Clinical care in craniofacial microsomia: a review of current management recommendations and opportunities to advance research

Craniofacial microsomia (CFM) is a complex condition associated with microtia, mandibular hypoplasia, and preauricular tags. It is the second most common congenital facial condition treated in many craniofacial centers and requires longitudinal multidisciplinary patient care. The purpose of this article is to summarize current recommendations for clinical management and discuss opportunities to advance clinical research in CFM.

In Their Own Words: Caregiver and Patient Perspectives on Stressors, Resources, and Recommendations in Craniofacial Microsomia Care

This study describes stressors, resources, and recommendations related to craniofacial microsomia (CFM) care from the perspective of caregivers of children with CFM and adults with CFM to inform improved quality of healthcare delivery. A mixed method design was used with fixed-response and open-ended questions from an online survey in English. The survey included demographics, CFM phenotypic information, and items about CFM-related experiences across settings. Themes were identified by qualitative analysis of responses to open-ended questions. Respondents (n = 51) included caregivers (n = 42; 90% mothers) and adults with CFM (n = 9; 78% female), who had a mean age of 45 ± 6 years. Most children were male (71%) with an average age of 7 ± 4 years. Respondents were primarily white (80%), non-Hispanic (89%), from the United States (82%), had a college degree (80%), and had private health insurance (80%). Reflecting the high rate of microtia (84%) in the sample, themes centered on the impact of hearing difficulties across settings with related language concerns. Negative social experiences were frequently described and school needs outlined. Multiple medical stressors were identified and corresponding suggestions included: providers need to be better informed about CFM, treatment coordination among specialists, and preference for a family-centered approach with reassurance, empathy, and clear communication. Advice offered to others with CFM included positive coping strategies. Overall, caregivers' and patients' responses reflected the complexity of CFM treatment. Incorporating these perspectives into routine CFM care has the potential to reduce family distress while improving their healthcare.

Healthcare and psychosocial experiences of individuals with craniofacial microsomia: Patient and caregivers perspectives

OBJECTIVE

Craniofacial microsomia (CFM) is primarily characterized by underdevelopment of the ear and mandible, with several additional possible congenital anomalies. Despite the potential burden of care and impact of CFM on multiple domains of functioning, few studies have investigated patient and caregiver perspectives. The objective of this study was to explore the diagnostic, treatment-related, and early psychosocial experiences of families with CFM with the aim of optimizing future healthcare delivery.

METHODS

Forty-two caregivers and nine adults with CFM responded to an online mixed-methods survey. Descriptive statistics and qualitative methods were used for the analysis.

RESULTS

Survey respondents reported high rates of subspecialty evaluations, surgeries, and participation in therapies. Some participants reported receiving inaccurate or incomplete information about CFM and experienced confusion about etiology. Communication about CFM among family members included mostly positive messages. Self-awareness of facial differences began at a mean age of three years and teasing at mean age six, with 43% of individuals four years or older reporting teasing. Teasing often involved name-calling and frequent reactions were ignoring and negative emotional responses. Participants ranked "understanding diagnosis and treatment" as a top priority for future research and had the most questions about etiology and treatment guidance.

CONCLUSIONS

The survey results on the healthcare and psychosocial experiences from birth through adulthood of individuals with CFM reinforce the need for ongoing psychological assessment and intervention. Healthcare provision could be improved through establishing diagnostic criteria and standardized treatment guidelines, as well as continued investigation of CFM etiology.

Effect of early orthopedic intervention on hemifacial microsomia patients: an approach to a cooperative evaluation of treatment results

The purpose of the present study was to analyze the effects of early orthopedic intervention in patients with hemifacial microsomia, clinically as well as radiologically, by computed tomographic examination to assess soft and hard tissue temporomandibular joint changes. Five patients, one with mandibular dysostosis, one with otomandibular dysostosis, two with Goldenhar syndrome, and one with a surgically revised fibroma of the right mandible that was reconstructed by a costochondral graft, were treated by means of an activator functional appliance. During functional appliance treatment, all patients showed improvement of function and occlusion, and facial asymmetry was reduced. Spiral computed tomographic examination before and during treatment provided data on the bony and muscular deficiencies. The volume and density of the lateral pterygoid muscle was measured with the standard computed tomography software. Evaluation of soft and hard tissue conditions before treatment has shown that the most important factor "lack of soft tissues" can be compensated by excellent cooperation during functional therapy. Pretreatment volume of the affected lateral pterygoid muscle in all patients was significantly smaller than on the unaffected side. In three patients, volume measurements between 4 and 8 years demonstrated that the lateral pterygoid muscle on the affected side had a third, less than a third, and a fifth of the volume of the unaffected side. Although increase, stability, and decrease of the ratio of left and right condylar dimension, muscular volume, and density were found, long-term prognosis cannot be given in the cases with extreme muscular deficiencies after cessation of growth. Prepubertal orthopedic treatment success is a desirable and feasible presurgical or nonsurgical treatment goal for the interdisciplinary team approach. From a study of the pathologic, we learn much about the normal.

Pseudotumor cerebri in a patient with Goldenhar's and Duane's syndromes

A 4-year-old boy presented with Goldenhar's syndrome, Duane's syndrome and bilateral papilledema. Magnetic resonance imaging of the brain was unremarkable. On lumbar puncture, the cerebrospinal fluid (CSF) pressure measured 36 cm H(2)O. CSF examination was normal. The diagnosis of pseudotumor cerebri was made, and treatment with acetazolamide was started. As the papilledema did not resolve, steroids were added to the treatment. Lumbar puncture was repeated after 1 month, and pressure was found to be 30 cm H(2)O. Because medical treatment was not effective in lowering the CSF pressure, optic nerve sheath fenestration was performed. Papilledema resolved over the next 2 months. To the best of our knowledge, this is the first case of Goldenhar's syndrome associated with pseudotumor cerebri.

Establishing an International Interdisciplinary Research Network in Craniofacial Microsomia: The CARE Program

OBJECTIVE

Craniofacial microsomia (CFM) is a broad clinical term used to describe a congenital condition most commonly involving the underdevelopment of the external ear, mandible, soft tissues, and facial nerve. Despite medical advances, understanding of the psychological health and healthcare experiences of individuals with CFM and their caregivers remains limited. This article describes a research program designed to address these knowledge gaps, and identify opportunities for psychosocial intervention and improved healthcare provision.

DESIGN

The Craniofacial microsomia: Accelerating Research and Education (CARE) research program aims to: 1) Conduct up to 160 narrative interviews with individuals and caregivers to validate a conceptual framework; 2) Administer an online international survey of up to 800 individuals with CFM and caregivers to identify predictors of psychological distress; 3) Perform up to 60 semi-structured interviews with healthcare providers and advocacy leaders to examine the extent to which current healthcare provisions address identified patient needs; and 4) Establish a participant registry to build a longitudinal database and develop an international community.

RESULTS

Teams in the USA and UK have been established, alongside an international, interdisciplinary Advisory Committee. Data analysis for Aim 1 is ongoing and informing the delivery of Aims 2-3. Aim 4 is also in development. A dedicated website serves as a recruitment tool, educational resource, and mechanism for engaging with the CFM community.

CONCLUSIONS

The CARE program provides a comprehensive approach to understanding the experiences of individuals with CFM and their caregivers. Challenges encountered and lessons learned are shared for the benefit of the community.

Treatment of hemifacial microsomia using conventional orthodontic techniques: Report of a case with long-term follow-up

BACKGROUND AND OVERVIEW

The authors successfully treat a case of hemifacial microsomia involving unilateral condylar hypoplasia using conventional orthodontic techniques followed by long-term retention.

CASE DESCRIPTION

A girl aged 10 years and 2 months received a diagnosis of hemifacial microsomia resulting from unilateral condylar hypoplasia. During a growth period, premature incisal contact was abolished. After her growth was complete, she received conventional orthodontic treatment with preadjusted edgewise appliances. After 27 months of multibracket treatment, acceptable occlusion with a class I canine and molar relationship was achieved. The occlusion remained stable throughout the 15-year retention period, although there was a slight facial change.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Early orthodontic management only can have some limitations but could be one of the treatment options for hemifacial microsomia.

[Diagnostic and therapeutic problems in a clinical case of oculoauricular dysplasia associated with mandibule-facial dysostosis (Franceschetti-Goldenhar syndrome)]

The authors present a case of oculo-auricular dysplasia (type Goldenhar) associated with France-schetti's syndrome (mandibulo-facial dysostosis) and complicated by paralytic strabismus and genital malformations. Complete investigation failed to establish a precise aetiology; one suggests an external disturbance in the course of the organogenesis of the branchial arches. Aesthetic improvement was undertaken--removal of epibulbar dermoids, correction of the squint, and ablation of the preauricular appendages; functional orthodontic treatment continues.

Bone-anchored hearing aid implantation in a patient with Goldenhar syndrome

Patients with Goldenhar syndrome exhibit a number of characteristic symptoms, including middle and internal ear malformations that may cause profound hearing loss. Bone-anchored hearing aids have been used to treat these patients in the past, although complications may arise due to the nature of the disease. Herein we present the case of a pediatric patient with Goldenhar syndrome whose hearing aid abutment extruded spontaneously because of poor bone quality, despite adequate thickness. We provide a brief review of the literature and suggest a flexible surgical plan for any syndromic pediatric patient.

[Goldenhar's syndrome: a case report]

A 13-mont-old infant bearer of a Goldenhar's syndrome with bilateral aplasia of pinnae, external auditory canals, mastoid processus, glenoid fossaes, condiloid processus, right micro-ophtalmy with micro-cornea and iris coloboma, death from bronchopneumonia, is reported. The AA. suggest as aetiological cause the triphasic conjugation of malnutrition, tobacco addiction and weed-killers, extensively employed in fieldwork. All three causes producing free radicals, which are known for its tera-togeneticy, that break the H bounds of DNA of germinative cells and consequently originating errors of blastogenesis with the corresponding congenital malformations.

Rural home care of a technology-dependent infant

A multidisciplinary approach is necessary to prepare for home care of technology-dependent infants. The environment must protect, support, and promote the physical, cognitive, and social growth and development of these infants. Parents and caregivers of technology-dependent infants should be taught cardiopulmonary resuscitation and should be helped to develop a plan for obtaining emergency medical assistance.

The Influence of Craniofacial Growth in a Case of Transverse Facial Cleft

This report presents the case of a female patient bearing a right-side transverse facial cleft. She has received interdisciplinary treatment since birth. At regular intervals, dental casts were made, and profile and full-face photographs, lateral and postero-anterior cephalograms were taken during the course of orthodontic treatment and maxillofacial surgery. We evaluated her diagnostic records with the intent of documenting the effects of growth and therapy on the skeletal structures of the facial cranium and on occlusion, and to show the influence on facial esthetics. Her facial morphology and occlusion were manifest at birth and in the primary dentition. The maxilla and mandible deviated from the midsagittal plane toward the cleft side, with the mandible considerably more affected, revealing a markedly posterior position. The lateral skeletal deviation of both jaws increased slightly during growth, yet the midline deviation of the dental arches and malocclusion clearly worsened. The increasing deviation was not obvious in full-face photographs. Especially in the primary and mixed dentition, the mandible shifted to the anterior, which was visible in both the lateral cephalograms and profile photographs. On the whole, however, no noteworthy alteration in the character of the craniofacial morphology occurred by the time growth was complete, despite functional jaw-orthopedic and maxillofacial surgical treatment consisting of two distraction osteogenesis procedures.

Management of unilateral craniofacial microsomia with orthopaedic functional appliances: A systematic literature review

The study aimed to summarize current knowledge regarding the use of orthopaedic functional appliances (OFA) in managing unilateral craniofacial microsomia (UCM). The eligibility criteria for the review were (1) assessing use of OFA as a stand-alone treatment and (2) using OFA in combination during or after MDO. The PICO (population, intervention, comparison and outcome) format formulated clinical questions with defined inclusion and exclusion criteria. No limitations concerning language and publication year were applied. Information sources: A literature search of Medline, Scopus, Embase, Cochrane Central Register of Controlled Trials, Web of Science databases without restrictions up to 30 September 2022. The risk of bias was assessed. According to Cochrane and PRISMA guidelines, two independent authors conducted data extraction. The level of evidence for included articles was evaluated based on the Oxford evidence-based medicine database. Due to the heterogeneity of studies and insufficient data for statistical pooling, meta-analysis was not feasible. Therefore, the results were synthesized narratively. A total of 437 articles were retrieved. Of these, nine met inclusion criteria: five assessing OFA and four assessing OFA during or after MDO. There is limited evidence to suggest that stand-alone and combination treatment with OFA is beneficial for treating mild-to-moderate UCM-related dentofacial deformities in short term. No studies assessed the burden of care. In the management of UCM, there is insufficient evidence supporting the efficacy of OFA as a stand-alone treatment or when combined with MDO. Additionally, there is a lack of evidence regarding treatment protocols and the effect on the condyles and the TMJ. The study was registered at Prospero database number CRD42020204969.

Oculo auriculo vertebral spectrum and CHARGE association

A boy in his early childhood was brought for a comprehensive eye examination as advised by a paediatrician. The child had plagiocephaly, absent left ear (anotia), facial asymmetry, deviation of mouth to the left side, receding chin and teeth, scoliosis and a Mongolian spot on the lower back. There was also absence of seventh and eighth cranial nerves on the left side on MRI of the brain. Echocardiography showed a small ventricular septal defect and a single umbilical artery. Gross motor milestones were delayed and on ocular examination, the child showed right eye preference and retinochoroidal coloboma in the left eye. The child was managed with a multidisciplinary approach involving the paediatrician, ENT specialist, ophthalmologist, clinical geneticist and rehabilitative services. The child was managed conservatively with spectacles and occlusion therapy of the right eye, and genetic counselling was given along with a left hearing aid and rehabilitation.

Goldenhar syndrome - a case report

Goldenhar syndrome is a developmental abnormality of 1st & 2nd branchial arch involving the craniofacial microsomia with ocular & vertebral abnormality. Though most of the cases are sporadic, some familial association is also found in autosomal dominant or recessive manner. Teratogenic effect of some toxic substances may lead to the condition. Ocular abnormalities are epibulbar dermoid, lipodermoid & coloboma. Otic defects are preauricular tags, microtia, anotia & conductive hearing loss. Cardio-pulmonary & genitourinary abnormalities are common associations. Here we have described the case of a 10 years old girl had ocular, auricular & vertebral changes consistent with Goldenhar syndrome, she was managed with multidisciplinary approach and she was symptomatically improved but corrective surgery was planned as schedule of respective department.