Efficacy and Complications of Mandibular Distraction Osteogenesis for Airway Obstruction in the Robin Sequence Population: A Comprehensive Literature Review

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.

The Montreal Children's Hospital Experience Managing Robin Sequence: An Analysis of Outcomes and Algorithm for Surgical Technique Selection

BACKGROUND

The development of mandibular distraction osteogenesis (MDO) and tongue-lip adhesion (TLA) has led to significant improvements in respiratory outcomes for the Robin sequence (RS) population. Despite such advances, there continues to be debate regarding management strategies. The authors present their experience managing the RS population with insights on technique selection.

METHODS

A retrospective review of RS patients treated at the senior author's institution from 2003 to 2021 was conducted. Baseline patient demographics and clinical parameters including feeding and respiratory status were recorded. Outcomes included the need for tracheostomy or tracheostomy, decannulation rates, and feeding status. Patients were evaluated through overnight oximetry and drug-induced sleep endoscopy (DISE). Outcomes were stratified according to management technique (MDO, TLA, versus conservative) and compared through statistical analysis.

RESULTS

Fifty-nine RS patients were included. Twenty-eight were managed conservatively, 19 underwent MDO, 10 underwent TLA, one underwent both TLA and MDO, and one underwent tracheostomy primarily. Overall, 1.7% of the cohort required a tracheostomy and 86% achieved oral feeding after the procedure. The MDO cohort had lower Apgar scores and mean birth weight compared with the conservative and TLA cohorts ( P < 0.05). There were no statistical differences in respiratory and feeding outcomes across all three cohorts.

CONCLUSIONS

A therapeutic algorithm was developed with insight into the use of DISE and risk stratification with overnight oximetry to guide procedural selection. Using this approach, safe and satisfactory respiratory outcomes were achieved with a low tracheostomy rate. Risk stratification is possible without polysomnography, and DISE is a promising tool (that requires further validation) for procedural selection in this population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Patient-specific distractors for customized mandibular distraction osteogenesis to relieve upper airway obstruction in infants with Pierre Robin sequence

The purpose of this article is to report the author's technique for using patient-specific distractors for customized distraction osteogenesis of the mandible in patients with Pierre Robin sequence and upper airway obstruction. The advantages of virtual planning and patient-specific plates in other aspects of craniomaxillofacial surgery, such as orthognathic and reconstructive surgery, have been reported previously. Similar to patient-specific plates, the theorized advantages of patient-specific distractors in infants with Robin sequence and upper airway obstruction include increased accuracy, decreased operating time, and less morbidity to vital anatomic structures such as the inferior alveolar nerve and developing tooth buds. This technique is novel in using patient-specific distractors in the craniomaxillofacial skeleton.

Craniofacial Distraction Osteogenesis

Distraction osteogenesis (DO) of the craniofacial skeleton has become an effective technique for the treatment of both nonsyndromic and syndromic conditions. The advent of craniofacial DO has allowed for earlier intervention in pediatric patients with less complication risk and morbidity compared to traditional techniques. In this review, we will discuss current application and technique for craniofacial DO by anatomical region and explore future applications in craniofacial surgery.

Tracheostomy, the Not So Definitive Airway?: Tracheostomy Morbidity in Pediatric Craniofacial Patients

BACKGROUND

Tracheostomy is the definitive treatment for airway management in severe cases of craniofacial-associated upper airway obstruction, like the Pierre-Robin sequence, but is associated with significant morbidity. The purpose of this study was to examine tracheostomy-associated morbidities and mortalities in craniofacial patients to identify opportunities to improve clinical care and patient prognosis.

METHODS

The study was a retrospective review of pediatric craniofacial patients who were tracheostomized between 2016 and 2022. Data regarding their demographics, craniofacial diagnoses, endoscopic airway anomalies, intubation grade of view classification, tracheostomy-related complications, and causes of mortality were analyzed.

RESULTS

Sixteen of the 17 tracheostomized pediatric patients had the Pierre-Robin sequence, with 5 of those patients having an additional syndromic craniofacial diagnosis. Additional airway anomalies were found in 82.4% of the patients. The mean length of hospital stay after tracheostomy was 4.08 months. Infection was the most common complication, observed in 94.1% of patients, followed by stomal granulation in 76.5% of patients. Two mortalities were observed: one following the compassionate removal of ventilator support and the other following the accidental dislodgment of the tracheostomy tube.

CONCLUSIONS

Tracheostomy-related complications were observed in all craniofacial patients in this group. Compared with the general pediatric population, tracheostomized craniofacial patients may endure longer hospital stays and greater stomal granulation rates. Mandibular distraction osteogenesis may allow for tracheostomy avoidance in these patients, and future research should focus on comparing the long-term complication rates and outcomes between tracheostomy mandibular distraction osteogenesis in this challenging patient population.

Complications of Mandibular Distraction Osteogenesis in Infants with Isolated Robin Sequence

Mandibular Distraction Osteogenesis (MDO) is now the preferred procedure to alleviate airway obstruction in infants with severe Robin Sequence (RS). However, there have been very few studies investigating complications related to MDO surgery performed on patients affected by isolated RS. In this study, age at distraction, weight at distraction, preoperative intubation, repeat MDO and complications associated with MDO were included as variables. Minor, moderate and major problems were evaluated and recorded as surgical site infections (SSI), injuries to the facial nerve, self-extinction hypertrophic scars, temporomandibular joint ankylosis, device failures, early ossification and fibrous non-union. One hundred and fifty one patients with isolated RS were included. At distraction, the mean age was 72 days (12-540 days) and the mean weight was 4.05 kg (2.4-12.2 kg). Only one patient needed tracheostomy after MDO, and none required further distraction. Ultimately, the complication rate was 15.23%, and there was a total of 7.95% minor, 9.27% moderate and 0% major complications. Minor incidents included surgical site infection (SSI) managed with antibiotics taken orally (n = 8), neuropraxia in the VII cranial nerve (CN) (n = 1), and hypertrophic scarring (n = 3). Incidents reported as moderate were SSIs managed with intravenous antibiotics (n = 9), incision and drainage (n = 3) and self-extubation (n = 2). There was no case of TMJ ankylosis. There were no cases of early or premature ossification, fibrous non-union and device fracture. In conclusion, MDO is an effective and appropriate management technique for infants with isolated RS and severe airway obstruction. Infections at the surgery site accounted for the vast majority of the complications. Further investigations may be needed to determine the long-term consequences of MDO.

Dental outcomes after neonatal mandibular distraction

PURPOSE OF REVIEW

The aim of this study was to understand dental complications associated with neonatal mandibular distraction and subsequent dental outcomes.

RECENT FINDINGS

Dental injury is often associated with neonatal mandibular distraction osteogenesis. Newer technology offers safer techniques to minimize this risk. Long-term follow up and dental outcomes in permanent dentition are needed to better understand the actual risk associated with the procedure.

SUMMARY

Surgeons performing neonatal mandibular distraction osteogenesis need to understand the associated risks to deciduous and permanent dentition as well as techniques to mitigate this risk.