A comparison of two classification systems for hemifacial microsomia

Dynamic Reconstruction of Facial Paralysis in Craniofacial Macrosomia

BACKGROUND

Craniofacial microsomia is associated with maxillomandibular hypoplasia, microtia, soft-tissue deficiency, and variable severity of cranial nerve dysfunction, most often of the facial nerve. This study evaluated the incidence of patients with craniofacial microsomia and facial paralysis and their outcomes after free functioning muscle transfer for dynamic smile reconstruction.

METHODS

A single-center, retrospective, cross-sectional study was performed from 1985 to 2018 to identify pediatric patients with craniofacial microsomia and severe facial nerve dysfunction who underwent dynamic smile reconstruction with free functioning muscle transfer. Preoperative and postoperative facial symmetry and oral commissure excursion during maximal smile were measured using photogrammetric facial analysis software.

RESULTS

This study included 186 patients with craniofacial microsomia; 41 patients (21 male patients, 20 female patients) had documented facial nerve dysfunction (22 percent), affecting all branches (51 percent) or the mandibular branch only (24 percent). Patients with severe facial paralysis (n = 8) underwent midfacial (i.e., smile) reconstruction with a free functioning muscle transfer neurotized either with a cross-face nerve graft (n = 7) or with the ipsilateral motor nerve to masseter (n =1). All patients achieved volitional muscle contraction with improvement in symmetry and oral commissure excursion (median, 8 mm; interquartile range, 3 to 10 mm). The timing of orthognathic surgery and facial paralysis reconstruction was an important consideration in optimizing patient outcomes.

CONCLUSIONS

The authors' institution's incidence of facial nerve dysfunction in children with craniofacial microsomia is 22 percent. Free functioning muscle transfer is a reliable option for smile reconstruction in children with craniofacial microsomia. To optimize outcomes, a novel treatment algorithm is proposed for craniofacial microsomia patients likely to require both orthognathic surgery and facial paralysis reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Epidemiology of Rare Craniofacial Anomalies: Retrospective Western Australian Population Data Linkage Study

OBJECTIVE

To describe birth prevalence of rare craniofacial anomalies and associations with antenatal and perinatal factors.

STUDY DESIGN

All live and stillbirths in Western Australia between 1980 and 2010 were identified from the Western Australian Birth Registrations and the Midwives Notification System (also provides information on antenatal and perinatal factors). Rare craniofacial anomalies (craniosynostosis, craniofacial microsomia, and others [Pierre Robin, Van der Woude, and Treacher Collins syndrome]) were ascertained from the Western Australian Register of Developmental Anomalies and linked to other data sources. Trends in prevalence, adjusted for sex and Indigenous status, were investigated by Poisson regression and presented as annual percent change (APC). Strengths of association of related factors were assessed using multivariable log-binomial regression adjusted for sex, Indigenous status, birth year, socioeconomic disadvantage, and remoteness and reported as risk ratios with 95% CIs.

RESULTS

There was a temporal increase in prevalence of metopic synostosis (APC 5.59 [2.32-8.96]) and craniofacial microsomia (Goldenhar syndrome) (APC 4.43 [1.94-6.98]). Rare craniofacial anomalies were more likely among infants born preterm, as twins or greater-order multiples, with growth restriction, to older parents, to mothers undertaking fertility treatments, and with pre-existing medical conditions, specifically epilepsy, diabetes, or hypothyroidism. Prenatal identification of rare craniofacial anomalies was uncommon (0.6%).

CONCLUSIONS

Our findings indicate a steady increase over time in prevalence of metopic synostosis and craniofacial microsomia (Goldenhar syndrome). Possible associations of fertility treatments and pre-existing maternal medical conditions with rare craniofacial anomalies require further investigation.

Craniofacial microsomia: Reflections on diagnosis and severity assessment based on a series of cases

This study aims to discuss diagnostic criteria and severity assessment for craniofacial microsomia (CFM). A series of 61 patients with diverse CFM phenotypes had their clinical data collected by experienced dysmorphologists using a single protocol. Genetic abnormalities were searched through karyotype and chromosomal microarray analysis. Sex ratio, prenatal risk factors, and recurrence rate corroborated the literature. Despite the wide variability of clinical findings, ear disruption was universal. Eight patients were assigned as syndromic, four of whom had demonstrable genetic alterations. The majority of patients (67.2%) fulfilled four known diagnostic criteria, while 9.8% fulfilled one of them. Data strengthened disruptions of the ear and deafness as a semiotically valuable sign in CFM. Facial impairment should consider asymmetry as a mild expression of microsomia. Spinal and cardiac anomalies, microcephaly, and developmental delay were prevalent among extra craniofacial features and should be screened before planning treatment and follow up. The severity index was able to recognize the less and the most affected patients. However, it was not useful to support therapeutic decisions and prognosis in the clinical scenario due to syndromic and non-syndromic phenotypes overlapping. These issues make contemporary the debate on diagnostic methods and disease severity assessment for CFM. They also impact care and etiopathogenetic studies.

Hemifacial Microsomia: Clinical Features and Associated Anomalies

ABSTRACT

Hemifacial microsomia (HFM) is the second most common congenital anomaly of the face after cleft lip and palate. There is a considerable variability in the extent and severity of affection of the bones and soft tissues of the face arising from these two arches. Different classification systems have been described for HFM with the mandible and/or the ear defects being key features needed for any classification system. Nowadays, the most widely used system is the orbital, mandibular, ear, facal nerve, soft tissue (OMENS) classification, later modified to the OMENS+ to include extracraniofacial manifestations.The aim of this study was to review the demographic characteristics and clinical findings of a group of Egyptian patients with HFM and to correlate the findings with data retrieved from the literature.Thirty-nine patients were identified and included in this study. Right side was predominantly affected in 19 patients (48.7%), 9 patients (23%) had left side affection (23%) and 11 patients (28.3%) had bilateral affection, with overall male-to-female ratio of 1:1.4. The majority of patients had a normal orbit (64%), mildly hypoplastic mandible with functioning temporomandibular joint (58% with type M1 or M2a), normal facial nerve (82%), and minimal to mild soft-tissue hypoplasia (52%). Significant ear deformity affected the bigger percentage of the patients (E3: 44%, E2: 14%)The data demonstrate the phenotypic variability of HFM and suggest a degree of relationship among the components of HFM. Some epidemiological aspects and clinical findings in our study did not always parallel those reported in western literatures. Small sample size is the main limitation of the study. Further, and if possible multi-center, studies are recommended.

Quantitative description of masseter muscle involvement in craniofacial microsomia

Masseter deficits are common in craniofacial microsomia (CFM), however studies on masseter muscle involvement are limited. The aim of this study was to describe the morphology and functional involvement of the masseter muscles quantitatively. Ninety-eight patients with CFM who underwent three-dimensional computed tomography and surface electromyography were included. The mean action potential during maximum voluntary contraction in the intercuspal position was recorded. Asymmetry of the compound muscle action potential (ACMAP) was calculated as an indicator of functional involvement. Differences between the affected and unaffected sides, the correlation between morphology and function, and the relationship between ACMAP and the OMENS-Plus classification were assessed by paired t-test, Pearson correlation analysis, and Spearman correlation analysis. The masseter muscle was absent on the affected side in 11 patients. In the remaining 87 patients, the mean volumes of the affected and unaffected masseters were 5.22±2.47cm³ and 9.62±3.30cm³, respectively, with mean action potentials of 41.40±28.52uV and 73.78±45.90uV, respectively. Both morphology and the function of the masseter showed moderate correlation with the OMENS 'M' classification. No significant correlation was found between ACMAP and the OMENS-Plus soft tissue grading. A masseter function classification is proposed: type I, ACMAP<0.2; type II, ACMAP 0.20-0.34; type III, ACMAP 0.35-0.54; type IV, ACMAP≥0.55. The masseter function classification may be a beneficial tool in patients with CFM.

Dermal-Fat Graft for Facial Contouring in Patients With Craniofacial Microsomia

Craniofacial microsomia (CFM) is a variable craniofacial malformation, related to the development of the structures originated from the first and second brachial arches, affecting skeletal tissue, soft tissue, and neuromuscular components. In the situation of subcutaneous tissue and chewing muscles hypoplasia, free tissue transfer is a treatment option. Dermal-fat graft allows easy modeling during surgery, volumetric gain and improvement of asymmetry. The aim of this study was to evaluate the facial contour and the percentage of symmetry after the use of dermal-fat graft in patients with CFM, who had already submitted to osteotomies, attended at the Associate Center for Cleft Lip and Palate (CAIF) during 2001 to 2018. For analysis, the authors selected 17 patients who fulfilled the above prerequisites. The symmetry study was done by the analysis of preoperative and postoperative photographs in the Image J software. Two standard points were used: nasal base and upper lip limit. On the nasal base, the preoperative analysis showed a hypoplastic side with a median of 93.00% of the normal side size, rising to 97.78% in the postoperative period. On the upper lip limit, the preoperative analysis showed a median of 87.80% and, in the postoperative period, 98.15%. Analysis of the interaction between the operative moments and the modified Pruzansky classification showed that there were no significant differences between grades. Long-term evaluation demonstrated that the use of a dermal-fat graft for correction of facial symmetry was effective and close to 100%, regardless of the degree of hypoplasia of the patient.

Craniofacial Microsomia

Clinicians use different diagnostic terms for patients with underdevelopment of facial features arising from the embryonic first and second pharyngeal arches, including first and second branchial arch syndrome, otomandibular dysostosis, oculoauriculovertebral syndrome, and hemifacial microsomia. Craniofacial microsomia has become the preferred term. Although no diagnostic criteria for craniofacial microsomia exist, most patients have a degree of underdevelopment of the mandible, maxilla, ear, orbit, facial soft tissue, and/or facial nerve. These anomalies can affect feeding, compromise the airway, alter facial movement, disrupt hearing, and alter facial appearance.

Methods and Challenges in a Cohort Study of Infants and Toddlers With Craniofacial Microsomia: The Clock Study

OBJECTIVE

The Craniofacial microsomia: Longitudinal Outcomes in Children pre-Kindergarten (CLOCK) study is a longitudinal cohort study of neurobehavioral outcomes in infants and toddlers with craniofacial microsomia (CFM). In this article, we review the data collection and methods used to characterize this complex condition and describe the demographic and clinical characteristics of the cohort.

SETTING

Craniofacial and otolaryngology clinics at 5 study sites.

PARTICIPANTS

Infants with CFM and unaffected infants (controls) ages 12 to 24 months were recruited from the same geographical regions and followed to age 36 to 48 months.

METHODS

Phenotypic, neurodevelopmental, and facial expression assessments were completed during the first and third waves of data collection (time 1 and time 3, respectively). Medical history data were taken at both of these time points and during an intermediate parent phone interview (time 2).

RESULTS

Our cohort includes 108 cases and 84 controls. Most cases and controls identified as white and 55% of cases and 37% of controls identified as Hispanic. Nearly all cases had microtia (95%) and 59% had mandibular hypoplasia. Cases received extensive clinical care in infancy, with 59% receiving care in a craniofacial clinic and 28% experiencing at least one surgery. Study visits were completed at a study site (92%) or at the participant's home (8%).

CONCLUSIONS

The CLOCK study represents an effort to overcome the challenges of characterizing the phenotypic and neurodevelopmental outcomes of CFM in a large, demographically and geographically diverse cohort.

One-Year Relapse of Mandibular Distraction for Hemifacial Microsomia Using Masseteric Botulinum Toxin Type A Injections

BACKGROUND

The relapse of hemifacial microsomia was thought to be highly related to the soft tissue envelope around the mandible angle mainly composed by masseter and medial pterygoid. According to the reason, we tried to apply masseter injection of type A botulinum toxin to weaken the soft envelope tension on the early stage post mandible distraction in adult HFM patients.

METHODS

Eight patients diagnosed with HFM were studied and randomly assigned to an experimental or control group. Patients in the experimental group were treated with DO, orthognathic surgeries, autologous fat grafting, and bilateral masseter muscle injection with type A botulinum toxin. The patients in control group were treated with the same procedures as the patients in experimental group except for masseter muscle injection with type A botulinum toxin. The recurrence rates of both groups were evaluated and analyzed after nearly 1 year of follow-up.

RESULTS

The mean recurrence rate was 26.30% ± 11.84% (range 7.62%-37.27%) in the 8 patients after 1-year follow-up. The relapse rate was 16.32% ± 7.78% (7.62%-26.22%) in the experimental group and 36.28% ± 1.03% (34.84%-37.27%) in the control group. There was a significant difference (P = 0.002) between the experimental group and the control group.

CONCLUSIONS

The combination of DO, orthognathic surgeries, autologous fat particle transplantation, and masseter muscle type A botulinum toxin injection technique could be a comprehensive treatment plan for adult patients of HFM. Furthermore, masseter injection of type A botulinum toxin might be an alternative method to reduce the early recurrence rate of postoperative adult patients of HFM.

Facial Expressiveness in Infants With and Without Craniofacial Microsomia: Preliminary Findings

OBJECTIVE

To compare facial expressiveness (FE) of infants with and without craniofacial macrosomia (cases and controls, respectively) and to compare phenotypic variation among cases in relation to FE.

DESIGN

Positive and negative affect was elicited in response to standardized emotion inductions, video recorded, and manually coded from video using the Facial Action Coding System for Infants and Young Children.

SETTING

Five craniofacial centers: Children's Hospital of Los Angeles, Children's Hospital of Philadelphia, Seattle Children's Hospital, University of Illinois-Chicago, and University of North Carolina-Chapel Hill.

PARTICIPANTS

Eighty ethnically diverse 12- to 14-month-old infants.

MAIN OUTCOME MEASURES

FE was measured on a frame-by-frame basis as the sum of 9 observed facial action units (AUs) representative of positive and negative affect.

RESULTS

FE differed between conditions intended to elicit positive and negative affect (95% confidence interval = 0.09-0.66, P = .01). FE failed to differ between cases and controls (ES = -0.16 to -0.02, P = .47 to .92). Among cases, those with and without mandibular hypoplasia showed similar levels of FE (ES = -0.38 to 0.54, P = .10 to .66).

CONCLUSIONS

FE varied between positive and negative affect, and cases and controls responded similarly. Null findings for case/control differences may be attributable to a lower than anticipated prevalence of nerve palsy among cases, the selection of AUs, or the use of manual coding. In future research, we will reexamine group differences using an automated, computer vision approach that can cover a broader range of facial movements and their dynamics.

Hearing Loss in Children with Craniofacial Microsomia

Objective

To evaluate the association between craniofacial phenotype and hearing loss in children with craniofacial microsomia.

Design

Retrospective cohort study.

Setting

Tertiary care children's hospital.

Patients

Individuals with craniofacial microsomia.

Main Outcome Measures

Ear-specific audiograms and standardized phenotypic classification of facial characteristics.

Results

A total of 79 participants were included in the study. The mean age was 9 years (range, 1 to 23 years) and approximately 60% were boys. Facial anomalies were bilateral in 39 participants and unilateral in 40 participants (24 right, 16 left). Microtia (hypoplasia of the ear) was the most common feature (94%), followed by mandibular hypoplasia (76%), soft tissue deficiency (60%), orbital hypoplasia or displacement (53%), and facial nerve palsy (32%). Sixty-five individuals had hearing loss (12 bilateral and 53 unilateral). Hearing loss was conductive in 73% of affected ears, mixed in 10%, sensorineural in 1%, and indeterminate in 16%. Hypoplasia of the ear or mandible was frequently associated with ipsilateral hearing loss, although contralateral hearing loss occurred in 8% of hemifaces.

Conclusions

Hearing loss is strongly associated with malformations of the ipsilateral ear in craniofacial microsomia and is most commonly conductive. Hearing loss can occur contralaterally to the side with malformations in children with apparent hemifacial involvement. Children with craniofacial microsomia should receive early diagnostic hearing assessments.

Maxillofacial features and systemic malformations in expanded spectrum Hemifacial Microsomia

Hemifacial microsomia (HFM) is a rare, multisystemic congenital disease with estimated frequency of 1/26370 births in Europe. Most cases are sporadic and caused by unilateral abnormal morphogenesis of the first and second pharyngeal arches. The aim of this study is to define the types and frequency of maxillofacial and systemic malformations in HFM patients. This is a case series study of patients with HFM evaluated at a single institution. Data were acquired through history, physical examination, photographs, diagnostic radiology, and laboratory and analyzed by the FileMakerPro database on 95 patients (54F; 41M) of which 89 met the inclusion criteria. Mandibular hypoplasia was observed in 86 patients with right-side preponderance (50). One patient had bilateral mandibular hypoplasia. Seventy-four had external ear anomalies (anotia or microtia). Eleven had bilateral malformed ears. Hearing impairment, associated with stenosis or atresia of the external ear canal, was found in 69 patients (eight with bilateral canal defects). Ocular anomalies were seen in 41 (23 with dermoid cysts) and 39 had orbital malformations. Facial nerve paralysis was observed in 38 patients. Cleft lip/palate (10), preauricular tags (55), and macrostomia (41) were also described. A total of 73/86 had systemic malformations, mainly vertebral (40), genitourinary (25), and cardiovascular (28). Sixteen had cerebral anomalies (four with intellectual disability). All patients suspected of HFM should undergo a complete systematic clinical and imaging investigation to define the full scope of anomalies. Since the disease is rare and complex, affected patients should be monitored by specialized multidisciplinary team centers.

Mutations in MYT1, encoding the myelin transcription factor 1, are a rare cause of OAVS

BACKGROUND

Oculo-auriculo-vertebral spectrum (OAVS) is a developmental disorder involving first and second branchial arches derivatives, mainly characterised by asymmetric ear anomalies, hemifacial microsomia, ocular defects and vertebral malformations. Although numerous chromosomal abnormalities have been associated with OAVS, no causative gene has been identified so far.

OBJECTIVES

We aimed to identify the first causative gene for OAVS.

METHODS

As sporadic cases are mostly described in Goldenhar syndrome, we have performed whole exome sequencing (WES) on selected affected individuals and their unaffected parents, looking for de novo mutations. Candidate gene was tested through transient knockdown experiment in zebrafish using a morpholino-based approach. A functional test was developed in cell culture in order to assess deleterious consequences of mutations.

RESULTS

By WES, we identified a heterozygous nonsense mutation in one patient in the myelin transcription factor 1 (MYT1) gene. Further, we detected one heterozygous missense mutation in another patient among a cohort of 169 patients with OAVS. This gene encodes the MYT1. Functional studies by transient knockdown of myt1a, homologue of MYT1 in zebrafish, led to specific craniofacial cartilage alterations. Treatment with all-trans retinoic acid (RA), a known teratogenic agent causing OAVS, led to an upregulation of cellular endogenous MYT1 expression. Additionally, cellular wild-type MYT1 overexpression induced a downregulation of RA receptor β (RARB), whereas mutated MYT1 did not.

CONCLUSION

We report MYT1 as the first gene implicated in OAVS, within the RA signalling pathway.

Congenital upper eyelid coloboma: embryologic, nomenclatorial, nosologic, etiologic, pathogenetic, epidemiologic, clinical, and management perspectives

Purpose:

To review the recent literature and describe the authors’ experience with congenital upper eyelid coloboma.

Methods:

In this review, we will summarize the embryologic and etiopathogenetic bases of congenital upper eyelid coloboma, and study the published clinical reports. We will also attempt to briefly shed some light on the rarer syndromic curiosities associated with upper eyelid coloboma.

Results:

Congenital upper eyelid colobomas are one of the few nontraumatic oculoplastic emergencies that may occasionally present in the first few days of life with a corneal ulcer and may even present with impending perforation. They can present with or without corneopalpebral adhesions, may be isolated findings or a part of a larger spectrum of congenital anomalies as in the case of Fraser syndrome or Goldenhar syndrome, or could be associated with other rare curiosities that could challenge the clinician with a huge diagnostic dilemma.

Conclusions:

Existing literature dealing with congenital colobomas of the upper eyelid is fraught with nosologic problems, confusing etiologies, and overlapping clinical features. We attempted to clarify the salient clinical features, outline the management principles, and until a time in the not-so-distant future where advances in molecular genetic testing would help redefine the etiology and the diverse clinical spectrum of genetic diseases associated with upper eyelid colobomas, we propose a simplified classification scheme based on the relation of the coloboma to the cornea, the presence or absence of systemic features, and all the syndromic and nonsyndromic associations of congenital coloboma of the upper eyelid known today.

In this review, the authors will describe the pathogenesis of upper eyelid coloboma, suggest a new simplified classification system, describe the clinical picture in detail, clarify the various syndromic associations of upper eyelid coloboma, and lay out the basic surgical principles of management.

The versatility of autologous fat transplantation in correction of facial deformities: a single-center experience

Deformities in the craniofacial region are of great social and functional importance. Several surgical techniques have been used to treat such pathologies often with high morbidity and lacking the ability to address smaller contour defects. The minimally invasive technique of fat transplantation has evolved rapidly within the last few decades. The objective of this paper is to present the versatility and applicability of fat transplantation in a wide range of contour deformities in the craniofacial region. We share our experiences in treating 13 patients with autoimmune disorders, congenital malformations, and acquired defects. Future perspectives of fat transplantation in the field of craniofacial reconstruction are discussed.

Characterization of Facial Paresis in Hemifacial Microsomia

Objective

To provide an overview of the incidence, characteristics, and proposed etiologic mechanisms of facial paresis in patients with manifestations of hemifacial microsomia.

Data Sources

PubMed database for English-language studies with no date restrictions.

Review Methods

A comprehensive literature review was performed identifying all studies that discussed incidence, characterization, or etiologic mechanisms for facial paresis in hemifacial microsomia/oculo-auriculo-vertebral spectrum.

Conclusions

This review supports that the prevalence of facial weakness in the spectrum of hemifacial microsomia/oculo-auriculo-vertebral spectrum ranges from 10% to 45%. Most of these patients have involvement of all facial nerve branches or lower branches only. The most commonly involved single nerve branch has yet to be described. The 2 most common associated anomalies involve the mandible and auricle. Dysmorphogeneisis of the temporal bone and its effects on the facial nerve are most likely implicated in the cause of facial weakness.

Implications for Practice

There is a wide variety of facial nerve presentations seen within oculo-auriculo-vertebral spectrum for which the exact etiologic mechanism is unclear. Through a better understanding of the presentation and etiology surrounding facial paresis in hemifacial microsomia, improved treatment options may be offered in the management of the facial weakness.

Hemifacial microsomia: clinical features and pictographic representations of the OMENS classification system

LEARNING OBJECTIVES

After reviewing this article, the participant should be able to: 1. Describe the fundamental malformations defining hemifacial microsomia. 2. Distinguish hemifacial microsomia from other congenital craniofacial anomalies sharing similar features. 3. Understand the variety of systems developed to clinically classify the features of this disorder. 4. Describe the format of the OMENS clinical classification system and appreciate its possible advantages and limitations.

BACKGROUND

The clinical manifestations of hemifacial microsomia comprise a spectrum that is both broad and complex. The fundamental features include unilateral hypoplasia of the craniofacial skeleton and its overlying soft tissue. Numerous schemes have been developed to classify this spectrum. One of the most recent classification systems, the OMENS system, scores five clinical manifestations of hemifacial microsomia according to dysmorphic severity on a scale from 0 to 3: orbital asymmetry, mandibular hypoplasia, ear deformity, nerve dysfunction, and soft-tissue deficiency.

METHODS

The authors describe the diverse features of hemifacial microsomia and the numerous attempts at its clinical classification, with particular emphasis on the OMENS system.

RESULTS

With the possible exception of the OMENS scheme, the various systems developed to classify the clinical features of hemifacial microsomia fail to possess the flexibility and versatility needed to categorize all potential phenotypes of this complex disorder.

CONCLUSIONS

The OMENS system represents the most comprehensive, versatile, objective, and easily adaptable attempt at clinical classification of hemifacial microsomia to date. The authors propose a concise clinical evaluation form using a modified version of the system to promote the use of the OMENS system, to aid in the evaluation of hemifacial microsomia patients, and to assist in data sharing among academic institutions.

Microtia in Finland: comparison of characteristics in different populations

OBJECTIVE

To compare the characteristics of microtia in Finland and in other populations.

METHODS

Retrospective case series and patient questionnaire of 190 microtia patients referred for reconstruction of the earlobe to the Helsinki University Central Hospital during the years 1980-2005.

RESULTS

The prevalence in Finland is 4.34/10,000 and varied in other populations from 0.83 to 17.4/10,000. Microtia is seen more in males (58%), as unilateral (88.4%), right-sided (59.5%) and it is almost always associated with aural atresia or stenosis (93%). There is conductive hearing loss in 96% and sensorineural hearing loss in 8% of the affected ears. 11% of the patients had congenital heart defects, and 5% had anomalies of extremities.

CONCLUSIONS

There is variation in the prevalence and characteristics of microtia in different populations.

Oculo-auriculo-vertebral spectrum (OAVS): clinical evaluation and severity scoring of 53 patients and proposal for a new classification

Oculo-auriculo-vertebral spectrum (OMIM164210) is a phenotypically and probably also a genetically heterogeneous disorder, characterized by anomalies of the ear (mostly microtia), hemifacial microsomia, and defects of the vertebral column. Associated clinical findings include anomalies of the eye and brain, and developmental delay. We have evaluated the clinical data and photographs of 53 unrelated patients with OAVS, all presenting with either isolated microtia or preauricular tags in association with hemifacial microsomia as minimal diagnostic criteria; five had a positive family history for OAVS. Based on the main clinical findings and unilateral or bilateral involvement, we have developed a new classification system for OAVS, consisting of six subgroups. There is a statistically significant correlation between the subgroup and number of associated clinical findings, and a statistically significant difference regarding prognosis in uni- and bilaterally affected patients, suggesting that this classification is clinically relevant to the categorization of patients with OAVS. The newly developed scoring system (two points for each main clinical finding and one for each associated clinical finding) presented here, also aids prognosis, especially for delay of motor development and brain anomalies, and statistical analysis revealed significant clustering between different clinical findings of OAVS confirming the clinical impression previously published by several authors.

An association between hemifacial microsomia and facial clefting

PURPOSE

Hemifacial microsomia (HFM) is a relatively uncommon malformation, a far second to cleft lip/palate (CL/P). Transverse oral cleft ("macrostomia") is known to be associated with HFM, but there are also reports of concurrent CL/P. We undertook a retrospective study of patients with HFM to document the prevalence of facial clefting. The hypothesis is that the coexistence of facial clefts and HFM suggests a common pathogenic mechanism.

MATERIALS AND METHODS

Records of 198 HFM patients from the database of the Craniofacial Centre at Boston Children's Hospital were reviewed. The age, gender, predominant side of HFM, OMENS classification, and presence, size, and type of cleft (CL/P, transverse oral cleft, or oro-ocular cleft) were documented. We performed chi 2 , t test, and Fishers exact analyses to evaluate the association of facial clefting with HFM.

RESULTS

There were 100 males and 98 females in the HFM study group, with a mean age of 15.3 years (range, 1 to 50 years); 90 were right-sided (45%), 79 were left-sided (40%), and 29 were bilateral (15%). Twenty patients had a CL/P (10%), and of these 15 had unilateral CL/P (UCL/P), equally distributed between right and left sides, and 5 had bilateral CL/P (BCL/P). There were 9 males and 11 females with combined HFM and CL/P. Cleft of the oral commissure (macrostomia) was present in 46 (23.0%) of the HFM patients with a left-to-right-to-bilateral ratio of 5:6:1. There was a significant association between the predominant side of HFM and the side of CL/P ( P < .001) and macrostomia ( P </= .001). We also showed a correlation between the severity of the orbital and mandibular deformities in HFM and the coexisting facial cleft.

CONCLUSIONS

An association implies concurrence, more often than by chance, of 2 or more anomalies and suggests an etiopathologic link. The finding of ipsilateral labial clefts in 10% of HFM patients, and the differing demographic distribution from common labial clefts, suggests an overlapping pathogenesis. Whether the cause is genetic or environmental, we hypothesize that there may be a common pathway leading to a disturbance in neural crest cell migration in HFM patients who also have a facial cleft.

Amniotic Band Sequence: The Use of Bone Grafting and Distraction Osteogenesis

Distraction has proven to be a useful technique in cases of severe bone deficiency in the craniofacial skeleton. This is a report of its use in the treatment of a child affected by amniotic band sequence. This 5 year old Hispanic female presented with transverse deficiences of one lower extremity and both upper extremities. Additionally, she was missing the mandible and overlying soft tissue from ramus to ramus. Although free fibula transfer was a possibility, due to the presence of only one lower extremity, it was elected to utilize the technique of distraction. After preliminary bone grafting to unite these two hemimanibles, the bone graft was distracted bilaterally to create a neomandible. Following consolidation and removal of the distraction devices, the child was markedly improved despite what appeared to be a pathologic fracture in the region of the mandibular angle. Repeat distraction was planned.

Hemifacial microsomia: use of the OMENS-Plus classification at the Royal Children's Hospital of Melbourne

Hemifacial microsomia is the most common facial congenital disability after cleft lip and palate, but as yet its pathogenesis remains unknown. Clinical classification systems have evolved over the last 30 years from those classifying only single components of the disorder, to those classifying according to the combination of deformities, to the most recent systems that grade each anatomical component separately, such as the Orbit, Mandible, Ear, Nerve, and Soft tissue (OMENS) system. The aim of the present study was to review the classification of patients with hemifacial microsomia treated by the Melbourne Craniofacial Unit at the Royal Children's Hospital using the OMENS-Plus system of classification and to correlate the findings with data from other centers. Records of patients treated by the craniofacial unit were reviewed and included in the study if adequate clinical records, photographs, and radiographs (anteroposterior, lateral, basal cephalometry, panoramic views) were available. The data were entered into a database file developed for this purpose. Seventy-one patients were identified from the hospital database, of which six were excluded because of incomplete data. Of the 65 patients, there were 31 (48 percent) with right-sided microsomia, 25 (38 percent) with left-sided microsomia, and nine (14 percent) with bilateral microsomia, with an overall male-to-female ratio of 1.2:1. The majority of patients had a normal orbit (77 percent), mildly hypoplastic mandibular ramus-condyle with functioning temporomandibular joint (57 percent with type M1 or M2a), normal facial nerve (76 percent), and mild soft-tissue hypoplasia (73 percent). There was a similar proportion of patients with mild ear anomalies (53 percent with grade 0 or 1) compared with those with more severe anomalies (47 percent with grade 2 or 3). Correlative analysis demonstrated a slight but positive correlation between the severity gradings of the five individual components. The correlation was lowest between the grading of the nerve and ear and that of the mandible and nerve. The data demonstrate the phenotypic variability of hemifacial microsomia and suggest a degree of relationship among the components of hemifacial microsomia. The OMENS-Plus system has provided a major advancement in the classification of hemifacial microsomia. The authors suggest refinements to the grading of the orbit and nerve components.

Hemifacial microsomia and treatment options for auricular replacement: A review of the literature

STATEMENT OF PROBLEM

Although surgical reconstruction is the treatment of choice for auricular deformities that result from hemifacial microsomia, the implant-retained auricular prosthesis must be considered when surgical reconstruction is not possible. The competent and successful practitioner should be knowledgeable of the nature of this congenital disease.

PURPOSE

This article reviewed the first and second branchial syndrome, treatment approaches, and potential advances in surgical and prosthetic rehabilitation for patients with hemifacial microsomia.

CONCLUSION

Advantages and disadvantages of autogenous and alloplastic ear reconstructions are discussed. New research initiatives, such as tissue engineering and fabrication of auricular prosthesis by CAD/CAM, offer the potential for improved treatment for the future treatment of hemifacial microsomia.

Mandibular malformations: growth characteristics and management in hemifacial microsomia and Nager syndrome

This review article describes normal and abnormal development of the mandible. The focus is on the characteristics of the mandible and its attached muscles in the various types of hemifacial microsomia and in Nager syndrome. Management protocols for these two types of malformations are presented in relation to development stages.

Current concepts in the understanding and management of hemifacial microsomia

Hemifacial microsomia (HFM) is a complex congenital condition. This review discusses recent research findings which affect all aspects of HFM, and addresses some prevailing misconceptions. Firstly, the broad phenotype is outlined, with an emphasis on the facial anomalies which are important for diagnosis, classification and treatment. The range of HFM anomalies and their possible embryology also account for the varied terms used in the literature. In addition, consideration of causation helps to shape our understanding of HFM as a clinical entity. Aetiology is described with particular emphasis on the involvement of genetic factors, although at present this is largely hypothetical. Finally, the principles of HFM management are reviewed. Attention is given to the integrated planning and team approach necessary to treat such patients. In addition, the possible attributes of new treatments, such as distraction osteogenesis, are highlighted.

OMENS-Plus: analysis of craniofacial and extracraniofacial anomalies in hemifacial microsomia

This review of 121 patients with hemifacial microsomia (HFM) revealed that 67 (55.4%) had extracraniofacial anomalies. Sixteen patients (13%) had one extracraniofacial anomaly and 51 patients (42.4%) had anomalies of multiple organ systems. There was no gender or side predominance in the cohort with the HFM "expanded spectrum." Central nervous system (CNS), cardiac, and skeletal anomalies were "associated" (i.e., had frequencies of 10% or more). Pulmonary, gastrointestinal, and renal deformities were equivocally associated. Statistical analysis indicated significant associations between several orbital, mandibular, ear, neural, and soft tissue (OMENS) variables and extracraniofacial anomalies. Patients with extracraniofacial structural defects had higher OMENS grades for individual craniofacial anatomic categories. Furthermore, patients with expanded spectrum had higher total OMENS scores. The frequency of cardiac anomalies (26%) supports the model of neural crest involvement in the pathogenesis of both hemifacial microsomia and conotruncal defects. The majority of the heart defects in this study were of either the outflow or septal type. We propose that the OMENS classification system for craniofacial anomalies of HFM be expanded to OMENS-Plus (+) to designate the presence of associated extracraniofacial anomalies.