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

Trends in Natural Decannulation in Patients with Robin Sequence: A Twenty-five Year Retrospective Review

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.

Obstructive Sleep Apnea in Neonates

Neonates have distinctive anatomic and physiologic features that predispose them to obstructive sleep apnea (OSA). The overall prevalence of neonatal OSA is unknown, although an increase in prevalence has been reported in neonates with craniofacial malformations, neurological disorders, and airway malformations. If remained unrecognized and untreated, neonatal OSA can lead to impaired growth and development, cardiovascular morbidity, and can even be life threatening. Polysomnography and direct visualization of the airway are essential diagnostic modalities in neonatal OSA. Treatment of neonatal OSA is based on the severity of OSA and associated co-morbidities. This may include medical and surgical interventions individualized for the affected neonate. Based on this, it is expected that infants with OSA have more significant healthcare utilization.

Managing infants with craniofacial malformations - Where to go next?

Treatment of infants with craniofacial malformations, e.g. Robin sequence, is characterized by considerable heterogeneity and a lack of randomized trials to identify an optimal approach. We propose to establish an international register using a common minimal dataset that will better allow for a comparison between key determinants and outcomes in these patients. In infants, this should include an assessment of mandibular micrognathia, glossoptosis, upper airway obstruction, weight gain and mode of feeding. Later on, neurocognition, speech development, hearing and quality of life should also be included. Together, these data will help better to advice parents on which treatment to choose for their baby with a craniofacial malformation.

The Surgical Treatment of Robin Sequence: Neonatal Mandibular Distraction Osteogenesis in the Unfavorable Patient

INTRODUCTION

Neonates with severe Pierre Robin sequence (PRS) can be treated by mandibular distraction osteogenesis (MDO), tongue-lip adhesion, or tracheostomy; however, there is an active debate regarding the indications of MDO in this patient population. Published algorithms identify tracheomalacia, bronchomalacia, laryngomalacia, hypotonic syndromes, and central sleep apnea as contraindications for MDO and indications for tracheostomy, but these comorbidities may exist along a spectrum of severity. The authors propose that appropriately selected neonates with PRS who concurrently express 1 or more of these traditional contraindications may be successfully treated with MDO.

METHODS

The authors performed a 5-year retrospective chart review of all neonates who underwent MDO for treatment of severe PRS. All patients expressed a comorbidity previously identified as an indication for tracheostomy. Pre- and postoperative characteristics were recorded. Apnea/hypopnea index (AHI) before and after MDO were compared using 2-tailed repeated measures t-test.

RESULTS

The authors identified 12 patients with severe PRS and conditions associated with contraindications to MDO: 9 (75.0%) patients had laryngomalacia, 6 (50.0%) patients had tracheomalacia, 2 (16.6%) patients had bronchomalacia, 1 (8.3%) patient had central sleep apnea, and 3 (25.0%) patients had hypotonia. Five (41.7%) patients underwent concurrent gastrostomy tube placement due to feeding insufficiency. Average birthweight was 3.0 kg. Average pre-op AHI was 34.8. Average post-op AHI was 7.3. All patients successfully underwent MDO with avoidance of tracheostomy.

CONCLUSIONS

By employing an interdisciplinary evaluation of patient candidacy, MDO can safely and effectively treat upper airway obstruction and avoid tracheostomy in higher-risk neonatal patients with traditional indications for tracheostomy.

Do Infants With Robin Sequence Have Improved Feeding and Weight Gain After Mandibular Distraction?

PURPOSE

Infants with Robin sequence (RS) typically have impaired weight gain, presumed to result primarily from upper airway obstruction. Operations that improve airway obstruction are therefore theorized to facilitate feeding and weight gain, but the relationship between airway intervention and feeding improvement remains unclear. The aim of this study was to evaluate weight gain over the first 3 years of life in patients with RS.

METHODS

This is a retrospective cohort study of patients with RS treated at Boston Children's Hospital from 1995 to 2016. The primary predictor variable was type of intervention (no operation, tongue-lip adhesion, mandibular distraction osteogenesis [MDO]). The primary outcome measure was weight-for-age Z-score. A control group of patients with isolated cleft palate without RS was also included. Individuals with tracheostomy or insufficient growth data were excluded. Descriptive statistics were calculated, and statistical significance was set at P < .05.

RESULTS

A total of 222 subjects were included: no operation, n = 61 (27.5%); tongue-lip adhesion, n = 78 (35.1%); MDO, n = 22 (9.9%); and control, n = 61 (27.5%). Mean age at tongue-lip adhesion was 37 ± 99 days compared with 247 ± 312 days for MDO (P < .05). At 6 months of age, the MDO group had the lowest mean weight (Z = -2.34 ± 1.88, P < .05) and both surgical groups were underweight compared with controls (P < .05). By 24 months of age, there were no weight differences between any study group. Individuals that had MDO at <3 months of age had significantly faster weight gain than those that had later operations (P < .05).

CONCLUSIONS

Patients with RS who had an airway operation in the first year of life demonstrated poorer early weight gain but caught up to controls by 2 years of age. Patients that had MDO before 3 months of age had faster weight gain than those that had later operations. Neither age at operation nor type of intervention affected growth outcomes by 3 years of age, which were comparable with controls.

Floating Bone Phenomenon in Pierre Robin Sequence

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

A Standardized Care Pathway following Mandibular Distraction in Infants Less Than 3 Months of Age

OBJECTIVES

To assess for differences in postoperative care following mandibular distraction osteogenesis (MDO) in infants before and after implementation of a standardized protocol.

STUDY DESIGN

Retrospective chart review.

SETTING

Urban tertiary pediatric hospital.

SUBJECTS AND METHODS

The inpatient charts of infants who underwent MDO before 90 days of age were assessed for metrics such as postoperative length of stay (LOS), duration of mechanical ventilation, and the choice and duration of sedating medications.

RESULTS

Over a 6-year period, 16 patients met inclusion criteria. The first 4 consecutive patients were managed at the discretion of the critical care staff. The remaining 12 infants were managed with a planned 4- to 6-day period of postoperative intubation, during which a standard protocol determined the choice, dosage, and duration of sedating medications. The mean age was similar between groups (preprotocol: mean, 26.5 days; protocol: mean, 20.3 days; P = .51). The mean postoperative LOS was 13.3 days less among infants managed with the protocol (P = .06), and the mean number of midazolam boluses was fewer among protocol patients (P < .01). A more consistent postoperative LOS, duration of mechanical ventilation, and exposure to sedating medications was observed among protocol subjects (P < .01). The LOS for 2 patients in the preprotocol group was extended due to iatrogenic withdrawal syndrome. There were no instances of accidental extubation or anoxia in either group.

CONCLUSIONS

Among infants undergoing MDO, standardizing postoperative airway and sedation practices may offer a more predictable postoperative course as compared with a case-by-case management philosophy.

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

There is a paucity of literature directly comparing tongue-lip adhesion versus mandibular distraction osteogenesis in surgical treatment of patients with Pierre Robin sequence. This study comprehensively reviews the literature for evaluating airway and feeding outcomes following mandibular distraction osteogenesis and tongue-lip adhesion. A search was performed using the MEDLINE and Embase databases for publications between 1960 and June of 2017. English-language, original studies subjects were included. Extracted data included prevention of tracheostomy (primary airway outcome) and ability to feed exclusively by mouth (primary feeding outcome). A total of 67 studies were included. Ninety-five percent of subjects (657 of 693) treated with mandibular distraction osteogenesis avoided tracheostomy, compared to 89% of subjects (289 of 323) treated with tongue-lip adhesion. Eighty-seven percent of subjects (323 of 370) treated with mandibular distraction osteogenesis achieved full oral feeds at latest follow-up. Seventy percent of subjects (110 of 157) treated with tongue-lip adhesion achieved full oral feeds at latest follow-up. The incidence of second intervention for recurrent obstruction ranged from 4 to 6 percent in mandibular distraction osteogenesis studies, compared to a range of 22 to 45 percent in tongue-lip adhesion studies. Variability of patient selection, surgical techniques, outcomes measurement methods, and follow-up length across studies precluded meta-analysis of the data. Both mandibular distraction osteogenesis and tongue-lip adhesion are effective alternatives to tracheostomy for patients who fail conservative management and improve feeding. Mandibular distraction osteogenesis may be superior to tongue-lip adhesion in long-term resolution of airway obstruction and avoidance of gastrostomy, but is associated with notable complications.

Peripartum Management of Neonatal Pierre Robin Sequence

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

Tongue Lip Adhesion in the Treatment of Robin Sequence: Respiratory, Feeding, and Surgical Outcomes

OBJECTIVE

Objective evaluation of the efficacy of tongue lip adhesion (TLA) in the management of Robin sequence (RS).

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary referral hospital.

PATIENTS, PARTICIPANTS

The craniofacial database of Amsterdam UMC, Vrije Universiteit Amsterdam was searched to identify infants with RS who underwent tong lip adhesion (TLA). Forty-one RS infants who underwent TLA from 1993 to 2016 were identified.

INTERVENTIONS

TLA.

MAIN OUTCOME MEASURE

The outcome measures were pre- and postoperative polysomnography results, nutritional status, weight gain, age at operation, hospital stay length, extubation time after TLA, and complications.

RESULTS

Forty-one RS patients were included who had TLA at an average age of 26.6 days. In 16 cases a pre- and postoperative polysomnography was performed. In 13 of these cases (81.3%) improvement was observed, in 2 (12.5%) the results were inconclusive, and in 1 (6.3%) no improvement was seen. Patients were extubated after a mean of 2.2 days.The mean hospital stay was 40.2 days. Reintervention was needed in 7 patients because of a wound dehiscence. The mean age of TLA release was 9.7 months. At discharge, 9 (22%) children still needed total nutritional support for persistent feeding difficulties. The average growth from birth to adhesion release was 4.6 kg.

CONCLUSION

This cohort demonstrates that TLA is a successful procedure in children with RS in terms of respiratory, feeding, and growth outcome. Only minor complications were seen in our cohort.

Resolution of obstructive sleep apnea after mandibular distraction osteogenesis in setting of delayed tongue-lip adhesion takedown: A case report

RATIONALE

There is a high prevalence of obstructive sleep apnea (OSA) in patients with Pierre Robin sequence (PRS), and treatment approaches are highly variable. One approach is a temporary tongue-lip adhesion (TLA) that acts as a temporizing measure while the mandible continues to grow and is usually taken down at 1 year of age.

PATIENT CONCERNS

Side effects of prolonged tongue-lip adhesion and optimal workup and treatment of persistent OSA in the setting of a tongue-lip adhesion.

DIAGNOSES

Pierre Robin sequence (PRS), persistent obstructive sleep apnea (OSA), and tongue-lip adhesion (TLA).

INTERVENTIONS

Mandibular distraction osteogenesis (MDO), adenotonsillectomy, and tongue-lip adhesion takedown.

OUTCOMES

Resolution of OSA.

LESSONS

This case puts into question the efficacy of isolated TLA in infants with Pierre Robin sequence and OSA, and places emphasis on the importance of considering an earlier workup of other potential causes of obstruction and the potential need for MDO as a primary or adjunctive approach to treatment.

Tongue–lip adhesion and tongue repositioning for obstructive sleep apnoea in Pierre Robin sequence: A systematic review and meta-analysis

Objective:

To search for studies on tongue–lip adhesion and tongue repositioning used as isolated treatments for obstructive sleep apnoea in children with Pierre Robin sequence.

Methods:

A systematic literature search of PubMed/Medline and three additional databases, from inception through to 8 July 2016, was performed by two authors.

Results:

Seven studies with 90 patients (59 tongue–lip adhesion and 31 tongue repositioning patients) met the inclusion criteria. Tongue–lip adhesion reduced the mean (± standard deviation) apnoea/hypopnoea index from 30.8 ± 22.3 to 15.4 ± 18.9 events per hour (50 per cent reduction). The apnoea/hypopnoea index mean difference for tongue–lip adhesion was −15.28 events per hour (95 per cent confidence interval = −30.70 to 0.15;p= 0.05). Tongue–lip adhesion improved the lowest oxygen saturation from 75.8 ± 6.8 to 84.4 ± 7.3 per cent. Tongue repositioning reduced the apnoea/hypopnoea index from 46.5 to 17.4 events per hour (62.6 per cent reduction). Tongue repositioning improved the mean oxygen saturation from 90.8 ± 1.2 to 95.0 ± 0.5 per cent.

Conclusion:

Tongue–lip adhesion and tongue repositioning can improve apnoea/hypopnoea index and oxygenation parameters in children with Pierre Robin sequence and obstructive sleep apnoea.

Craniofacial disorders associated with airway obstruction in the neonate

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