Treatment of macroglossia in Beckwith-Wiedemann syndrome

Assessment of the tongue frenulum in Beckwith-Wiedemann syndrome: Pre- and post-frenectomy findings

AIM

To report the pre- and post-frenectomy findings of a patient with Beckwith-Wiedemann syndrome.

METHODS AND RESULTS

Clinical case report of a patient with a confirmed genetic-molecular diagnosis of the referred syndrome. The minor was evaluated and reassessed by the protocol for the evaluation of the tongue's frenulum for babies in two moments: pre-surgical and 2 months after the frenectomy. The surgical procedure was performed using the traditional technique and, after the procedure, the minor was breastfed and received photobiomodulation with a red laser. The minor obtained 16 points in the neonatal tongue screening test, indicating the need for a frenectomy. Thus, she was referred to a dentist for surgery. After the surgical procedure, macroglossia was observed as a maternal complaint (previously not mentioned). The wound healing was satisfactory, and the total score obtained in the reapplication of the protocol (five points) showed functional results of improvements in sucking and tongue mobility, justifying the importance of the frenectomy.

CONCLUSION

Frenectomy, despite showing macroglossia related to the Beckwith-Wiedemann syndrome, allowed anatomical and functional advances of the tongue in the present clinical case.

The Utility of Early Tongue Reduction Surgery for Macroglossia in Beckwith-Wiedemann Syndrome

BACKGROUND

Macroglossia, a cardinal feature of the (epi)genetic disorder Beckwith-Wiedemann syndrome, is associated with obstructive sleep apnea, speech and/or feeding difficulties, and dental or jaw malalignment. These sequelae may be treated and/or prevented with tongue reduction surgery; the authors sought to determine whether certain Beckwith-Wiedemann syndrome patients may benefit from early surgical intervention before age 12 months.

METHODS

The authors conducted a retrospective review of patients with Beckwith-Wiedemann syndrome who underwent tongue reduction from 2014 to 2019. The authors assessed primary outcomes of change in obstructive sleep apnea by polysomnography, respiratory support required, and feeding route before and after tongue reduction, and reviewed postoperative complications and the need for repeated tongue reduction.

RESULTS

Of the 36 patients included, the median age at tongue reduction was 9.5 months (interquartile range, 3.8 to 22.8 months). For those with severe obstructive sleep apnea, there was a significant reduction in the obstructive apnea hypopnea index from 30.9 ± 21.8 per hour to 10.0 ± 18.3 per hour (p =0.019) and improvement in nadir oxyhemoglobin saturation from 72 ± 10 percent to 83 ± 6 percent (p =0.008). Although there was no significant change in overall supplemental feeding tube or respiratory support, there were specific patients who experienced clinically meaningful improvement. Of note, these positive outcomes applied equally to those who underwent surgery at a younger age (<12 months). To date, only one patient required a repeated tongue reduction.

CONCLUSION

Based on improved polysomnographic findings and rarity of surgical complications or repeated surgery, the authors' data support the safety and efficacy of this early intervention when clinical indications are present and an experienced multidisciplinary team is available for consultation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Beckwith-Wiedemann syndrome with asymmetric mosaic of paternal disomy causing hemihyperplasia

Beckwith-Wiedemann syndrome (BWS) is a congenital disorder with 3 main features-overgrowth in infancy, macroglossia, and abdominal wall defects. Here, we report on a 5-month old girl with hemihyperplasia and macroglossia caused by paternal uniparental disomy (pUPD) asymmetric mosaic on chromosome 11p15.5. She could not retract her tongue into her mouth and the midline of the tongue was shifted to the left. Glossectomy was performed at age 1 year. A specimen of the tongue showed normal skeletal muscle, but the muscle fibers were closely spaced, and there were fewer stroma components in the tissue from the right side of the tongue than that from the left side. With respect to pUPD of chromosome 11p15.5, microsatellite marker analysis of the tongue tissue specimen revealed a higher mosaic rate in the tissue from the right side of the tongue (average 48.3%) than that from the left side (average 16.9%). Methylation analysis of Kv differentially methylated region (DMR) 1 (KvDMR1) and H19DMR revealed hypomethylation of KvDMR1 and hypermethylation of H19DMR in the tissue on the right side of the tongue (hyperplastic side). In this case, the difference in mosaic rate of pUPD in the 11p15.5 region was hypothesized to influence the expression level of insulin-like growth factor 2. This result may be helpful to clinicians, especially surgeons, when planning plastic surgery for hemihyperplasia.

Beckwith-Wiedemann Syndrome: Open bite evolution after tongue reduction

BACKGROUND

Macroglossia causes functional deficits such as airway obstruction, drooling, phonation difficulties, and leads to protrusion of dentoalveolar structures resulting in an anterior open bite and a prognathic mandibular appearance. Macroglossia is present in the majority of patients with Beckwith-Wiedemann syndrome (BWS) and surgical treatment may be indicated.

MATERIAL AND METHODS

A retrospective review was conducted including BWS patients who underwent surgical tongue reduction between 2000 and 2015 at the Hospital Universitario La Paz, Madrid.

RESULTS

Out of 16 patients with BWS, surgery was performed in 11 cases. Tongue protrusion with open bite was the main indication for surgical treatment. Reduction glossectomy was performed using the keyhole technique. We analysed the relationship between age at surgery and evolution of open bite. Complications were minimal and satisfactory outcomes were observed with a decrease in anterior open bite.

CONCLUSIONS

In this study we have observed that surgical treatment in patients with BWS and open bite accompanied by macroglossia seems to provide positive results with a satisfactory outcome in dentoskeletal alterations.

Tongue volume in adults with skeletal Class III dentofacial deformities

Background

The size of the tongue is implicated as an essential etiological factor in the development of malocclusions. The aim of our study was to assess tongue size in skeletal Class III (SCIII) patients in comparison to adults with normal occlusion, using three-dimensional (3D) ultrasound.

Methods

The SCIII group consisted of 54 subjects; 34 females and 20 males and the control group contained 36 subjects, 18 from each gender with Class I relationship. 3D ultrasound images of the tongues were acquired, and then the tongues’ volumes were assessed.

Results

The males in both the SCIII and control groups had significantly larger tongue volumes than the female subjects (mean SCIII 100.8 ± 6.3 and control 92.4 ± 9.8 cm³ in males vs. SCIII 77.4 ± 10.2 and control 67.2 ± 5.6 cm³ in females). The highly significantly larger tongue volumes were in SCIII patients of both genders (p were less than 0.01 for female and 0.03 for male). The tongue volumes within the whole SCIII group were significantly larger with more negative Wits values.

Conclusion

The tongue volumes are significantly bigger in SCIII subjects than normal. Larger tongues correlate with more severe SCIII. The clinical importance of this data is that limited mandibular setback planning is necessary to prevent narrowing of respiratory airways.

Tongue reduction for macroglossia in Beckwith Wiedemann syndrome: review and application of new technique

Beckwith Wiedemann syndrome (BWS) is a rare, congenital overgrowth disorder that is characterized by macroglossia, anterior abdominal wall defects, visceromegaly, gigantism, and neonatal hypoglycaemia. Macroglossia may contribute to anterior open bite malocclusion with prognathism, speech articulation disturbances, drooling and the perception of intellectual disability. It was the purpose of this study to review a series of BWS patients who underwent surgical reduction of the tongue by a modified technique with respect to aesthetic and functional outcomes. Seven BWS patients, age 6 months to 21 months, had a 'stellate/anterior wedge' reduction with an anterior rotation flap and were followed up from 4 months to 9 years postoperatively. Assessment of aesthetics together with tongue morphology and mobility were recorded and a postoperative speech evaluation was performed. Minor contour deformities were present in two patients during function but all parents were satisfied with the results. The speech pathology assessment results indicated positive outcomes for speech, oral structure and function, and feeding for all children assessed. This modified technique allows for an adequate reduction of tongue volume with conservation of motor and sensory function as well as preservation of anatomical contour.

A multidisciplinary approach to the treatment of oral manifestations associated with Beckwith-Wiedemann syndrome: a long-term case report

BACKGROUND

Beckwith-Wiedemann syndrome (BWS) is a congenital disorder that involves a somatic overgrowth during the patient's first years of life. Exomphalos, macroglossia and gigantism are the main clinical symptoms.

CASE DESCRIPTION

The authors describe a 15-year follow-up in a patient with BWS. They focus on a multidisciplinary approach to treating the patient's oral manifestations from age 9 months. The approach included an initial physiotherapy treatment, a partial glossectomy, a first phase of orthopedic treatment with a tongue crib and chin cap, and a second phase of orthodontic treatment with an edgewise appliance.

CLINICAL IMPLICATIONS

To obtain long-term positive and stable results, an appropriate treatment plan for patients with BWS and dentoskeletal alterations, including macroglossia, requires surgical tongue reduction when the patient is young, combined with physiotherapeutic phases and orthopedic and orthodontic treatment.

[New modification of Reynwald macroglossia reduction]

INTRODUCTION

Macroglossia usually occurs as isolated malformation, however it can coexist with some of the hereditary defect. Enlargement of the tongue can cause cosmetic and functional difficulties.

AIM

The aim of this paper was to analyzed patients with macroglossia operated with own modified Reynwald method. It was based on analysis of surgical treatment and rehabilitation of patients with: Down syndrome, oral-facial-digital syndrome and cerebral palsy, treated at the Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Lodz.

MATERIAL AND METHODS

63 patients (32 females and 31 males) with Down syndrome (60), oral-facial-digital syndrome (2) and cerebral palsy (1) were operated at the Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Lodz, because of hypertrophy of the tongue. 42 patients were operated with partial resection of macroglossia, 2 of them with additional correction of the tongue border and 21 patients with own modified Reynwald method.

RESULTS

Postoperative treatment was non-complicated in all the patients. Early and long-lasting postoperative results were regard as satisfactory, and lead to improvement of basic physiological functions.

CONCLUSIONS

1. 3–6 years are the optimal age to partial macroglossia reduction. 2. Analyze of surgical macroglossia treatment showed effectiveness of methods based on partial resection of tongue. Surgical treatment with own modified Reynwald method lead to increase of number of satisfied postoperative results. 3. Partial resection of macroglossia influence on patients look, integration and environment acceptance; in children with deep retardation it simplify nursing.

The effects of macroglossia on speech: a case study

This article presents a case study of speech production in a 14-year-old Amharic-speaking boy. The boy had developed secondary macroglossia, related to a disturbance of growth hormones, following a history of normal speech development. Perceptual analysis combined with acoustic analysis and static palatography is used to investigate the specific articulatory compensations arising from the macroglossia. The subset of sounds chosen for study were the denti-alveolar and alveolar plosives, fricatives, ejectives, nasal, lateral and trill produced in single words, as well as in short phrases. The phonetic analysis revealed both spatial and temporal atypicalities in the realisations of the sounds in question. Speaking rate was slow relative to his peer's speech and attempts to increase speech rate resulted in dysfluent speech. Given the phonological system of Amharic, however, the atypical segmental realisations, while reducing both the intelligibility and acceptability of the participant's speech production, did not result in loss of phonological contrasts.

[Macroglossia and Beckwith-Wiedemann syndrome]

INTRODUCTION

In 1963 Beckwith presented a report on the first patient with extreme cytomegaly of adrenal cortex, hyperplasia of kidneys and pancreas and Leydig cell hyperplasia. Wiedemann completed description of the new syndrome by adding umbilical hernia and macroglossia. The diagnosis is made based on the clinical signs of omphalocele or some other umbilical deformity, macroglossia, congenital asymmetry, visceromegaly (liver, pancreas, and kidneys).

CASE OUTLINE

A 16-month-old male child was admitted for examination because of macroglossia. He underwent examination on several occasions by an endocrinologist due to recurrent hypoglycaemic crisis. The patient was observed by a paediatric neurophysicatrist for disorders of mental development. Hypoglycaemia, muscular hypotonia of the anterior abdominal wall with umbilical hernia and macroglossia were observed by clinical examination. Inratraoral examination revealed macroglossia with microstomia, suckling and swallowing difficulties, hypotonia of the perioral muscles with increased salivation. It was therefore decided to perform surgical reduction of the prominent tongue and develop good condition for nutrition, speech function and the development of orofacial system.

CONCLUSION

The diagnosis of macroglossia is based on subjective clinical criteria such as the morphology and amount of protrusion of the tongue, difficulty in articulating sounds, breathing, and hypersalivation. Some authors have suggested that the tongue size may be analyzed radiographically with a cephalogram. Treatment of macroglossia is controversial because of the absence of objective clinical criteria.

Síndrome de Beckwith-Wiedmann: relato de caso da intervenção fonoaudiológica

TEMA: descrever a evolução de um caso de Síndrome de Beckwith-Wiedmann com macroglossia submetido à fonoterapia quanto aos aspectos estruturais e miofuncionais do sistema estomatognático. PROCEDIMENTOS: inicialmente foram coletados os dados do prontuário e foi realizada a entrevista inicial com a mãe. Após, a paciente, com 1 ano e 2 meses de idade, foi submetida à avaliação fonoaudiológica clínica e foram realizados exames complementares (avaliação otorrinolaringológica, exame videofluoroscópico e avaliação audiológica). Após seis meses de terapia miofuncional com a utilização de técnicas passivas, foi realizada uma reavaliação. RESULTADOS: na avaliação fonoaudiológica inicial observou-se flacidez de lábios e bochechas; ausência de vedamento labial; língua com tensão diminuída, hemi-hipertrofia direita e acentuada projeção anterior; dificuldades na mastigação e na deglutição de alimentos sólidos. Decorridos seis meses de terapia miofuncional, constatou-se maior rigidez da musculatura de lábios e bochechas, posteriorização da língua com aumento da tensão muscular, e desempenho adequado na mastigação e deglutição de alimentos sólidos. CONCLUSÃO: a intervenção fonoaudiológica precoce, baseada em técnicas de terapia miofuncional, apresentou resultados considerados satisfatórios para este caso de Síndrome de Beckwith-Wiedmann com macroglossia.

Long-term impact of tongue reduction on speech intelligibility, articulation and oromyofunctional behaviour in a child with Beckwith-Wiedemann syndrome

The purpose of the present case study was to determine the long-term impact of partial glossectomy (using the keyhole technique) on overall speech intelligibility and articulation in a Dutch-speaking child with Beckwith-Wiedemann syndrome (BWS). Furthermore the present study is meant as a contribution to the further delineation of the phonation, resonance, articulation and language characteristics and oral behaviour in a child with BWS. Detailed information on the speech and language characteristics of children with BWS may lead to better guidance of pediatric management programs. The child's speech was assessed 9 years after partial glossectomy with regard to ENT characteristics, overall intelligibility (perceptual consensus evaluation), articulation (phonetic and phonological errors), voice (videostroboscopy, vocal quality), resonance (perceptual, nasometric assessment), language (expressive and receptive) and oral behaviour. A class III malocclusion, an anterior open bite, diastema, overangulation of lower incisors and an enlarged but normal symmetric shaped tongue were present. The overall speech intelligibility improved from severely impaired (presurgical) to slightly impaired (5 months post-glossectomy) to normal (9 years postoperative). Comparative phonetic inventory showed a remarkable improvement of articulation. Nine years post-glossectomy three types of distortions seemed to predominate: a rhotacism and sigmatism and the substitution of the alveolar /z/. Oral behaviour, vocal characteristics and resonance were normal, but problems with expressive syntactic abilities were present. The long-term impact of partial glossectomy, using the keyhole technique (preserving the vascularity and the nervous input of the remaining intrinsic tongue muscles), on speech intelligibility, articulation, and oral behaviour in this Dutch-speaking child with congenital macroglossia can be regarded as successful. It is not clear how these expressive syntactical problems demonstrated in this child can be explained. Certainly they are not part of a more general developmental delay, hearing problems or cognitive malfunctioning. To what extent the presence of expressive syntactical problems is a possible aspect of the phenotypic spectrum of children with BWS is subject for further research. Multiple variables, both known and unknown can affect the long-term outcome after partial glossectomy in a child with BWS. The timing and type of the surgical technique, hearing and cognitive functioning are known variables in this study. But variables such as children's motivation, the contribution of the motor-oriented speech therapy, the parental articulation input and stimulation and other family, school and community factors are unknown and are all factors which can influence speech outcome after partial glossectomy. Detailed analyses in a greater number of subjects with BWS may help further illustrate the long-term impact of partial glossectomy.