Craniofacial dysostosis: airway obstruction and craniofacial surgery

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.

Secondary Le Fort III after Early Fronto-Facial Monobloc Normalizes Sleep Apnea in Faciocraniosynostosis: A Cohort Study

BACKGROUND

This study aims to assess the improvement of sleep apnea after secondary Le Fort III facial advancement with distraction (LF3) in faciocraniosynostosis (FCS) patients with sleep apnea who have previously undergone fronto-facial monobloc advancement (FFMBA) with distraction.

METHODS

Patients having undergone secondary LF3 were selected from a cohort of FCS patients with documented sleep apnea who had previously undergone fronto-facial monobloc advancement. Patient charts and polysomnographic records were reviewed. Apnea-hypopnea index (AHI) was recorded before and at least 6 months after secondary LF3. The primary outcome was normalization of AHI (less than 5/h was considered normal). Hierarchical multilevel analysis was performed to predict postoperative AHI evolution.

RESULTS

Seventeen patients underwent a secondary LF3, 7.0 ± 3.9 years after the primary FFMBA. The mean age was 9.6 ± 3.9 years. A total of 15 patients (88%) normalized their AHI. Two of four patients were decannulated (50%). There was a statistically significant decrease in AHI (preoperative AHI 21.5/h vs. 3.9/h postoperatively, p=0.003). Hierarchic multilevel modeling showed progressive AHI decrease postoperatively.

CONCLUSION

Secondary LF3 improves residual or relapsing sleep apnea in FCS patients who have previously had FFMBA.

ERS Statement on pediatric long term noninvasive respiratory support

Long term noninvasive respiratory support, comprising continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV), in children is expanding worldwide, with increasing complexities of children being considered for this type of ventilator support and expanding indications such as palliative care. There have been improvements in equipment and interfaces. Despite growing experience, there are still gaps in a significant number of areas: there is a lack of validated criteria for CPAP/NIV initiation, optimal follow-up and monitoring; weaning and long term benefits have not been evaluated. Therapeutic education of the caregivers and the patient is of paramount importance, as well as continuous support and assistance, in order to achieve optimal adherence. The preservation or improvement of the quality of life of the patient and caregivers should be a concern for all children treated with long term CPAP/NIV. As NIV is a highly specialised treatment, patients are usually managed by an experienced pediatric multidisciplinary team. This Statement written by experts in the field of pediatric long term CPAP/NIV aims to emphasize on the most recent scientific input and should open up to new perspectives and research areas.

Successful management of anesthesia complications in a child with Crouzon syndrome

Crouzon syndrome (CS) is a rare autosomal dominant inherited disorder caused by mutations in the fibroblast growth factor receptor 2 (FGFR2) gene. The disease is characterized by premature fusion of the coronal and sagittal sutures of the skull, resulting in clinical manifestations of midfacial hypoplasia, shallow orbit, maxillary dysplasia, and occasional upper respiratory obstruction. This article presents the case of a child aged 2 years and 7 months with CS scheduled for bilateral tonsillectomy and adenoidectomy. The patient had a difficult procedure of extubation and was reintubated and the tracheal intubation was removed 2 days after surgery. The CS is a rare condition with physical characteristics that can result in difficult airway manipulation. It is important for anesthesiologists to recognize and avoid potential airway complications in the management of such patients through detailed preoperative evaluation and careful observation after surgery to reduce perioperative risks.

Patient with Crouzon Syndrome Treated with Modified Le Fort III Osteotomy without Previous Orthodontic Treatment: Case Report and a Review of the Literature

Crouzon syndrome is the most common type of craniofacial dysostosis anomaly which presents a great challenge for clinicians since birth. Multiple synostoses in the sutures of the cranial base in this syndrome result in the hypoplasia of the midface, shallow orbits, a short nasal dorsum, maxillary hypoplasia, and, in severe cases, obstruction of the upper airways. Apart from esthetic and functional problems, these patients suffer from various psychological problems which mandate correction of midface deformities at younger ages. The aim of this report is to describe the case of a 26-year-old female patient with Crouzon syndrome displaying severe midface hypoplasia and proptosis with no history of orthodontic treatment, who was treated with modified Le Fort III osteotomy with a coronal and intraoral approach without periocular incisions.

The Effect of Midface Advancement Surgery on Obstructive Sleep Apnoea in Syndromic Craniosynostosis

BACKGROUND

Children with syndromic craniosynostosis frequently suffer from obstructive sleep apnoea (OSA). The aim of the authors' study was to investigate if midface advancement surgery for patients with SC improved the severity of OSA by examining the results of sleep studies before and after surgery.

METHODS

A retrospective comparison of the pre and postoperative sleep study data of children undergoing midface advancement surgery at Great Ormond Street Hospital between 2007 and 2016.

RESULTS

A total of 65 children underwent midface advancement surgery between 2007 and 2016 at Great Ormond Street Hospital and had recorded pre- and postoperative sleep studies. Thirteen patients were excluded from the analysis as their sleep study techniques before and after surgery were not comparable (e.g., different conditions with prong/continuous positive airway pressure use). Fifty-six percent of the patients were treated by monobloc surgery and the remainder with bipartition surgery. A greater proportion of patients had a normal OSA grading following midface advancement (42.3% postoperatively vs. 23.1% preoperatively, P = 0.059) although no statistically significant categorical changes in OSA grade were observed. Seventy-one percent of the patients had a decrease in Apnoea-Hypopnoea Index after surgery (21 patients 2011 onward). Similarly, there was no significant change in median oxygen desaturation index or in oxygen saturation nadir following surgery.

CONCLUSION

The authors report one of the largest reviews of the effects of midface advancement surgery on sleep study parameters. Most patients showed improvements in Apnoea-Hypopnoea Index and OSA grading, although measures of oxygenation showed no consistent change.

Anesthetic Implications in a Child with Crouzon Syndrome

Crouzon syndrome (CS) is an autosomal dominant genetic disorder characterized by craniofacial dysostosis. Premature fusion of skull base leads to midfacial hypoplasia, shallow orbit, mandibular prognathism, overcrowding of upper teeth, high-arched palate, and upper airway obstruction. It is important for anesthesiologists managing such patients to recognize and avoid potential airway complications. Here, we present a case of a 10-year-old child with CS posted for ptosis correction surgery. Use of peripheral nerve blocks to cut down opioid requirement, inhalational induction, and maintenance are key aspects in successful management of such cases.

Crouzon's Syndrome: A Rare Genetic Disorder

Crouzon's syndrome, also known as brachial arch syndrome, is an autosomal dominant disorder with complete penetrance and variable expressivity. Described by a French neurosurgeon in 1912, it is a rare genetic disorder. Crouzon's syndrome is caused by mutation in the fibroblast growth factor receptor 2 (FGFR2) gene. Normally, the sutures in the human skull fuse after the complete growth of the brain, but if any of these sutures close early, then it may interfere with the growth of the brain. The disease is characterized by craniosynostosis, with associated dentofacial anomalies. This report describes the different clinical features in a 10-year-old male patient, with particular reference to characteristic findings of this syndrome.

HOW TO CITE THIS ARTICLE

Kaushik A, Bhatia H, Sharma N. Crouzon's Syndrome: A Rare Genetic Disorder. Int J Clin Pediatr Dent 2016;9(4):384-387.

Screening for symptoms of obstructive sleep apnea in children with severe craniofacial anomalies: assessment in a multidisciplinary unit

OBJECTIVE

To assess the incidence of airway obstruction symptoms and the presence of obstructive sleep apnea in children with severe craniofacial anomalies by a proactive screening program using a standard questionnaire and cardiorespiratory polygraphy.

PATIENTS AND METHODS

Children with severe craniofacial anomalies referred to our paediatric airway unit from February 2001 to June 2011 were eligible to be included in this retrospective, single centre study. Symptoms of airway obstruction were proactively investigated using the shorter version of the Pediatric Sleep Questionnaire (PSQ). Obstructive sleep apnea was assessed by means of cardiorespiratory polygraphy. Demographic data and reason for referral were also recorded. Primary outcomes were the prevalence of symptoms of airway obstruction and OSA.

RESULTS

44 children (24 girls) with severe craniofacial anomalies (15 Crouzon, 13 Apert, 9 Goldenhar, 5 Treacher-Collins, 2 Pfeiffer) were included, at a mean age of 5 years (range 8 months to 14 years). Reason for referral was routine follow up in 30 patients and overt OSA symptoms and signs in the remaining 14. PSQ results showed symptoms of airway obstruction in 82% of patients, being snoring the most frequent symptom (64.1%) followed by apneas (33.3%). Polygraphic studies showed inconclusive results in 8 children (18.2%), normal apnea-hypopnea index (AHI) in 16 (36.4%), mild obstructive sleep apnea in 9 (20.4%), moderate in 4 (9.1%) and severe obstructive sleep apnea in 7 (15.9%).

CONCLUSIONS

Children with craniofacial anomalies have a high prevalence of symptoms of airway obstruction and obstructive sleep apnea that support a proactive screening strategy in this highly selected population.

Airway considerations in craniofacial patients

Children with syndromic craniosynostosis have an increased risk of airway obstruction. Addressing this issue early in their clinical course helps ensure a safe result. Because of their abnormal airways and a higher risk of sleep-related breathing disorders, regular evaluation of the airway is recommended. An algorithm for evaluation, including sleep study, and management of such children is proposed. Patients with abnormal sleep studies should undergo endoscopy (nasendoscopy or flexible fiberoptic bronchoscopy) to determine the site of the obstruction and then adenotonsillectomy when appropriate. Continuous positive airway pressure, nasopharyngeal airways, or surgery, including osteotomy or even tracheostomy, may be necessary. Regular evaluation of the airway is critical, because the airway status may improve or worsen with growth of the child. Finally, ongoing communication with the craniofacial team allows planning of various procedures in the individual patient with optimal management of the airway.

Crouzon's syndrome: A review of literature and case report

Crouzon's syndrome is an autosomal dominant disorder with complete penetrance and variable expressivity. Described by a French neurosurgeon in 1912, it is a rare genetic disorder. Crouzon's syndrome is caused by mutation in the fibroblast growth factor receptor 2 (FGFR2) gene. Normally, the sutures in the human skull fuse after the complete growth of the brain, but if any of these sutures close early then it may interfere with the growth of the brain. The disease is characterized by premature synostosis of coronal and sagittal sutures which begins in the first year of life. Case report of a 7 year old boy is presented with characteristic features of Crouzon's syndrome with mental retardation. The clinical, radiographic features along with the complete oral rehabilitation done under general anesthesia and preventive procedures done are described.

Early orthodontic management of Crouzon Syndrome: a case report

Crouzon Syndrome is an autosomal dominant disorder with complete penetrance and variable expressivity. Described by a French neurosurgeon in 1912, it is a rare genetic disorder. Crouzon syndrome is caused by mutation in the fibroblast growth factor receptor 2 (FGFR2) gene. The disease is characterized by premature synostosis of coronal and sagittal sutures which begins in the first year of life. Once the sutures become closed, growth potential to those sutures is restricted. However, multiple sutural synostoses frequently extend to premature fusion of skull base causing midfacial hypoplasia, shallow orbit, maxillary hypoplasia and occasional upper airway obstruction.The case of a 7-year-old South African black boy with Crouzon Syndrome is presented. He presented with characteristic triad of cranial deformity, maxillary hypoplasia and exophthalmos. The clinical, cephalometric features and initial orthodontic management of this patient are discussed as part of multidisciplinary management.

Morphology and Growth of the Mandible in Crouzon, Apert, and Pfeiffer Syndromes

The purpose of this study was to examine mandibular morphology and growth in patients with Crouzon, Pfeiffer, and Apert syndromes using posteroanterior cephalograms. Fifteen patients with Apert (n = 2), Crouzon (n = 11), and Pfeiffer (n = 2) (11 female, 4 male) syndrome were included in this study. All patients had serial posteroanterior cephalograms at 5, 10, and 15 years of age. The bicondylar width, bigonial width, bicondylar/bigonial ratio, and ramus to intercondylar plane angle for each patient were measured on the cephalograms and compared with age-match controls. An analysis of variance analysis was carried out to detect differences between patients and controls and sex differences between patients. In both male and female patients, there was a statistically significant reduction in bicondylar width compared with age-matched controls. Male patients also had a statistically significant increase in bigonial width compared with controls and female patients at 10 and 15 years. The resulting bicondylar/bigonial ratios were significantly reduced, and the ramus to intercondylar plane angles were significantly increased in both male and female patients compared with controls. Unlike previous reports of patients with syndromic synostosis, this study demonstrates that the mandible has significant morphologic and growth abnormalities, including constriction of bicondylar width with near normal bigonial width in female patients. These findings suggest a narrowing at the cranial base with resulting restriction of normal transverse mandibular growth at the condyle. The secondary nature of the mandibular finding is suggested by the near normal or increased transverse growth at the gonion in females and males, respectively. Consequently, the ramus appears torqued inward, forming a greater angle with the cranial base.

Crouzon syndrome

BACKGROUND

Crouzon syndrome is a rare genetic disorder characterized by distinctive malformations of the skull and facial region. Premature cranial suture closure is the most common skull abnormality. Optic disc edema and proptosis are among the most common ocular findings.

CASE REPORT

We present a case of a 5-year-old girl with Crouzon syndrome displaying classic facial abnormalities along with proptosis and papilledema. The child's condition was improved dramatically after a monoblock advancement procedure.

CONCLUSIONS

The differential diagnosis of the condition and treatment options are discussed. The referring optometrist can play an integral role in the multidisciplinary care the patients require.

Undiagnosed obstructive sleep apnea syndrome in children with syndromal craniofacial synostosis

Children with syndromal craniofacial synostosis have a high risk for obstructive sleep apnea syndrome. Early diagnosis and treatment can relieve symptoms and morbidity. Little is known about the development and natural history of obstructive sleep apnea syndrome through life. The aim of this study was to investigate our experience of clinical history and treatment modalities concerning obstructive sleep apnea syndrome from birth until the current age in children with syndromal craniofacial synostosis. Children with one of the three syndromal craniofacial synostoses (Apert, Crouzon, or Pfeiffer) born between 1984 and 2001 were evaluated. The medical history and symptoms of obstructive sleep apnea syndrome were assessed by retrospective analysis of the medical records. The present and past complaints were explored by means of a questionnaire. Retrospective analysis of the medical records showed a suspicion for obstructive sleep apnea syndrome in 26% of the children compared with 53% in the questionnaire. The severity and presentation of obstructive sleep apnea syndrome were not related to the age of the child. Obstructive sleep apnea syndrome symptoms occurred in almost half of the children during colds. Several symptoms were significantly more common in children with a high suspicion for obstructive sleep apnea syndrome. Treatment modalities consisted of adenotonsillectomies, continuous positive airway pressure, and Le Fort III surgery. Use of a standard questionnaire showed that the suspicion for obstructive sleep apnea syndrome in children with syndromal craniofacial synostosis is much higher than reported in the medical records. Regular screening for obstructive sleep apnea syndrome with a standard questionnaire could be of additional value for the detection of obstructive sleep apnea syndrome in children with syndromal craniofacial synostosis.

Advances in Craniosynostosis Research and Management

The purpose of the present paper is to analyze the most recent advances in the field of craniosynostosis basic and clinical research and management, and to give an overview of the more frequently adopted surgical strategies. After reviewing some basic concepts regarding normal craniofacial embryology and growth, aetiopathogenesis of craniosynostosis and craniofacial dysostosis, classification and diagnosis and historical evolution of surgical treatment, the authors elaborate on a selection of topics that have modified our current understanding of and therapeutical approach to these disease processes. Areas covered include advances in molecular biology and genetics, imaging techniques and surgical planning, resorbable fixation technology, bone substitutes and tissue engineering, distraction osteogenesis and the spring-mediated cranioplasties, resorbable distractor devices, minimally invasive surgery and in utero surgery. A review of the main subtypes of craniosynostosis and craniofacial dysostosis is presented, including their specific clinical features and a commentary on the presently available surgical options.

OSAS in craniofacial syndromes: an unsolved problem

Although the incidence of Obstructive Sleep Apnea syndrome (OSAS) in craniofacial syndromes is high, it is often not recognized and thus not treated. In order to study the diagnostics and treatment options for these patients, we studied a group of 72 patients treated in our hospital for Apert, Crouzon, or Pfeiffer syndrome, and compared our findings with the literature. There appears to be agreement on polysomnography (PSG) and airway endoscopy as the main diagnostic options, but therapies are very diverse. Early diagnostics and prompt therapy will prevent serious complications.