Is There a Role for Comfort Care in Neonates With Severe Craniofacial Anomalies? Case Report and Review of Quality-of-Life Literature

This article aims to determine how quality of life (QoL) is defined and assessed in cases of severe craniofacial anomalies, as well as the impact such considerations may have on the treatment of a neonate with these conditions with respect to palliative neonatal care. Our literature review found insufficient evidence to suggest that craniofacial anomalies result in consistently poor QoL. Based on these findings and in line with the current acceptable standards for the ethical care of neonates, with the exception of rare cases, resuscitative efforts should always be performed on patients with isolated craniofacial anomalies, as demonstrated in the management of this reported patient.

The Role of Digital Surgical Planning and Surgical Guides in the Treatment of Unilateral Condylar Hyperplasia

Unilateral condylar hyperplasia (UCH) results in facial asymmetry, malocclusion, and temporomandibular joint dysfunction. Treatment consists of both surgical and orthodontic intervention. A review was performed for 4 patients with UCH who underwent digital surgical planning (DSP)-assisted condylectomy. All patients were female, aged 14 to 35 years at the time of operation with facial asymmetry and class III malocclusion. None of the patients had prior treatment and all had perioperative orthodontic appliances to provide fixation and postoperative elastic therapy. All patients underwent DSP-guided condylectomy, and intraoperative surgical cutting guides were used for 3 of the patients. All had significant improvement in facial symmetry and occlusion. None had recurrence, and additional intervention has not been required. If UCH is recognized before marked secondary changes in the maxilla, mandible, and occlusion, future orthognathic surgery may be potentially obviated. Craniomaxillofacial surgeons should consider using DSP and surgical guides in the treatment of UCH.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Crouzon Syndrome Spanning Three Generations: Advances in the Treatment of Syndromic Midface Deficiency

Background

Crouzon syndrome is an autosomal dominant genetic disorder characterized by craniosynostosis, midface retrusion, and exophthalmos. Over the past century, the treatment of craniofacial disorders like Crouzon syndrome has evolved significantly.

Methods

An institutional review board-approved retrospective study was conducted to ascertain the treatment of three individuals with Crouzon syndrome from one family, complemented with a series of literature searches to examine the evolution of craniofacial surgical history.

Results

Dr. David Williams Cheever developed the Le Fort I level to correct malocclusion, maxillomandibular malformations, and midface hypoplasia. Later, Dr. Paul Tessier introduced the Le Fort II and III osteotomies to treat syndromic midface hypoplasia. In 1978, Dr. Fernando Ortiz-Monasterio and Dr. Antonio Fuente del Campo published the first series of monobloc osteotomies, allowing for simultaneous correction of supraorbital and midface malformations, although complicated by blood loss and high infection rates. In 1992, McCarthy et al introduced the concept of gradual distraction to the craniofacial skeleton. In 1995, Polley et al performed the first monobloc advancement using external distraction. Subsequently, in 1997, Polley and Figueroa introduced a rigid external distraction device with multiple vector control to manage severe cleft maxillary hypoplasia. The technique was further refined and applied to treat syndromic midface hypoplasia, reducing complication rates. Currently, either external or internal distraction approaches are used to safely treat this challenging group of patients.

Conclusion

The treatment of syndromic midface deficiency has significantly evolved over the past 50 years, as evidenced by this report of three generations of Crouzon syndrome.

TMJ Ankylosis Following Mandibular Distraction Osteogenesis: Management With Simultaneous Midface External Distraction and Bilateral Temporomandibular Joint Replacement

Early mandibular distraction osteogenesis (MDO) can decrease upper airway and feeding complications in pediatric patients with micrognathia; however, temporomandibular joint (TMJ) complications like TMJ ankylosis (TMJA) may occur. TMJA can disturb pediatric patients' function and craniofacial growth, resulting in significant physical and psychosocial consequences. Additional surgical procedures may also be required, increasing the burden of care on patients and their families. CMF surgeons must discuss the potential complications of early MDO surgery with families as well as potential solutions should these problems occur. This report presents the case of a 17-year-old male with a severe craniofacial anomaly with features of Treacher-Collins syndrome (TCS) and a surgical history of tracheostomy, cleft palate repair, mandibular reconstruction with harvested costochondral grafts, and MDO with resultant bilateral TMJA and limited mouth opening. The patient Was treated with bilateral custom alloplastic TMJ replacements and simultaneous maxillary DO using a Rigid External Distraction (RED) device.

Uvular Dermoid Cyst: More Than Just a Lump in the Throat-Management of Resultant Velopharyngeal Insufficiency

To seal the passage between the nasal and oral cavities during speech and swallowing, velopharyngeal closure is required. However, in velopharyngeal dysfunction, uncoupling of the nasal and oral cavities can be impaired, resulting in hypernasality, nasal air emission, and decreased vocal intensity. Velopharyngeal dysfunction can develop following velopharyngeal mislearning, oral surgery, or a congenital palatal malformation. Rare dermoid cysts of the palate may interrupt normal palatal development, resulting in velopharyngeal insufficiency (VPI). While speech therapy is the standard treatment, some cases may necessitate surgical correction of structural insufficiencies. In this report, we present the case of a 7-year-old female with a past surgical history of a uvular dermoid cyst removal at 14 months of age with VPI that was treated with Furlow Z-palatoplasty. To the author's knowledge, this is one of but a few cases of a uvular dermoid cyst with VPI.

Cleft Lip and Palate: LeFort I Distraction with Halo and Hybrid Internal Maxillary Distractors

Distraction osteogenesis is a viable treatment option for patients with a cleft associated with severe maxillary retrusion. A rigid external distraction device and a hybrid internal maxillary distractor have been used to advance the maxilla allowing for predictable and stable results. These techniques can be applied by itself or as an adjunct to traditional orthognathic procedures. The technical aspects are presented. These procedures tend to be simpler and demonstrate great stability compared to traditional surgical methods. The reasons for stability are discussed.

Abstract 5015: Tumor infiltrating lymphocytes and regression in cutaneous melanoma in the elderly: A link with clinical behavior

Background: The incidence of melanoma in patients ≥65 years has increased threefold over the past 25 years. Differences in melanoma biology and host factors such as immunosenescence may contribute to the adverse prognostic effect of age and sex on outcome. Tumor-infiltrating lymphocytes (TILs) and regression are considered a manifestation of the host immune response to tumor, but the influence of TILs and regression on outcome remains controversial. We undertook the present study to evaluate the association of these factors with other prognostic markers and outcome among elderly melanoma patients in our community surgical oncology practice.

Methods: From our Melanoma Registry we identified 250 consecutive cutaneous melanoma patients aged ≥65 years (median 75, range 65-97 years) at the time of diagnosis of their index primary melanoma. Patient and tumor data were verified by individual record and report review. Mean (median) follow up for surviving patients was 72±3.8 (65) months. An SAS software package was used for statistical analysis.

Results: 134 patients (54%) were male and 98% were Caucasian. Melanoma site was extremity in 42%, trunk in 32% and head/neck in 23%. The most common histologic type was superficial spreading (43%), mean tumor thickness was 1.4±0.1 mm, 16% were ulcerated, the mean mitotic index was 2.88±0.47, a brisk TIL infiltrate was seen in 24%, non-brisk TIL in 15% and regression in 13%. T stage distribution included 36% T1, 14% T2, 14% T3 and 9% T4 tumors. 6% of patients had lymph node (LN) metastases. LN metastases were more prevalent in male (11%) than female (3%) patients, p=0.007 and more prevalent in patients with melanomas with brisk TILs (16%) than absent/non-brisk TILs (4%), p=0.02. There were no significant sex differences in TILs or regression. During follow up, 22% of patients recurred, 21% died of unrelated causes and 12% died of melanoma. The mean (median) time to recurrence was 33.8 ± 5.3 (16) months. Recurrence was 4-fold greater in patients with absent/non-brisk TILs (22%) than with brisk TILs (5%), p=0.02, and two-fold greater in male (27%) than female (14%) patients, p=0.01. Regression was not predictive of recurrence. Disease-free survival (DFS) was worse for male than female patients: 5 y (10 y) DFS 68% (64%) vs 84% (72%), p=0.005, and worse for patients with absent/non-brisk TILs than brisk TILs: 5 y (10y) DFS 76% (71%) vs 91% (90%), p=0.06.

Conclusions: A brisk TIL infiltrate, together with female sex, was associated with a diminished risk of recurrence after treatment of cutaneous melanoma in our elderly patient population, despite the finding that brisk TILs conferred a 4-fold greater risk for LN involvement. Further investigation of the clinical significance and applicability of these apparently paradoxical findings is warranted.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 5015. doi:10.1158/1538-7445.AM2011-5015

Primary prevention of overweight and obesity: an analysis of national survey data

BACKGROUND

Obesity is rapidly approaching tobacco as the leading cause of preventable morbidity and mortality. Health care providers have the opportunity to address this through primary prevention strategies.

OBJECTIVE

To assess whether health care professionals provide primary prevention for overweight and obesity by examining the percentage of healthy-weight (body mass index [BMI] = 18.5-24.9 kg/m(2)) individuals who report being advised to maintain a healthy weight.

DESIGN

Cross-sectional analysis of the 2003 Behavioral Risk Factor Surveillance Survey data.

PARTICIPANTS

Noninstitutionalized U.S. adults >18 years of age.

RESULTS

Among healthy BMI respondents, only 2.6% reported receiving primary prevention. Logistic regression analyses yielded that healthy-weight adults receiving primary prevention were more likely to report: being 18-49 years of age, annual household incomes <$35,000, having at least 1 comorbidity, having a health care provider, changed eating habits to include less fat or fewer calories, and using physical activity to maintain or lose weight. Men were also more likely to receive primary prevention.

CONCLUSIONS

Only a very small proportion of healthy-weight adults received primary prevention, which suggests that physicians are missing opportunities to help address the epidemic of adult obesity in the US.