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Fouda MA, Seltzer LA, Zappi K, Hoffman C, Pannullo SC. Posterior cranial vault distraction in children with syndromic craniosynostosis: the era of biodegradable materials-a comprehensive review of the literature and proposed novel global application. Childs Nerv Syst 2024; 40:759-768. [PMID: 37966499 DOI: 10.1007/s00381-023-06221-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/06/2023] [Indexed: 11/16/2023]
Abstract
Distraction osteogenesis is utilized to increase intracranial volume in the treatment of restrictive pathologies, most commonly syndromic synostosis. Children too young for open calvarial vault expansion or other systemic or local contraindications to a direct reconstructive approach benefit greatly from distraction osteogenesis, typically addressing posterior vault expansion. Wound infection, cerebrospinal fluid (CSF) leak, device failure, need for a second surgery for removal, and cost, are issues that can limit the use of this approach. These challenges are more pronounced in low- and middle-income countries (LMICs) due to lack of access to the device, the financial burden of the need for a second surgery, and the severity of the implications of infection and CSF leak. Over the last five decades, there has been an increased acceptance of bioresorbable instrumentation in craniofacial surgery. Poly L-lactic acid, polyglycolic acid, and polydioxanone are the most commonly used polymers. New resorbable fixation tools such as ultrasound-activated pins and heat-activated pins are superior to conventional bioresorbable screws in allowing attachment to thinner bone plates. In this paper, we present a review of the literature on cranial vault distraction and the use of bioresorbable materials and propose a novel design of a fully absorbable cranial distractor system using external magnetic distraction control, eliminating the need for external activation ports and a second surgery to remove the hardware. The application of this technology in LMIC settings could advance access to care and treatment options for patients with syndromic synostosis.
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Affiliation(s)
- Mohammed A Fouda
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, Box 99, New York, NY, USA.
| | | | - Kyle Zappi
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, Box 99, New York, NY, USA
| | - Caitlin Hoffman
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, Box 99, New York, NY, USA
| | - Susan C Pannullo
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, Box 99, New York, NY, USA
- Department of Biomedical Engineering, Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, USA
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Yamada K, Akita S, Ando N, Tamura T, Hayashi M, Isono S, Mitsukawa N. Changes in mandibular position during midface distraction in patients with syndromic craniosynostosis. J Craniomaxillofac Surg 2024; 52:340-346. [PMID: 38326126 DOI: 10.1016/j.jcms.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 10/20/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024] Open
Abstract
The purpose of this study was to evaluate changes in mandibular position during midface distraction. Midface distraction was performed in patients with syndromic craniosynostosis to increase upper airway volume. Although this treatment resulted in changes in occlusion, the concomitant changes in mandibular position were poorly understood. In this retrospective study, three-dimensional (3D) cephalograms were obtained before and after midface distraction in 15 patients with syndromic craniosynostosis. Perioperative polysomnography scores and changes in maxillary and mandibular position, mandibular volume, and upper airway volume were analyzed. Results showed a significant improvement in apnea-hypopnea index (AHI) (from 20.6 ± 21.3 to 6.9 ± 5.1, p < 0.05) and upper airway volume (from 2951.65 ± 2286.38 to 5218.04 ± 3150.05 mm3, p < 0.001). When the lowest point of the sella turcica was set as the reference point, the mandible moved significantly in an anterior direction (from 47.9 ± 11.5 to 51.9 ± 9.8 mm, p < 0.05). Mandibular volume did not change significantly perioperatively (from 32530.19 ± 10726.01 to 35590.50 ± 14879.21 mm3, p = 0.10). There were positive correlations between the rates of improvement in AHI and the amount of mandibular movement in the anterior and inferior directions (both p < 0.05). Within the limitations of the study, it seems that the mandible moved in the anterior-inferior direction after midface distraction, and the amount of movement correlated with improvement in respiratory function. Therefore, it is important to consider the position of the mandible when determining the direction of midface distraction, as it may influence the therapeutic effect.
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Affiliation(s)
- Kahoko Yamada
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shinsuke Akita
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Nobuhiro Ando
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takeshi Tamura
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Minoru Hayashi
- Department of Plastic and Reconstructive Surgery, St. Mary's Hospital, Fukuoka, Japan
| | - Shiroh Isono
- Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.
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Abstract
This article reviews the most common craniofacial syndromes encountered in clinical practice. Key physical features of each condition are highlighted to aid in accurate recognition and diagnosis. Optimal individualized treatment approaches are discussed.
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Affiliation(s)
- Robert J Tibesar
- Pediatric ENT and Craniofacial Surgery, Children's Hospital Minnesota, 2530 Chicago Avenue South CSC 450, Minneapolis, MN 55404, USA.
| | - Andrew R Scott
- Pediatric ENT and Craniofacial Surgery, Tufts Medical Center, Floating Building, 6th Floor, 755 Washington Street Box 850, Boston, MA 02111, USA
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Chang Y, Yu Y, Zhang W, Gao Y, Feng J, Li M, Han F. The effect of continuous positive airway pressure on obstructive sleep apnea in children with syndromic craniosynostosis. Sleep Breath 2024:10.1007/s11325-023-02981-3. [PMID: 38180682 DOI: 10.1007/s11325-023-02981-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is common in children with syndromic craniosynostosis (SC). However, objective data on the treatment of OSA in children with SC remain inadequate. This study aimed to explore the efficacy of continuous positive airway pressure (CPAP) in the management of OSA in children with SC. METHODS A retrospective study was performed in children with SC and OSA diagnosed by polysomnography (PSG), which was defined as an apnea hypopnea index (AHI) ≥ 1. Patients were included if they were treated with CPAP and had baseline PSG and follow-up sleep studies. Clinical and demographic data were collected from all enrolled subjects. RESULTS A total of 45 children with SC and OSA were identified, with an average age of 6.8 ± 4.7 years. Among them, 36 cases had moderate to severe OSA (22 with severe OSA) and received CPAP therapy followed by post-treatment sleep studies. Notably, there was a significant reduction in the AHI observed after CPAP treatment (3.0 [IQR: 1.7, 4.6] versus 38.6 [IQR: 18.2, 53.3] events/h; P < 0.001). CONCLUSIONS CPAP is effective and acceptable in treating severe OSA in children with SC.
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Affiliation(s)
- Yuan Chang
- Department of Sleep Medicine, Peking University Pepole's Hospital, 11 Xizhimennan Road, Beijing, 100044, China
| | - Yongbo Yu
- Sleep Center, Peking University International Hospital, Beijing, China
| | - Wei Zhang
- Sleep Center, Peking University International Hospital, Beijing, China
| | - Yinghui Gao
- Sleep Center, Peking University International Hospital, Beijing, China
| | - Junjun Feng
- Sleep Center, Peking University International Hospital, Beijing, China
| | - Mengjie Li
- Sleep Center, Peking University International Hospital, Beijing, China
| | - Fang Han
- Department of Sleep Medicine, Peking University Pepole's Hospital, 11 Xizhimennan Road, Beijing, 100044, China.
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Stanbouly D, Asi AM, Ascherman JA, Chuang SK, Kinard B, Melville JC. Are Patients with Syndromic Craniosynostosis at Greater Risk for Epilepsy than Patients with Nonsyndromic Craniosynostosis? World Neurosurg 2024; 181:e45-e54. [PMID: 37327863 DOI: 10.1016/j.wneu.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE The aim of this study was to determine whether patients with syndromic craniosynostosis (SCS) are at increased risk for epilepsy relative to patients with nonsyndromic craniosynostosis (NSCS). METHODS A retrospective cohort study was completed using the Kids' Inpatient Database (KID). All patients diagnosed with craniosynostosis (CS) were included. The primary predictor variable was study grouping (SCS vs. NSCS). The primary outcome variable was a diagnosis of epilepsy. Descriptive statistics, univariate analyses and multivariate logistic regression were performed to identify independent risk factors for epilepsy. RESULTS The final study sample included a total of 10,089 patients (mean age, 1.78 years ± 3.70; 37.7% female). 9278 patients (92.0%) had NSCS, and the remaining 811 patients (8.0%) had SCS. A total of 577 patients (5.7%) had epilepsy. Not controlling for other variables, patients with SCS were at increased risk for epilepsy relative to patients with NSCS (OR 2.1, P < 0.001). After controlling for all significant variables, patients with SCS were no longer at increased risk for epilepsy relative to patients with NSCS (OR 0.73, P = 0.063). Hydrocephalus, Chiari malformation (CM), obstructive sleep apnea (OSA), atrial septal defect (ASD), gastro-esophageal reflux disease (GERD) were all independent risk factors (P < 0.05) for epilepsy. CONCLUSIONS Syndromic craniosynostosis (SCS) in itself is not a risk factor for epilepsy relative to NSCS. The greater prevalence of hydrocephalus, CM, OSA, ASD, and GERD, all of which were risk factors for epilepsy, in patients with SCS relative to patients with NSCS likely explains the greater prevalence of epilepsy in SCS relative to NSCS.
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Affiliation(s)
- Dani Stanbouly
- Columbia University College of Dental Medicine, New York, New York, USA.
| | - Abdalla M Asi
- Departments of Oral and Maxillofacial Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Jeffrey A Ascherman
- Thomas S. Zimmer Professor of Reconstructive Surgery, Division of Plastic Surgery, Department of Surgery, Columbia University College of Physicians & Surgeons, New York, New York, USA; Cleft and Craniofacial Team of the Children's Hospital of NewYork-Presbyterian, New York, New York, USA
| | - Sung-Kiang Chuang
- Department of Oral and Maxillofacial Surgery, University of Pennsylvania, School of Dental Medicine, Philadelphia, Pennsylvania, USA; Department of Oral and Maxillofacial Surgery, Good Samaritan Medical Center, Brockton, MA, USA; Department of Oral and Maxillofacial Surgery, Kaohsiung Medical University, School of Dentistry, Kaohsiung, Taiwan; Department of Oral and Maxillofacial Surgery, National University of Singapore, School of Dentistry, Singapore
| | - Brian Kinard
- Department of Oral and Maxillofacial Surgery, Department of Orthodontics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James C Melville
- Departments of Oral and Maxillofacial Surgery and Oral, Head, and Neck Oncology, and Microvascular Surgery, University of Texas Health Sciences Center at Houston, School of Dentistry, Houston, Texas, USA
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Brown KW, Edwards SR, Hoppe IC. Perioperative Management of Obstructive Sleep Apnea in Patients With Syndromic Craniosynostosis Undergoing LeFort III Osteotomy With Distraction: A Case Series. Craniomaxillofac Trauma Reconstr 2023; 16:301-305. [PMID: 38047148 PMCID: PMC10693261 DOI: 10.1177/19433875221142676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Study Design Retrospective observational study. Objective The purpose of this publication is to address the absence of literature detailing respiratory management in patients with syndromic craniosynostosis and obstructive sleep apnea during the immediate postoperative interval following LeFort III advancement with placement of distraction hardware but prior to sufficient midface advancement. Methods After IRB approval, the investigators retrospectively selected candidates for inclusion in this case series. The sample was composed of four patients ranging from 10 to 19 years of age undergoing LeFort III midface advancement during a one-year span at a single tertiary care center. All operations were performed by a single surgeon. Three of the selected patients suffered significant obstructive sleep apnea necessitating the operation, as determined by polysomnography. One patient experienced persistent apnea postoperatively requiring prolonged ICU level care. Results Three of the four patients had severe OSA diagnosed by polysomnography with a median AHI of 28.3. Two of the three patients with preoperative OSA experienced no untoward respiratory compromise in the immediate postoperative period; one required nightly oxygen tent and the other required no supplemental oxygen. Patient 1 experienced significant postoperative respiratory distress with nightly apneic episodes and desaturations requiring supplemental oxygen and frequent stimulation. Conclusions The present study suggests that early involvement of sleep medicine and management of patient expectations is vital. Extremely close postoperative monitoring in the ICU is necessary. Future studies are needed to protocolize perioperative management of obstructive sleep apnea in patients undergoing LeFort III osteotomy prior to initiation and completion of midface advancement.
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Affiliation(s)
- Kathryn W. Brown
- Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Shelley R. Edwards
- Department of Neuroscience, School of Graduate Studies in Health Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ian C. Hoppe
- Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, MS, USA
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Calandrelli R, Pilato F, Massimi L, D'Apolito G, Colosimo C. Facial skeleton dysmorphology in syndromic craniosynostosis: differences between FGFR2 and no-FGFR2-related syndromes and relationship with skull base and facial sutural patterns. Childs Nerv Syst 2023; 39:3235-3247. [PMID: 37195419 DOI: 10.1007/s00381-023-05962-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/16/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE To assess the role of FGFR2 mutations and sutural synostotic patterns on facial skeleton dysmorphology in children with syndromic craniosynostosis. METHODS Preoperative high-resolution CT images in 39 infants with syndromic craniosynostosis were evaluated. Patients were divided into infants with and without FGFR2 mutations; each group was split according to synostotic involvement of minor sutures/synchondroses: isolated or combined involvement of middle (MCF) and posterior cranial fossae (PCF). Quantitative analysis of the midface and mandible measures was performed. Each subgroup was compared with a group of age-matched healthy subjects. RESULTS Twenty-four patients with FGFR2 related syndromes were clustered in 3 subgroups: MCF + PCF (8 patients, 5.4 ± 1.75 months), MCF (8 patients, 3.62 ± 1.68 months), and PCF (8 patients, 2.75 ± 0.46 months). Fifteen no-FGFR2 patients were clustered in 2 subgroups: MCF + PCF (7 patients, 9.42 ± 0.78 months) and PCF (8 patients, 7.37 ± 2.92 months). Both FGFR2 and no-FGFR2 groups with involvement of minor sutures coursing in MCF showed more facial sutural synostoses. Children with minor suture/synchondrosis synostosis of MCF (MCF-PCF and MCF subgroups) showed altered position of glenoid fossa and mandibular inclination ([Formula: see text]), but children in the FGFR2 group had also reduced midfacial depth and maxillary length ([Formula: see text]). Children with minor suture/synchondrosis synostosis of PCF (PCF subgroups) had reduced posterior mandibular height, but those children in the FGFR2 group also showed reduced intergonion distance ([Formula: see text]). CONCLUSIONS In children with syndromic craniosynostosis, both skull base and facial suture synostosis affect facial dysmorphology/hypoplasia. FGFR2 mutations may worsen facial hypoplasia both acting on bone development and causing an earlier premature closure of facial sutures.
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Affiliation(s)
- Rosalinda Calandrelli
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 1, Rome, 00168, Italy.
| | - Fabio Pilato
- Unit of Neurology, Department of Medicine, Neurophysiology, Università Campus Bio-Medico, Via Alvaro del Portillo, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, Rome, Italy
| | - Luca Massimi
- Pediatric Neurosurgery, Neurosurgery Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 1, Rome, 00168, Italy
| | - Gabriella D'Apolito
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 1, Rome, 00168, Italy
| | - Cesare Colosimo
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 1, Rome, 00168, Italy
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赵 琛, 滕 利. [Application and development of orthognathic surgery in treatment of syndromic craniosynostosis]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2023; 37:879-884. [PMID: 37460186 PMCID: PMC10352517 DOI: 10.7507/1002-1892.202302102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 07/20/2023]
Abstract
Objective To summarize the application and recent development of orthognathic surgery in treating syndromic craniosynostosis. Methods The related literature at home and abroad in recent years was extensively reviewed, and the indications, routine procedures, and protocols of orthognathic surgery in the treatment of syndromic craniosynostosis were summarized and analyzed. Results Craniosynostosis is a common congenital craniofacial malformation. Syndromic craniosynostosis usually involves premature fusion of multiple cranial sutures and is associated with other deformities. Orthognathic surgery is the necessary and effective means to improve the midfacial hypoplasia and malocclusion. Le Fort I osteotomy combined with sagittal split ramus osteotomy are the common surgical options. Orthognathic surgery should combine with craniofacial surgery and neurosurgery, and a comprehensive long-term evaluation should be conducted to determine the best treatment plan. Conclusion Orthognathic surgery plays an important role in the comprehensive diagnosis and treatment of syndromic craniosynostosis. The development of digital technology will further promote the application and development of orthognathic surgery in the treatment of syndromic craniosynostosis.
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Affiliation(s)
- 琛杰 赵
- 中国医学科学院北京协和医学院整形外科医院颅颌面二中心(北京 100144)The Second Department of Craniomaxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100144, P. R. China
| | - 利 滕
- 中国医学科学院北京协和医学院整形外科医院颅颌面二中心(北京 100144)The Second Department of Craniomaxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100144, P. R. China
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Raposo-Amaral CE, Ghizoni E, Raposo-Amaral CA. Apert Syndrome: Selection Rationale for Midface Advancement Technique. Adv Tech Stand Neurosurg 2023; 46:245-266. [PMID: 37318579 DOI: 10.1007/978-3-031-28202-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Apert syndrome is characterized by a wide spectrum of craniofacial clinical features that have been successfully addressed via a variety of midface advancement techniques. Although surgeons have individual preferences as to which specific procedures should be performed to best treat Apert patients, craniofacial plastic surgeons, working in tandem with pediatric neurosurgeons, can identify and evaluate functional limitations and facial morphologic disproportions, and establish appropriate criteria for effective midface advancement technique indication and selection. The purpose of this review article is to present and discuss our rationale for midface advancement technique selection based upon the most common craniofacial characteristics presented by Apert syndrome patients. The present article also provides a grading system that stratifies as major, moderate, and mild, the effect of each midface advancement technique on the different types of Apert syndrome facial features. Surgeons should take into consideration the maximum effect and benefit of each craniofacial osteotomy and how these procedures will alter the craniofacial skeleton. By understanding the long-term effect of each osteotomy on the most common craniofacial characteristics of Apert syndrome patients, craniofacial plastic surgeons and neurosurgeons will be able to customize the surgical procedures they perform in order to achieve the best possible outcomes.
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Affiliation(s)
- Cassio Eduardo Raposo-Amaral
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, São Paulo, Brazil
- Department of Neurology, University of Campinas (UNICAMP), São Paulo, Brazil
| | - Enrico Ghizoni
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, São Paulo, Brazil
- Department of Neurology, University of Campinas (UNICAMP), São Paulo, Brazil
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Afshari FT, Gallo P, Shafi A, Grant J, Drew A, Noons P, Jagadeesan J, Evans M, Brittain H, Rodrigues D. ERF-related craniosynostosis and surgical management in the paediatric cohort. Childs Nerv Syst 2022. [PMID: 36209295 DOI: 10.1007/s00381-022-05700-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/03/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION ERF mutation is one of the most recently identified genetic aberrations associated with syndromic craniosynostosis. Data on the pattern of craniosynostosis, surgical management of ERF-related craniosynostosis and outcomes is limited. We report on our single-centre experience in paediatric cohort of patients with syndromic craniosynostosis secondary to ERF mutation. METHODS A retrospective review of all paediatric craniofacial cases was performed over an 8-year period (2014-2022). All patients with genetically confirm ERF-related craniosynostosis were identified, and clinical parameters including, age, sex, pattern of craniosynostosis, associated tonsillar herniation and follow-up period were further analysed from electronic clinical and imaging systems. All patients were selected and discussed in multidisciplinary craniofacial meeting (composed of neurosurgical, maxillofacial, plastics and genetics teams) prior to any surgical intervention. RESULTS Overall, 10 patients with ERF-related craniosynostosis were identified with a male-to-female ratio of 4:1 with mean age at the time of surgery of 21.6 months with a mean follow-up period of 5.2 years. ERF-confirmed cases led to variable craniosynostosis pattern with multi-sutural synostosis with concurrent sagittal and bilateral lambdoid involvement as the most common pattern (7/10). No patient pre-operatively had evidence of papilloedema on ophthalmological assessment. Eight out of 10 patients had associated low-lying tonsils/hind brain hernia pre-operatively. Eight out of 10 patients required surgery which included 2 fronto-orbital advancement, 3 calvarial remodelling, 2 posterior calvarial remodelling/release and 1 insertion of ventriculoperitoneal shunt. CONCLUSION Involvement of sagittal and lambdoid sutures is the most common pattern of craniosynostosis. ERF-related craniosynostosis can have variable pattern of suture fusion, and management of each patient requires unique surgical planning and execution based on clinical needs for the optimal outcomes.
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Chen K, Kondra K, Nagengast E, Hammoudeh JA, Urata MM. Syndromic Synostosis: Frontofacial Surgery. Oral Maxillofac Surg Clin North Am 2022; 34:459-466. [PMID: 35786530 DOI: 10.1016/j.coms.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Frontofacial surgery, encompassing the monobloc with or without facial bipartition and the box osteotomy, can treat the frontal bone and midface simultaneously, providing comprehensive improvement in facial balance. Complex pediatric patients with genetic syndromes and craniosynostosis are most optimized by an interdisciplinary team of surgeons, pediatricians, geneticists, speech pathologists, audiologists, dietitians, pediatric dentists, orthodontists, and psychosocial support staff to manage the myriad of challenges and complications throughout early childhood and beyond. Despite early treatment of the anterior and posterior cranial vault, these patients frequently have resultant frontal and/or midface hypoplasia and orbital abnormalities that are best managed with simultaneous surgical treatment.
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Affiliation(s)
- Kevin Chen
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, 4650 West Sunset Boulevard, Mailstop 96, Los Angeles, CA 90027, USA
| | - Katelyn Kondra
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, 4650 West Sunset Boulevard, Mailstop 96, Los Angeles, CA 90027, USA
| | - Eric Nagengast
- Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, 1520 San Pablo Street, Los Angeles, CA 90033, USA
| | - Jeffrey A Hammoudeh
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, 4650 West Sunset Boulevard, Mailstop 96, Los Angeles, CA 90027, USA; Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, 1520 San Pablo Street, Los Angeles, CA 90033, USA; Herman Ostrow School of Dentistry, University of Southern California, 925 West 34th Street, Los Angeles, CA 90089, USA; Division of Oral and Maxillofacial Surgery, University of Southern California, 925 West 34th Street, Los Angeles, CA 90089, USA.
| | - Mark M Urata
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, 4650 West Sunset Boulevard, Mailstop 96, Los Angeles, CA 90027, USA; Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, 1520 San Pablo Street, Los Angeles, CA 90033, USA; Herman Ostrow School of Dentistry, University of Southern California, 925 West 34th Street, Los Angeles, CA 90089, USA; Division of Oral and Maxillofacial Surgery, University of Southern California, 925 West 34th Street, Los Angeles, CA 90089, USA
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Affiliation(s)
- Daniel Schlieder
- Department of Oral and Maxillofacial Surgery, San Antonio Military Medical Center, San Antonio, TX; Craniofacial Anomaly Team, Wilford Hall Surgery Center, Lackland AFB TX.
| | - Michael R Markiewicz
- Department of Oral and Maxillofacial Surgery, School of Dental Medicine, University at Buffalo, 3435 Main Street, 112 Squire Hall, Buffalo, NY 14214, USA; Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY; Division of Pediatric Surgery, Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA; Craniofacial Center of Western New York, John Oishei Children's Hospital, Buffalo, NY; Roswell Park Comprehensive Cancer Center, Buffalo, NY
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Haber SE, Leikola J, Nowinski D, Fauroux B, Morisseau-Durand MP, Paternoster G, Khonsari RH, Arnaud E. Secondary Le Fort III after Early Fronto-Facial Monobloc Normalizes Sleep Apnea in Faciocraniosynostosis: A Cohort Study. J Plast Reconstr Aesthet Surg 2022; 75:2706-2718. [PMID: 35431130 DOI: 10.1016/j.bjps.2022.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 07/26/2021] [Accepted: 02/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study aims to assess the improvement of sleep apnea after secondary Le Fort III facial advancement with distraction (LF3) in faciocraniosynostosis (FCS) patients with sleep apnea who have previously undergone fronto-facial monobloc advancement (FFMBA) with distraction. METHODS Patients having undergone secondary LF3 were selected from a cohort of FCS patients with documented sleep apnea who had previously undergone fronto-facial monobloc advancement. Patient charts and polysomnographic records were reviewed. Apnea-hypopnea index (AHI) was recorded before and at least 6 months after secondary LF3. The primary outcome was normalization of AHI (less than 5/h was considered normal). Hierarchical multilevel analysis was performed to predict postoperative AHI evolution. RESULTS Seventeen patients underwent a secondary LF3, 7.0 ± 3.9 years after the primary FFMBA. The mean age was 9.6 ± 3.9 years. A total of 15 patients (88%) normalized their AHI. Two of four patients were decannulated (50%). There was a statistically significant decrease in AHI (preoperative AHI 21.5/h vs. 3.9/h postoperatively, p=0.003). Hierarchic multilevel modeling showed progressive AHI decrease postoperatively. CONCLUSION Secondary LF3 improves residual or relapsing sleep apnea in FCS patients who have previously had FFMBA.
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Affiliation(s)
- Samer E Haber
- Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris; Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, Université de Paris; Paris, France
| | - Junnu Leikola
- Cleft Palate and Craniofacial Center, Department of Plastic Surgery, Töölö Hospital, Helsinki University Central Hospital, P.O. Box 266, FI-00029, Helsinki, Finland
| | - Daniel Nowinski
- Department of Surgical Sciences, Uppsala University, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Brigitte Fauroux
- Service de Ventilation Non-Invasive et Sommeil de l'Enfant; Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris; EA7330 VIFASOM (Vigilance Fatigue Sommeil et Santé Publique); Université Paris-Descartes, Université Sorbonne Paris Cité; Paris, France
| | - Marie-Paule Morisseau-Durand
- Service d'Otorhinolaryngologie pédiatrique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris; Centre de Référence Maladies Rares MALO, Filière Maladies Rares TeteCou; Université de Paris, Université Paris Descartes; Paris, France
| | - Giovanna Paternoster
- Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris; Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, Université de Paris; Paris, France
| | - Roman H Khonsari
- Service de chirurgie maxillofaciale et chirurgie plastique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris; Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou; Université de Paris, Université de Paris; Paris, France
| | - Eric Arnaud
- Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris; Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, Université de Paris; Paris, France; Clinique Marcel Sembat, Ramsay Générale de Santé, 92100 Boulogne, France.
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Choi TM, Lijten OW, Mathijssen IMJ, Wolvius EB, Ongkosuwito EM. Craniofacial morphology and growth in Muenke syndrome, Saethre-Chotzen syndrome, and TCF12-related craniosynostosis. Clin Oral Investig 2021. [PMID: 34904178 DOI: 10.1007/s00784-021-04275-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/07/2021] [Indexed: 11/20/2022]
Abstract
Objectives To determine whether the midface of patients with Muenke syndrome, Saethre-Chotzen syndrome, or TCF12-related craniosynostosis is hypoplastic compared to skeletal facial proportions of a Dutch control group. Material and methods We included seventy-four patients (43 patients with Muenke syndrome, 22 patients with Saethre-Chotzen syndrome, and 9 patients with TCF12-related craniosynostosis) who were referred between 1990 and 2020 (age range 4.84 to 16.83 years) and were treated at the Department of Oral Maxillofacial Surgery, Special Dental Care and Orthodontics, Children’s Hospital Erasmus University Medical Center, Sophia, Rotterdam, the Netherlands. The control group consisted of 208 healthy children. Results Cephalometric values comprising the midface were decreased in Muenke syndrome (ANB: β = –1.87, p = 0.001; and PC1: p < 0,001), Saethre-Chotzen syndrome (ANB: β = –1.76, p = 0.001; and PC1: p < 0.001), and TCF12-related craniosynostosis (ANB: β = –1.70, p = 0.015; and PC1: p < 0.033). Conclusions In this study, we showed that the midface is hypoplastic in Muenke syndrome, Saethre-Chotzen syndrome, and TCF12-related craniosynostosis compared to the Dutch control group. Furthermore, the rotation of the maxilla and the typical craniofacial buildup is significantly different in these three craniosynostosis syndromes compared to the controls. Clinical relevance The maxillary growth in patients with Muenke syndrome, Saethre-Chotzen syndrome, or TCF12-related craniosynostosis is impaired, leading to a deviant dental development. Therefore, timely orthodontic follow-up is recommended. In order to increase expertise and support treatment planning by medical and dental specialists for these patients, and also because of the specific differences between the syndromes, we recommend the management of patients with Muenke syndrome, Saethre-Chotzen syndrome, or TCF12-related craniosynostosis in specialized multidisciplinary teams. Supplementary Information The online version contains supplementary material available at 10.1007/s00784-021-04275-y.
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Tcherbbis Testa V, Jaimovich S, Argañaraz R, Mantese B. Management of ventriculomegaly in pediatric patients with syndromic craniosynostosis: a single center experience. Acta Neurochir (Wien) 2021; 163:3083-3091. [PMID: 34570275 DOI: 10.1007/s00701-021-04980-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Management of ventriculomegaly in pediatric patients with syndromic craniosynostosis (SC) requires understanding the underlying mechanisms that cause increased intracranial pressure (ICP) and the role of cerebrospinal fluid (CSF) in cranial vault expansion in order to select the best treatment option for each individual patient. METHODS A total of 33 pediatric patients with SC requiring craniofacial surgery were retrospectively evaluated. Cases of nonsyndromic craniosynostosis and shunt-induced craniosynostosis were excluded. Six syndrome-based categories were distinguished: Crouzon syndrome, Pfeiffer syndrome, Apert syndrome, cloverleaf skull syndrome, and others (Muenke syndrome, Sensenbrenner syndrome, unclassified). All of the patients were treated surgically for their cranial deformity between 2010 and 2016. The presence of ventriculomegaly and ventriculoperitoneal (VP) shunt requirement with its impact in cranial vault expansion were analyzed. Clinical and neuroimaging studies covering the time from presentation through the follow-up period were revised. The mean postoperative follow-up was 6 years and 3 months. A systematic review of the literature was conducted through a PubMed search. RESULTS Of the total of 33 patients with SC, 18 (54.5%) developed ventriculomegaly and 13 (39.4%) required ventriculoperitoneal (VP) shunt placement. Six patients (18.2%) required shunt placement previous to craniofacial surgery. Seven patients (21.2%) required a shunt after craniofacial surgery. Seven fixed pressure ventriculoperitoneal shunts and six programmable valves were placed as first choice. All patients improved their clinical symptoms after shunt placement. Aesthetic results seemed to be better in patients with programmable shunts. CONCLUSIONS Unless clear criteria for overt hydrocephalus are present, it is recommended to perform craniofacial surgery as a first step in the management of patients with SC in order to preserve the expansive effect of CSF for cranial vault expansion. In our experience, the use of externally programmable valves allows for the treatment of hydrocephalus while maintaining the expansive effect of CSF for the remodeling of the cranial vault. Prospective evaluations are needed to determine causality.
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Casteleyn T, Horn D, Henrich W, Verlohren S. Differential diagnosis of syndromic craniosynostosis: a case series. Arch Gynecol Obstet 2021; 306:49-57. [PMID: 34633507 PMCID: PMC9300495 DOI: 10.1007/s00404-021-06263-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 09/15/2021] [Indexed: 11/30/2022]
Abstract
Purpose Syndromic craniosynostosis is a rare genetic disease caused by premature fusion of one or multiple cranial sutures combined with malformations of other organs. The aim of this publication is to investigate sonographic signs of different syndromic craniosynostoses and associated malformations to facilitate a precise and early diagnosis. Methods We identified in the period of 2000–2019 thirteen cases with a prenatal suspected diagnosis of syndromic craniosynostosis at our department. We analyzed the ultrasound findings, MRI scans, genetic results as well as the mode of delivery, and postnatal procedures. Results Eight children were diagnosed with Apert Syndrome, two with Saethre Chotzen syndrome, one with Crouzon syndrome, and one with Greig cephalopolysyndactyly syndrome. One child had a mutation p.(Pro253Leu) in the FGFR2 gene. We identified characteristic changes of the head shape as well as typical associated malformations. Conclusion Second trimester diagnosis of syndromic craniosynostosis is feasible based on the identified sonographic signs. In case of a suspected diagnosis a genetic, neonatal as well as surgical counseling is recommended. We also recommend to offer a fetal MRI. The delivery should be planned in a perinatal center.
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Affiliation(s)
- Tamara Casteleyn
- Department of Gynecology and Obstetrics, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Denise Horn
- Institute of Medical Genetics and Human Genetics, Charité - Universitätsmedizin, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité - Universitätsmedizin, Berlin, Germany
| | - Stefan Verlohren
- Department of Obstetrics, Charité - Universitätsmedizin, Berlin, Germany.
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Protzenko T, Bellas A, Ribeiro CMC, Gonzalez SMC, Horovitz DDG. Venous anomalies in hypoplastic posterior fossa: unsolved questions. Childs Nerv Syst 2021; 37:3177-87. [PMID: 34406451 DOI: 10.1007/s00381-021-05315-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Anomalous intracranial venous anatomy is described in patients with syndromic craniosynostosis and is of significant importance when it comes to surgical morbidity. However, it is still controversial its origin, type of circulation in each syndrome, how it behaves over time, when it can be interrupted and wether it needs to be studied. The purpose of this paper is to discuss these issues by reviewing the literature. METHODS A literature search was performed using the PubMed database with a focus on papers including detailed descriptions of the venous outflow in complex and syndromic craniosynostosis. Search details used were the following: ("veins"[MeSH Terms] OR "veins"[All Fields] OR "venous"[All Fields]) AND ("abnormalities"[Subheading] OR "abnormalities"[All Fields] OR "anomalies"[All Fields]) AND syndromic[All Fields] AND ("craniosynostoses" [MeSH Terms] OR "craniosynostoses"[All Fields] OR "craniosynostosis"[All Fields]). Studies that exposed details of venous anomalies found in syndromic or complex craniosynostosis were selected. RESULTS Of a total of 211 articles found, 11 were selected for this review. Of these, 5 were case reports, 5 retrospective studies, and only 1 prospective study. From the 6 series of cases presented, 5 discussed the relationship between jugular foramen stenosis (JFS) and collateral venous drainage. The authors discuss data from the literature for each leading question presented: 1-collateral circulation: is it an intrinsic trouble, a consequence of stenosis of the cranial base foramina or related to raised intracranial pressure (ICP)?; 2-what venous anomalies should we search for, and what is the best exam to study them?; 3-collateral circulation changes with time?; 4-can neurosurgeons interrupt the collateral circulation?; 5-should we study all complex types of craniosynostosis? CONCLUSION The importance of the study of the venous outflow in patients with complex craniosynostosis is evident in the literature. The real relationship between intracranial hypertension, hypoplastic skull base foramen, Chiari I malformation, hydrocephalus, and venous collateral circulation remains unknown. Prospective studies focusing on molecular biology analysis will possibly solve all of these leading questions.
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Raposo-Amaral CE, Oliveira YM, Denadai R, Raposo-Amaral CA, Ghizoni E. Severe craniolacunae and upper and lower extremity anomalies resulting from Crouzon syndrome, FGFR2 mutation, and Ser347Cys variant. Childs Nerv Syst 2021; 37:2391-2397. [PMID: 33404724 DOI: 10.1007/s00381-020-04993-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/30/2020] [Indexed: 02/05/2023]
Abstract
Crouzon syndrome is a rare form of syndromic craniosynostosis (SC) characterized by premature fusion of the cranial and facial sutures, elevated intracranial pressure, varying degrees of ocular exposure due to exorbitism, and airway compromise caused by midface retrusion. Craniolacunae and upper and lower extremity anomalies are not frequently found in Crouzon syndrome. We present a girl with Crouzon syndrome caused by c.1040 C > G, p.Ser347Cys, a pathogenic mutation in the FGFR2 gene with atypical characteristics, including craniolacunae resembling severe Swiss cheese type of bone formation, and upper and lower extremity anomalies which are more commonly associated with Pfeiffer syndrome patients. Distinguishing between severe Crouzon syndrome patients and patients who have mild and/or moderate Pfeiffer syndrome can be challenging even for an experienced craniofacial surgeon. An accurate genotype diagnosis is essential to distinguishing between these syndromes, as it provides predictors for neurosurgical complications and facilitates appropriate family counseling related to long-term outcomes.
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Affiliation(s)
- Cassio Eduardo Raposo-Amaral
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo, 13084-880, Brazil. .,Department of Neurology, University of Campinas (UNICAMP), São Paulo, Brazil.
| | - Yuri Moresco Oliveira
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo, 13084-880, Brazil
| | - Rafael Denadai
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo, 13084-880, Brazil
| | - Cesar Augusto Raposo-Amaral
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo, 13084-880, Brazil
| | - Enrico Ghizoni
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo, 13084-880, Brazil.,Department of Neurology, University of Campinas (UNICAMP), São Paulo, Brazil
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Hariri F, Farhana NA, Abdullah NA, Ibrahim N, Ramli NM, Mohd Abdullah AA, May CM, Khaliddin N. Optic canal characteristics in pediatric syndromic craniosynostosis. J Craniomaxillofac Surg 2021; 49:1175-1181. [PMID: 34247917 DOI: 10.1016/j.jcms.2021.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/28/2021] [Accepted: 06/22/2021] [Indexed: 10/21/2022] Open
Abstract
The aim of this study was to compare optic canal parameters of syndromic craniosynostosis patients with those of normal patients to visit the possibility of optic nerve impingement as a cause of visual impairment. Computed tomography scan images were processed using the Materialise Interactive Medical Image Control System (MIMICS) Research 21.0 software (Materialise NV, Leuven, Belgium). Eleven optic canal parameters were measured: 1) height of optic canal on the cranial side, 2) height of optic canal on the orbital side 3) length of the medial wall of the optic canal, 4) length of the lateral canal wall of the optic canal, 5) diameter of the optic canal at five points (Q1-Q4 and mid canal), and 6) area and perimeter of optic canal. These measurements were obtained for both the right and left optic canals. The study sample comprised four Crouzon syndrome, five Apert syndrome, and three Pfeiffer syndrome patients. The age of these syndromic craniosynostosis patients ranged from 2 to 63 months. The height of the optic canal on the orbital side (p = 0.041), diameter of the mid canal (p = 0.040), and diameter between the mid-canal and the cranial opening (Q3) (p = 0.079) for syndromic craniosynostosis patients were statistically narrower compared with those of normal patients when a significance level of 0.1 was considered. Scatter plots for the ages of patients versus the above parameters gave three separated clusters that suggested the arresting of optic canal development with age. The findings from this study demonstrated a narrowing of the optic canal in syndromic craniosynostosis patients, and indicate that optic canal anatomical characteristics may have an association with visual impairment among pediatric syndromic craniosynostosis patients.
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Affiliation(s)
- Firdaus Hariri
- Oro-Craniomaxillofacial Research and Surgical (OCReS) Group, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Nurul Aiman Farhana
- Oro-Craniomaxillofacial Research and Surgical (OCReS) Group, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Norli Anida Abdullah
- Mathematics Division, Centre for Foundation Studies in Science, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Norliza Ibrahim
- Oro-Craniomaxillofacial Research and Surgical (OCReS) Group, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Norlisah Mohd Ramli
- Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Azlindarita Aisyah Mohd Abdullah
- Department of Ophthalmology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia; Department of Ophthalmology, Faculty of Medicine, Universiti Teknologi MARA, 47000, Sungai Buloh, Selangor, Malaysia
| | - Choo May May
- Department of Ophthalmology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Nurliza Khaliddin
- Department of Ophthalmology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
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Raposo-Amaral CE, de Oliveira YM, Denadai R, Raposo-Amaral CA, Ghizoni E. Syndrome-related outcomes following posterior vault distraction osteogenesis. Childs Nerv Syst 2021; 37:2001-9. [PMID: 33866411 DOI: 10.1007/s00381-021-05169-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/13/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE The most commonly occurring syndromic craniosynostoses are Apert syndrome, Crouzon syndrome, Pfeiffer syndrome, and Saethre-Chotzen syndrome. There is insufficient data regarding postoperative syndrome-related outcomes following the posterior vault distraction osteogenesis (PVDO) procedure, as well as data addressing whether or not additional procedures will be subsequently necessary to comprehensively treat children who undergo PVDO. Thus, the objective of this study is to describe and compare syndrome-related potential complications and outcomes associated with the PVDO procedure. METHODS An observational retrospective study was performed on consecutive patients (n=24) with Apert syndrome, Crouzon syndrome, Pfeiffer syndrome, or Saethre-Chotzen syndrome, respectively, who underwent PVDO between 2012 and 2019. Demographic data (patient gender and age when the PVDO procedure was performed), diagnosis, surgery-related data, and outcome data (perioperative and midterm complications and need for additional surgery) were verified. RESULTS Total relative blood transfusion volumes per kilogram for the patients were as follows: 22.75 ± 9.30 ml for Apert syndrome, 10.73 ± 2.28 ml for Crouzon syndrome (Apert versus Crouzon, p<0.05), 18.53 ± 8.08 ml for Pfeiffer syndrome, and 19.74 ± 9.12 ml for Saethre-Chotzen syndrome. None of the patients required a secondary procedure to alleviate intracranial pressure except for a Saethre-Chotzen patient. CONCLUSION PVDO is an effective technique to address elevated intracranial pressure in SC patients that alleviates the need for secondary procedures at midterm follow-up. Apert syndrome patients presented relatively higher total blood transfusion rates than Crouzon syndrome patients who were operated on at a later age and weighed more.
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Abstract
Posterior cranial vault distraction osteogenesis is a powerful, reliable, low-morbidity method to achieve intracranial expansion. It is particularly useful in treating turribrachycephaly seen in syndromic craniosynostosis, allowing for gradual expansion of the bone while stretching the soft tissues over several weeks allowing greater volumetric expansion than conventional techniques. Posterior cranial vault distraction osteogenesis constitutes a more gradual remodeling modality, with infrequent complications. As a first step in intracranial expansion, it preserves the frontal cranium for future frontofacial procedures. A drawback is the need for a second surgery to remove the device, and this must be taken into account during counseling.
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Affiliation(s)
- Laura S Humphries
- Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Children's of Mississippi Hospital, 2500 N. State Street, Jackson, MS 39216, USA. https://twitter.com/ls_humphries
| | - Jordan W Swanson
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Scott P Bartlett
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Jesse A Taylor
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Raposo-Amaral CE, Vieira PH, Denadai R, Ghizoni E, Raposo-Amaral CA. Treating Syndromic Craniosynostosis with Monobloc Facial Bipartition and Internal Distractor Devices: Destigmatizing the Syndromic Face. Clin Plast Surg 2021; 48:521-529. [PMID: 34051903 DOI: 10.1016/j.cps.2021.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Monobloc and facial bipartition combined with distraction osteogenesis (MFBDO) has gained popularity over the past several years as a treatment of syndromic craniosynostosis, in part because this surgical technique effectively removes many stigmatic clinical features associated with the syndromic face. The objective of this study is to detail the surgical planning used to achieve medialization of the orbits and describe the authors' experience using MFBDO to destigmatize the syndromic face. By using MFBDO, hypertelorism, vertical orbital dystopia, and downslanting of the palpebral fissure were surgically corrected in all patients, thereby destigmatizing the syndromic face.
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Affiliation(s)
- Cassio Eduardo Raposo-Amaral
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo 13084-880, Brazil; Department of Neurology, University of Campinas (UNICAMP), São Paulo, Brazil.
| | - Pedro Henrique Vieira
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo 13084-880, Brazil
| | - Rafael Denadai
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo 13084-880, Brazil
| | - Enrico Ghizoni
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo 13084-880, Brazil; Department of Neurology, University of Campinas (UNICAMP), São Paulo, Brazil
| | - Cesar Augusto Raposo-Amaral
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo 13084-880, Brazil
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Abstract
Severe midface hypoplasia is often managed by Le Fort III distraction. Le Fort II distraction with zygomatic repositioning is a modification of the Le Fort III distraction operation aimed to correct abnormal facial ratios of patients with greater central than lateral midface deficiency. The operation starts with Le Fort III osteotomies and is followed by separation and fixation of bilateral zygomas. The central nasomaxillary Le Fort II segment is then distracted to achieve independent movements of the central and lateral midface. The Le Fort II zygomatic repositioning operation has become our procedure of choice for patients with Apert facial dysmorphology.
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Affiliation(s)
- Richard A Hopper
- The Craniofacial Center, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA; Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA, USA.
| | - Howard D Wang
- The Craniofacial Center, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA; Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ezgi Mercan
- The Craniofacial Center, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA
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Paternoster G, Haber SE, Khonsari RH, James S, Arnaud E. Craniosynostosis: Monobloc Distraction with Internal Device and Its Variant for Infants with Severe Syndromic Craniosynostosis. Clin Plast Surg 2021; 48:497-506. [PMID: 34051901 DOI: 10.1016/j.cps.2021.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The introduction of distraction osteogenesis to frontofacial monobloc advancement has increased the safety of the procedure. One hundred forty-seven patients with syndromic craniosynostosis underwent frontofacial monobloc advancement using 4 internal distractors. Twenty-five were aged 18 months or less. Ten patients presented with a tracheostomy, 5 (50%) were decannulated after surgery, and 3 others (30%) required an additional intervention before decannulation. Six patients required the addition of a transfacial pin and external traction. Very early frontofacial monobloc with 4 internal distractors is a safe and effective treatment to protect the ophthalmic, neurologic, and respiratory functions in infants with severe syndromic craniosynostosis.
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Affiliation(s)
- Giovanna Paternoster
- Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, Université Paris Descartes, ERN Cranio, 149 rue de Sèvres, 75015, Paris, France
| | - Samer Elie Haber
- Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, Université Paris Descartes, ERN Cranio, 149 rue de Sèvres, 75015, Paris, France
| | - Roman Hossein Khonsari
- Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, Université Paris Descartes, ERN Cranio, 149 rue de Sèvres, 75015, Paris, France; Service de chirurgie maxillofaciale et chirurgie plastique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, Université de Paris, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Syril James
- Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, Université Paris Descartes, ERN Cranio, 149 rue de Sèvres, 75015, Paris, France; Clinique Marcel Sembat, Ramsay Générale de Santé, 105 boulevard Victor Hugo, 92100 Boulogne, France
| | - Eric Arnaud
- Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, Université Paris Descartes, ERN Cranio, 149 rue de Sèvres, 75015, Paris, France; Clinique Marcel Sembat, Ramsay Générale de Santé, 105 boulevard Victor Hugo, 92100 Boulogne, France.
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Tamburrini G, Offi M, Massimi L, Frassanito P, Bianchi F. Posterior vault "free-floating" bone flap: indications, technique, advantages, and drawbacks. Childs Nerv Syst 2021; 37:3143-7. [PMID: 34268594 DOI: 10.1007/s00381-021-05281-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/29/2021] [Indexed: 10/24/2022]
Abstract
BACKGROUND The enlargement of the posterior cranial fossa volume is considered one of the main steps of the surgical management of children with multiple sutures craniosynostosis. Different management options have been proposed including fixed expansive craniotomy, free bone flap craniotomy, and distraction osteogenesis. OBJECTIVES To review indications to "free bone flap" craniotomy for the posterior fossa expansion, detailing advantages, disadvantages, and complications related to the technique. RESULTS AND CONCLUSIONS A review of the literature shows that "free bone flap" posterior expansion cranioplasty still has a role, particularly in infants with thin and "honeycomb" structure of the bone, allowing to gain adequate intracranial volume increases and to postpone to a more adequate time surgery aimed at anterior cranial fossa expansion.
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Doerga PN, Rijken BFM, Bredero-Boelhouwer H, Joosten KFM, Neuteboom RF, Tasker RC, Dremmen MHG, Lequin MH, van Veelen MLC, Mathijssen IMJ. Neurological deficits are present in syndromic craniosynostosis patients with and without tonsillar herniation. Eur J Paediatr Neurol 2020; 28:120-125. [PMID: 32782184 DOI: 10.1016/j.ejpn.2020.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Children with syndromic craniosynostosis (sCS) have a higher incidence of cerebellar tonsillar herniation (TH) than the general population. In the general population, TH ≥ 5 mm below the foramen magnum is associated with typical neurological deficits but, in sCS, we do not know whether this degree of TH is required before such deficits occur. OBJECTIVE This prospective cohort study aimed to determine the association between findings on neurological assessment and cerebellar tonsillar position. METHODS Magnetic resonance imaging (MRI) was used to determine TH ≥ 5 mm and the presence of syringomyelia. In regard to the outcome of neurological deficits, these were categorized according to: A, cerebellar function; B, cranial nerve abnormalities; and C, sensory or motor dysfunction. RESULTS Twenty of 63 patients with sCS (32% [95% confidence interval 21-45%]) had TH ≥ 5 mm and/or syringomyelia. There was no significant difference in proportion between individual forms of sCS: 16/34 Crouzon, 2/11 Muenke, 2/12 Apert, and 0/7 Saethre-Chotzen patients. Neurological deficits were prevalent (73% [95% confidence interval 60-83%]), and as frequent in patients with TH ≥ 5 mm and/or syringomyelia as those without. Surgery occurred in 3 patients overall, and only in Crouzon patients. CONCLUSION Determining the effect of TH ≥ 5 mm on neurologic functioning in sCS patients is used to better determine when surgical intervention is warranted. However, we have found that neurological deficits are prevalent in sCS patients, irrespective of cerebellar tonsillar position, suggesting that such findings are developmental and, in part, syndrome-specific central nervous system features.
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Affiliation(s)
- P N Doerga
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Sophia Children's Hospital, Dutch Craniofacial Center, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - B F M Rijken
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Sophia Children's Hospital, Dutch Craniofacial Center, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - H Bredero-Boelhouwer
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Sophia Children's Hospital, Dutch Craniofacial Center, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - K F M Joosten
- Pediatric Intensive Care Unit, Sophia Children's Hospital, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - R F Neuteboom
- Department of Pediatric Neurology, Sophia Children's Hospital, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - R C Tasker
- Department of Anaesthesia (Pediatrics) and Division of Critical Care Medicine, Harvard Medical School and Boston Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts, 02115, USA
| | - M H G Dremmen
- Department of Neurosurgery, Sophia Children's Hospital, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - M H Lequin
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - M L C van Veelen
- Department of Neurosurgery, Sophia Children's Hospital, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - I M J Mathijssen
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Sophia Children's Hospital, Dutch Craniofacial Center, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Abstract
Subcranial and frontofacial distraction osteogenesis have emerged as powerful tools for management of hypoplasia involving the upper two-thirds of the face. The primary goal of subcranial or frontofacial distraction is to improve the orientation of the upper face and midface structures (frontal bone, orbitozygomatic complex, maxilla, nasal complex) relative to the cranial base, globes, and mandible. The various techniques used are tailored for management of specific phenotypic differences in facial position and may include segmental osteotomies, differential vectors, or synchronous maxillomandibular rotation.
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Affiliation(s)
- Richard A Hopper
- Craniofacial Center, Division of Plastic and Craniofacial Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Hitesh Kapadia
- Craniofacial Center, Division of Craniofacial Orthodontics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Srinivas M Susarla
- Craniofacial Center, Divisions of Craniofacial and Plastic Surgery and Oral-Maxillofacial Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
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28
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Cornille M, Dambroise E, Komla-Ebri D, Kaci N, Biosse-Duplan M, Di Rocco F, Legeai-Mallet L. Animal models of craniosynostosis. Neurochirurgie 2019; 65:202-209. [PMID: 31563616 DOI: 10.1016/j.neuchi.2019.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 07/22/2019] [Accepted: 09/16/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Various animal models mimicking craniosynostosis have been developed, using mutant zebrafish and mouse. The aim of this paper is to review the different animal models for syndromic craniosynostosis and analyze what insights they have provided in our understanding of the pathophysiology of these conditions. MATERIAL AND METHODS The relevant literature for animal models of craniosynostosis was reviewed. RESULTS Although few studies on craniosynostosis using zebrafish were published, this model appears useful in studying the suture formation mechanisms conserved across vertebrates. Conversely, several mouse models have been generated for the most common syndromic craniosynostoses, associated with mutations in FGFR1, FGFR2, FGFR3 and TWIST genes and also in MSX2, EFFNA, GLI3, FREM1, FGF3/4 genes. The mouse models have also been used to test pharmacological treatments to restore craniofacial growth. CONCLUSIONS Several zebrafish and mouse models have been developed in recent decades. These animal models have been helpful for our understanding of normal and pathological craniofacial growth. Mouse models mimicking craniosynostoses can be easily used for the screening of drugs as therapeutic candidates.
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Affiliation(s)
- M Cornille
- Inserm U1163, Paris university, institut Imagine, 75015 Paris, France
| | - E Dambroise
- Inserm U1163, Paris university, institut Imagine, 75015 Paris, France
| | - D Komla-Ebri
- Inserm U1163, Paris university, institut Imagine, 75015 Paris, France; Molecular Endocrinology Laboratory, Department of Medicine, Imperial College London, W12 ONNLondon, United Kingdom
| | - N Kaci
- Inserm U1163, Paris university, institut Imagine, 75015 Paris, France; Inovarion, 75013 Paris, France
| | - M Biosse-Duplan
- Inserm U1163, Paris university, institut Imagine, 75015 Paris, France
| | - F Di Rocco
- Centre de référence craniosténoses, université de Lyon, 69677 Bron France; Service de neurochirurgie pédiatrique, université Lyon, hôpital Femme-Mère-Enfant, 69677, Bron, France.
| | - L Legeai-Mallet
- Inserm U1163, Paris university, institut Imagine, 75015 Paris, France.
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Affiliation(s)
- Cory M Resnick
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard School of Dental Medicine, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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O'Hara J, Ruggiero F, Wilson L, James G, Glass G, Jeelani O, Ong J, Bowman R, Wyatt M, Evans R, Samuels M, Hayward R, Dunaway DJ. Syndromic Craniosynostosis: Complexities of Clinical Care. Mol Syndromol 2019; 10:83-97. [PMID: 30976282 DOI: 10.1159/000495739] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Patients with syndromic craniosynostosis have a molecularly identified genetic cause for the premature closure of their cranial sutures and associated facial and extra-cranial features. Their clinical complexity demands comprehensive management by an extensive multidisciplinary team. This review aims to marry genotypic and phenotypic knowledge with clinical presentation and management of the craniofacial syndromes presenting most frequently to the craniofacial unit at Great Ormond Street Hospital for Children NHS Foundation Trust.
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Affiliation(s)
- Justine O'Hara
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Federica Ruggiero
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Louise Wilson
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Greg James
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Graeme Glass
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Owase Jeelani
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Juling Ong
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Richard Bowman
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Michelle Wyatt
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Robert Evans
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Martin Samuels
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Richard Hayward
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - David J Dunaway
- Great Ormond Street Craniofacial Unit, UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Choi TM, Kragt L, Goos JAC, Mathijssen IMJ, Wolvius EB, Ongkosuwito EM. Deviating dental arch morphology in mild coronal craniosynostosis syndromes. Clin Oral Investig 2019; 23:2995-3003. [PMID: 30392078 DOI: 10.1007/s00784-018-2710-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 10/17/2018] [Indexed: 11/21/2022]
Abstract
Objectives To determine whether the intramaxillary relationship of patients with Muenke syndrome and Saethre-Chotzen syndrome or TCF12-related craniosynostosis are systematically different than those of a control group. Material and methods Forty-eight patients (34 patients with Muenke syndrome, 8 patients with Saethre-Chotzen syndrome, and 6 patients with TCF12-related craniosynostosis) born between 1982 and 2010 (age range 4.84 to 16.83 years) that were treated at the Department of Oral Maxillofacial Surgery, Special Dental Care and Orthodontics, Children’s Hospital Erasmus University Medical Center, Sophia, Rotterdam, the Netherlands, were included. Forty-seven syndromic patients had undergone one craniofacial surgery according to the craniofacial team protocol. The dental arch measurements intercanine width (ICW), intermolar width (IMW), arch depth (AD), and arch length (AL) were calculated. The control group existed of 329 nonsyndromic children. Results All dental arch dimensions in Muenke (ICW, IMW, AL, p < 0.001, ADmax, p = 0.008; ADman, p = 0.002), Saethre-Chotzen syndrome, or TCF12-related craniosynostosis patients (ICWmax, p = 0.005; ICWman, IMWmax, AL, p < 0.001) were statistically significantly smaller than those of the control group. Conclusions In this study, we showed that the dental arches of the maxilla and the mandible of patients with Muenke syndrome and Saethre-Chotzen syndrome or TCF12-related craniosynostosis are smaller compared to those of a control group. Clinical relevance To gain better understanding of the sutural involvement in the midface and support treatment capabilities of medical and dental specialists in these patients, we suggest the concentration of patients with Muenke and Saethre-Chotzen syndromes or TCF12-related craniosynostosis in specialized teams for a multi-disciplinary approach and treatment.
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Müller-Hagedorn S, Wiechers C, Arand J, Buchenau W, Bacher M, Krimmel M, Reinert S, Poets CF. Less invasive treatment of sleep-disordered breathing in children with syndromic craniosynostosis. Orphanet J Rare Dis 2018; 13:63. [PMID: 29688857 PMCID: PMC5914055 DOI: 10.1186/s13023-018-0808-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 04/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infants and children with syndromic craniosynostosis (SCS), such as Apert-, Crouzon- or Pfeiffer syndrome, are prone to sleep disordered breathing (SDB) including obstructive sleep apnea and upper airway resistance syndrome (OSAS, UARS), potentially leading to tracheostomy. We modified the Tübingen Palatal Plate (TPP), an oral appliance with a velar extension effectively treating airway obstruction in Robin sequence, by attaching a tube to its velar extension to bridge the narrow pharyngeal airway in SCS patients. Here, we evaluated this treatment concept. METHODS Our hospital's electronic patient files were searched for all children with a diagnosis of SCS admitted between 01/01/2004 and 31/12/2016. Children with isolated craniosynostosis were excluded. OSAS was defined as a mixed-obstructive apnea-hypopnea index (MOAHI) > 1, and UARS as more than 1 episode with nasal flow limitation/h, but absent OSAS. Children with a diagnosis of OSAS received the TPP and fiberoptic nasopharyngoscopy to assess the type of obstruction and to adjust the plate. Growth and weight gain, determined as standard deviation scores, were also evaluated before and during treatment. RESULTS Of 34 patients included, 24 presented with SDB (19 OSAS, 5 UARS) and 27 had midface hypoplasia. Proportions of SDB were 78% in those with, and 22% in those without midface hypoplasia. In the OSAS group (n = 19), 13 patients were treated with palatal plates, with the remaining receiving continuous positive airway pressure, midface surgery or tracheal intubation. The MOAHI decreased across all children receiving palatal plate treatment from 14.6 (range 0.0-50.7) at admission to 0.9 (range 0.0-3.5) at discharge (p = 0.002). SDS for weight and body length also improved (p < 0.05 for weight and p = 0.05 for body length). Only one child required tracheostomy. CONCLUSION Treatment of upper airway obstruction by a modified TPP in these children with SCS was shown to be mostly effective and safe. If confirmed in larger prospective studies, it may help to avoid more invasive interventions.
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Affiliation(s)
- Silvia Müller-Hagedorn
- Department of Orthodontics, Rostock University Hospital, Rostock, Germany.,Department of Orthodontics, Tübingen University Hospital, Tübingen, Germany.,Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany
| | - Cornelia Wiechers
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Neonatology, Tübingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany
| | - Jörg Arand
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Neonatology, Tübingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany
| | - Wolfgang Buchenau
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Neonatology, Tübingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany
| | | | - Michael Krimmel
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Maxillofacial Surgery, Tübingen University Hospital, Tübingen, Germany
| | - Siegmar Reinert
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany.,Department of Maxillofacial Surgery, Tübingen University Hospital, Tübingen, Germany
| | - Christian F Poets
- Center for Cleft Palate & Craniofacial Malformations, Tübingen University Hospital, Tübingen, Germany. .,Department of Neonatology, Tübingen University Hospital, Calwerstrasse 7, 72076, Tuebingen, Germany.
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Narro-Donate JM, Méndez-Román P, Huete-Allut A, Escribano-Mesa JA, Gomar-Alba M, Contreras-Jiménez A, Pedrero-García F, Masegosa-González J. Anterior Unilateral Plagiocephaly in Patient with Alagille Syndrome: Case Report. World Neurosurg 2018. [PMID: 29530693 DOI: 10.1016/j.wneu.2018.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The polymalformative syndromes and craniofacial anomalies association is a well-known phenomenon in patients with Crouzon, Pfeiffer, Apert, or Muenke disease. Recently, other less frequent pathologies, such as Alagille syndrome, have shown an association with alterations in the development of cranial sutures, resulting in serious cosmetic defects and neurologic disorders. CASE DESCRIPTION We report an exceptional case of a 30-month-old girl, a nephroblastoma survivor diagnosed with Alagille syndrome, who was referred to our department with progressive anterior plagiocephaly and premature left coronal suture closure associated with a large compensating right bossing. Despite the patient's age, we offered aggressive surgical treatment performing a new forehead harvested from the skull vertex with orbital rim reconstruction. CONCLUSIONS Alagille syndrome is a complex multisystem pathology with a poor craniosynostosis association and only 3 cases have been described in the literature.
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Affiliation(s)
| | - Paddy Méndez-Román
- Department of Neurosurgery, Torrecárdenas Hospital Complex, Almería, Spain
| | | | | | - Mario Gomar-Alba
- Department of Neurosurgery, Torrecárdenas Hospital Complex, Almería, Spain
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Xu Y, Sun S, Li N, Yu T, Wang X, Wang J, Bao N. Identification and analysis of the genetic causes in nine unrelated probands with syndromic craniosynostosis. Gene 2017; 641:144-150. [PMID: 29037998 DOI: 10.1016/j.gene.2017.10.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/29/2017] [Accepted: 10/12/2017] [Indexed: 12/31/2022]
Abstract
Syndromic craniosynostosis is a group of multiple conditions with high heterogeneity, and many rare syndromes still remain to be characterized. To identify and analyze causative genetic variants in nine unrelated probands mainly manifested as syndromic craniosynostosis, we reviewed the relevant medical information of the patients and performed the whole exome sequencing, further verified with Sanger sequencing and parental background. Bioinformatics analysis was used to evaluate the potential deleterious or benign effect of each genetic variant through evolutionary conservation alignment, multi-lines of computer predication and the allele frequency in population dataset (control and patient). The Standards and guidelines from American College of Medical Genetics and Genomics was used to classify and interpret the pathogenicity for each genetic variant. All the nine probands were found to carry the possibly causative variants, among which three variants including two missense mutations (c.3385C>T in IFT122 gene, c.3581A>G in SMC1A gene) and a frameshift mutation (c.434dupA in TWIST1 gene) have never been reported in patients before. We suggested Cornelia de Lange syndrome caused by SMC1A variant is a neglected syndromic craniosynostosis. Our study not only expanded genotypic and phenotypic spectrum of the rare syndromes, but also confirmed that there existed an underlying genetic mechanism. We emphasized that deliberate selection of both the potential candidates and comprehensive detection methods for genetic analysis is important to increase the genetic diagnosis yield of syndromic craninosynostosis.
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Affiliation(s)
- Yufei Xu
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Institute of Pediatric Translational Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Shouqing Sun
- Department of Neurosurgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Niu Li
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Institute of Pediatric Translational Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Tingting Yu
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Institute of Pediatric Translational Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Xiumin Wang
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Jian Wang
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China; Institute of Pediatric Translational Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China.
| | - Nan Bao
- Department of Neurosurgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China.
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Tomita S, Miyawaki T, Nonaka Y, Sakai S, Nishimura R. Surgical strategy for Apert syndrome: Retrospective study of developmental quotient and three-dimensional computerized tomography. Congenit Anom (Kyoto) 2017; 57:104-108. [PMID: 28338248 DOI: 10.1111/cga.12222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 11/28/2022]
Abstract
There are many surgical techniques for craniosynostosis. However, the indications for and timing of surgery still remain unclarified. Most of the skull growth in craniosynostosis is completed in the first year, and the bone is strong enough to undergo distraction osteogenesis. However, previous reports showed that patients operated on before 1 year of age had better IQ than those operated later in life. This report aims to consider the best timing for cranial expansion and surgical strategy for Apert syndrome. From January 2002 to December 2011, 13 patients with Apert syndrome were operated on and were followed up for more than 5 years. Nine patients underwent operations before 1 year of age (early surgery group) and three patients underwent operations later in life (late surgery group). They underwent fronto-orbital advancement for primary surgery. We evaluated postoperative developmental quotient every year and cephalic index (CI) measured by three-dimensional computerized tomography (3D-CT) at the age over 5 years retrospectively. Eleven of 13 patients improved their developmental quotient scores, with no significant intergroup differences. The CI evaluation showed cases with remnant brachycephalic deformity in both groups. Two patients with remnant plagiocephalic deformities tend to have primary surgery early in life compared to the others. Thus the delay in primary surgery had little influence on psychological development. We conclude that the primary surgery can be delayed unless the intracranial pressure needs to be controlled. In addition, fronto-orbital advancement could not sufficiently improve the brachycephalic appearance, other procedures like posterior vault distraction might be better alternatives.
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Affiliation(s)
- Shoichi Tomita
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Miyawaki
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuichirou Nonaka
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinsuke Sakai
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Reiji Nishimura
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Ginelliová A, Farkaš D, Iannaccone SF, Vyhnálková V, Vasovčák P. Sudden death associated with syndromic craniosynostosis. Forensic Sci Med Pathol 2016; 12:506-509. [PMID: 27891566 DOI: 10.1007/s12024-016-9818-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2016] [Indexed: 11/29/2022]
Abstract
In this paper we report the autopsy findings of a 7 year old girl who presented with headache, nausea and repeated vomiting and died unexpectedly at home. She had no previous history of major illnesses and no history of epileptic seizures. External examination revealed ocular abnormalities. Internal examination demonstrated severe cerebral edema with tonsillar herniation, premature fusion of the cranial bone sutures, and prominent convolutional markings of the inner table of the skull. Death was due to severe cerebral edema complicating syndromic craniosynostosis. The craniofacial features in this case were in keeping with a diagnosis of Crouzon syndrome which was confirmed by molecular testing of the FGFR2 gene. Crouzon syndrome is a genetic disorder characterized by premature fusion of the cranial bone sutures resulting in distinctive malformations of the craniofacial region.
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Affiliation(s)
- Alžbeta Ginelliová
- Medico-Legal and Pathological-Anatomical Department of Health Care Surveillance Authority, Letná 47, 040 01, Košice, Slovak Republic.
| | - Daniel Farkaš
- Medico-Legal and Pathological-Anatomical Department of Health Care Surveillance Authority, Letná 47, 040 01, Košice, Slovak Republic
| | - Silvia Farkašová Iannaccone
- Department of Forensic Medicine, Faculty of Medicine, Pavol Jozef Šafárik University, Trieda SNP 1, 040 11, Košice, Slovak Republic
| | - Vlasta Vyhnálková
- Medico-Legal and Pathological-Anatomical Department of Health Care Surveillance Authority, Letná 47, 040 01, Košice, Slovak Republic
| | - Peter Vasovčák
- Alpha Medical s.r.o., Hraničná 2, 040 17, Košice, Slovak Republic
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Agochukwu NB, Solomon BD, Muenke M. Hearing loss in syndromic craniosynostoses: otologic manifestations and clinical findings. Int J Pediatr Otorhinolaryngol 2014; 78:2037-47. [PMID: 25441602 DOI: 10.1016/j.ijporl.2014.09.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 09/16/2014] [Accepted: 09/19/2014] [Indexed: 01/13/2023]
Abstract
OBJECTIVE This review addresses hearing loss as it occurs and has been reported in Muenke syndrome as well as six additional FGFR related craniosynostosis syndromes (Apert syndrome, Pfeiffer syndrome, Crouzon syndrome, Beare-Stevenson syndrome, Crouzon syndrome with acanthosis nigricans, and Jackson-Weiss syndrome. DATA SOURCES Pub-Med, Medline, Cochrane Database, Science Direct, NLM Catalog. REVIEW METHODS A Medline search was conducted to find all reported cases of the 7 FGFR related syndromic craniosynostosis. Special attention was paid to literature that reported hearing findings and the audiology literature. RESULTS Hearing loss occurs in variable percentage as a component part of all FGFR related craniosynostosis syndromes. Our literature review revealed the following incidences of hearing loss in FGFR craniosynostoses: 61% in Muenke syndrome, 80% in Apert Syndrome, 92% in Pfeiffer syndrome, 74% in Crouzon syndrome, 68% in Jackson Weiss syndrome, 4% in Beare Stevenson syndrome and 14% in Crouzon syndrome with Acanthosis Nigricans. The majority of the hearing loss is a conductive hearing loss, with the exception of Muenke syndrome where the majority of patients have a sensorineural hearing loss and Crouzon syndrome where almost half of patients have a pure or component of sensorineural hearing loss. CONCLUSION This manuscript presents a diagnostic and management algorithm for patients with syndromic craniosynostosis. It will aid clinicians in treating these patients and further, the recognition of a possible syndrome in patients with hearing loss who also have syndromic features.
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Affiliation(s)
- Nneamaka B Agochukwu
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, NIH, MSC 3717, Building 35, Room 1B-207, Bethesda, MD 20892, USA; Clinical Research Training Program, National Institutes of Health, Bethesda, MD, USA.
| | - Benjamin D Solomon
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, NIH, MSC 3717, Building 35, Room 1B-207, Bethesda, MD 20892, USA
| | - Maximilian Muenke
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, NIH, MSC 3717, Building 35, Room 1B-207, Bethesda, MD 20892, USA
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Pagnoni M, Fadda MT, Spalice A, Amodeo G, Ursitti F, Mitro V, Iannetti G. Surgical timing of craniosynostosis: what to do and when. J Craniomaxillofac Surg 2013; 42:513-9. [PMID: 24075801 DOI: 10.1016/j.jcms.2013.07.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Revised: 05/22/2013] [Accepted: 07/31/2013] [Indexed: 11/27/2022] Open
Abstract
Craniosynostosis, both isolated and syndromic, are challenging malformations for the craniofacial team. They present the team with an articulated cascade of choices, which need to be addressed early in life and in the growing age to intercept, remove, or correct the direct and indirect consequences of the malformation. Timing of treatment is thus critical and it stands on the experience of a multi-specialty trained craniofacial team. In this paper the authors discuss the timing of treatment of the major craniosynostosis, isolated and syndromic, reviewing the options for treatment and their experience in this complex field.
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Affiliation(s)
- Mario Pagnoni
- Department of Maxillo-Facial Surgery, Policlinico Umberto I, Sapienza University of Rome, Piazzale Aldo Moro 9, 00185 Rome, Italy
| | - Maria Teresa Fadda
- Department of Maxillo-Facial Surgery, Policlinico Umberto I, Sapienza University of Rome, Piazzale Aldo Moro 9, 00185 Rome, Italy
| | - Alberto Spalice
- Department of Pediatrics, Child Neurology Division, Policlinico Umberto I, Sapienza University of Rome, Piazzale Aldo Moro 9, 00185 Rome, Italy
| | - Giulia Amodeo
- Department of Maxillo-Facial Surgery, Policlinico Umberto I, Sapienza University of Rome, Piazzale Aldo Moro 9, 00185 Rome, Italy.
| | - Fabiana Ursitti
- Department of Pediatrics, Child Neurology Division, Policlinico Umberto I, Sapienza University of Rome, Piazzale Aldo Moro 9, 00185 Rome, Italy
| | - Valeria Mitro
- Department of Maxillo-Facial Surgery, Policlinico Umberto I, Sapienza University of Rome, Piazzale Aldo Moro 9, 00185 Rome, Italy
| | - Giorgio Iannetti
- Department of Maxillo-Facial Surgery, Policlinico Umberto I, Sapienza University of Rome, Piazzale Aldo Moro 9, 00185 Rome, Italy
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