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Chocron Y, Cote A, Alabdulkarim A, Barone N, Gilardino MS. The Montreal Children's Hospital Experience Managing Robin Sequence: An Analysis of Outcomes and Algorithm for Surgical Technique Selection. Plast Reconstr Surg 2024; 153:597e-604e. [PMID: 37104466 DOI: 10.1097/prs.0000000000010587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
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.
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Affiliation(s)
- Yehuda Chocron
- From the Divisions of Plastic and Reconstructive Surgery
| | - Aurore Cote
- Pediatric Respirology, McGill University Health Centre, Montreal Children's Hospital
| | - Abdulaziz Alabdulkarim
- Plastic Surgery, Department of Surgery, College of Medicine, Prince Sattam Bin Abdulaziz University
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2
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Čverha M, Varga I, Trenčanská T, Šufliarsky B, Thurzo A. The Evolution of Robin Sequence Treatment Based on the Biomimetic Interdisciplinary Approach: A Historical Review. Biomimetics (Basel) 2023; 8:536. [PMID: 37999177 PMCID: PMC10669884 DOI: 10.3390/biomimetics8070536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/01/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023] Open
Abstract
The Robin sequence is a congenital anomaly characterized by a triad of features: micrognathia, glossoptosis, and airway obstruction. This comprehensive historical review maps the evolution of approaches and appliances for its treatment from the past to the current modern possibilities of an interdisciplinary combination of modern engineering, medicine, materials, and computer science combined approach with emphasis on designing appliances inspired by nature and individual human anatomy. Current biomimetic designs are clinically applied, resulting in appliances that are more efficient, comfortable, sustainable, and safer than legacy traditional designs. This review maps the treatment modalities that have been used for patients with a Robin sequence over the years. Early management of the Robin sequence focused primarily on airway maintenance and feeding support, while current management strategies involve both nonsurgical and surgical interventions and biomimetic biocompatible personalized appliances. The goal of this paper was to provide a review of the evolution of management strategies for patients with the Robin sequence that led to the current interdisciplinary biomimetic approaches impacting the future of Robin Sequence treatment with biomimetics at the forefront.
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Affiliation(s)
- Martin Čverha
- Clinic of Pediatric Otorhinolaryngology of the Medical Faculty Comenius University in Bratislava and National Institute of Children’s Diseases, 83101 Bratislava, Slovakia;
| | - Ivan Varga
- Institute of Histology and Embryology, Faculty of Medicine, Comenius University in Bratislava, 81372 Bratislava, Slovakia;
| | - Tereza Trenčanská
- Clinic of Pediatric Otorhinolaryngology of the Medical Faculty Comenius University in Bratislava and National Institute of Children’s Diseases, 83101 Bratislava, Slovakia;
| | - Barbora Šufliarsky
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Comenius University in Bratislava and University Hospital, 81372 Bratislava, Slovakia;
| | - Andrej Thurzo
- Department of Orthodontics, Regenerative and Forensic Dentistry, Faculty of Medicine, Comenius University in Bratislava, 81102 Bratislava, Slovakia
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3
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Resnick CM, Katz E, Varidel A. MicroNAPS: A Novel Classification for Infants with Micrognathia, Robin Sequence, and Tongue-based Airway Obstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5283. [PMID: 37744769 PMCID: PMC10513129 DOI: 10.1097/gox.0000000000005283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/02/2023] [Indexed: 09/26/2023]
Abstract
Background Robin sequence (RS) describes a heterogeneous population with micrognathia, glossoptosis, and upper airway obstruction (UAO). Workup, treatment, outcomes assessment, and research inclusion are widely variable. Despite several classifications and algorithms, none is broadly endorsed. The objective of this investigation was to develop and trial a novel classification system designed to enhance clinical communication, treatment planning, prognostication, and research. Methods This is a retrospective cross-sectional study. A classification system was developed with five elements: micrognathia, nutrition, airway, palate, syndrome/comorbidities (MicroNAPS). Definitions and a framework for "stage" assignment (R0-R4) were constructed. Stage "tongue-based airway obstruction" (TBAO) was defined for infants with glossoptosis and UAO without micrognathia. MicroNAPS was applied to 100 infants with at least 1-year follow-up. Clinical course, treatment, airway, and feeding characteristics were assessed. Descriptive and analytic statistics were calculated and a P value less than 0.05 was considered significant. Results Of the 100 infants, 53 were male. Mean follow-up was 5.0 ± 3.6 years. R1 demonstrated feeding-predominant mild RS for which UAO was managed nonoperatively but gastrostomy tubes were prevalent. R2 was characterized by airway-predominant moderate RS, typically managed with mandibular distraction or tongue-lip adhesion, with few gastrostomy tubes and short lengths-of-stay. R3 denoted severe RS, with similar UAO treatment to R2, but with more surgical feeding tubes and longer admissions. R4 represented a complex phenotype with 33% tracheostomies, protracted hospitalizations, and delayed palatoplasty. R0 ("at risk") and TBAO groups displayed the most variability. Conclusions MicroNAPS is easy to use and associated with relevant disease characteristics. We propose its adoption in clinical and research settings.
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Affiliation(s)
- Cory M. Resnick
- From the Department of Oral and Maxillofacial Surgery, Harvard Medical School, Boston, Mass
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Mass
| | - Eliot Katz
- Department of Pediatrics, Harvard Medical School, Boston, Mass
- Department of Pulmonary-Sleep Medicine, Boston Children’s Hospital, Boston, Mass
| | - Alistair Varidel
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Mass
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4
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Analysis of Upper Airway Flow Dynamics in Robin Sequence Infants Using 4-D Computed Tomography and Computational Fluid Dynamics. Ann Biomed Eng 2023; 51:363-376. [PMID: 35951208 DOI: 10.1007/s10439-022-03036-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/20/2022] [Indexed: 01/25/2023]
Abstract
Robin Sequence (RS) is a potentially fatal craniofacial condition characterized by undersized jaw, posteriorly displaced tongue, and resultant upper airway obstruction (UAO). Accurate assessment of UAO severity is crucial for management and diagnosis of RS, yet current evaluation modalities have significant limitations and no quantitative measures of airway resistance exist. In this study, we combine 4-dimensional computed tomography and computational fluid dynamics (CFD) to assess, for the first time, UAO severity using fluid dynamic metrics in RS patients. Dramatic intrapopulation differences are found, with the ratio between most and least severe patients in breathing resistance, energy loss, and peak velocity equal to 40:1, 20:1, and 6:1, respectively. Analysis of local airflow dynamics characterized patients as presenting with primary obstructions either at the location of the tongue base, or at the larynx, with tongue base obstructions resulting in a more energetic stenotic jet and greater breathing resistance. Finally, CFD-derived flow metrics are found to correlate with the level of clinical respiratory support. Our results highlight the large intrapopulation variability, both in quantitative metrics of UAO severity (resistance, energy loss, velocity) and in the location and intensity of stenotic jets for RS patients. These results suggest that computed airflow metrics may significantly improve our understanding of UAO and its management in RS.
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5
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Manica D, Schweiger C. The role of upper airway endoscopy in craniofacial malformations. Semin Fetal Neonatal Med 2021; 26:101293. [PMID: 34561176 DOI: 10.1016/j.siny.2021.101293] [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: 11/29/2022]
Abstract
OBJECTIVE To study the role of upper airway endoscopy (UAE) in craniofacial malformations in all different management approaches described in the literature. METHODS A narrative review was performed, based on a search in pubmed. RESULTS UAE use was reviewed over five domains: 1) Diagnosis of glossoptosis and endoscopic classification: drug-induced sleep endoscopy is recommended to graduate tongue base obstruction; there is still no consensus on the graduation system to be used. 2) Airway abnormalities: there is a high incidence of additional lesions in conjunction with glossoptosis. 3) Swallowing evaluation: a formal comparison with fluoroscopy (gold standard) has not yet been performed in this population. 4) Intubation: thin bronchoscopes allow intubation of small babies; moreover, intubation with rigid video-assisted laryngoscopes show a high success rate in this population. 5) Treatment outcome monitoring: there is no consensus on the ideal parameters to be checked. CONCLUSION Some approaches have already been well established in the management of patients with craniofacial malformations, e.g. the endocopic evaluation of glossoptosis and associated lesions and its role as an intubation assistance tool, while others need to be subject of further research, e.g. its role in swallowing investigation and as a postoperative success control predictor.
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Affiliation(s)
- Denise Manica
- Otolaryngology Department, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil.
| | - Cláudia Schweiger
- Otolaryngology Department, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil; Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Universidade Federal do Rio Grande do Sul, Rio Grande do Sul, Brazil.
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6
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Arganbright JM, Lee JC, Weatherly RA. Pediatric drug-induced sleep endoscopy: An updated review of the literature. World J Otorhinolaryngol Head Neck Surg 2021; 7:221-227. [PMID: 34430829 PMCID: PMC8356111 DOI: 10.1016/j.wjorl.2021.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The field of drug-induced sleep endoscopy (DISE) has grown considerably over the last 10∼15 years, to now include its use in pediatric patients. In this review article, we outline our approach to the use of this technology in Children with Airway Obstruction, most specifically in the management of children with airway obstruction and known or suspected adenotonsillar enlargement.
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Affiliation(s)
- Jill M Arganbright
- Children's Mercy Kansas City, Division of Otolaryngology, Kansas City, MO, USA.,University of Missouri, Kansas City School of Medicine, Kansas City, MO, USA
| | - Jason C Lee
- University of Kansas Medical Center, Department of Otolaryngology, Kansas City, KS, USA
| | - Robert A Weatherly
- Children's Mercy Kansas City, Division of Otolaryngology, Kansas City, MO, USA.,University of Missouri, Kansas City School of Medicine, Kansas City, MO, USA
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7
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Lam AS, Bindschadler MD, Evans KN, Friedman SD, Blessing MS, Bly R, Cunningham ML, Egbert MA, Ettinger RE, Gallagher ER, Hopper RA, Johnson K, Perkins JA, Romberg EK, Sie KCY, Susarla SM, Zdanski CJ, Wang X, Otjen JP, Perez FA, Dahl JP. Accuracy and Reliability of 4D-CT and Flexible Laryngoscopy in Upper Airway Evaluation in Robin Sequence. Otolaryngol Head Neck Surg 2021; 166:760-767. [PMID: 34253111 DOI: 10.1177/01945998211027353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To evaluate the performance of 4-dimensional computed tomography (4D-CT) in assessing upper airway obstruction (UAO) in patients with Robin sequence (RS) and compare the accuracy and reliability of 4D-CT and flexible fiber-optic laryngoscopy (FFL). STUDY DESIGN Prospective survey of retrospective clinical data. SETTING Single, tertiary care pediatric hospital. METHODS At initial and 30-day time points, a multidisciplinary group of 11 clinicians who treat RS rated UAO severity in 32 sets of 4D-CT visualizations and FFL videos (dynamic modalities) and static CT images. Raters assessed UAO at the velopharynx and oropharynx (1 = none to 5 = complete) and noted confidence levels of each rating. Intraclass correlation and Krippendorff alpha were used to assess intra- and interrater reliability, respectively. Accuracy was assessed by comparing clinician ratings with quantitative percentage constriction (QPC) ratings, calculated based on 4D-CT airway cross-sectional area. Results were compared using Wilcoxon rank-sum and signed-rank tests. RESULTS There was similar intrarater agreement (moderate to substantial) with 4D-CT and FFL, and both demonstrated fair interrater agreement. Both modalities underestimated UAO severity, although 4D-CT ratings were significantly more accurate, as determined by QPC similarity, than FFL (-1.06 and -1.46 vs QPC ratings, P = .004). Overall confidence levels were similar for 4D-CT and FFL, but other specialists were significantly less confident in FFL ratings than were otolaryngologists (2.25 and 3.92, P < .0001). CONCLUSION Although 4D-CT may be more accurate in assessing the degree of UAO in patients with RS, 4D-CT and FFL assessments demonstrate similar reliability. Additionally, 4D-CT may be interpreted with greater confidence by nonotolaryngologists who care for these patients.
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Affiliation(s)
- Austin S Lam
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Michael D Bindschadler
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kelly N Evans
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Seth D Friedman
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Matthew S Blessing
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Randall Bly
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Michael L Cunningham
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Mark A Egbert
- Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Oral and Maxillofacial Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Oral and Maxillofacial Surgery, University of Washington, Seattle, Washington, USA
| | - Russell E Ettinger
- Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Plastic Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Emily R Gallagher
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Richard A Hopper
- Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Plastic Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Kaalan Johnson
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jonathan A Perkins
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Erin K Romberg
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathleen C Y Sie
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Srinivas M Susarla
- Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Oral and Maxillofacial Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Plastic Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Carlton J Zdanski
- Department of Otolaryngology/Head & Neck Surgery and Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Xing Wang
- Biostatistics, Epidemiology and Analytics in Research (BEAR) Core, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jeffrey P Otjen
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Francisco A Perez
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
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8
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Lam AS, Bindschadler MD, Evans KN, Friedman SD, Otjen JP, Zdanski CJ, Perez FA, Dahl JP. 4D Computed Tomography for Dynamic Upper Airway Evaluation in Robin Sequence. Otolaryngol Head Neck Surg 2021; 165:905-908. [PMID: 33689485 DOI: 10.1177/01945998211002156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Thorough assessment of dynamic upper airway obstruction (UAO) in Robin sequence (RS) is critical, but traditional evaluation modalities have significant limitations. Four-dimensional computed tomography (4D-CT) is promising in that it enables objective and quantitative evaluation throughout all phases of respiration. However, there exist few protocols or analysis tools to assist in obtaining and interpreting the vast amounts of obtained data. A protocol and set of data analysis tools were developed to enable quantification and visualization of dynamic 4D-CT data. This methodology was applied to a sample case at 2 time points. In the patient with RS, overall increases in normalized airway caliber were observed from 5 weeks to 1 year. There was, however, continued dynamic obstruction at all airway levels, though objective measures of UAO did improve at the nasopharynx and oropharynx. Use of 4D-CT and novel analyses provide additional quantitative information to evaluate UAO in patients with RS.
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Affiliation(s)
- Austin S Lam
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Michael D Bindschadler
- Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kelly N Evans
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Seth D Friedman
- Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jeffrey P Otjen
- Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Carlton J Zdanski
- Department of Otolaryngology-Head and Neck Surgery and Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Francisco A Perez
- Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
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9
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Perez FA, Hottinger DG, Evans KN, Giles M, Otto RK, Hunyady A, Gentry KR. Longer upper airway lengths in Robin Sequence: A case-control study using computed tomography. Paediatr Anaesth 2020; 30:683-690. [PMID: 32277728 DOI: 10.1111/pan.13869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/29/2020] [Accepted: 03/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Direct laryngoscopy and intubation are often difficult in children with Robin Sequence. Previous research characterizing anatomic airway differences has focused on parameters influencing airway patency; there is a paucity of data pertaining to intubation trajectories and depth. Such information could impact airway management approaches and decrease the incidence of endotracheal tube malpositioning. AIM The study goal was to examine whether longitudinal airway parameters pertaining to intubation are different in children with Robin Sequence compared with age-matched controls. METHOD This case-control study compared patients with RS <4 years of age who had computed tomography scans of the head and neck to age- and sex-matched controls. Measurements were made of the nasopharynx, oropharynx, hypopharynx, tongue, hyoid, and the front teeth to vocal cord, nares to vocal cord, and nasion-basion distances. Statistical analysis was performed using multiple ANCOVA models with the categorical predictor of Robin Sequence vs control and potential covariates including subject height/length, weight, and age. RESULTS Thirty-three patients with Robin Sequence and 33 control subjects were included. After controlling for subject height/length, mean front teeth to vocal cord distance was 1.2 cm longer (95% CI: 0.9 to 1.6 cm, P < .001) and mean nares to vocal cord distance was 0.8 cm longer (95% CI: 0.4 to 1.2 cm, P < .001) in patients with Robin Sequence than in controls. The tongue was positioned on average 0.5 cm higher (95% CI: 0.3 to 0.8, P < .001) and 0.9 cm more posterior (95% CI: 0.6 to 1.0 cm, P < .001) in cases than in controls. Moreover, in patients with Robin Sequence, the hyoid was positioned on average 0.5 cm more inferiorly (95% CI: 0.2 to 0.8 cm, P < .001) and 0.2 cm more posteriorly (95% CI: 0.1 to 0.4 cm, P < .01) than controls. CONCLUSION In patients with Robin Sequence under 4 years of age, the mean front teeth to vocal cord distance was found to be 1.2 cm longer while the mean nares to vocal cord distance was found to be 0.8 cm longer controlling for subject length. Clinicians should account for these differences when selecting and placing endotracheal tubes, particularly those with a preformed bend.
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Affiliation(s)
- Francisco A Perez
- Department of Radiology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | | | - Kelly N Evans
- Department of Pediatrics, Division of Craniofacial Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Marian Giles
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Agnes Hunyady
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Anesthesiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Katherine R Gentry
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Anesthesiology, University of Washington School of Medicine, Seattle, WA, USA
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10
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Fayoux P, Daniel SJ, Allen G, Balakrishnan K, Boudewyns A, Cheng A, De Alarcon A, Goel D, Hart CK, Leboulanger N, Lee G, Moreddu E, Muntz H, Rahbar R, Nicollas R, Rogers-Vizena CR, Russell J, Rutter MJ, Smith RJH, Wyatt M, Zalzal G, Resnick CM. International Pediatric ORL Group (IPOG) Robin Sequence consensus recommendations. Int J Pediatr Otorhinolaryngol 2020; 130:109855. [PMID: 31896499 DOI: 10.1016/j.ijporl.2019.109855] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/26/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To provide recommendations for the comprehensive management of airway obstruction in patients with Robin Sequence. METHODS Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). RESULTS The consensus statement provides recommendations for medical specialists who manage infants with Robin Sequence including: evaluation and treatment considerations for commonly debated issues in post-natal airway obstruction, assessment of antenatal obstruction and perinatal airway management. CONCLUSION Consensus recommendations are aimed at improving management of airway obstruction in patients with Robin Sequence.
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Affiliation(s)
- Pierre Fayoux
- Department of Pediatric Otolaryngology-Head Neck Surgery, Jeanne de Flandre Hospital, CHU Lille, Université de Lille, Lille, France.
| | - Sam J Daniel
- Department of Otolaryngology, Head and Neck Surgery, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Gregory Allen
- Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, CO, USA
| | | | - An Boudewyns
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, University of Antwerp, Belgium
| | - Alan Cheng
- Department of Pediatric Otolaryngology, The Sydney Children's Hospital Network-Westmead Campus, The University of Sydney, Sydney, NSW, Australia
| | - Alessandro De Alarcon
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Dimple Goel
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Catherine K Hart
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Nicolas Leboulanger
- Pediatric ENT Department, Hôpital Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | - Gi Lee
- Department of Otolaryngology, Boston Children's Hospital, Boston, MA, USA
| | - Eric Moreddu
- Department of Pediatric Otolaryngology Head and Neck Surgery, La Timone Children's Hospital, Aix-Marseille Université, Marseille, France
| | - Harlan Muntz
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, UT, USA
| | - Reza Rahbar
- Department of Otolaryngology, Boston Children's Hospital, Boston, MA, USA
| | - Richard Nicollas
- Department of Pediatric Otolaryngology Head and Neck Surgery, La Timone Children's Hospital, Aix-Marseille Université, Marseille, France
| | | | - John Russell
- Department of Otorhinolaryngology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Michael J Rutter
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Richard J H Smith
- Department of Otolaryngology, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Michelle Wyatt
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - George Zalzal
- Department of Otolaryngology, Children's National Hospital, Washington, DC, USA
| | - Cory M Resnick
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
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