1
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Choo H, Davis AS, Bain LC, Ahn H. Weight Gain of Infants with Robin Sequence Treated Nonsurgically Using the Stanford Orthodontic Airway Plate (SOAP): 1-Year Follow-Up. Cleft Palate Craniofac J 2024:10556656241233239. [PMID: 38373407 DOI: 10.1177/10556656241233239] [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: 02/21/2024] Open
Abstract
OBJECTIVE To identify weight gain trends of infants with Robin sequence (RS) treated by the Stanford Orthodontic Airway Plate treatment (SOAP). DESIGN Retrospective longitudinal cohort study. SETTING Single tertiary referral hospital. PATIENTS Eleven infants with RS treated with SOAP. INTERVENTIONS Nonsurgical SOAP. MAIN OUTCOME MEASURES Body weight, Weight-for-age (WFA) Z-scores, and WFA percentiles at birth (T0), SOAP delivery (T1), SOAP graduation (T2), and 12-months old (T3). RESULTS Between T0 and T1, the weight increased but the WFA percentile decreased from 36.5% to 15.1%, and the Z-score worsened from -0.43 to -1.44. From T1 to T2, the percentile improved to 22.55% and the Z-score to -0.94. From T2 to T3, the percentile and the Z-scores further improved to 36.59% and -0.48, respectively. CONCLUSIONS SOAP provided infants experiencing severe respiratory distress and oral feeding difficulty with an opportunity to gain weight commensurate with the WHO healthy norms without surgical intervention.
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Affiliation(s)
- HyeRan Choo
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Neonatal and Pediatric Craniofacial Airway Orthodontics, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Alexis S Davis
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Lisa C Bain
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - HyoWon Ahn
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Neonatal and Pediatric Craniofacial Airway Orthodontics, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
- Department of Orthodontics, School of Dentistry, Kyung Hee University, Seoul, Korea
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McGrath JL, Mantilla-Rivas E, Aivaz M, Manrique M, Rana MS, Crowder HR, Oh NS, Rogers GF, Oh AK. Predicting Failure of Conservative Airway Management in Infants with Robin Sequence: The EARN Factors. Cleft Palate Craniofac J 2024:10556656231224194. [PMID: 38166451 DOI: 10.1177/10556656231224194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024] Open
Abstract
OBJECTIVE Evaluate infants with Robin Sequence (RS) who were successfully treated with conservative airway measures alone vs. those who failed and eventually underwent surgical airway intervention after a protracted course of conservative management. DESIGN Retrospective review of prospectively gathered database. SETTING Large tertiary care institution. PATIENTS Infants diagnosed with RS (n = 122) who underwent primary airway management at a single institution from 1994-2020. MAIN OUTCOME MEASURE Patient demographics, nutritional and respiratory status, laboratory values, and polysomnographic results were compared between patients who were discharged after successful conservative airway management (Group 1, n = 61) and patients that underwent surgical airway intervention after failing a prolonged course of conservative management (Group 2, n = 61). Receiver operating characteristic (ROC) curve analysis was done to assess continuous variables that may predict failure of conservative airway management. RESULTS 122 infants with RS were investigated. While several variables were significantly different between groups, the following polysomnographic EARN factors, with cut points, were identified as most predictive of failed conservative airway management: ETCO2 (max) > 49 mmHg, AHI > 16.9 events/hour, OAHI REM >25.9 events/hour, OAHI Non-REM > 23.6 events/hour. CONCLUSIONS We identified factors in infants with RS that were associated with severe UAO that failed to improve despite weeks of conservative airway management. Our results may expedite earlier definitive treatment of these critical patients and reduce risks for known complications of prolonged UAO.
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Affiliation(s)
- Jennifer L McGrath
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Esperanza Mantilla-Rivas
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Marudeen Aivaz
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Monica Manrique
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Md Sohel Rana
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Hannah R Crowder
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Nathanael S Oh
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Gary F Rogers
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Albert K Oh
- From the Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
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3
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Magge HN, Schild SD, Mantilla-Rivas E, Landry EC, Afsar NM, Behzadpour HK, Manrique M, Rana MS, Oh AK, Reilly BK. Trends in Natural Decannulation in Patients with Robin Sequence: A Twenty-five Year Retrospective Review. Ann Otol Rhinol Laryngol 2024; 133:69-77. [PMID: 37497838 DOI: 10.1177/00034894231187290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE Robin sequence (RS) consists of micrognathia and glossoptosis that result in upper airway obstruction (UAO). In RS patients who undergo tracheostomy, long-term goals include natural decannulation (ND) without further surgical airway intervention. The objective of this study was to identify long-term trends in the rate and length of time to ND. METHODS Retrospective chart review on 144 patients with RS treated from 1995 to 2020 at a pediatric tertiary care center. Patients were grouped by year of tracheostomy. Demographic data, UAO management, postoperative care, complications, and time to decannulation were recorded. RESULTS Thirty-six patients met the inclusion criteria. Tracheostomy was performed at a median age of 45.5 days. 19 (53%) patients experienced ND at a median time of 66.1 months. ND rate was higher in non-syndromic patients (93% non-syndromic vs 27% syndromic; P < .0001) and during the first study period (1995-2006: 78%, 2007-2020: 28%; P = .003). Cox proportional-hazard regression demonstrated that white race [aHR 0.15 (0.03-0.8); P = .023] and higher birthweight [aHR 0.9 (0.8-0.98); P = .018] were associated with a higher likelihood of ND while a syndromic diagnosis had a negative association with ND [aHR 12.5 (3.3-50.0); P < .001]. CONCLUSIONS Our study documented that ND in patients with RS who underwent tracheostomy was significantly associated with ethnicity, birthweight, and syndromic status. The negative impact on successful ND was most observed in patients with syndromic associations. Additionally, ND rates are lower in the 2007 to 2020 subgroup. We suspect this is because alternative management techniques such as tongue lip adhesion and mandibular distraction osteogenesis became primary surgical treatment in severe RS upper airway obstruction at our institution starting in 2007.
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Affiliation(s)
- Hari N Magge
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sam D Schild
- Division of Otolaryngology, Children's National Hospital, Washington, DC, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Evie C Landry
- Division of Otolaryngology, Children's National Hospital, Washington, DC, USA
| | - Nina M Afsar
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Monica Manrique
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Md Sohel Rana
- Division of Surgery, Children's National Hospital, Washington, DC, USA
| | - Albert K Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Brian K Reilly
- Division of Otolaryngology, Children's National Hospital, Washington, DC, USA
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4
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White JJ, Cambron JD, Gottlieb M, Long B. Evaluation and Management of Airway Foreign Bodies in the Emergency Department Setting. J Emerg Med 2023; 64:145-155. [PMID: 36806432 DOI: 10.1016/j.jemermed.2022.12.008] [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: 05/17/2022] [Revised: 11/03/2022] [Accepted: 12/13/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND Airway foreign body can be a life-threatening issue in pediatric and adult patients, and the majority of these patients will first present to the emergency department. OBJECTIVE This article provides a narrative review of the diagnosis and management of airway foreign bodies for the emergency clinician. DISCUSSION Foreign bodies in the upper and lower airways are potentially life threatening. This affects all age groups but is more common in pediatric patients. A history of a witnessed ingestion or aspiration event should raise the clinical suspicion for an aspirated foreign body. Patients with upper-airway foreign bodies are more likely to present in respiratory distress when compared with lower-airway foreign bodies, which often present with more subtle signs. Stridor, drooling, and wheezing suggest respiratory distress, but the presenting clinical picture is often unclear and may only include a cough. Immediate intervention is required in the patient with hemodynamic instability or respiratory distress. Airway management including laryngoscopy, fiberoptic bronchoscopy, and cricothyrotomy may be needed in these patients, with the emphasis on removing the obstructing foreign body and securing the airway. Specialist consultation can assist in retrieving the foreign body and managing the airway. If the patient is stable, imaging and specialist consultation for potential operating room intervention should be considered. CONCLUSIONS An understanding of the presentation, evaluation, and management of the patient with an airway foreign body is essential for emergency clinicians.
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Affiliation(s)
- Joshua J White
- Department of Emergency Medicine, Christus Spohn Shoreline, Corpus Christi, Texas
| | - John D Cambron
- Department of Emergency Medicine, Christus Spohn Shoreline, Corpus Christi, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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5
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Poets CF, Wiechers C, Koos B, Muzaffar AR, Gozal D. Pierre Robin and breathing: What to do and when? Pediatr Pulmonol 2022; 57:1887-1896. [PMID: 33580741 DOI: 10.1002/ppul.25317] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/06/2021] [Accepted: 02/09/2021] [Indexed: 01/09/2023]
Abstract
Robin sequence is characterized by mandibular retrognathia, airway obstruction, and glossoptosis; 80%-90% also have a cleft palate. Various treatment approaches exist, and although controlled studies are rare, objective assessment of treatment outcomes that address the leading clinical issues, namely obstructive sleep apnea and failure to thrive, are essential. Sleep-disordered breathing may be detected using cardiorespiratory polygraphy or polysomnography. Pulse oximetry alone may miss infants with frequent obstructive apneas, yet no intermittent hypoxia. Among conservative treatment options, the Tubingen Palatal Plate with a velar extension shifting the tongue base forward is the only approach that corrects the underlying anatomy and that has undergone appropriate evaluation. Of the surgical treatment options, which are not necessarily the first line of therapy, mandibular distraction osteogenesis (MDO) is effective and has been most extensively adopted. Notwithstanding, it is puzzling that MDO is frequently used in some countries, yet hardly ever in others, despite similar tracheostomy rates. Thus, prospective multicenter studies with side-by-side comparisons aimed at identifying an optimal treatment paradigm for this potentially life-threatening condition are urgently needed.
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Affiliation(s)
- Christian F Poets
- Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Neonatology, Tübingen University Hospital, Tübingen, Germany
| | - Cornelia Wiechers
- Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Neonatology, Tübingen University Hospital, Tübingen, Germany
| | - Bernd Koos
- Interdisciplinary Center for Cleft Palate and Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Orthodontics, Tübingen University Hospital, Tübingen, Germany
| | - Arshad R Muzaffar
- Division of Plastic Surgery, University of Missouri, Columbia, Missouri, USA
| | - David Gozal
- Department of Child Health, University of Missouri, Columbia, Missouri, USA
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6
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Choo H, Galera RI, Balakrishnan K, Lin HFC, Ahn H, Lorenz P, Khosla RK, Profit J, Poets CF, Lee JS. Disruptive Therapy Using a Nonsurgical Orthodontic Airway Plate for the Management of Neonatal Robin Sequence: 1-Year Follow-up. Cleft Palate Craniofac J 2022; 60:758-767. [PMID: 35167404 DOI: 10.1177/10556656221076980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We recently published the 3-month follow-up of 2 neonates with Robin sequence whose mandibular hypoplasia and restricted airway were successfully treated with an orthodontic airway plate (OAP) without surgical intervention. Both infants were successfully weaned off the OAP after several months of continuous use. We present the course of OAP treatment in these patients with a focus on breathing, feeding, and facial growth during their first year of life. Both infants demonstrated stable mandibular projection, resolution of obstructive sleep apnea, and normal development.
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Affiliation(s)
- HyeRan Choo
- Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Rhona I. Galera
- Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Karthik Balakrishnan
- Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hung-Fu C. Lin
- Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA, USA
| | - HyoWon Ahn
- KyungHee University Dental Hospital, Seoul, Korea
| | - Peter Lorenz
- Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Rohit K. Khosla
- Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jochen Profit
- Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Janice S. Lee
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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7
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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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8
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Abbas DB, Lavin C, Fahy EJ, Choo H, Truong MT, Bruckman KC, Khosla RK, Lorenz HP, Momeni A, Wan DC. A Systematic Review of Mandibular Distraction Osteogenesis Versus Orthodontic Airway Plate for Airway Obstruction Treatment in Pierre Robin Sequence. Cleft Palate Craniofac J 2021; 59:365-376. [PMID: 34075816 DOI: 10.1177/10556656211011886] [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: 11/17/2022] Open
Abstract
OBJECTIVE Mandibular distraction osteogenesis (MDO) is frequently performed to address airway obstruction in patients with Pierre Robin sequence (PRS), though more recently the technique of orthodontic airway plating (OAP) has gained traction. We aimed to evaluate OAP compared to MDO for airway obstruction in PRS. DESIGN A systematic literature search across PubMed, Embase, and Google Scholar identified all studies published in English, which involved MDO or any form of OAP as treatments for PRS. All relevant articles were reviewed in detail and reported on, adhering to PRISMA guidelines. MAIN OUTCOME MEASURES Airway (tracheostomy avoidance, decannulation rate), feeding (full oral feeding tolerance). RESULTS Literature search identified 970 articles, of which 42 MDO studies and 9 OAP studies met criteria for review. A total of 1159 individuals were treated with MDO, and 322 individuals were treated with OAP. Primary outcomes appear similar for MDO and OAP at face value; however, this must be interpreted with different pretreatment contexts in mind. CONCLUSIONS Orthodontic airway plating may be considered for airway obstruction in PRS, as some airway-related and feeding-related outcomes appear similar with MDO, per existing evidence in the literature. However, since PRS severity differed between studies, OAP cannot be uniformly considered a replacement for MDO. Further research is required to more comprehensively assess these treatment modalities inclusive of metrics that allow for direct comparison.
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Affiliation(s)
- Darren B Abbas
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Christopher Lavin
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Evan J Fahy
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - HyeRan Choo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Mai Thy Truong
- Division of Pediatric Otolaryngology, Department of Otolaryngology, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Karl C Bruckman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Rohit K Khosla
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - H Peter Lorenz
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Arash Momeni
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Derrick C Wan
- Hagey Laboratory for Pediatric Regenerative Medicine, 10624Stanford University School of Medicine, Stanford, CA, USA
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9
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Choo H, Khosla RK, Meister KD, Wan DC, Lin HFC, Feczko R, Bruckman K, Hopkins E, Truong MT, Lorenz HP. Nonsurgical Orthodontic Airway Plate Treatment for Newborns With Robin Sequence. Cleft Palate Craniofac J 2021; 59:403-410. [PMID: 33845627 DOI: 10.1177/10556656211007689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite promising outcomes for >50 years, nonsurgical orthodontic airway plates (OAP) are only infrequently offered for babies with Robin sequence in a few parts of the world. This article demonstrates possibility of providing functional improvement using an OAP to help these babies overcome their functional and structural difficulties on their own. Two consecutively treated cases are presented exemplifying that OAP treatment that had originated from Europe is reproducible and effective in an institution in the United States.
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Affiliation(s)
- HyeRan Choo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.,Craniofacial and Airway Orthodontic Clinic, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Rohit K Khosla
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Kara D Meister
- Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.,Division of Head and Neck Surgery, Department of Otolaryngology, 10624Stanford University School of Medicine, Palo Alto, CA, USA
| | - Derrick C Wan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Hung-Fu C Lin
- Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Robert Feczko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Karl Bruckman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Elena Hopkins
- Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Mai Thy Truong
- Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.,Division of Head and Neck Surgery, Department of Otolaryngology, 10624Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hermann P Lorenz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 10624Stanford University School of Medicine, Palo Alto, CA, USA.,Cleft and Craniofacial Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
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10
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Amaddeo A, Khirani S, Griffon L, Teng T, Lanzeray A, Fauroux B. Non-invasive Ventilation and CPAP Failure in Children and Indications for Invasive Ventilation. Front Pediatr 2020; 8:544921. [PMID: 33194886 PMCID: PMC7649204 DOI: 10.3389/fped.2020.544921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/18/2020] [Indexed: 12/14/2022] Open
Abstract
Non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) are effective treatments for children with severe sleep disordered breathing (SBD). However, some patients may present too severe SDB that do not respond to NIV/CPAP or insufficient compliance to treatment. A careful revaluation of the interface and of ventilator settings should be performed before considering alternative treatments. In patients with obstructive sleep apnea (OSA), alternatives to CPAP/NIV rely on the underlying disease. Ear-nose-throat (ENT) surgery such as adeno-tonsillectomy (AT), turbinectomy or supraglottoplasty represent an effective treatment in selected patients before starting CPAP/NIV and should be reconsidered in case of CPAP failure. Rapid maxillary expansion (RME) is restricted to children with OSA and a narrow palate who have little adenotonsillar tissue, or for those with residual OSA after AT. Weight loss is the first line therapy for obese children with OSA before starting CPAP and should remain a priority in the long-term. Selected patients may benefit from maxillo-facial surgery such as mandibular distraction osteogenesis (MDO) or from neurosurgery procedures like fronto-facial monobloc advancement. Nasopharyngeal airway (NPA) or high flow nasal cannula (HFNC) may constitute efficient alternatives to CPAP in selected patients. Hypoglossal nerve stimulation has been proposed in children with Down syndrome not tolerant to CPAP. Ultimately, tracheostomy represents the unique alternative in case of failure of all the above-mentioned treatments. All these treatments require a multidisciplinary approach with a personalized treatment tailored on the different diseases and sites of obstruction. In patients with neuromuscular, neurological or lung disorders, non-invasive management in case of NIV failure is more challenging. Diaphragmatic pacing has been proposed for some patients with central congenital hypoventilation syndrome (CCHS) or neurological disorders, however its experience in children is limited. Finally, invasive ventilation via tracheotomy represents again the ultimate alternative for children with severe disease and little or no ventilatory autonomy. However, ethical considerations weighting the efficacy against the burden of this treatment should be discussed before choosing this last option.
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Affiliation(s)
- Alessandro Amaddeo
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France.,Université de Paris, VIFASOM, Paris, France
| | - Sonia Khirani
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France.,Université de Paris, VIFASOM, Paris, France.,ASV Sante, Gennevilliers, France
| | - Lucie Griffon
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France.,Université de Paris, VIFASOM, Paris, France
| | - Theo Teng
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Agathe Lanzeray
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Brigitte Fauroux
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France.,Université de Paris, VIFASOM, Paris, France
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11
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Ho ACH, Wong RWK, Cheung T, Ng DK, Siu KK, Fung SC. Orthodontic plate for management of obstructive sleep apnoea in infants with Pierre Robin sequence: experience and protocol in Hong Kong. J Orthod 2019; 46:367-373. [DOI: 10.1177/1465312519880557] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To present the application of the pre-epiglottic baton plate (PEBP) in infants with Pierre Robin sequence (PRS) in the Southern Chinese population (Hong Kong) and to present the diagnosis and management protocol of these infants in our centre. Design: Retrospective case series of three patients with PRS. Setting: Neonatal Intensive Care Unit in Kwong Wah Hospital and Craniofacial Orthodontic Centre in United Christian Hospital, Hong Kong. Participants: Three new-born infants (two girls, one boy) with PRS and upper airway obstruction due to glossoptosis. Methods: A protocol for the diagnosis and management of these infants in the Southern Chinese population (Hong Kong) was presented. The three patients received nasal high-flow oxygen and/or continuous positive airway pressure (CPAP) as first-line respiratory support, followed by PEBP for 3–5 months. A two-stage approach was undertaken to ensure accurate positioning of the PEBP. Results: All three infants had improvement in clinical signs, symptoms and polysomnography upon discharge. PEBP and other respiratory aids were weaned off at 3–6 months. Conclusions: The PEBP, combined with other respiratory support, is a useful modality in the treatment of obstructive sleep apnoea in infants with PRS.
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Affiliation(s)
- Angus CH Ho
- Department of Dentistry and Maxillofacial Surgery, United Christian Hospital, Hong Kong
| | - Ricky WK Wong
- Department of Dentistry and Maxillofacial Surgery, United Christian Hospital, Hong Kong
| | | | - Daniel K Ng
- Department of Paediatrics, Kwong Wah Hospital, Hong Kong
| | - KK Siu
- Department of Paediatrics, Kwong Wah Hospital, Hong Kong
| | - SC Fung
- Department of Dentistry and Maxillofacial Surgery, United Christian Hospital, Hong Kong
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Poets CF, Koos B, Reinert S, Wiechers C. The Tübingen palatal plate approach to Robin sequence: Summary of current evidence. J Craniomaxillofac Surg 2019; 47:1699-1705. [PMID: 31477439 DOI: 10.1016/j.jcms.2019.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/05/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022] Open
Abstract
Various treatments, many of them considerably invasive, are currently applied to infants with Robin sequence (RS) and accompanying upper airway obstruction (UAO). We present a narrative review of our data on the Tübingen palatal plate (TPP) which show the following: a) in a randomized trial, the TPP was superior to a sham procedure in alleviating UAO; b) children treated with the TPP in infancy showed an intellectual development within the reference range; c) prone positioning is no alternative, as it is ineffective and associated with an increased risk of sudden death; d) the TPP reduces the mixed-obstructive apnea index to near-normal values, both in isolated and most (83%) syndromic RS, e) of 443 infants (129 syndromic) treated with the TPP in our center, 23 (5%) ultimately received a tracheostomy (all with syndromic RS), f) recent data suggest that the TPP may induce mandibular catch-up growth, g) the TPP may also help to reduce respiratory complications following cleft closure in RS, and h) TPP treatment is applied by various centers around the world, although it is unclear if its effectiveness is invariably controlled by endoscopy and sleep studies, although both are necessary. Given these data from peer-reviewed studies, it may be questioned whether the "First do no harm" principle is always adhered to when subjecting RS infants to more invasive procedures such as mandibular distraction osteogenesis or tongue-lip adhesion.
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Affiliation(s)
- Christian F Poets
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Germany; Department of Neonatology and Pediatric Sleep Lab, Tübingen University Hospital, Germany.
| | - Bernd Koos
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Germany; Department of Orthodontics, Tübingen University Hospital, Germany
| | - Siegmar Reinert
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Germany; Department of Craniomaxillofacial Surgery, Tübingen University Hospital, Germany
| | - Cornelia Wiechers
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Germany; Department of Neonatology and Pediatric Sleep Lab, Tübingen University Hospital, Germany
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13
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The role of flexible fiberoptic laryngoscopy in Robin Sequence: A systematic review. J Craniomaxillofac Surg 2017; 45:210-215. [DOI: 10.1016/j.jcms.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/29/2016] [Accepted: 11/10/2016] [Indexed: 11/17/2022] Open
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Davies K, Bruce IA, Bannister P, Callery P. Safe sleeping positions: practice and policy for babies with cleft palate. Eur J Pediatr 2017; 176:661-667. [PMID: 28331972 PMCID: PMC5415579 DOI: 10.1007/s00431-017-2893-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 11/01/2022]
Abstract
UNLABELLED Guidance recommends 'back to sleep' positioning for infants from birth in order to reduce the risk of sudden infant death. Exceptions have been made for babies with severe respiratory difficulties where lateral positioning may be recommended, although uncertainty exists for other conditions affecting the upper airway structures, such as cleft palate. This paper presents research of (i) current advice on sleep positioning provided to parents of infants with cleft palate in the UK; and (ii) decision making by clinical nurse specialists when advising parents of infants with cleft palate. A qualitative descriptive study used data from a national survey with clinical nurse specialists from 12 regional cleft centres in the UK to investigate current practice. Data were collected using semi-structured telephone interviews and analysed using content analysis. Over half the regional centres used lateral sleep positioning based on clinical judgement of the infants' respiratory effort and upper airway obstruction. Assessment relied upon clinical judgement augmented by a range of clinical indicators, such as measures of oxygen saturation, heart rate and respiration. CONCLUSION Specialist practitioners face a clinical dilemma between adhering to standard 'back to sleep' guidance and responding to clinical assessment of respiratory effort for infants with cleft palate. In the absence of clear evidence, specialist centres rely on clinical judgement regarding respiratory problems to identify what they believe is the most appropriate sleeping position for infants with cleft palate. Further research is needed to determine the best sleep position for an infant with cleft palate. What is Known • Supine sleep positioning reduces the risk of sudden infant death in new born infants. • There is uncertainty about the benefits or risks of lateral sleep positioning for infants with upper airway restrictions arising from cleft palate. What is New • Variability exists in the information/advice provided to parents of infants with cleft palate regarding sleep positioning. • Over half the national specialist centres for cleft palate in the UK advise positioning infants with CP in the lateral position as a routine measure to reduce difficulties with respiration.
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Affiliation(s)
- Karen Davies
- Division of Nursing, Midwifery and Social Work, University of Manchester, Jean Mc Farlane Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Iain A Bruce
- 0000 0004 0417 0074grid.462482.ePaediatric ENT Department, Royal Manchester Children’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL UK ,0000000121662407grid.5379.8Respiratory and Allergy Centre, Institute of Inflammation and Repair, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Patricia Bannister
- 0000000121662407grid.5379.8Cleft and Craniofacial Clinical Research Centre, Division of Dentistry, University of Manchester, Manchester, M15 6FH UK
| | - Peter Callery
- 0000000121662407grid.5379.8Division of Nursing, Midwifery and Social Work, University of Manchester, Jean Mc Farlane Building, Oxford Road, Manchester, M13 9PL UK
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15
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Paes EC, de Vries IAC, Penris WM, Hanny KH, Lavrijsen SW, van Leerdam EK, Rademaker MM, Veldhoen ES, Eijkemans RMJC, Kon M, Breugem CC. Growth and prevalence of feeding difficulties in children with Robin sequence: a retrospective cohort study. Clin Oral Investig 2016; 21:2063-2076. [PMID: 27868158 PMCID: PMC5487830 DOI: 10.1007/s00784-016-1996-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 11/01/2016] [Indexed: 01/20/2023]
Abstract
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.
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Affiliation(s)
- Emma C Paes
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Centre, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Iris A C de Vries
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Centre, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - Wouter M Penris
- Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, The Netherlands
| | - Karlijn H Hanny
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Centre, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - Selma W Lavrijsen
- Department of Pediatrics, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Elselien K van Leerdam
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Centre, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - Maaike M Rademaker
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Centre, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - Esther S Veldhoen
- Department of Pediatrics, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Rene M J C Eijkemans
- Department of Biostatistics and Research Support, Julius Centre, University Medical Centre, Utrecht, The Netherlands
| | - Moshe Kon
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Centre, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - Corstiaan C Breugem
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital, University Medical Centre, PO Box 85500, 3508, GA, Utrecht, The Netherlands
- Department of Plastic Surgery, Meander Medical Center, Amersfoort, The Netherlands
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16
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Paes EC, van Nunen DPF, Speleman L, Muradin MSM, Smarius B, Kon M, Mink van der Molen AB, Niers TLEM, Veldhoen ES, Breugem CC. A pragmatic approach to infants with Robin sequence: a retrospective cohort study and presence of a treatment algorithm. Clin Oral Investig 2015; 19:2101-14. [PMID: 25680705 PMCID: PMC4592702 DOI: 10.1007/s00784-015-1407-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 01/14/2015] [Indexed: 11/26/2022]
Abstract
Objectives Initial approaches to and treatments of infants with Robin sequence (RS) is diverse and inconsistent. The care of these sometimes critically ill infants involves many different medical specialties, which can make the decision process complex and difficult. To optimize the care of infants with RS, we present our institution’s approach and a review of the current literature. Material and methods A retrospective cohort study was conducted among 75 infants diagnosed with RS and managed at our institution in the 1996–2012 period. Additionally, the conducted treatment regimen in this paper was discussed with recent literature describing the approach of infants with RS. Results Forty-four infants (59 %) were found to have been treated conservatively. A significant larger proportion of nonisolated RS infants than isolated RS infants needed surgical intervention (53 vs. 25 %, p = .014). A mandibular distraction was conducted in 24 % (n = 18) of cases, a tracheotomy in 9 % (n = 7), and a tongue–lip adhesion in 8 % (n = 6). Seventy-seven percent of all infants had received temporary nasogastric tube feeding. The literature review of 31 studies showed that initial examinations and the indications to perform a surgical intervention varied and were often not clearly described. Conclusions RS is a heterogenic group with a wide spectrum of associated anomalies. As a result, the decisional process is challenging, and a multidisciplinary approach to treatment is desirable. Current treatment options in literature vary, and a more uniform approach is recommended. Clinical Relevance We provide a comprehensive and pragmatic approach to the analysis and treatment of infants with RS, which could serve as useful guidance in other clinics.
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Affiliation(s)
- Emma C Paes
- Department of Plastic, Reconstructive and Hand Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands.
- Department of Pediatric Plastic Surgery, Wilhelmina Children's Hospital Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Daan P F van Nunen
- Department of Plastic, Reconstructive and Hand Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Lucienne Speleman
- Department of Otorhinolaryngology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Marvick S M Muradin
- Department of Oral and Cranio-Maxillofacial Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Bram Smarius
- Department of Plastic, Reconstructive and Hand Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Moshe Kon
- Department of Plastic, Reconstructive and Hand Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | | | - Titia L E M Niers
- Department of Pediatrics, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Esther S Veldhoen
- Department of Pediatrics, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Corstiaan C Breugem
- Department of Plastic, Reconstructive and Hand Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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Isolated Robin sequence in siblings: Review of current concepts. J Plast Reconstr Aesthet Surg 2014; 67:e259-65. [DOI: 10.1016/j.bjps.2014.08.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 06/30/2014] [Accepted: 08/18/2014] [Indexed: 11/19/2022]
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18
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Hartzell LD, Kilpatrick LA. Diagnosis and Management of Patients with Clefts. Otolaryngol Clin North Am 2014; 47:821-52. [DOI: 10.1016/j.otc.2014.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Petrova E, Neuner C, Haaf T, Schmid M, Wirbelauer J, Jurkutat A, Wermke K, Nanda I, Kunstmann E. A Boy with an LCR3/4-Flanked 10q22.3q23.2 Microdeletion and Uncommon Phenotypic Features. Mol Syndromol 2014; 5:19-24. [PMID: 24550761 DOI: 10.1159/000355847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2013] [Indexed: 11/19/2022] Open
Abstract
The recurrent 10q22.3q23.2 deletion with breakpoints within low copy repeats 3 and 4 is a rare genomic disorder, reported in only 13 patients to date. The phenotype is rather uncharacteristic, which makes a clinical diagnosis difficult. A phenotypic feature described in almost all patients is a delay in speech development, albeit systematic studies are still pending. In this study, we report on a boy with an LCR3/4-flanked 10q22.3q23.2 deletion exhibiting an age-appropriate language development evaluated by a standardized test at an age of 2 years and 3 months. The boy was born with a cleft palate - a feature not present in any of the patients described before. Previously reported cases are reviewed, and the role of the BMPR1A gene is discussed. The phenotype of patients with an LCR3/4-flanked 10q22.3q23.2 deletion can be rather variable, so counseling the families regarding the prognosis of an affected child should be done with caution. Long-term studies of affected children are needed to delineate the natural history of this rare disorder.
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Affiliation(s)
- E Petrova
- Institute for Human Genetics, University of Wuerzburg, Wuerzburg, Germany
| | - C Neuner
- Institute for Human Genetics, University of Wuerzburg, Wuerzburg, Germany
| | - T Haaf
- Institute for Human Genetics, University of Wuerzburg, Wuerzburg, Germany
| | - M Schmid
- Institute for Human Genetics, University of Wuerzburg, Wuerzburg, Germany
| | - J Wirbelauer
- University Children's Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - A Jurkutat
- Department of Special Education, Speech and Language Pathology, University of Wuerzburg, Wuerzburg, Germany
| | - K Wermke
- Department of Orthodontics, Center for Pre-Speech Development and Developmental Disorders, University of Wuerzburg, Wuerzburg, Germany
| | - I Nanda
- Institute for Human Genetics, University of Wuerzburg, Wuerzburg, Germany
| | - E Kunstmann
- Institute for Human Genetics, University of Wuerzburg, Wuerzburg, Germany
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20
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Incidence of concomitant airway anomalies when using the university of California, Los Angeles, protocol for neonatal mandibular distraction. Plast Reconstr Surg 2013; 131:1116-1123. [PMID: 23629092 DOI: 10.1097/prs.0b013e3182865da0] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In newborns with micrognathia and severe upper airway obstruction, understanding potential airway lesions is important for determining appropriate treatment: observation, mandibular distraction, or tracheostomy. When concomitant airway anomalies are present, mandibular distraction is often unsuccessful at alleviating causes of obstruction, mandating the need for tracheostomy. The first part of this study evaluates 10-year results using the University of California, Los Angeles, algorithm for surgical candidacy to identify patients who will benefit from neonatal mandibular distraction. The second part describes the concomitant airway abnormalities found at the time of diagnostic laryngoscopy/bronchoscopy and how these anomalies affect neonatal distraction candidacy of these patients. METHODS Newborns admitted to the neonatal intensive care unit with micrognathia and upper airway obstruction (n = 133) were subjected to a decision tree model protocol formulated by a multidisciplinary team at the University of California, Los Angeles, to decide on appropriate treatment. Concomitant airway abnormalities were recorded and outcomes were documented for the first 5 years of life. RESULTS Fifty-five percent of patients underwent internal mandibular distraction with 97 percent success. Home observation with a nasopharyngeal tube was chosen in 11 percent of patients, and 34 percent had tracheostomies. On endoscopic examination, 51.7 percent of the nondistracted patients had concomitant airway anomalies: laryngomalacia (53.3 percent), tracheal web (20.0 percent), vocal cord paralysis (13.3 percent), epiglottal collapse (6.7 percent), and infraglottal narrowing (6.7 percent). CONCLUSIONS For the management of neonatal upper airway obstruction with micrognathia, a decision tree algorithm is useful to determine candidates for mandibular distraction. Diagnostic laryngoscopy/bronchoscopy is an important component of this algorithm because a multitude of airway anomalies may be present. CLINICAL QUESTION/LEVEL OF EVIDENCE : Therapeutic, IV.
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21
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Treacher Collins syndrome: clinical implications for the paediatrician--a new mutation in a severely affected newborn and comparison with three further patients with the same mutation, and review of the literature. Eur J Pediatr 2012; 171:1611-8. [PMID: 22729243 DOI: 10.1007/s00431-012-1776-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Accepted: 06/10/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED Treacher Collins syndrome (TCS) is the most common and well-known mandibulofacial dysostosis caused by mutations in at least three genes involved in pre-rRNA transcription, the TCOF1, POLR1D and POLR1C genes. We present a severely affected male individual with TCS with a heterozygous de novo frameshift mutation within the TCOF1 gene (c.790_791delAG,p.Ser264GlnfsX7) and compare the clinical findings with three previously unpublished, milder affected individuals from two families with the same mutation. We elucidate typical clinical features of TCS and its clinical implications for the paediatrician and mandibulofacial surgeon, especially in severely affected individuals and give a short review of the literature. CONCLUSION The clinical data of these three families illustrate that the phenotype associated with this specific mutation has a wide intra- and interfamilial variability, which confirms that variable expressivity in carriers of TCOF1 mutations is not a simple consequence of the mutation but might be modified by the combination of genetic, environmental and stochastic factors. Being such a highly complex disease treatment of individuals with TCS should be tailored to the specific needs of each individual, preferably by a multidisciplinary team consisting of paediatricians, craniofacial surgeons and geneticists.
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Han KD, Seruya M, Oh AK, Zalzal GH, Preciado DA. “Natural” Decannulation in Patients with Robin Sequence and Severe Airway Obstruction. Ann Otol Rhinol Laryngol 2012; 121:44-50. [DOI: 10.1177/000348941212100108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Airway management in infants with Robin sequence (RS) remains controversial, ranging from conservative to operative methods. In some centers, tracheostomy remains the mainstay for those infants with severe respiratory obstruction. The goals of this retrospective case cohort study were to determine the length of time to decannulation without further surgical intervention (ie, “natural” decannulation) in patients with severe RS who underwent tracheostomy and to investigate potential factors associated with successful decannulation. Methods: We reviewed all infants with RS treated at a large tertiary center from 1994 to 2010. Patients who had undergone tracheostomy were identified. Baseline demographics, complications, deaths, and time to “natural” decannulation were recorded. Statistical analysis was performed with univariate analysis and Kaplan-Meier log-rank tests. Results: Of 61 infants with RS with obstructive events, 25 infants (14 with isolated RS and 11 with syndromic RS) required tracheostomy. At a mean follow-up of 4 years, the rate of tracheostomy-specific complications was 52%; the tracheostomy-specific mortality rate was 12%. Overall, 13 of 25 infants (52%) were “naturally” decannulated, with a median time to decannulation of 97 months. Patients with syndromic RS had a significantly longer median time to decannulation than did those with isolated RS (more than 73 months versus 19 months, respectively; p = 0.019). In addition, patients with long-term tracheostomy dependence had significantly higher maximum carbon dioxide levels before tracheostomy than did patients who were successfully decannulated (82.4 versus 63.2 mEq/L, respectively; p = 0.02). Conclusions: Tracheostomy in infants with RS is associated with inordinately high rates of mortality, morbidity, and long-term tracheostomy dependence, particularly in patients with syndromic RS and in those with high maximum carbon dioxide levels before tracheostomy.
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Poets CF, Bacher M. Treatment of upper airway obstruction and feeding problems in Robin-like phenotype. J Pediatr 2011; 159:887-92. [PMID: 21885059 DOI: 10.1016/j.jpeds.2011.07.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 05/31/2011] [Accepted: 07/20/2011] [Indexed: 11/17/2022]
Affiliation(s)
- Christian F Poets
- Department of Neonatology, Tübingen University Hospital, Tübingen, Germany.
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