1
|
Gasparin M, Barth FL, Schweiger C, Collares MVM, Levy DS, Marostica PJC. Sensory-Motor-Oral Stimulation Combined with Early Sucking During the Mandibular Distraction Osteogenesis Process in Children with Robin Sequence. Cleft Palate Craniofac J 2024:10556656241264710. [PMID: 39051575 DOI: 10.1177/10556656241264710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
OBJECTIVE To describe the findings of children with Robin Sequence (RS) who received sensory-motor-oral stimulation combined with early sucking during mandibular distraction osteogenesis (MDO), compared with children who did not receive the intervention. DESIGN A quasi-experimental study. Setting: A tertiary public hospital. Patients: Children with RS referred to MDO. A historical group from the same population but managed according to the institution's standard protocol (no sucking) served as a control group. Interventions: Sensory-motor-oral stimulation, including sucking, starting 24 h after MDO (intervention group). Main Outcome Measure: Our hypothesis is that sensory-motor-oral stimulation, including sucking during the DOM process, do not negatively affect surgical outcomes. RESULTS Twenty-nine children were included. Eight (72.7%) of the 11 patients in the intervention group and 13 (72.2%) of the 18 controls had MDO complications, with no significant difference between the groups (p = 1.000). The most common surgical outcome was antibiotic therapy for surgical site infection (76.2%). Six months after MDO, 22 (75.9%) children attained full oral feeding or associated with alternative feeding methods. CONCLUSION The intervention group did not have higher complication rates, from a surgical point of view, than control group. The protocol adopted by some centers that contraindicates sucking during MDO should be revised to consider the benefits of such stimulation. Keywords: Pierre Robin Syndrome, deglutition, therapeutics, child development.
Collapse
Affiliation(s)
- Marisa Gasparin
- Postgraduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Fabiola Luciane Barth
- Postgraduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Cláudia Schweiger
- Postgraduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Otorhinolaryngology Service, Pediatric Otorhinolaryngology Unit, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | | | | | - Paulo José Cauduro Marostica
- Postgraduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Pediatric Pulmonology Unit, Pediatrics Service, HCPA, Porto Alegre, Brazil
| |
Collapse
|
2
|
Govaerts D, Kalantary S, Van de Casteele E, Nadjmi N. Mandibular distraction osteogenesis in children with Pierre Robin sequence: long-term analysis of teeth and jaw growth. Br J Oral Maxillofac Surg 2024; 62:551-558. [PMID: 38902108 DOI: 10.1016/j.bjoms.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/16/2024] [Accepted: 04/20/2024] [Indexed: 06/22/2024]
Abstract
Treatment of children with Pierre Robin sequence (PRS) having a hypoplastic mandible and upper airway distress after birth may consist of external distraction devices. Shape anomalies of the permanent molars and positional changes due to surgery have been documented. The aim of this study is to compare the long-term effects (>5 years) on the growth pattern of PRS-patients treated with an external mandibular distraction device with no-surgery cases and to investigate the dental development or damage. A retrospective cohort study was performed. PRS-patients with and without surgery were included. A digital cephalometric analysis was made to evaluate the growth pattern of the mandible between groups as well as with normal values. Nine of 19 patients underwent an external mandibular distraction. All children were extubated after 4-5 days with no signs of respiratory distress. Screw and device loosening presented in one patient. The articular and sellar angles were significantly larger and smaller, respectively, in the Surgery group. Mandibular distraction surgery might result in a 'growth boost' compared to the No-surgery group. No significant difference in dental development was found. Mandibular distraction osteogenesis is an effective way of relieving severe upper airway obstruction.
Collapse
Affiliation(s)
- Dries Govaerts
- Department of Cranio-Maxillofacial Surgery, Antwerp University Hospital, Drie Eikenstraat 655, 2650 Edegem, Belgium; Oral & Maxillofacial Surgery, ZMACK Association, AZ Monica Hospital Antwerp, Harmoniestraat 68, 2018 Antwerp, Belgium; Faculty of Medicine & Health Sciences, University of Antwerp, Campus Drie Eiken, Universiteitsplein 1, 2610 Antwerp, Belgium
| | - Sofia Kalantary
- Department of Cranio-Maxillofacial Surgery, Antwerp University Hospital, Drie Eikenstraat 655, 2650 Edegem, Belgium; Oral & Maxillofacial Surgery, ZMACK Association, AZ Monica Hospital Antwerp, Harmoniestraat 68, 2018 Antwerp, Belgium; Faculty of Medicine & Health Sciences, University of Antwerp, Campus Drie Eiken, Universiteitsplein 1, 2610 Antwerp, Belgium
| | - Elke Van de Casteele
- Department of Cranio-Maxillofacial Surgery, Antwerp University Hospital, Drie Eikenstraat 655, 2650 Edegem, Belgium; Oral & Maxillofacial Surgery, ZMACK Association, AZ Monica Hospital Antwerp, Harmoniestraat 68, 2018 Antwerp, Belgium; Faculty of Medicine & Health Sciences, University of Antwerp, Campus Drie Eiken, Universiteitsplein 1, 2610 Antwerp, Belgium; All for Research VZW, Harmoniestraat 68, 2018 Antwerp, Belgium
| | - Nasser Nadjmi
- Department of Cranio-Maxillofacial Surgery, Antwerp University Hospital, Drie Eikenstraat 655, 2650 Edegem, Belgium; Oral & Maxillofacial Surgery, ZMACK Association, AZ Monica Hospital Antwerp, Harmoniestraat 68, 2018 Antwerp, Belgium; Faculty of Medicine & Health Sciences, University of Antwerp, Campus Drie Eiken, Universiteitsplein 1, 2610 Antwerp, Belgium; All for Research VZW, Harmoniestraat 68, 2018 Antwerp, Belgium.
| |
Collapse
|
3
|
Resnick CM, Rottgers SA, Wright JM, Vyas RM, Goldstein JA, Swanson JW, Padula MA, Coghill CH, Ahmad I, Molter DW, Menezes MD, Naing KW, Cielo CM. Surgical Outcome and Treatment Trends in 1289 Infants with Micrognathia: A Multicenter Cohort. Plast Reconstr Surg 2024; 154:155e-166e. [PMID: 37184511 DOI: 10.1097/prs.0000000000010639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Studies of infants with micrognathia, especially Robin sequence, are limited by its rarity and both phenotypic and diagnostic variability. Most knowledge of this condition is sourced from small, single-institution samples. METHODS This is a cross-sectional study including infants with micrognathia admitted to 38 Children's Hospital Neonatal Consortium centers from 2010 through 2020. Predictor variables included demographic data, birth characteristics, cleft, and syndrome status. Outcome variables included length of stay, death, feeding or respiratory support, and secondary airway operations. RESULTS A total of 1289 infants with micrognathia had surgery to correct upper airway obstruction. Mean age and weight at operation were 34.8 ± 1.8 weeks and 3515.4 ± 42 g, respectively. A syndromic diagnosis was made in 150 (11.6%) patients, with Stickler (5.4%) and Treacher Collins (2.2%) syndromes being the most common. Operations included mandibular distraction osteogenesis (MDO) in 66.3%, tracheostomy in 25.4%, and tongue-lip adhesion (TLA) in 8.3%. Patients receiving a tracheostomy had lower birthweight, head circumference, gestational age, and Apgar scores. Patients undergoing MDO were less likely to need a second airway operation compared with patients undergoing TLA (3.5% versus 17.8%; P < 0.001). The proportion of infants feeding exclusively orally at hospital discharge differed significantly, from most to least: MDO, TLA, and tracheostomy. Hospital length of stay was not statistically different for patients who had MDO or TLA, but was longer for those with primary tracheostomy. The mortality rate was low for all operations (0.5%). CONCLUSIONS In this surgical patient cohort, MDO was associated with shorter hospital stay, improved oral feeding, and lower rates of secondary airway operations. Prospective multicenter studies are necessary to support these conclusions. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
Collapse
Affiliation(s)
- Cory M Resnick
- From the Department of Plastic and Oral Surgery, Boston Children's Hospital
| | - S Alex Rottgers
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital
| | - Joshua M Wright
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital
| | - Raj M Vyas
- Department of Aesthetic and Plastic Surgery, University of California, Irvine
| | | | | | | | | | - Irfan Ahmad
- Division of Neonatology, Children's Hospital of Orange County
| | - David W Molter
- Department of Otolaryngology, St. Louis Children's Hospital
| | | | | | | |
Collapse
|
4
|
Willershausen I, Krautkremer N, Ströbel A, Abu-Tair T, Paulsen F, Strobel K, Kopp M, May MS, Uder M, Krautkremer F, Gölz L. Evaluation of hard palate and cleft morphology in neonates with Pierre Robin Sequence and Cleft Palate Only. Orthod Craniofac Res 2024. [PMID: 38783751 DOI: 10.1111/ocr.12818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES This study aimed to establish a fully digital measurement protocol for standardizing the description of hard palate and cleft morphology in neonates with an isolated cleft palate (CPO) and Pierre Robin sequence (PRS). MATERIALS AND METHODS A total of 20 digitized plaster models of neonates with CPO and 20 digitized plaster models of neonates with PRS were retrospectively investigated. For the control group, the hard palate was segmented from 21 pre-existing 1.5 T MRI datasets of neonates and exported as an STL file. The digital models were marked with predefined reference points by three raters. Distance, angular, and area measurements were performed using Blender and MeshLab. RESULTS Neonates with CPO (20.20 ± 2.33 mm) and PRS (21.41 ± 1.81 mm) had a significantly shorter hard palate than the control group (23.44 ± 2.24 mm) (CPO vs. control: P < .001; PRS vs. control: P = .014). Notably, neonates with PRS (33.05 ± 1.95 mm) demonstrated a significantly wider intertuberosity distance than those with CPO (30.52 ± 2.28 mm) (P = .012). Furthermore, there were also significant differences measured between the cleft and control groups (25.22 ± 2.50 mm) (P < .001). CONCLUSIONS The data from this study demonstrate the feasibility of using MRI datasets to generate digital models of the hard palate. The presence of a cleft palate leads to pronounced adaptations of the total palatal surface area, dorsal width, and length of the hard palate. Mandibular retrognathia and altered tongue position in PRS, as opposed to CPO, might further impact palatal morphology and intertuberosity distance.
Collapse
Affiliation(s)
- Ines Willershausen
- Department of Orthodontics and Orofacial Orthopedics, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Nils Krautkremer
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technische Universität München, Munich, Germany
| | - Armin Ströbel
- Center for Clinical Studies (CCS), Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Tariq Abu-Tair
- Department of Pediatric Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Friedrich Paulsen
- Institute of Functional and Clinical Anatomy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Karin Strobel
- Department of Orthodontics and Orofacial Orthopedics, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Markus Kopp
- Institute of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Matthias Stefan May
- Institute of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Uder
- Institute of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Franziska Krautkremer
- Department of Orthodontics and Orofacial Orthopedics, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Lina Gölz
- Department of Orthodontics and Orofacial Orthopedics, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| |
Collapse
|
5
|
Resnick CM, Katz E, Varidel A. Application of the MicroNAPS Classification for Robin Sequence. Cleft Palate Craniofac J 2024:10556656241229892. [PMID: 38303142 DOI: 10.1177/10556656241229892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE The only findings consistent among infants with Robin sequence (RS) are the presence of micrognathia, glossoptosis, and upper airway obstruction (UAO). Feeding and growth dysfunction are typical. The etiopathogenesis of these findings, however, is highly variable, ranging from sporadic to syndromic causes, with widely disparate levels of severity. This heterogeneity has created inconsistency within RS literature and debate about appropriate workup and treatment. Despite several attempts at stratification, no system has been broadly adopted. DESIGN We recently presented a novel classification that is summarized by the acronym MicroNAPS. Each of 5 elements is scored: Micrognathia, Nutrition, Airway, Palate, Syndrome/comorbidities, and element scores are summarized into a "stage". RESULTS Testing of this system in a sample of 100 infants from our center found it to be clinically relevant and to predict important management decisions and outcomes. CONCLUSIONS We herein present an interactive website (www.prscalculator.com) and printable reference card for simple application of MicroNAPS, and we advocate for this classification system to be adopted for clinical care and research.
Collapse
Affiliation(s)
- Cory M Resnick
- Associate Professor of Oral and Maxillofacial Surgery, Harvard Medical School, Boston, MA, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Eliot Katz
- Assistant Professor of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Pulmonary-Sleep Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Alistair Varidel
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
- Fellow in Pediatric Craniofacial Surgery, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
6
|
Padula MA, Naing K, Wenger TL, Ahmad I, Coghill CH, Wild KT, Rottgers SA, Resnick CM, Goldstein J, Ehsan Z, Watkins D, Deptula N, Lai KC, Lioy J, Gogcu S, Cielo CM. Spectrum of Disease in Hospitalized Newborns with Congenital Micrognathia: A Cohort of 3,236 Infants at North American Tertiary-Care Intensive Care Units. J Pediatr 2024; 265:113799. [PMID: 37879601 PMCID: PMC10872910 DOI: 10.1016/j.jpeds.2023.113799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/15/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To describe the spectrum of disease and burden of care in infants with congenital micrognathia from a multicenter cohort hospitalized at tertiary care centers. STUDY DESIGN The Children's Hospitals Neonatal Database was queried from 2010 through 2020 for infants diagnosed with micrognathia. Demographics, presence of genetic syndromes, and cleft status were summarized. Outcomes included death, length of hospitalization, neonatal surgery, and feeding and respiratory support at discharge. RESULTS Analysis included 3,236 infants with congenital micrognathia. Cleft palate was identified in 1266 (39.1%). A genetic syndrome associated with micrognathia was diagnosed during the neonatal hospitalization in 256 (7.9%). Median (IQR) length of hospitalization was 35 (16, 63) days. Death during the hospitalization (n = 228, 6.8%) was associated with absence of cleft palate (4.4%, P < .001) and maternal Black race (11.6%, P < .001). During the neonatal hospitalization, 1289 (39.7%) underwent surgery to correct airway obstruction and 1059 (32.7%) underwent gastrostomy tube placement. At the time of discharge, 1035 (40.3%) were exclusively feeding orally. There was significant variability between centers related to length of stay and presence of a feeding tube at discharge (P < .001 for both). CONCLUSIONS Infants hospitalized with congenital micrognathia have a significant burden of disease, commonly receive surgical intervention, and most often require tube feedings at hospital discharge. We identified disparities based on race and among centers. Development of evidence-based guidelines could improve neonatal care.
Collapse
Affiliation(s)
- Michael A Padula
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Khatija Naing
- School of Public Health, University of Illinois Chicago, Chicago, IL
| | - Tara L Wenger
- Division of Genetic Medicine, University of Washington, Seattle, WA
| | - Irfan Ahmad
- Division of Neonatology, Children's Hospital of Orange County, Orange, CA
| | - Carl H Coghill
- Division of Neonatology, Children's of Alabama, Birmingham, AL
| | - K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - S Alex Rottgers
- Division of Plastic & Reconstructive Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Cory M Resnick
- Department of Plastic & Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Jeffrey Goldstein
- Department of Plastic & Reconstructive Surgery, Children's Mercy Hospital, Kansas City, MO
| | - Zarmina Ehsan
- Section of Pulmonary and Sleep Medicine, Children's Mercy Hospital, Kansas City, MO
| | - Donna Watkins
- Division of Neonatology, Riley Hospital for Children IU Health Physicians, Indianapolis, IN
| | - Nicole Deptula
- Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO
| | - Kuan-Chi Lai
- Division of Neonatology, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Janet Lioy
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Semsa Gogcu
- Division of Neonatology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christopher M Cielo
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| |
Collapse
|
7
|
Gasparin M, Barth FL, Pauletti LF, Simon MISDS, da Nóbrega Figueiredo RI, Schweiger C, Levy DS, Marostica PJC. Therapeutic Management with Airway Clearance in Children with Robin Sequence and Association with Swallowing Outcomes: A Systematic Review and Meta-analysis. Dysphagia 2023; 38:1267-1276. [PMID: 36763186 DOI: 10.1007/s00455-023-10561-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023]
Abstract
Dysphagia in Robin Sequence can be present in varying degrees, requiring multidisciplinary management and specific swallowing assessment by a specialist. Most studies published to date have evaluated only respiratory outcomes, and the available evidence on the improvement of swallowing is questionable. To conduct a systematic review and meta-analysis of studies evaluating swallowing in children with Robin Sequence before and after airway clearance procedures. The research question was developed based on the PICO strategy. The literature search was performed in electronic databases and gray literature. Studies were selected by 3 independent reviewers. The risk of bias and level of evidence of the studies were assessed. A proportion meta-analysis was performed to calculate the prevalence of dysphagia after airway clearance procedures. The search identified 4938 studies, 5 of which were included. All studies had limitations in terms of design and sample size. The prevalence of dysphagia after airway clearance was obtained by analyzing treatment subgroups: mandibular distraction osteogenesis, mandibular distraction osteogenesis + tracheostomy tube, and nasopharyngeal tube. Clinical and/or instrumental assessment was assessed by a swallowing specialist. The meta-analysis was precluded by the limitations of the studies, especially regarding sample size, which affected the accuracy of the findings. Dysphagia remained unresolved in 55% of children (95% CI 1-99%). The methodological quality of the studies indicated a high risk of bias and very low level of evidence. It was not possible to confirm that airway clearance techniques used in Robin Sequence improve dysphagia.
Collapse
Affiliation(s)
- Marisa Gasparin
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), R. Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil.
| | - Fabiola Luciane Barth
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), R. Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil
| | - Luciane Ferreira Pauletti
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), R. Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil
| | - Miriam Izabel Souza Dos Santos Simon
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), R. Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil
| | | | - Cláudia Schweiger
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), R. Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil
- Department of Otolaryngology, Pediatric Otolaryngology Unit, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, Av. Protásio Alves, 211, Porto Alegre, RS, 90035-903, Brazil
| | - Deborah Salle Levy
- School of Speech-Language Pathology and Audiology, UFRGS, Rua Ramiro Barcelos 2492, Porto Alegre, RS, 90035-003, Brazil
| | - Paulo José Cauduro Marostica
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), R. Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil
- Department of Pediatrics, Pediatric Pulmonology Unit, HCPA, Rua Ramiro Barcelos, 2350, Av. Protásio Alves, 211, Porto Alegre, RS, 90035-903, Brazil
| |
Collapse
|
8
|
Abstract
Safe and effective management of the neonatal airway requires knowledge, teamwork, preparation and experience. At baseline, the neonatal airway can present significant challenges to experienced neonatologists and paediatric anaesthesiologists, and increased difficulty can be due to anatomical abnormalities, physiological instability or increased situational stress. Neonatal airway obstruction is under recognised, and should be considered an emergency until the diagnosis and physiological implications are understood. When multiple types of difficulties are present or there are multiple levels of anatomical obstruction, the challenge increases exponentially. In these situations, preparation, multi-disciplinary teamwork and a consistent hospital-wide approach will help to reduce errors and morbidity.
Collapse
Affiliation(s)
- Toby Kane
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Australia
| | - David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Department of Neonatology, Royal Children's Hospital, Parkville, Australia.
| | - Anastasia Pellicano
- Department of Neonatology, Royal Children's Hospital, Parkville, Australia; Paediatric Infant Perinatal Emergency Retrieval, Royal Children's Hospital, Parkville, Australia
| | - Stefano Sabato
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Australia; Anaesthetics, Murdoch Children's Research Institute, Parkville, Australia
| |
Collapse
|
9
|
Resnick CM, Katz E, Varidel A. MicroNAPS: A Novel Classification for Infants with Micrognathia, Robin Sequence, and Tongue-based Airway Obstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5283. [PMID: 37744769 PMCID: PMC10513129 DOI: 10.1097/gox.0000000000005283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/02/2023] [Indexed: 09/26/2023]
Abstract
Background Robin sequence (RS) describes a heterogeneous population with micrognathia, glossoptosis, and upper airway obstruction (UAO). Workup, treatment, outcomes assessment, and research inclusion are widely variable. Despite several classifications and algorithms, none is broadly endorsed. The objective of this investigation was to develop and trial a novel classification system designed to enhance clinical communication, treatment planning, prognostication, and research. Methods This is a retrospective cross-sectional study. A classification system was developed with five elements: micrognathia, nutrition, airway, palate, syndrome/comorbidities (MicroNAPS). Definitions and a framework for "stage" assignment (R0-R4) were constructed. Stage "tongue-based airway obstruction" (TBAO) was defined for infants with glossoptosis and UAO without micrognathia. MicroNAPS was applied to 100 infants with at least 1-year follow-up. Clinical course, treatment, airway, and feeding characteristics were assessed. Descriptive and analytic statistics were calculated and a P value less than 0.05 was considered significant. Results Of the 100 infants, 53 were male. Mean follow-up was 5.0 ± 3.6 years. R1 demonstrated feeding-predominant mild RS for which UAO was managed nonoperatively but gastrostomy tubes were prevalent. R2 was characterized by airway-predominant moderate RS, typically managed with mandibular distraction or tongue-lip adhesion, with few gastrostomy tubes and short lengths-of-stay. R3 denoted severe RS, with similar UAO treatment to R2, but with more surgical feeding tubes and longer admissions. R4 represented a complex phenotype with 33% tracheostomies, protracted hospitalizations, and delayed palatoplasty. R0 ("at risk") and TBAO groups displayed the most variability. Conclusions MicroNAPS is easy to use and associated with relevant disease characteristics. We propose its adoption in clinical and research settings.
Collapse
Affiliation(s)
- Cory M. Resnick
- From the Department of Oral and Maxillofacial Surgery, Harvard Medical School, Boston, Mass
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Mass
| | - Eliot Katz
- Department of Pediatrics, Harvard Medical School, Boston, Mass
- Department of Pulmonary-Sleep Medicine, Boston Children’s Hospital, Boston, Mass
| | - Alistair Varidel
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Mass
| |
Collapse
|
10
|
Analysis of Upper Airway Flow Dynamics in Robin Sequence Infants Using 4-D Computed Tomography and Computational Fluid Dynamics. Ann Biomed Eng 2023; 51:363-376. [PMID: 35951208 DOI: 10.1007/s10439-022-03036-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/20/2022] [Indexed: 01/25/2023]
Abstract
Robin Sequence (RS) is a potentially fatal craniofacial condition characterized by undersized jaw, posteriorly displaced tongue, and resultant upper airway obstruction (UAO). Accurate assessment of UAO severity is crucial for management and diagnosis of RS, yet current evaluation modalities have significant limitations and no quantitative measures of airway resistance exist. In this study, we combine 4-dimensional computed tomography and computational fluid dynamics (CFD) to assess, for the first time, UAO severity using fluid dynamic metrics in RS patients. Dramatic intrapopulation differences are found, with the ratio between most and least severe patients in breathing resistance, energy loss, and peak velocity equal to 40:1, 20:1, and 6:1, respectively. Analysis of local airflow dynamics characterized patients as presenting with primary obstructions either at the location of the tongue base, or at the larynx, with tongue base obstructions resulting in a more energetic stenotic jet and greater breathing resistance. Finally, CFD-derived flow metrics are found to correlate with the level of clinical respiratory support. Our results highlight the large intrapopulation variability, both in quantitative metrics of UAO severity (resistance, energy loss, velocity) and in the location and intensity of stenotic jets for RS patients. These results suggest that computed airflow metrics may significantly improve our understanding of UAO and its management in RS.
Collapse
|
11
|
Lam AS, Bindschadler MD, Evans KN, Friedman SD, Blessing MS, Bly R, Cunningham ML, Egbert MA, Ettinger RE, Gallagher ER, Hopper RA, Johnson K, Perkins JA, Romberg EK, Sie KCY, Susarla SM, Zdanski CJ, Wang X, Otjen JP, Perez FA, Dahl JP. Accuracy and Reliability of 4D-CT and Flexible Laryngoscopy in Upper Airway Evaluation in Robin Sequence. Otolaryngol Head Neck Surg 2021; 166:760-767. [PMID: 34253111 DOI: 10.1177/01945998211027353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To evaluate the performance of 4-dimensional computed tomography (4D-CT) in assessing upper airway obstruction (UAO) in patients with Robin sequence (RS) and compare the accuracy and reliability of 4D-CT and flexible fiber-optic laryngoscopy (FFL). STUDY DESIGN Prospective survey of retrospective clinical data. SETTING Single, tertiary care pediatric hospital. METHODS At initial and 30-day time points, a multidisciplinary group of 11 clinicians who treat RS rated UAO severity in 32 sets of 4D-CT visualizations and FFL videos (dynamic modalities) and static CT images. Raters assessed UAO at the velopharynx and oropharynx (1 = none to 5 = complete) and noted confidence levels of each rating. Intraclass correlation and Krippendorff alpha were used to assess intra- and interrater reliability, respectively. Accuracy was assessed by comparing clinician ratings with quantitative percentage constriction (QPC) ratings, calculated based on 4D-CT airway cross-sectional area. Results were compared using Wilcoxon rank-sum and signed-rank tests. RESULTS There was similar intrarater agreement (moderate to substantial) with 4D-CT and FFL, and both demonstrated fair interrater agreement. Both modalities underestimated UAO severity, although 4D-CT ratings were significantly more accurate, as determined by QPC similarity, than FFL (-1.06 and -1.46 vs QPC ratings, P = .004). Overall confidence levels were similar for 4D-CT and FFL, but other specialists were significantly less confident in FFL ratings than were otolaryngologists (2.25 and 3.92, P < .0001). CONCLUSION Although 4D-CT may be more accurate in assessing the degree of UAO in patients with RS, 4D-CT and FFL assessments demonstrate similar reliability. Additionally, 4D-CT may be interpreted with greater confidence by nonotolaryngologists who care for these patients.
Collapse
Affiliation(s)
- Austin S Lam
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Michael D Bindschadler
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kelly N Evans
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Seth D Friedman
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Matthew S Blessing
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Randall Bly
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Michael L Cunningham
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Mark A Egbert
- Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Oral and Maxillofacial Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Oral and Maxillofacial Surgery, University of Washington, Seattle, Washington, USA
| | - Russell E Ettinger
- Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Plastic Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Emily R Gallagher
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Richard A Hopper
- Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Plastic Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Kaalan Johnson
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jonathan A Perkins
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Erin K Romberg
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathleen C Y Sie
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Srinivas M Susarla
- Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Oral and Maxillofacial Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Division of Plastic Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Carlton J Zdanski
- Department of Otolaryngology/Head & Neck Surgery and Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Xing Wang
- Biostatistics, Epidemiology and Analytics in Research (BEAR) Core, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jeffrey P Otjen
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Francisco A Perez
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA.,Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| |
Collapse
|