Long Term Speech Outcomes Following Midface Advancement in Syndromic Craniosynostosis

The Kaleidoscope of Midface Management in Apert Syndrome: A 23-Year Single-Institution Experience

BACKGROUND

This study assesses operative trends over time and outcomes of 5 osteotomy techniques used to treat the midface in Apert syndrome. Using clinical and photogrammetric data, the authors present their institution's selection rationale for correcting specific dysmorphologies of the midface in Apert syndrome based on the individual phenotype.

METHODS

The authors retrospectively reviewed patients with Apert syndrome who underwent midface distraction from 2000 through 2023. Patients were temporally divided by 2012 to assess differences in surgical approach. Postoperative facial dimension changes, surgical and perioperative characteristics, and complications data were compared across techniques.

RESULTS

A total of 39 patients with Apert syndrome underwent 41 midface distraction procedures (23 [56%] in the early cohort and 18 [44%] in the late cohort). The use of segmental osteotomies for frontofacial advancement increased from 0% before 2012 to 61% from 2012 onwards ( P < 0.001). Monobloc with bipartition was the only technique associated with decreased intercanthal distance ( P = 0.016), and Le Fort II with zygomatic repositioning achieved the greatest median change in bilateral canthal tilt of 8.7 degrees (interquartile range, 1.3, 8.7 degrees; P = 0.068). Monobloc with Le Fort II achieved the greatest median change in facial convexity of -34.9 degrees (interquartile range, -43.3, -29.2 degrees; P = 0.031). Severity of complications, stratified by Clavien-Dindo grade, was greater in transcranial than subcranial procedures, but similar between segmental and nonsegmental osteotomies ( P = 0.365).

CONCLUSIONS

In studying the midface in Apert syndrome and attempting to resolve its varying functional and aesthetic issues, the authors document an evolution toward multipiece osteotomies over time. With an appreciation for differential midface hypoplasia, segmentation is found to be associated with more effective normalization of the face in Apert syndrome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Characterizing age at velopharyngeal dysfunction in patients with cleft palates

BACKGROUND

Rates of velopharyngeal dysfunction (VPD) after palatoplasty are classically reported between the ages of 3 and 6 years. Here, we examined the continued risk of VPD in patients with cleft palates beyond age 6 years in our 40-year institutional cohort.

METHODS

We included patients with cleft palate and VPD who underwent follow-up in our team clinic from 1997 to 2017 and were at least 13 years old. We collected Veau class, dates of team visits, and dates of surgical interventions for VPD. Survival analysis was used to examine the age at which VPD was treated, the age differences between repair types, and the age differences between the first (1980-2001) and second (2001-2022) halves of the repair period.

RESULTS

Ninety-four patients received surgical interventions for VPD. The median age at VPD repair was 6.1 years. Repairs occurring after age 6 years totaled 51% (48/94). Secondary repair type was associated with age at VPD procedure (p < 0.01) with a median age at palatal re-repair of 12.1 years, compared to a median age of pharyngeal flap or sphincter pharyngoplasty of 4.8 and 5.2 years, respectively. Relative proportions of each repair type differed between the first and second halves of the study period (p < 0.01), with a significant reduction in sphincter pharyngoplasty (82%-18%, p < 0.01), and a significant increase in palatal re-repair (0%-71%, p < 0.01).

CONCLUSIONS

A significant proportion of patients with cleft palates required secondary palatoplasty for VPD at ages >6 years. These findings highlight the importance of interval perceptual speech evaluations through adolescence to promote optimal velopharyngeal outcomes.

Speech and Language Development, Hearing, and Feeding in Patients With Genetically Confirmed Crouzon Syndrome With Acanthosis Nigricans: A 36-Year Longitudinal Retrospective Review of Patients at the Oxford Craniofacial Unit

OBJECTIVE

Crouzon syndrome with acanthosis nigricans (CAN) is caused by the specific mutation c.1172C>A (p.Ala391Glu) in the fibroblast growth factor receptor 3 gene, and has an estimated prevalence of 1:1,000,000 births. Most cases occur de novo; however, autosomal dominant inheritance may occur. The clinical presentation typically includes craniosynostosis, midface and maxillary hypoplasia, choanal atresia/stenosis, hydrocephalus, and intracranial hypertension. Patients develop acanthosis nigricans, a hyperkeratotic skin disorder. The authors present the first known study to investigate the speech, language, hearing, and feeding of patients with CAN.

METHODS

A retrospective case-note review of patients with a genetically confirmed diagnosis of CAN attending the Oxford Craniofacial Unit during a 36-year period (1987-2023) was undertaken.

RESULTS

Participants were 6 patients with genetically-confirmed CAN (5 females, 1 male), all cases arose de novo. All patients had craniosynostosis (n = 5/6 multisuture synostosis, n = 1/6 left unicoronal synostosis). Hydrocephalus was managed through ventriculoperitoneal shunt in 67% (n = 4/6) of patients, and 67% (n = 4/6) had a Chiari 1 malformation. Patients had a complex, multifactorial feeding history complicated by choanal atresia/stenosis (100%; n = 6/6), and significant midface hypoplasia. All patients required airway management through tracheostomy (83%; n = 5/6); and/or continuous positive airway pressure (67%; n = 4/6). All patients underwent adenotonsillectomy (100%; n = 6/6). Initial failure to thrive, low weight, and/or height were seen in 100% (n = 6/6) patients; 80% (n = 4/5) had reflux; 100% (n = 6/6) had nasogastric, or percutaneous endoscopic gastrostomy based feeding during their treatment journey. All patients had hearing loss (100%; n = 6/6). Early communication difficulties were common: receptive language disorder (50%; n = 3/6); expressive language disorder (50%; n = 3/6); and speech sound disorder in 50% (n = 3/6)-necessitating the use of Makaton in 80% of patients (n = 3/5).

CONCLUSIONS

Patients with CAN experience significant respiratory, neurological, and structural obstacles to hearing, speech, language, and feeding. The authors present a recommended pathway for management to support patients in these domains.

What We Know About Intracranial Hypertension in Children With Syndromic Craniosynostosis

OBJECTIVE

A scoping review of literature about mechanisms leading to intracranial hypertension (ICH) in syndromic craniosynostosis (sCS) patients, followed by a narrative synopsis of whether cognitive and behavioral outcome in sCS is more related to genetic origins, rather than the result of ICH.

METHODS

The scoping review comprised of a search of keywords in EMBASE, MEDLINE, Web of science, Cochrane Central Register of Trials, and Google scholar databases. Abstracts were read and clinical articles were selected for full-text review and data were extracted using a structured template. A priori, the authors planned to analyze mechanistic questions about ICH in sCS by focusing on 2 key aspects, including (1) the criteria for determining ICH and (2) the role of component factors in the Monro-Kellie hypothesis/doctrine leading to ICH, that is, cerebral blood volume, cerebrospinal fluid (CSF), and the intracranial volume.

RESULTS

Of 1893 search results, 90 full-text articles met criteria for further analysis. (1) Invasive intracranial pressure measurements are the gold standard for determining ICH. Of noninvasive alternatives to determine ICH, ophthalmologic ones like fundoscopy and retinal thickness scans are the most researched. (2) The narrative review shows how the findings relate to ICH using the Monro-Kellie doctrine.

CONCLUSIONS

Development of ICH is influenced by different aspects of sCS: deflection of skull growth, obstructive sleep apnea, venous hypertension, obstruction of CSF flow, and possibly reduced CSF absorption. Problems in cognition and behavior are more likely because of genetic origin. Cortical thinning and problems in visual function are likely the result of ICH.

A novel p.Pro871Leu missense mutation in SPECC1L gene causing craniosynostosis in a patient

INTRODUCTION

Craniosynostosis is one of the most common craniofacial abnormalities. It involves premature closure of one or more cranial sutures. Mutations in many genes have been and continue to be identified in patients.

SETTINGS AND SAMPLE POPULATION

Whole blood samples were collected from the patient and family members.

MATERIAL AND METHODS

Whole exome sequencing was performed to identify potential mutations in the patient. The results were verified by Sanger sequencing by comparing SPECC1L gene sequence of blood samples from 100 unrelated population-matched controls.

RESULTS

The patient presented with craniosynostosis with fusion of the bicoronal and sagittal sutures. A novel missense mutation (c.2612C>T, p.Pro871Leu) in the SPECC1L gene was identified. Gene analysis showed a missense mutation in exon1 of SPECC1L that led to an amino acid substitution in the region between coiled-coil domain 3 and calponin homology domain.

CONCLUSION

Our observations expand the molecular spectrum of gene mutations in craniosynostosis and emphasize the importance of gene testing in the diagnosis of craniosynostosis. The observations also reinforce the characteristics of SPECC1L-related cranial disorders.