-282] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Tongue-lip adhesion (TLA), mandibular distraction osteogenesis (MDO), and subperiosteal release of the floor of the mouth (SPRFM) are the most commonly performed surgical procedures to treat severe airway obstruction in infants born with Pierre Robin sequence (PRS). Objectives To determine the rate of failure of each type of procedure, in terms of mortality and the need for tracheostomy, and to determine what proportion of infants have significant airway obstruction postoperatively as determined by polysomnography (PSG) and compare the data by procedure type. Method A comprehensive literature search (1981 through June 2015) was done of the National Library of Medicine database using PubMed. Extracted data included diagnosis, type of surgery, and outcome including mortality, need for postoperative tracheostomy and details of PSG. Persistence of significant airway obstruction was defined as an apnea-hypopnea index > 15 events/h on PSG. Results Both mortality rate and need for tracheostomy were low for all procedures. Many studies lacked sufficient detail to identify significant airway obstruction postoperatively. In studies with sufficient data, MDO was associated with the lowest percentage of significant airway obstruction postprocedure (3.6%) compared to 50% for infants who underwent TLA. Insufficient PSG data was available for patients who were treated with SPRFM. Conclusions There is a paucity of objective PSG data to definitively assess postoperative airway outcomes for PRS. MDO appears to be the most effective technique based on the available PSG data. Standardized use of PSG may lead to better identification and treatment of patients at risk for suboptimal airway outcomes postoperatively.
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Affiliation(s)
- Athari Almajed
- Pediatric Pulmonology Division, Mubarak Al Kabeer Hospital, Kuwait
| | | | - Mirko S. Gilardino
- McGill University, Plastic Surgeon, Division of Plastic and Reconstructive Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Canada
| | - Roberto L. Flores
- New York University, Plastic Surgeon, Department of Plastic Surgery, NYU Langone Medical Center, New York, New York
| | - Sunil S. Tholpady
- Indiana University School of Medicine, Plastic Surgeon, Division of Plastic Surgery, Indiana University Medical Center, Indianapolis, Indiana
| | - Aurore Côté
- McGill University, Pediatric Pulmonologist, Division of Respiratory Medicine, The Montreal Children's Hospital, Montreal, Canada
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15
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Non-surgical and surgical interventions for airway obstruction in children with Robin Sequence. J Craniomaxillofac Surg 2016; 44:1871-1879. [DOI: 10.1016/j.jcms.2016.06.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 05/17/2016] [Accepted: 06/27/2016] [Indexed: 11/20/2022] Open
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16
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Clinical Factors Associated with the Non-Operative Airway Management of Patients with Robin Sequence. Arch Plast Surg 2016; 43:506-511. [PMID: 27896179 PMCID: PMC5122537 DOI: 10.5999/aps.2016.43.6.506] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 06/06/2016] [Accepted: 06/21/2016] [Indexed: 11/21/2022] Open
Abstract
Background The indications for surgical airway management in patients with Robin sequence (RS) and severe airway obstruction have not been well defined. While certain patients with RS clearly require surgical airway intervention and other patients just as clearly can be managed with conservative measures alone, a significant proportion of patients with RS present with a more confusing and ambiguous clinical course. The purpose of this study was to describe the clinical features and objective findings of patients with RS whose airways were successfully managed without surgical intervention. Methods The authors retrospectively reviewed the medical charts of infants with RS evaluated for potential surgical airway management between 1994 and 2014. Patients who were successfully managed without surgical intervention were included. Patient demographics, nutritional and respiratory status, laboratory values, and polysomnography (PSG) findings were recorded. Results Thirty-two infants met the inclusion criteria. The average hospital stay was 16.8 days (range, 5–70 days). Oxygen desaturation (<70% by pulse oximetry) occurred in the majority of patients and was managed with temporary oxygen supplementation by nasal cannula (59%) or endotracheal intubation (31%). Seventy-five percent of patients required a temporary nasogastric tube for nutritional support, and a gastrostomy tube placed was placed in 9%. All patients continued to gain weight following the implementation of these conservative measures. PSG data (n=26) demonstrated mild to moderate obstruction, a mean apneahypopnea index (AHI) of 19.2±5.3 events/hour, and an oxygen saturation level <90% during only 4% of the total sleep time. Conclusions Nonsurgical airway management was successful in patients who demonstrated consistent weight gain and mild to moderate obstruction on PSG, with a mean AHI of <20 events/hour.
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A Systematic Review of the Effectiveness of Tongue Lip Adhesion in Improving Airway Obstruction in Children With Pierre Robin Sequence. J Craniofac Surg 2016; 27:1453-6. [DOI: 10.1097/scs.0000000000002721] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Infant Mandibular Distraction for Upper Airway Obstruction: A Clinical Audit. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e812. [PMID: 27536491 PMCID: PMC4977140 DOI: 10.1097/gox.0000000000000822] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/20/2016] [Indexed: 11/26/2022]
Abstract
Background: Mandibular distraction osteogenesis (MDO) is an effective method of treating upper airway obstruction (UAO) in micrognathic infants. The short-term outcomes include relief of UAO, avoidance of tracheostomy, and prompt discharge from hospital. However, it is a significant surgical procedure with potential associated morbidities. This study describes a cohort of infants managed using MDO over a twelve-year period. Methods: A retrospective chart review was undertaken for children who had MDO before the age of 5 years between 2000 and 2012. This was followed by a clinical review of the same cohort specifically looking for dental anomalies, nerve injuries, and scar cosmesis. Results: Seventy-three children underwent MDO at a mean age of 2 months [interquartile range (IQR), 1.7–4.2] for nonsyndromic infants and 3.3 months (IQR, 2.1–7.4) for those with syndromes. Infants were discharged from hospital, on average, 15 days after procedure. After MDO, of the 9 who were previously tracheostomy dependent, 5 (56%) were decannulated within 12 months and none of the nontracheostomy-dependent children required further airway assistance. The majority of children required supplemental feeding preoperatively but, 12 months postoperatively, 97% of the nonsyndromic infants fed orally. Thirty-nine children (53%) were reviewed clinically [median age, 5.1 y (IQR, 3.9–6.5)] with 18 being syndromic. Many of the mandibular first permanent and second primary molars had developmental defects, but there was a low rate of neurosensory deficit and good scar cosmesis. Conclusions: This study contributes further to the evidence base underpinning the management of micrognathic infants with UAO.
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Tan HL, Kheirandish-Gozal L, Abel F, Gozal D. Craniofacial syndromes and sleep-related breathing disorders. Sleep Med Rev 2016; 27:74-88. [PMID: 26454241 PMCID: PMC5374513 DOI: 10.1016/j.smrv.2015.05.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/22/2015] [Accepted: 05/28/2015] [Indexed: 01/15/2023]
Abstract
Children with craniofacial syndromes are at risk of sleep disordered breathing, the most common being obstructive sleep apnea. Midface hypoplasia in children with craniosynostosis and glossoptosis in children with Pierre Robin syndrome are well recognized risk factors, but the etiology is often multifactorial and many children have multilevel airway obstruction. We examine the published evidence and explore the current management strategies in these complex patients. Some treatment modalities are similar to those used in otherwise healthy children such as adenotonsillectomy, positive pressure ventilation and in the refractory cases, tracheostomy. However, there are some distinct approaches such as nasopharyngeal airways, tongue lip adhesion, mandibular distraction osteogenesis in children with Pierre Robin sequence, and midface advancement in children with craniosynostoses. Clinicians should have a low threshold for referral for evaluation of sleep-disordered-breathing in these patients.
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Affiliation(s)
- Hui-Leng Tan
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Leila Kheirandish-Gozal
- Sections of Pediatric Sleep Medicine and Pediatric Pulmonology, Department of Pediatrics, Comer Children's Hospital, Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA
| | - François Abel
- Department of Paediatric Respiratory Medicine, Great Ormond Street Hospital for Children, London, UK
| | - David Gozal
- Sections of Pediatric Sleep Medicine and Pediatric Pulmonology, Department of Pediatrics, Comer Children's Hospital, Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA.
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Maas C, Poets CF. Initial treatment and early weight gain of children with Robin Sequence in Germany: a prospective epidemiological study. Arch Dis Child Fetal Neonatal Ed 2014; 99:F491-4. [PMID: 25164557 DOI: 10.1136/archdischild-2014-306472] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND To investigate birth prevalence of Robin Sequence (RS), distribution of implemented treatments and factors influencing weight gain during initial hospitalisation. METHODS Prospective population-based survey (August 2011-July 2013) on new hospital admissions of infants with RS in Germany. RS was defined as retrognathia/micrognathia and at least one of the following: upper airway obstruction, snoring or hypoxaemia; glossoptosis; feeding difficulties; failure to thrive; cleft palate or RS-associated syndrome. Birth prevalence was calculated using data from the National Bureau of Statistics and in-hospital weight gain evaluated by calculating differences in SD scores (SDS) for weight. Comparisons between cohorts were performed using the Wilcoxon/Kruskal-Wallis test or Fisher's exact test. RESULTS 151 patients with RS could be verified resulting in a birth prevalence of 11.3 per 100,000 live births. Orthodontic therapy (feeding plate or pre-epiglottic baton plate, PEBP) was applied most frequently (107 infants), followed by prone positioning (97 infants). Tracheotomy was rarely performed (n=7). For 115 infants, implementation of more than one intervention was reported. Infants with serious respiratory difficulties during initial hospitalisation (n=58) showed a more pronounced decrease in SDS for weight (median (IQR) -0.81 (-1.32 to -0.26) vs -0.48 (-0.86 to 0.02); p=0.008) whereas treatment with PEBP was associated with better weight gain (SDS-difference for weight -0.37 (-1.06 to 0.02) vs -0.74 (-1.09 to -0.35); p=0.022). CONCLUSIONS Non-surgical management is preferred for infants with RS in Germany. The extent of upper airway obstruction seemed to influence in-hospital weight gain, while use of the PEBP was associated with improved early weight gain.
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Affiliation(s)
- Christoph Maas
- Department of Neonatology, University Hospital, Tuebingen, Germany
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The Importance of Extreme Weight Percentile in Postoperative Morbidity in Children. J Am Coll Surg 2014; 218:988-96. [DOI: 10.1016/j.jamcollsurg.2013.12.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/30/2013] [Accepted: 12/30/2013] [Indexed: 11/18/2022]
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Smith CB, Walker K, Badawi N, Waters KA, MacLean JE. Impact of sleep and breathing in infancy on outcomes at three years of age for children with cleft lip and/or palate. Sleep 2014; 37:919-25. [PMID: 24790270 DOI: 10.5665/sleep.3660] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
STUDY OBJECTIVES To evaluate the relationship between sleep disordered breathing (SDB) in early infancy and outcomes at 3 years of age in children with cleft lip and/or palate (CL/P). DESIGN Observational follow-up study. SETTING Multidisciplinary CL/P clinic, tertiary centre. PARTICIPANTS Children with CL/P who participated in a study of sleep and breathing in infancy. MEASUREMENTS AND RESULTS The families of 52 children were approached for this follow-up study. The children underwent neurocognitive (Bayley Scales of Infant and Toddler Development, Third Edition; BSID-III), quality of life (Infant/Toddler Quality of Life Questionnaire; ITQOL), and growth assessments at 3 years. The families of 33 children (66%) completed follow-up at 36.7 ± 1.4 months. The apnea-hypopnea index (AHI) in infancy was 23.9 ± 18.0 events/h. Mean group BSID-III scores fell within the standardized normal range (10 ± 3) for all domains; however, language scores were lower than control children. Quality of life scores and growth parameter z-scores were similar to published control data. PSG variables in infancy showed significant relationships with outcomes at 3 years of age; lower percentage of AS/REM sleep was associated with lower cognition score; more obstructive events were associated with lower global behavior ITQOL score; and higher number of respiratory events in infancy was associated with lower weight z-score. CONCLUSION Neurocognition, quality of life, and growth measures from children with CL/P fall within a normal range; however, scores in the language domain are lower than controls. Sleep and respiratory elements of SDB in infancy appear to modify these outcomes at 3 years of age.
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Affiliation(s)
- Courtney B Smith
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia ; Medical Program, University of New South, Sydney, NSW, Australia
| | - Karen Walker
- Discipline of Paediatrics & Child Health, University of Sydney, Sydney, NSW, Australia ; Neonatal Intensive Care Unit, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Nadia Badawi
- Discipline of Paediatrics & Child Health, University of Sydney, Sydney, NSW, Australia ; Neonatal Intensive Care Unit, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Karen A Waters
- Discipline of Paediatrics & Child Health, University of Sydney, Sydney, NSW, Australia ; Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Joanna E MacLean
- Department of Pediatrics & The Women & Children's Research Institute, University of Alberta, Edmonton, AB, Canada ; Discipline of Paediatrics & Child Health, University of Sydney, Sydney, NSW, Australia ; Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia
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Abstract
James Sidman, MD, and Sherard A. Tatum, MD, address the following questions for discussion and debate. Is neonatal distraction osteogenesis (DO) better than lip-tongue adhesion or tracheotomy for micrognathic airway compromise? What role does DO have in adult orthognathic surgery situations? In monobloc and Le Fort III procedures, are internal or external devices preferable? What role does DO play in craniofacial microsomia? Is endoscopic DO better than open procedures for synostosis management? How has your technique changed or evolved over the past 5 years and what has doing this technique taught you?
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Affiliation(s)
- James Sidman
- ENT and Facial Plastic Surgery, Children's Hospitals and Clinics of Minnesota, University of Minnesota Medical School, 2530 Chicago Avenue S, Suite 450, Minneapolis, MN 55404, USA.
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Outcomes after tongue–lip adhesion or mandibular distraction osteogenesis in infants with Pierre Robin sequence and severe airway obstruction. Int J Oral Maxillofac Surg 2013; 42:1418-23. [DOI: 10.1016/j.ijom.2013.07.747] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 07/18/2013] [Accepted: 07/20/2013] [Indexed: 11/21/2022]
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Fayoux P, Hosana G, Bonne N, Nicollas R. Tongue-lip adhesion. Eur Ann Otorhinolaryngol Head Neck Dis 2013; 130:99-102. [DOI: 10.1016/j.anorl.2012.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 07/30/2012] [Indexed: 10/27/2022]
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Daniel M, Bailey S, Walker K, Hensley R, Kol-Castro C, Badawi N, Cheng A, Waters K. Airway, feeding and growth in infants with Robin sequence and sleep apnoea. Int J Pediatr Otorhinolaryngol 2013; 77:499-503. [PMID: 23313433 DOI: 10.1016/j.ijporl.2012.12.019] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 12/13/2012] [Accepted: 12/15/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Robin sequence (RS) is associated with airway abnormalities that result in functional problems of obstructive sleep apnoea (OSA), feeding difficulties, and consequent poor growth. We evaluated the relationships between OSA severity, airway and feeding interventions, and weight at 12 months in infants with RS and OSA. METHODS Retrospective notes review of children with RS managed at our neonatal unit (1998-2010, inclusive). RESULTS Of 39 infants studied, 10 (25.6%) had mild/moderate OSA, and 29 (74.4%) severe. Infants with severe OSA required more airway interventions in hospital (82.8 vs 30.0%, p = 0.004) and at discharge (72.4 vs 20.0%, p = 0.007) than those with mild/moderate OSA; 30.0% of infants with mild/moderate OSA required continuous positive airway pressure (CPAP) during admission and 20.0% on discharge, but amongst those with severe OSA 82.8% required airway interventions as an inpatient, 17.2% underwent mandibular distraction osteogenesis, and 55.2% required CPAP on discharge. Those with severe OSA were also more likely to require tube feeding on discharge (89.7 vs 50.0%, p = 0.02). Overall, children were on a lower weight centiles at discharge compared to birth (-10.2 centiles) and at 12 months of age compared to birth (-14.8 centiles), but this occurred irrespective of OSA severity or need for airway interventions or tube feeding. CONCLUSIONS Infants with RS commonly have OSA, feeding and airway difficulties. Weight at 12 months appeared not to be influenced by OSA severity, feeding or airway problems, suggesting that current intervention/management strategy results in the severely affected infants growing as well as those affected less severely.
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Affiliation(s)
- M Daniel
- Children's Hospital, Westmead, Sydney, Australia.
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Tutor JD, Gosa MM. Dysphagia and aspiration in children. Pediatr Pulmonol 2012; 47:321-37. [PMID: 22009835 DOI: 10.1002/ppul.21576] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 08/11/2011] [Indexed: 11/08/2022]
Abstract
Aspiration is a significant cause of respiratory morbidity and sometimes mortality in children. It occurs when airway protective reflexes fail, especially, when dysphagia is also present. Clinical symptoms and physical findings of aspiration can be nonspecific. Advances in technology can lead to early diagnosis of dysphagia and aspiration, and, new therapeutic advances can significantly improve outcome and prognosis. This report first reviews the anatomy and physiology involved in the normal process of swallowing. Next, the protective reflexes that help to prevent aspiration are discussed followed by the pathophysiologic events that occur after an aspiration event. Various disease processes that can result in dysphagia and aspiration in children are discussed. Finally, the various methods for diagnosis and treatment of dysphagia in children are reviewed.
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Affiliation(s)
- James D Tutor
- Program in Pediatric Pulmonary Medicine, University of Tennessee Health Science Center, LeBonheur Children's Hospital, St. Jude Children's Research Hospital, Memphis, Tennessee 38103, USA.
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Poets CF, Bacher M. Treatment of upper airway obstruction and feeding problems in Robin-like phenotype. J Pediatr 2011; 159:887-92. [PMID: 21885059 DOI: 10.1016/j.jpeds.2011.07.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 05/31/2011] [Accepted: 07/20/2011] [Indexed: 11/17/2022]
Affiliation(s)
- Christian F Poets
- Department of Neonatology, Tübingen University Hospital, Tübingen, Germany.
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Bookman LB, Melton KR, Pan BS, Bender PL, Chini BA, Greenberg JM, Saal HM, Taylor JA, Elluru RG. Neonates with Tongue-Based Airway Obstruction. Otolaryngol Head Neck Surg 2011; 146:8-18. [DOI: 10.1177/0194599811421598] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. In this systematic review, the authors summarize the current evidence in the literature regarding diagnosis, treatment, and long-term outcomes in neonates with tongue-based airway obstruction (TBAO) and assess the level of evidence of included studies. Data Sources. The terms Pierre Robin syndrome/sequence, micrognathia, retrognathia, and cleft palate were combined with airway obstruction, treatment, tongue-lip plication, and osteogenesis distraction to perform an Ovid literature search, yielding 341 references. The authors excluded references containing patients with isolated choanal/nasal obstruction, patients older than 12 months, and expert opinion papers, yielding 126 articles. Review Methods. The authors searched 3 electronic databases and reference lists of existing reviews from 1980 to October 2010 for articles pertaining to the diagnosis, treatment, and outcomes of TBAO. Reviewers assigned a level of evidence score based on Oxford’s Centre for Evidence Based Medicine scoring system and recorded relevant information. Results. Most studies were case studies and single-center findings. The lack of standardization of diagnostic and treatment protocols and the heterogeneity of cohorts both within and between studies precluded a meta-analysis. There was little evidence beyond expert opinion and single-center evaluation regarding diagnosis, treatment, and long-term outcomes of neonates with TBAO. Conclusions. The variability in the phenotype of the cohorts studied and the absence of standardized indications for intervention preclude deriving any definitive conclusions regarding diagnostic tools to evaluate this patient population, treatment choices, or long-term outcomes. A coordinated multicenter study with a standardized diagnostic and treatment algorithm is recommended to develop evidence for the diagnosis and treatment of neonates with TBAO.
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Affiliation(s)
- Laurel B. Bookman
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kristin R. Melton
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Brian S. Pan
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Barbara A. Chini
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Howard M. Saal
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jesse A. Taylor
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Evans KN, Sie KC, Hopper RA, Glass RP, Hing AV, Cunningham ML. Robin sequence: from diagnosis to development of an effective management plan. Pediatrics 2011; 127:936-48. [PMID: 21464188 PMCID: PMC3387866 DOI: 10.1542/peds.2010-2615] [Citation(s) in RCA: 186] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The triad of micrognathia, glossoptosis, and resultant airway obstruction is known as Robin sequence (RS). Although RS is a well-recognized clinical entity, there is wide variability in the diagnosis and care of children born with RS. Systematic evaluations of treatments and clinical outcomes for children with RS are lacking despite the advances in clinical care over the past 20 years. We explore the pathogenesis, developmental and genetic models, morphology, and syndromes and malformations associated with RS. Current classification systems for RS do not account for the heterogeneity among infants with RS, and they do not allow for prediction of the optimal management course for an individual child. Although upper airway obstruction for some infants with RS can be treated adequately with positioning, other children may require a tracheostomy. Care must be customized for each patient with RS, and health care providers must understand the anatomy and mechanism of airway obstruction to develop an individualized treatment plan to improve breathing and achieve optimal growth and development. In this article we provide a comprehensive overview of evaluation strategies and therapeutic options for children born with RS. We also propose a conceptual treatment protocol to guide the provider who is caring for a child with RS.
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Affiliation(s)
- Kelly N. Evans
- Division of Craniofacial Medicine, Department of Pediatrics, ,Children's Craniofacial Center, Seattle Children's Hospital, Seattle, Washington
| | - Kathleen C. Sie
- Division of Pediatric Otolaryngology, Department of Otolaryngology Head and Neck Surgery, and ,Children's Craniofacial Center, Seattle Children's Hospital, Seattle, Washington
| | - Richard A. Hopper
- Division of Plastic Surgery, Department of Surgery, and ,Children's Craniofacial Center, Seattle Children's Hospital, Seattle, Washington
| | - Robin P. Glass
- Division of Rehabilitation Medicine, Department of Occupational Therapy, University of Washington, Seattle, Washington; ,Children's Craniofacial Center, Seattle Children's Hospital, Seattle, Washington
| | - Anne V. Hing
- Division of Craniofacial Medicine, Department of Pediatrics, ,Children's Craniofacial Center, Seattle Children's Hospital, Seattle, Washington
| | - Michael L. Cunningham
- Division of Craniofacial Medicine, Department of Pediatrics, ,Children's Craniofacial Center, Seattle Children's Hospital, Seattle, Washington
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Pinheiro Neto CD, Alonso N, Sennes LU, Goldenberg DC, Santoro PDP. Polysomnography evaluation and swallowing endoscopy of patients with Pierre Robin sequence. Braz J Otorhinolaryngol 2010; 75:852-6. [PMID: 20209287 PMCID: PMC9446090 DOI: 10.1016/s1808-8694(15)30549-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 03/30/2009] [Indexed: 11/16/2022] Open
Abstract
The Pierre Robin sequence is characterized by micrognathia, glossoptosis and upper airway obstruction. Symptom severity varies, and this makes the treatment of these patients a true challenge. Aim to identify the presence of sleep hypopnea-apnea in patients with Pierre-Robin sequence. Materials and Methods retrospective study in which we assessed 14 children with Pierre-Robin sequence, eight girls. The children were submitted to swallowing video-endoscopy study and polysomnography. Results eight patients were included in this study. Six had normal polysomnography and only one patient had mild central hypopnea-apnea. Swallowing video-endoscopy was normal in five patients and moderate dysphagia was detected in three patients, who were then submitted to gastrostomy. Mandible distraction was carried out in four patients who were also submitted to tracheostomy during the same procedure. Conclusions dysphagia was more prevalent than sleep apnea. Swallowing video-endoscopy proved to be a dynamic test and one able to detect feeding disorders in patients with Pierre Robin sequence.
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Affiliation(s)
- Carlos Diógenes Pinheiro Neto
- Skull-Maxillofacial Surgery and Skull Base Surgery, Department of Ophthalmology and Otorhinolaryngology of the University of Sao Paulo Medical School.
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Cozzi F, Totonelli G, Cozzi D. Longitudinal study of the growth of infants with isolated Robin sequence considered being severe cases. Acta Paediatr 2009; 98:4. [PMID: 19086937 DOI: 10.1111/j.1651-2227.2008.01126.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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