Airway interventions in children with Pierre Robin Sequence

Systematic review and meta-analysis of surgical approaches for improving airway stability in infants with Robin sequence: evaluating complications and outcomes

The purpose of this systematic review and meta-analysis was to determine the most effective and least morbid surgical technique for relieving retroglossal airway obstruction in infants with Robin sequence (RS). The study adhered to PRISMA guidelines and included 25 studies (24 cohorts and one case series) that investigated interventions for airway improvement, including conservative measures, tongue-lip adhesion (TLA), mandibular distraction osteogenesis (MDO), and tracheostomy. The primary outcome variable was complication rate, while predictor variable was the use of interventions for airway improvement. Results showed that conservative measures were the preferred initial management strategy in most studies, while TLA was recommended for infants with mild obstruction, and MDO or tracheostomy was reserved for severe cases. Only complications could be analysed via meta-analysis due to data heterogeneity, revealing that tracheostomy had a summary odds ratio of 5.39 in favour of TLA, while MDO had a ratio of 2.8 over TLA, and the complication rates were similar between MDO and tracheostomy. If conservative measures fail, the study recommends mandibular distraction as the preferable technique for stable airway improvement. If the infant is unsuitable for distraction, tongue-lip adhesion may serve as an alternative, while tracheostomy should be reserved for cases of severe multi-level obstruction. The authors propose that large-scale, multicentre trials comparing long-term outcomes are required to establish definitive guidelines.

Prognostic Risks for Tracheostomy in Pierre Robin Sequence: A Cohort From a Tertiary Hospital in Thailand

BACKGROUND

Pierre Robin sequence (PRS), characterized by micrognathia, glossoptosis, cleft palate, and obstructed airways, is one of the craniofacial conditions challenging various approaches to managing compromised airways, ranging from conservative measures to invasive airway surgery. This study was conducted to identify predictive risk factors for tracheostomy in the PRS.

METHODS

A retrospective chart review was conducted at a tertiary referral hospital in Thailand. Children diagnosed with PRS from January 2010 to December 2021 were enrolled. Univariate and multivariate analysis methods were used to identify the risk factors.

RESULTS

Sixty-five patients with PRS were identified in electronic medical records, but 6 were excluded. Thirteen of the remaining 59 patients underwent tracheostomy. There were no significant differences in sex, preterm gestational age, cleft palate, associated syndromes, chromosome abnormalities, or cardiac or neurological involvement between patients who received tracheostomy and those who did not. However, patients with oropharyngeal dysfunction who received tracheostomy tended to use a nasogastric tube or percutaneous gastrostomy 92.3% of the time ( P = 0.043). In addition, patients with abnormal airways from endoscopy were more likely to undergo tracheostomy (odds ratio, 2.17; 95% confidence interval [CI], 1.20-3.90). Interestingly, patients with a sum of Apgar scores at 1 and 5 minutes <15 were more likely to undergo tracheostomy (adjusted odds ratio, 9.91; 95% CI, 1.32-74.52). Furthermore, patients with at least 3 identified comorbidities were more likely to undergo tracheostomy (adjusted odds ratio, 11.34; 95% CI, 1.16-111.15).

CONCLUSIONS

The need for tracheostomy depends on comorbidities, Apgar scores, and abnormal airway anatomy. Feeding methods can become more complex with tracheostomy. Prognostic risk factors can help guide treatment and counseling for health care workers and caregivers.

Management of Obstructive Sleep Apnea in the Infant and Newborn

Obstructive sleep apnea in newborns and infants presents a unique challenge with distinct differences in sleep physiology, etiologies, and management compared to older children. The indications for and interpretation of polysomnography are less well defined in infants. There are also no broadly accepted clinical practice guidelines for treating sleep apnea in this age group. Etiologies include general causes of upper airway obstruction in infants such as laryngomalacia, micrognathia, and nasal obstruction in addition to adenotonsillar hypertrophy. Treatment strategies must be tailored to the specific anatomic features and comorbidities of the specific patients and often require a multidisciplinary approach.

Efficacy of Systematic Early-Second-Trimester Ultrasound Screening for Facial Anomalies: A Comparison between Prenatal Ultrasound and Postmortem Findings

Second-trimester 2D ultrasound (US) assessment of the fetal anatomy, as proposed by worldwide guidelines, allows detecting the majority of fetal malformation. However, the detection rates of fetal facial anomalies seem to still be low, mostly in cases of isolated facial malformation. The purpose of this research was to assess and analyze the concordance between the antenatal imaging findings from second-trimester US screening and the results of fetal postmortem autopsy. Between January 2010 and January 2020, there were 43 cases where fetuses with prenatal ultrasound diagnosis of a face abnormality, associated or not with a genetic syndrome or chromosomal disorder, following intrauterine death (IUD) or termination of pregnancy (TOP) after the 13 weeks of pregnancy, underwent autopsy in the Pathological Anatomy section of Bari Polyclinic specializing in feto-placental autopsies. The diagnosis of the fetal facial defects at ultrasound was compared with the findings at autopsy in all cases. A very high level of agreement between prenatal ultrasound and autopsy findings was found for facial abnormalities associated with genetic syndromes or numerical abnormality of chromosomes. A lower level of concordance was instead found in isolated facial defects or those associated with other organ anomalies, but not associated with genetic syndrome or numerical chromosome anomaly. A detailed examination of aborted fetuses led to successful quality control of early-second-trimester ultrasound detection of facial anomalies; however, it was less accurate for the isolated ones. It is, thus, reasonable to propose a systematic early-second-trimester prenatal ultrasound screening for facial anatomy by operators specialized in fetal medicine field, using 2D, 3D, and 4D techniques (two-, three-, and four-dimensional ultrasound).

Pierre Robin Sequence and Respiratory Distress: Long-Term Evolution in Patients Submitted to the Conservative Treatment

BACKGROUND

Pierre Robin Sequence (PRS) is characterized by micrognathia, glossoptosis, cleft palate, and airway distress. The aims of initial treatment are the improvement of airway and feeding. There are many therapeutic options, including conservative techniques (prone positioning and nasopharyngeal tube) and invasive procedures (mandibular distraction and tracheostomy). In our center, initially conservative treatment is the rule and many patients have been treated with nasopharyngeal tube.

OBJECTIVE

The aim was to analyze of the clinical evolution of respiratory distress in infants with PRS submitted to nonsurgical treatment.

METHODS

A retrospective and observational descriptive evaluation was carried out with 56 patients with the PRS at Centro de Atendimento Integral ao Fissurado Labiopalatal (CAIF). 21 patients were selected to a transversal phase.

RESULTS

The treatment has started in an average age of 1.5 months (±2.09) and 17 (94.4%) had respiratory distress at birth. Polysomnographic exams showed an average apnea/hypopnea index of 0.93, an average number of central apnea/hour of 0.3, an average number of obstructive apnea of 0.6 and an average oxygen saturation of 92%. There was the predominance of esthetic profile in class II with 16 (88.9%) patients in this group, and orthodontic profile in class II with 15 (83.3%) patients.

CONCLUSION

The conservative treatment has presented remarkable results in the treatment of respiratory distress in bearers of PRS with a decrease of obstructive sleep events considering the growth of patient and the development of mandibular growth as well.

The management of upper airway obstruction in Pierre Robin Sequence

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.

Cleft Palate Repair in Robin Sequence following Mandibular Distraction Osteogenesis Compared to Tongue-Lip Adhesion

OBJECTIVE

To evaluate the timing and safety of cleft palate (CP) repair in patients with Robin sequence (RS) treated with mandibular distraction osteogenesis (MDO) or tongue-lip adhesion (TLA) for airway obstruction.

DESIGN

Retrospective cohort study.

SETTING

Tertiary Pediatric Hospital during 2004-2020.

PATIENTS

148 patients with RS underwent MDO, 66 met inclusion by having MDO and followed by palatoplasty. 26 patients with RS underwent TLA, 14 met inclusion by having TLA and followed by palatoplasty.

MAIN OUTCOME MEASURES

Patient characteristics, hospital/operative details, postoperative complications, and polysomnographic (PSG) data were compared.

RESULTS

Groups were well-matched except more patients with syndromes underwent MDO (N = 27, 41%, P ≤ .002). In the MDO and TLA cohorts, mean CP repair age was 12.8 ± 1.9 months and 14.6 ± 1.6 months, respectively (P ≤ .002). Despite the earlier CP repair in the MDO group, there were no differences in peri-operative complication rates after palatoplasty in either group. All sleep respiratory parameters improved after MDO/TLA prior to palatoplasty P ≤ .050. All PSG parameters remained significantly improved after palatoplasty compared to preoperative values, P ≤ .043. Obstructive apnea hypopnea index and Oxygen saturation nadir further improved after palatoplasty within the MDO group, P ≤ .050, while no changes in the TLA group, P ≥ .500.

CONCLUSIONS

MDO was associated with earlier age at palatoplasty than TLA with a similar perioperative risk profile. In those patients with pre- and post-palatoplasty PSG data, palatoplasty was not associated with a deterioration in PSG parameters, and in fact in the MDO group, PSG data improved.

Syndromes associated with Robin sequence: a national prospective cohort study

OBJECTIVES

To determine the prevalence of syndromic Robin sequence (RS) in the UK and if this group of patients had an increased need for airway and feeding management compared with a non-syndromic RS cohort.

DESIGN

A prospective national multicentre study of cases submitted to the Cleft Collective cohort studies.

SETTING

Specialist cleft services in the UK.

PATIENTS

259 participants who fulfilled the diagnosis of RS. This group was compared with 548 participants with cleft palate only (CPO).

MAIN OUTCOME MEASURES

The primary outcome measure was the presence of a syndrome in patients with RS and CPO. Secondary outcome measures included the use of airway and feeding adjuncts.

RESULTS

An associated syndrome was seen in 28% of patients with RS and 14% of patients with CPO. The most common syndrome for the RS group was Stickler syndrome (27%). Syndromic status was significantly higher among patients with RS compared with those with CPO (OR 2.36, 95% CI 1.65 to 3.39; p<0.001). Patients with syndromic RS have an increased reliance on airway adjuncts compared with the patients without syndromic RS (OR 2.02, 95% CI 1.13 to 3.64; p=0.018). There was no evidence of a difference in the use of feeding adjuncts between syndromic and non-syndromic RS groups (OR 2.43, 95% CI 0.78 to 7.58; p=0.126).

CONCLUSION

The presence of a syndrome has implications for management of patients with RS. Early identification of a syndrome may help prevent the consequences of a missed syndromic diagnosis. Routine ophthalmological and genetic screening for Stickler syndrome should be mandatory for all patients with RS.

[The Pierre Robin sequence from an anesthesiologic perspective : Presentation of the procedure based on a retrospective analysis at a university hospital]

INTRODUCTION

As part of surgical interventions in pediatric patients, children with craniofacial malformations and syndromes are presented in the field of oral and maxillofacial surgery, anesthesia and also in all other clinical disciplines. In particular, the Pierre Robin sequence in the clinical context leads to a situation albeit a rare one, which should be given high attention in preoperative, intraoperative and postoperative care.

MATERIAL AND METHODS

In a retrospective analysis from 1993 to 2020 in the Department of Oral and Maxillofacial Surgery at the University Hospital Halle (Saale), a total of 54 patients were identified with syndromic changes and a need for surgical treatment. During this period, 12 patients with a Pierre Robin sequence were genetically confirmed, who received a total of 20 surgical interventions under general anesthesia at different times. Statistical analysis was performed using SPSS 17.0.

RESULTS

In 12 patients with a Pierre Robin sequence, 20 surgical procedures were performed with the patient under general anesthesia. The youngest patients had an average age of 6 months, the oldest 16 years at the time of the operation. The average age was 5.7 years. In addition to the genetic component, all children were assigned to the ASA I classification. The surgical indication was initially an isolated cleft palate in all patients, followed by further interventions such as dental restorations, corrective surgery in the area of the palate or ear nose throat (ENT) examinations. Drug induction of general anesthesia was weight-adapted using propofol 1%, fentanyl or remifentanil and rocuronium. In our study, out of 18 orotracheal intubations, only 2 patients had to be intubated by video laryngoscopy. One patient required nasal intubation and another was fitted with a laryngeal mask. The success rate of conventional intubation was 89.5%. Postoperatively, one infant had recurrent drops in saturation, so that reintubation was necessary.

Modified mandible traction with wires to treat neonatal Pierre Robin sequence: A case report

Background

Pierre Robin sequence (PRS) is a congenital craniofacial deformity characterized by micrognathia, glossoptosis and airway obstruction. Some affected neonates are born with severe life-threatening upper airway obstruction that requires surgery. If without timely treatment, it is possible to cause not only organ damage and developmental abnormalities but also early newborn mortality.

Case presentation

In this report, a 51-hours-old neonate was diagnosed with PRS, who had severe upper airway obstruction and required surgery. We performed the modified mandible traction with wires at four days old and achieved a satisfactory result in improving airway obstruction. No other complications were observed except for mild local infection. No overlap of other more complex syndromes was found, such as ocular abnormalities, hearing loss, other skeletal abnormalities, cardiac abnormalities or other atypical abnormalities. At the present follow-up until 2 years old, there were no significant differences in the maxillofacial appearance, teeth growth, breathing, feeding, growth and development between the patient and normal children.

Conclusion

The modified mandible traction with wires can safely and effectively resolve micrognathia, the key to treating PRS, which is minimally invasive, simple and provides immediate relief of airway obstruction with no long term complications compared with other surgical methods. This report aims to provide more evidence of the successful treatment of neonatal PRS micrognathia by modified mandible traction with wires.

Three-dimensional comparison of mandibular morphology in young people with Treacher Collins syndrome and Pierre Robin sequence

INTRODUCTION

Treacher Collins syndrome (TCS) and nonsyndromic Pierre Robin sequence (PRS) share mandibular deficiency as a similar clinical finding. This study aimed to compare the mandibular size and morphology of subjects with TCS and PRS.

METHODS

Group TCS was composed of 17 subjects (7 male, 10 female) with a mean age of 11.5 years (standard deviation, 4.4) from a single center. Group PRS was composed of 17 subjects paired by age and sex with group TCS. Preorthodontic cone-beam computed tomography examinations of all patients were evaluated using Mimics Innovation Suite 17.0 (Materialise, Leuven, Belgium). Nine 3-dimensional measurements were performed in segmented 3D images of the mandible. Intragroup comparisons were performed using paired t tests. Intergroup comparisons were performed using analysis of variance and Tukey tests. The significance level considered was 5%.

RESULTS

TCS showed a significant dimensional difference between less and more affected sides for ramus, condyles, and mandibular body. The mandibular dimensions in PRS were more symmetrical. Group TCS presented a smaller mandibular effective length and mandibular body length compared with PRS. The condyle width and height and the ramus width were also decreased in TCS. The gonial angle was greater in TCS compared with the PRS group.

CONCLUSIONS

Young subjects with TCS presented a smaller, more vertical, and more asymmetrical mandible compared with nonsyndromic PRS.

The Safety and Efficacy of Mandibular Distraction Osteogenesis Among Infants Less Than 3 kg

OBJECTIVES/HYPOTHESIS

Mandibular distraction osteogenesis (MDO) is a safe and effective surgery to address respiratory and feeding issues due to micrognathia in patients with Robin Sequence (RS). Previous studies examining postoperative complications in neonates receiving MDO have considered 4 kg as the cut-off for low weight; however, an increasing number of MDO interventions are performed in infants <4 kg. To determine if a weight <3 kg at time of MDO is a risk factor for postoperative complications or need for subsequent tracheostomy or gastrostomy tube (G-tube).

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective review of all infants <6 months of age undergoing MDO at two tertiary pediatric hospitals from 2008 to 2018. Demographic data, syndromic status, weight, and age at time of surgery, length of postoperative hospital stay, and postoperative outcomes were recorded including tracheostomy placement, G-tube placement, hardware infection, reintubation, facial/marginal mandibular nerve damage, and need for revision MDO.

RESULTS

Sixty-nine patients with RS were included. The mean age at MDO was 25 ± 20 days and mean weight was 3.32 ± 0.44 kg. There was no statistically significant correlation between weight (P = .699) or age (P = .422) and unfavorable postoperative outcomes. No patients (0%) underwent tracheostomy pre-MDO. Two patients (2.9%) required tracheostomy postsurgery; neither was <3 kg. Eight patients (11.6%) required a G-tube postoperatively.

CONCLUSION

Newborns <3 kg who undergo MDO experience the same rates of success and complication as larger infants, suggesting that MDO is a safe and efficacious procedure in infants less than 3 kg. Laryngoscope, 2021.

Long Term Speech and Feeding Outcomes in Patients With Pierre Robin Sequence

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.

Retrospective Examination of the GILLS Algorithm Applied to Mandibular Distraction

Background: The GILLS (gastroesophageal reflux, preoperative intubation, late intervention (>14 days), low birth weight (<2500 g), and syndromic diagnosis) score is a validated predictor of success for tongue-lip adhesion (TLA) in patients with Robin sequence (RS). Objective: To evaluate the application of the GILLS score to mandibular distraction osteogenesis (MDO) for airway management in patients with RS and the associated syndromes. Methods: A retrospective chart review of 21 patients diagnosed with RS and treated with MDO surgery between the years 2006 and 2016 was performed. Success was defined by tracheostomy status outcome measures. Statistical analysis of the success was completed. Results: A GILLS score limit of ≤3 had a positive predictive value of 100%, a negative predictive value of 50%, 83% sensitivity, and 100% specificity. Conclusions: These data imply that the GILLS scoring algorithm is applicable to aiding in the selection of patients with RS for MDO, including patients with known syndromes.

Rigid Video Laryngoscopy for Intubation in Severe Pierre Robin Sequence: A Retrospective Review

OBJECTIVES/HYPOTHESIS

The anatomy of children with severe Pierre Robin sequence can present a challenge for direct laryngoscopy and intubation. Advanced techniques including flexible fiberoptic laryngoscopic intubation have been described but require highly specialized skill and equipment. Rigid video laryngoscopy is more accessible but has not been described in this population.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective review was completed at a tertiary care center of all children between January 2016 and March 2020 with Pierre Robin sequence who underwent a mandibular distraction osteogenesis procedure. Intubation events were collected, and a descriptive analysis was performed. A univariate logistic regression model was applied to direct laryngoscopy and flexible fiberoptic laryngoscopy with rigid video laryngoscopy as a reference.

RESULTS

Twenty-five patients were identified with a total of 56 endotracheal events. All patients were successfully intubated. Direct laryngoscopy was successful at first intubation attempt in 47.3% (9/19) of events. Six direct laryngoscopy events required switching to another device. Rigid video laryngoscopy was successful at first intubation attempt in 80.5% (29/36) of events. Two cases required switching to another device. Flexible fiberoptic laryngoscopy was found successful at first intubation attempt in 88.9% (8/9) of events. Direct laryngoscopy was 4 times more likely to fail first intubation attempt when compared to rigid video laryngoscopy (P < .05). There was no significant difference between rigid video laryngoscopy and flexible fiberoptic laryngoscopy for intubation.

CONCLUSIONS

For children with Pierre Robin sequence rigid video laryngoscopy should be considered as a first attempt intubation device both in the operating room and for emergent situations.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1647-1651, 2021.

Floating Bone Phenomenon in Pierre Robin Sequence

After a failed mandibular osteodistraction, the wrong positioned mandible of a few patients with Pierre Robin sequence returned in the most functional position and regained a proper symmetry, without external intervention. The study aims to explain this self-adjustment and introduce the floating bone phenomenon.The inclusion criteria were severe micrognathia, Fast and Early Mandibular Distraction Osteogenesis protocol, postoperative mandibular wrong positioning, presurgery, immediate postsurgery, and long-term computed tomography scan. Five patients were included. The considered parameters were the distance between mandibular dental centerline and midsagittal facial axis, the rotation of the mandibular body, the magnitude of elongation, and the lowering of the mandibular body.Three patients went from a decentralization >4 mm in the activation phase to a normalization of the said value in the follow-up. In the same period, the interincisal point of 2 patients moved respectively from 0.5 mm on the left and 0.8 mm on the right to 1.2 mm and 1.6 mm on the right, respectively. The rotation of the mandibular body was meanly 25.6° among all patients. The mean value of the distraction was 14.1 mm. A difference of about 4.4 mm between the left and the right side was measured. The lowering of the mandible varied between 2.8 and 12.6 mm.All patients improved their symmetry. Four of them improved in all the measured parameters, while 1 patient presented a worsening in the decentralization of the interincisal point.The floating bone phenomenon could break new grounds in the management of patients with Pierre Robin sequence.

A retrospective study of patients with Robin sequence: Patient characteristics and their impact on clinical outcomes

INTRODUCTION

Robin sequence (RS) is a congenital set of abnormalities of the head and neck, consisting of a hypoplastic mandible (micrognathia), a tongue that is displaced posteriorly (glossoptosis), and obstruction of the airway. A clear set of diagnostic criteria for this complex condition has recently been established, but there is still no consensus in the literature with respect to managing the associated airway, feeding, and hearing difficulties. The objectives of the study are: 1) to describe the management of airway and feeding issues in children with RS; and 2) to evaluate the impact of airway and feeding strategies on important clinical outcomes.

METHODS

A retrospective chart review was conducted of all pediatric patients diagnosed with RS at London Health Sciences Centre from January 1995 until September 2017. The frequencies of all airway and feeding interventions were collected. Data were collected on several clinical outcomes including initial admission length, enteral feeding duration, tympanostomy tube insertion frequency, and hearing thresholds. Statistical analyses to evaluate the impact of airway and feeding strategies on clinical outcomes were carried out using independent samples t-tests and Chi-square tests, where appropriate.

RESULTS

Twenty-four patients were identified. Five patients (20.8%) required airway surgery and 18 patients (75.0%) required enteral feeding. Airway surgery was significantly associated with a longer ICU admission (15.8 vs. 4.3 days, p < 0.05), a longer overall hospital admission (73.0 vs. 25.2 days, p < 0.05), a delay in introducing oral feeds (222.8 vs. 11.5 days, p < 0.05), and a higher frequency of tympanostomy tube insertions (80% vs. 23.5% requiring ≥2 insertions, p < 0.05). Enteral feeding was significantly associated with a longer ICU admission (8.8 vs. 0 days, p < 0.05) and a longer overall hospital admission (43.9 vs. 5.6 days, p < 0.05).

CONCLUSIONS

This study demonstrates the substantial impact that airway and feeding difficulties have on RS patient morbidity, particularly with respect to length of hospital and ICU admission. This information has prognostic value and may be helpful in generating a management algorithm for this complex patient population.

Optimal duration of mechanical ventilation and influencing factors following mandibular distraction osteogenesis in infants with Pierre Robin sequence

Mandibular distraction osteogenesis (MDO) is an effective treatment for tongue-based airway obstruction in infants with severe Pierre Robin sequence (PRS). Most infants receiving MDO require postoperative mechanical ventilation (MV) to assist breathing. Optimal MV time for each individual patient and factors influencing the time must be identified to guide clinical decision-making.A retrospective analysis was performed on 75 infants with PRS receiving MDO from November 2016 to August 2018. Twenty-six were females and 47 were males. Data extracted from the hospital information system included sex, age, weight, history of preterm labor, preoperative pulmonary infection, laryngomalacia/tracheomalacia, laryngoscope exposure classification, anesthesia duration, operation duration, postoperative treatment site, situation of distraction, postoperative complications and MV duration. Statistical analyses were conducted to investigate the potential associations of these factors with MV time.Seventy-three PRS syndrome patients received anesthesia for MDO device procedures were considered eligible for study. Patient sex, history of preterm labor, preoperative pulmonary infection, laryngomalacia/tracheomalacia, laryngoscopy exposure difficulty, postoperative treatment site (neonatal or pediatric intensive care unit), ventilator-associated pneumonia, age, weight, anesthesia duration, and operation duration had no significant influence on postsurgical MV time (P > .05). Amount of distraction at the time of extubation had statistically significant influence on postoperative MV time (P < .05). In addition, scatter plots revealed linear relationships between postoperative MV time and amount of distraction at extubation.According to this analysis, amount of distraction was associated with MV time following MDO for severe PRS and roughly 6 days post-surgery is a generally safe extubation time.

Surgical Management and Outcomes of Pierre Robin Sequence: A Comparison of Mandibular Distraction Osteogenesis and Tongue-Lip Adhesion

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.

Obstructive Sleep Apnea and Sleep Position: Does It Matter for Infants With a Cleft Palate?

Objective:

To determine whether nonsupine sleep improves obstructive sleep apnea (OSA) in infants with cleft palate undergoing polysomnography (PSG).

Design:

Retrospective chart review.

Setting:

Tertiary care pediatric hospital.

Patients:

Twenty-seven infants (1 month to 1 year) with cleft palate with or without cleft lip (CP ± L) undergoing PSG testing for suspected OSA were included.

Main Outcome Measures:

Polysomnography measures included obstructive apnea–hypopnea index (OAHI), central apnea–hypopnea index (CAHI), oxygen saturation (SpO2) nadir, SpO2, and end-tidal carbon dioxide (ETCO2).

Results:

Twenty-three PSGs with at least 20 minutes of sleep in both the supine and the nonsupine positions were analyzed. The supine OAHI (mean: 16.8 events/hour; standard deviation [SD]: 18.5) and nonsupine OAHI (mean: 12.6 events/hour; SD: 12.6) did not differ significantly ( P = .10). The supine CAHI (mean: 1.9 events/hour; SD: 2.7) and nonsupine CAHI (mean: 3.1 events/hour; SD: 3.7; P = .15), the supine SpO2nadir (mean: 81.2%; SD: 6.3) and nonsupine SpO2nadir (mean: 81.8%; SD: 5.3; P = .70), the supine mean SpO2(mean: 95.5%; SD: 1.9) and nonsupine mean SpO2saturation (mean: 95.3%; SD: 2.4; P = .34), and the supine ETCO2(mean: 45.4 mm Hg; SD: 5.3) and nonsupine ETCO2(mean: 42.5 mm Hg; SD: 10.1; P = .24) were also similar.

Conclusions:

There were no significant improvements in OSA metrics during nonsupine sleep in infants with CP ± L. Prior to recommending nonsupine positioning which increases infant’s exposure to sudden infant death syndrome risk, we advocate obtaining a PSG to verify an objective improvement in OSA.

Peripartum Management of Neonatal Pierre Robin Sequence

Pierre Robin sequence (PRS) is a congenital condition characterized by the presence of micrognathia, glossoptosis, and cleft palate. PRS has varying effects on airway patency and feeding ability and thus has a broad range of management options. The purpose of this article is to describe the nature of the background of the condition and address the previous and current trends in diagnosis and management of PRS.

Male individuals with Robin Sequence: emerging significant association with ABO and RhD blood group phenotypes

Background

This study investigated the association of Robin Sequence with ABO and RhD blood group phenotypes.

Methods

A retrospective cross-sectional study was performed of a cohort of Robin Sequence patients of the Hospital de Reabilitação de Anomalias Craniofaciais – Universidade de São Paulo (USP), Brazil. The study group was composed of 339 individuals of both genders with Robin Sequence referred for specific treatment. A control group was composed of 1780 individuals without syndromes. The groups were compared using the Pearson’ chi-square test (χ²) with statistical significance being defined for an alpha error of 5% (p-value < 0.05).

Results

A comparison of gender found a significant difference for the AB phenotype between groups (p-value = 0.007). Comparing blood type by gender there was no significant difference within the same group (p-value = 0.117 and 0.388 respectively, for Robin Sequence and the control group). When comparing the AB blood type between groups, there was no difference for females (p-value = 0.577), but there was a significant difference for males (p-value = 0.0029).

Conclusions

This study showed that the population with Robin Sequence had different patterns related to gender concerning the phenotypic distribution of ABO and RhD blood group phenotypes. Robin Sequence is more common among females. The AB phenotype was significantly higher in males with Robin Sequence than in males of the Control Group. The prevalence of the RhD-negative phenotype is higher in individuals with Robin Sequence. This result suggests a possible association of ABO and RhD phenotypes with Robin Sequence that should be better investigated by molecular studies, as it deserves greater attention.

A Single Lab Test to Aid Pierre Robin Sequence Severity Diagnosis

Objective:

The workup of patients with Pierre Robin sequence (PRS) consists of a physical examination, O2 saturation, and polysomnography to determine the severity of respiratory obstruction and need for surgery. We suggest that capillary blood gas (CBG) may be a better physiologic representation of airway obstruction and should be routinely used in the management of patients with PRS.

Design:

This is a multicenter study based on a retrospective review of medical records.

Setting:

The study was performed at tertiary care centers.

Interventions:

Patients with PRS <1 year old underwent mandibular distraction osteogenesis.

Main Outcome Measure:

Using successful treatment outcome as a reference standard, receiver operating characteristic (ROC) curve was used to determine the accuracy of the diagnostic test and values for the best sensitivity and specificity to determine the need for surgical intervention.

Results:

Of 73 patients, 48 had sporadic PRS, 23 had syndromes, 2 had micrognathia, not otherwise specified. Mandibular distraction osteogenesis was performed in 62 patients at a mean age of 39 days. The mean initial Apnea-Hypopnea Index (AHI) in nonsurgical versus surgical groups was 10 versus 31 ( P = .063), pH 7.41 versus 7.34 ( P = .003), pCO2 43 versus 56 ( P < .001), and HCO3 27 versus 30 ( P = .022). The ROC curve showed that pCO2 of 49.5 has the best specificity (100%) and sensitivity (72.6%) profile in terms of need for definitive airway.

Conclusion:

A simple CBG heel stick may better predict the physiologic effects of obstructive apnea; therefore, it should be added to the algorithm of PRS workup.

Pierre Robin Sequence: Cost-Analysis and Qualitative Assessment of 89 Patients at the Hospital for Sick Children

Introduction

Children with Pierre Robin sequence (PRS) have a complex clinical presentation and requires many health-care providers. Thus, multiple clinical pathways have been proposed on how to manage this population, with some opting for conservative measures while others opting for a surgical approach. However, no consensus has been reached on the most appropriate protocol.

Objective

To present the treatment protocol for PRS at the Hospital for Sick Children. This will be evaluated through a qualitative examination of the approach from the patient's perspective, and a micro-costing analysis of the financial aspects of providing care.

Methods

A retrospective cohort study was conducted to evaluate infants who were admitted with PRS and failure to thrive from January 2004 to December 2015. This was followed by a micro-costing analysis to evaluate the cost of the management protocol. Finally, a qualitative evaluation of the parent's perspective was done.

Results

Eighty-nine patients were admitted with failure to thrive during the study period. Fourteen patients underwent surgical management. Fourteen patients required readmission for airway or feeding issues secondary to PRS. The average cost per patient was Can$105 996. With regard to the qualitative evaluation, key themes that were generated included stress upon hospital admission, variable methods of understanding PRS, good level of communication with the team, excellent hospital process, and challenging transition home.

Conclusion

These results will aid in the continual evolution of a protocol and provide important information on PRS to both families and centers that manage these children.

Multidisciplinary Aspects of 104 Patients with Pierre Robin Sequence

Objective

To describe Pierre Robin sequence patients with a cleft palate from a multidisciplinary perspective.

Patients

A total of 104 individuals with Pierre Robin sequence and cleft palate, born between 1980 and 2010.

Method

Data were collected retrospectively and compared with large control groups.

Results

Of 104 patients, 19 (18.3%) were treated with a nasopharyngeal or oropharyngeal tube, continuous positive airway pressure, and/or a tracheotomy. The mean weight percentile for newborns with Pierre Robin sequence was 30.9. It decreased to 29.9 at the time of cleft palate repair (mean age, 13.7 months) ( P = .78). Of 87 patients, 30 (34.5%) developed normal speech after cleft palate repair. Of 93 nonsyndromic Pierre Robin sequence patients, 31 (33.3%) had or are having surgery for velopharyngeal insufficiency, a rate that is significantly higher when compared with a control group of cleft palate–only patients (19.4%; P = .004). Of 31 patients, 25 (80.6%) developed normal resonance after surgery for velopharyngeal insufficiency. There was no significant difference in the rate of syndromes between the Pierre Robin sequence patients and a control group of cleft palate patients without Pierre Robin sequence ( P = .25). Seven of 39 boys (17.9%) with Pierre Robin sequence had a diagnosis of autism spectrum disorder.

Conclusion

Even though the mean weight percentile for newborns with Pierre Robin sequence was low, the patients did not show a growth spurt during the first year of life. The high rate of velopharyngeal insufficiency after cleft palate repair in patients with Pierre Robin sequence needs further investigation. Also, the high rate of autism spectrum disorder among boys with Pierre Robin sequence prompts further investigation.

Severity of Retrognathia and Glossoptosis Does Not Predict Respiratory and Feeding Disorders in Pierre Robin Sequence

Pierre Robin sequence (PRS) may lead to life-threatening respiratory and feeding disorders. With the aim to analyse the association of the severities of retrognathia and glossoptosis with those of respiratory and feeding disorders, we retrospectively studied a series of 50 infants with retrognathia, glossoptosis, cleft palate, and airway obstruction. The patients were managed from birth to at least 6 years of age by a single pediatric team at the Armand Trousseau Hospital in Paris within a 12 years period (2000-2012). Retrognathia and glossoptosis were graded in the neonatal period according to a specific clinical examination. Ventilation assistance was required for 32/50 (64%) patients, and enteral feeding for 41/50 (82%). The grades of retrognathia and glossoptosis and the severity of respiratory disorders did not differ between patients with isolated PRS and syndromic PRS. Severe respiratory disorders were more common and long-lasting feeding (>12 months) was more frequently required in patients with syndromic PRS compared with isolated PRS (42 vs. 13%, p = 0.04 and 42 vs. 4%, p < 0.01 respectively). Using univariate analysis, neurological impairments and laryngomalacia were associated with severe respiratory disorders [Odds ratio (OR) 5.0, 95% CI 1.3-19.6; and OR 14.6, 95% CI 1.3-161.4; p < 0.05] as well as with long-lasting feeding (>12 months) disorders (OR 18.6, 95% CI 3.9-89.2 and OR 20.4, 95% CI 3,4-122.8; p < 10^-2). Syndromic SPR status was also associated with severe respiratory disorders (OR 4.9, 95% CI 1-32.5; p < 0.05). Using multivariate analysis, only syndromic PRS status was predictive for severe respiratory disorders (adjusted OR 8, 95% CI 1.47-44.57; p < 0.05); and only neurological impairments remained a significant risk for long lasting feeding disorders (>12 months) (adjusted OR 21.72, 95% CI 3.4-138.63; p < 10^-2). The grades of retrognathia and glossoptosis were not predictive factors for the severity of respiratory and feeding disorders. Conclusion: In children with PRS, the severity of clinical conditions may not correlate with anatomic variables but rather with laryngeal abnormalities, neurological impairement and syndromic PRS status.

ERS statement on obstructive sleep disordered breathing in 1- to 23-month-old children

The present statement was produced by a European Respiratory Society Task Force to summarise the evidence and current practice on the diagnosis and management of obstructive sleep disordered breathing (SDB) in children aged 1-23 months. A systematic literature search was completed and 159 articles were summarised to answer clinically relevant questions. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are identified. Morbidity (pulmonary hypertension, growth delay, behavioural problems) and coexisting conditions (feeding difficulties, recurrent otitis media) may be present. SDB severity is measured objectively, preferably by polysomnography, or alternatively polygraphy or nocturnal oximetry. Children with apparent upper airway obstruction during wakefulness, those with abnormal sleep study in combination with SDB symptoms (e.g. snoring) and/or conditions predisposing to SDB (e.g. mandibular hypoplasia) as well as children with SDB and complex conditions (e.g. Down syndrome, Prader-Willi syndrome) will benefit from treatment. Adenotonsillectomy and continuous positive airway pressure are the most frequently used treatment measures along with interventions targeting specific conditions (e.g. supraglottoplasty for laryngomalacia or nasopharyngeal airway for mandibular hypoplasia). Hence, obstructive SDB in children aged 1-23 months is a multifactorial disorder that requires objective assessment and treatment of all underlying abnormalities that contribute to upper airway obstruction during sleep.

Early Airway Intervention for Craniofacial Anomalies

This article reviews the presentation of children with craniofacial anomalies by the most common sites of airway obstruction. Major craniofacial anomalies may be categorized into those with midface hypoplasia, mandible hypoplasia, combined midface and mandible hypoplasia, and midline deformities. Algorithms of airway interventions are provided to guide the initial management of these complex patients.

Robin sequence: what the multidisciplinary approach can do

Robin sequence (RS) is a commonly encountered triad of micrognathia, glossoptosis, and airway obstruction, with or without a cleft palate. The management of airway obstruction is of paramount importance, and multiple reviews and retrospective series outline the diagnosis and treatment of RS. This article focuses on the multidisciplinary nature of RS and the specialists’ contributions and thought processes regarding the management of the RS child from birth to skeletal maturity. This review demonstrates that the care of these children extends far beyond the acute airway obstruction and that thorough monitoring and appropriate intervention are required to help them achieve optimal outcomes.

A Simple Mandibular Distraction Protocol to Avoid Tracheostomy in Patients with Pierre Robin Sequence

Objective

Recent treatment goals for Pierre Robin sequence (PRS) focus on avoiding tracheostomy through modalities such as mandibular distraction osteogenesis (MDO). We primarily evaluated the efficacy of our straightforward MDO treatment protocol for resolution of PRS-associated airway obstruction while secondarily analyzing patient characteristics associated with success or failure of MDO.

Design

A retrospective chart review before and after treatment.

Setting

Tertiary institutional center and private practice setting.

Patients

All patients were diagnosed with PRS and treated with MDO, according to the MDO treatment protocol, by a single surgeon with the same operative technique from 1999 to 2013. A sample size of n = 38 met the inclusion criteria. Data assessed included tracheostomy status (pre-MDO, post-MDO, or none), microlaryngoscopy and bronchoscopy (MLB) findings, multipositional airway study results, clinical resolution of airway obstruction following MDO, and patient characteristics.

Main Outcome Measure

Resolution of airway obstruction with avoidance of a tracheostomy.

Results

Prior to referral for MDO, five patients required urgent tracheostomy. Of patients without a pre-MDO tracheostomy (n = 33), two patients required tracheostomy post-MDO, while 94% avoided tracheostomy with clinical resolution of airway obstruction (n = 31). On secondary analysis, anatomic abnormalities diagnosed by MLB were associated with a higher rate of tracheostomy ( P = .037), confirming the utility of preoperative evaluation with MLB; otherwise, no patient characteristics demonstrated significance in patient selection. Follow-up ranged from 6 months to 10 years (mean = 6.45 years, median = 7.61 years).

Conclusions

Our treatment protocol demonstrates MDO is highly effective for resolving severe airway obstruction related to PRS. Based on secondary analysis, our simplified protocol does not require amendment.

Growth and prevalence of feeding difficulties in children with Robin sequence: a retrospective cohort study

OBJECTIVES

In addition to breathing problems, patients with Robin sequence (RS) often encounter feeding difficulties (FD). Data regarding the occurrence of FD and possible influencing factors are scarce. The study aim was to elucidate these factors to improve treatment strategies.

MATERIAL AND METHODS

A retrospective comparative cohort study was conducted, consisting of 69 infants diagnosed with both RS and a cleft palate and 64 isolated cleft palate only (iCPO) infants. Data regarding FD, growth, and airway intervention were collected during the first 2 years of life. A systematic review of the literature was conducted to identify reported FD in RS patients.

RESULTS

RS patients had more FD (91 %) than iCPO patients (72 %; p = 0.004). Also, nasogastric (NG)-tube feeding was necessary more frequently and for a longer period (both p < 0.001). Growth was lower in RS than iCPO infants (p = 0.008) and was not affected by the kind of airway management (conservative/surgical; p = 0.178), cleft palate grade (p = 0.308), or associated disorders (p = 0.785). By contrast, surgical intervention subtype did significantly affect growth. Mean reported FD for RS in the literature is 80 % (range = 47-100 %), and 55 % (range = 11-100 %) of infants need NG-tube feeding.

CONCLUSIONS

FD is present in a large proportion of infants with RS, which indicates the need for early recognition and proper treatment to ensure optimal growth. Growth during the first 2 years of life is significantly lower in RS patients than iCPO patients, which indicates the need for careful attention and long-term follow-up.

CLINICAL RELEVANCE

This study indicates the need for early recognition and proper treatment of FD in RS to ensure optimal growth. In addition, growth needs careful attention and long-term follow-up.

Craniofacial disorders associated with airway obstruction in the neonate

In infants with craniofacial disorders, upper airway obstruction is one of the primary causes for morbidity and mortality in the neonatal period. Infants with craniofacial disorders, including Pierre Robin sequence, are at high risk for obstructive sleep apnea syndrome. Because of the complexity of their care, these neonates are usually followed by a multidisciplinary team to ensure timely evaluation and optimal treatment. In addition to history and physical examination, clinical evaluation may include genetic testing, imaging, endoscopy, and polysomnography. There are various treatment options, both surgical and non-surgical, that may be used depending on clinical assessment, underlying condition, and severity of disease. Recent advances have led to better assessment and treatment of these patients, but many questions remain. This review outlines the available literature pertaining to the evaluation and management of upper airway obstruction in the neonate with craniofacial conditions, with a particular focus on Pierre Robin sequence.

Logistic regression analysis of Pierre Robin sequence patients requiring surgical intervention

OBJECTIVES/HYPOTHESIS

Determine predictive patient characteristics that guide the decision to proceed with surgical management of tongue-based airway obstruction (TBAO) in Pierre Robin sequence (PRS) patients.

STUDY DESIGN

Retrospective review of PRS patients between 2005 and 2014 requiring observation in the neonatal intensive care unit (NICU).

METHODS

Patient charts were reviewed for prenatal diagnoses, clinical course, and need for surgical intervention (tracheotomy or mandibular distraction osteogenesis), and the nonsurgical and surgical group were compared with a logistic regression model.

RESULTS

Thirty-eight PRS patients who were identified with TBAO and required NICU observation had an average follow-up of 5.4 years. Associated anomalies identified in the PRS patients included neurologic disease (n = 6), renal abnormalities (n = 5), limb abnormalities (n = 4), and cardiac abnormalities (n = 12). Nonsurgical management of PRS TBAO included side (n = 12)/stomach positioning (n = 15), oral airway (n = 6), nasopharyngeal airway (NPA) (n = 14), and intubation (n = 12). Surgical intervention occurred in 13 patients, with tracheotomy in eight due to unstable airway, and mandible distraction in five due to NPA dependence. Factors with significant uncontrolled correlations with the need for surgical airways included presence of cardiac disease (P = .03), cardiac disease severity (P = .03), neurologic disease (P = .01), and continuous positive airway pressure (CPAP)/bilevel positive airway pressure (BiPAP) use (P = .006). Further, stepwise regression showed strong predictive value for CPAP/BiPAP use (odds ratio [OR]: 10.43) and presence of neurological disease (OR: 9.16). PRS TBAO patients required multiple modalities of noninvasive surgical intervention to stabilize their airway.

CONCLUSIONS

This study identified patient characteristics predictive of progression to a surgical airway to address TBAO, which may decrease healthcare utilization and improve quality of life for these families.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:945-949, 2017.

Continuous Positive Airway Pressure for Upper Airway Obstruction in Infants with Pierre Robin Sequence

The aim of the study was to evaluate noninvasive continuous positive airway pressure as first-line treatment for upper airway obstruction in neonates with Pierre Robin sequence. Forty-four neonates were enrolled and classified in 4 groups: ventilator-dependent patients (severe upper airway obstruction group), patients with clinical upper airway obstruction, an abnormal (moderate upper airway obstruction group) or normal polygraphy (mild upper airway obstruction group), and those with no clinical upper airway obstruction (no upper airway obstruction group). Five neonates in the severe upper airway obstruction group (n = 9) were successfully managed by noninvasive continuous positive airway pressure and 4 required a tracheotomy. The moderate upper airway obstruction group (n = 4) was successfully managed by noninvasive continuous positive airway pressure and the other patients by prone positioning. Continuous positive airway pressure represents an effective treatment of upper airway obstruction in Pierre Robin sequence and may be recommended in selected patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Craniofacial syndromes and sleep-related breathing disorders

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.

Anesthetic Challenges in an Adult with Pierre Robin Sequence, Severe Juvenile Scoliosis, and Respiratory Failure

Anesthesiologists have the privilege and challenge of providing care for an extremely diverse population of patients, at times in urgent or emergent situations. We present a case of a 31-year-old woman with Pierre Robin sequence, severe juvenile scoliosis, and respiratory failure who underwent successful awake nasal fiberoptic intubation for tracheostomy at an adult tertiary care medical center. Familiarity with patient conditions infrequently encountered within our practice, as well as adherence to practice guidelines, proved essential to providing our patient with the safest care possible.

Clinical, cytogenetic, and molecular outcomes in a series of 66 patients with Pierre Robin sequence and literature review: 22q11.2 deletion is less common than other chromosomal anomalies

Pierre Robin sequence (PRS) is an important craniofacial anomaly that can be seen as an isolated finding or manifestation of multiple syndromes. 22q11.2 deletion and Stickler syndrome are cited as the two most common conditions associated with PRS, but their frequencies are debated. We performed a retrospective study of 66 patients with PRS and reviewed their genetic testing, diagnoses, and clinical findings. The case series is complemented by a comprehensive literature review of the nature and frequency of genetic diagnosis in PRS. In our cohort 65% of patients had associated anomalies; of these, a genetic diagnosis was established in 56%. Stickler syndrome was the most common diagnosis, comprising approximately 11% of all cases, followed by Treacher Collins syndrome (9%). The frequency of 22q11.2 deletion was 1.5%. Chromosome arrays, performed for 72% of idiopathic PRS with associated anomalies, revealed two cases of 18q22→qter deletion, a region not previously reported in association with PRS. A review of the cytogenetic anomalies identified in this population supports an association between the 4q33-qter, 17q24.3, 2q33.1, and 11q23 chromosomal loci and PRS. We found a low frequency of 22q11.2 deletion in PRS, suggesting it is less commonly implicated in this malformation. Our data also indicate a higher frequency of cytogenetic anomalies in PRS patients with associated anomalies, and a potential new link with the 18q22→qter locus. The present findings underscore the utility of chromosomal microarrays in cases of PRS with associated anomalies and suggest that delaying testing for apparently isolated cases should be considered.

Evaluation of upper airway obstruction in infants with Pierre Robin sequence and the role of polysomnography--Review of current evidence

Pierre Robin sequence (PRS) is a heterogeneous condition presenting with upper airway obstruction (UAO) of varying severity. Polysomnography (PSG) is an objective investigation to assess the severity of obstructive sleep apnea and UAO. Its role in the management of PRS has not been well defined. This review summarizes the available evidence on the role of PSG in the assessment of infants with PRS in the context of other commonly used methods of assessment.

Heart Failure in an Infant with Pierre Robin Sequence: Is There a Diagnostic Test to Aid in Treatment Planning and Monitoring?

This case report describes an infant with Pierre Robin sequence who was managed conservatively until he presented at 4 months of age with right-sided heart failure. This rare clinical presentation displays the physiologic response to chronic respiratory obstruction and the acid-base disturbances, which become evident on metabolic panel and blood gas. We suggest that these tests can be added to the workup, especially in conservatively managed infants, to help predict which infants may fail conservative treatment and to avoid the rare complication of heart failure in infants with Pierre Robin sequence.

Effectiveness of Tongue-lip Adhesion for Obstructive Sleep Apnea in Infants With Robin Sequence Measured by Polysomnography

OBJECTIVE

Tongue-lip adhesion (TLA) is commonly used to relieve obstructive sleep apnea (OSA) in infants with Robin sequence (RS), but few studies have evaluated its efficacy with objective measures. The purpose of this study was to measure TLA outcomes using polysomnography. Our hypothesis was that TLA relieves OSA in most infants.

METHODS

This is a retrospective study of infants with RS who underwent TLA from 2011 to 2014 and had at least a postoperative polysomnogram. Predictor variables included demographic and birth characteristics, surgeon, syndromic diagnosis, GILLS score, preoperative OSA severity, and clinical course. A successful outcome was defined as minimal OSA (apnea-hypopnea index score < 5) on postoperative polysomnogram and no need for additional airway intervention. Descriptive, bivariate, and regression statistics were computed, and statistical significance was set at P < .05.

RESULTS

Eighteen subjects who had TLA at a mean age of 28 ± 4.7 days were included. Thirteen (72.2%) had a confirmed or suspected syndrome, and the mean GILLS score was 3 ± 0.3. All parameters trended toward improvement from the preoperative to postoperative polysomnograms, and improvement in OSA severity, oxygen saturation nadir, and arousals per hour was statistically significant (P < .02). This effect was significant across categories of surgeon, syndrome, and GILLS score. Nine subjects (50%) met the criteria for a successful outcome. Bivariate and regression analyses did not demonstrate a significant relationship between success and any predictor variable.

CONCLUSIONS

TLA improved airway obstruction in all infants with RS but resolved OSA in only nine patients, and success was unpredictable.