Evaluation of keyhole-pattern reduction glossoplasty for macroglossia in beckwith-wiedemann syndrome: A multidimensional analysis of postoperative course and outcomes

The aim of this study was to evaluate the postoperative course and long-term functional and aesthetic outcomes in patients with Beckwith-Wiedemann syndrome (BWS) following surgical reduction of macroglossia, using multiple questionnaires. Patients with BWS who underwent keyhole reduction for macroglossia were included in this study. The postoperative course for each patient was recorded, and multiple questionnaires were administered to evaluate aesthetic concerns, oral incompetence or feeding difficulties, sleep-disordered breathing symptoms, and speech. Nine patients underwent ten reduction glossoplasty surgeries. The mean age at surgery was 22 months. The postoperative course for each case was uneventful, except for one patient who had wound dehiscence. The questionnaires revealed significant improvements in tongue appearance, feeding, drooling, facial appearance, and psychosocial outcomes. There was also a significant reduction in sleep-disordered breathing symptoms after surgery. Keyhole reduction glossoplasty is a safe and effective procedure for the treatment of macroglossia in BWS patients, with excellent functional and aesthetic outcomes and a low complication rate.

Beckwith-Widemann Macroglossia: The Role of Surgical Tongue Reduction

Objective: This review was conducted to define the natural history of unoperated Beckwith-Wiedemann syndrome (BWS) macroglossia and the effect of tongue reduction surgery upon breathing, eating, speaking and dentoskeletal development in individuals having BWS. Design: This is a retrospective study of medical records.

SETTING

All patients were evaluated and treated in one of two Children's Hospitals by an ACPA approved Craniofacial Team.

PATIENTS/PARTICIPANTS

Medical records were reviewed of 526 individuals having a diagnosis of BWS and evaluated in-person by a single craniofacial surgeon between 1986 and 2014 in conjunction with a series of multi-disciplinary craniofacial team colleagues. 28 individuals were excluded having had multiple tongue reductions elsewhere. 498 individuals comprise the "pre tongue-reduction group". The "post tongue-reduction group" consists of 391 individuals who underwent surgical tongue reduction by one surgeon using one technique between 1986 and 2014.

MAIN OUTCOME MEASURES

The primary outcome measure was change in anterior dental occlusion following tongue reduction surgery. Tongue reduction surgery was performed on the assumption that it would improve dentoskeletal relationships. Secondary outcome measures were: breathing, feeding/swallowing, and speech. Results: A significant difference (p<0.001) over time between the two groups was found with less anterior occlusal abnormality in the tongue reduction group. Tongue reduction surgery had no mortality and minimal morbidity for breathing, feeding/swallowing, and speech and can ameliorate obstructive sleep apnea. Conclusions: Surgical tongue reduction for BWS macroglossia is recommended for the infant or child in primary dentition with a grossly abnormal anterior tooth/jaw relationship and/or obstructive sleep apnea.

Tongue and Mandibular Disorders of the Pediatric Patient

Robin sequence, macroglossia, and ankyloglossia are disorders affecting the tongue and mandible in the pediatric population. Each of these can have a significant impact on breathing, feeding, speech, dentition, and craniofacial growth. This review discusses the interdependent and coordinated development of both the tongue and mandible, the functional impacts of these disorders, and appropriate management strategies.

Comprehensive review of the timing of surgical management of macroglossia in Beckwith-Wiedemann syndrome

Beckwith-Wiedemann Syndrome (BWS) is a rare genetic disorder that causes developmental defects as well as an elevated risk of malignancies. Macroglossia, or an enlarged tongue, is a common symptom of BWS that may have a negative influence on a person's quality of life. The aim of this systematic review is to look at the present state of knowledge about the repercussions of macroglossia, as well as the influence of the timing of surgical resection, or glossectomy, in the treatment of severe cases of macroglossia (Ref. 35). Keywords: macroglossia, Beckwith-Wiedemann syndrome, glossectomy.

Dentoskeletal features and growth pattern in Beckwith-Wiedemann spectrum: is surgical tongue reduction always necessary?

OBJECTIVES

The role of tongue reduction surgery (TRS) in preventing excessive mandibular growth and anterior open bite in children with Beckwith-Wiedemann Spectrum (BWSp) is still controversial. This cross-sectional study aimed at comparing craniofacial growth pattern in children affected by BWSp either treated or not treated with early TRS for severe macroglossia. Considering the invasive nature of such surgery, the present study could help in clarifying the need for TRS to reduce or prevent growth disturbances.

MATERIALS AND METHODS

Orthopantomography and lateral skull x-ray images were taken either from surgically treated or non-surgically treated patients, aged 5 to 8 years, to compare dentoskeletal features and craniofacial growth by cephalometric analysis. Molecular testing results were collected from their medical records.

RESULTS

Eighteen BWSp patients were consecutively recruited: 8 underwent TRS at 14.9 ± 2.2 months of age, while 10 did not. Anterior open bite and dental class III were more frequently observed in the surgically treated group, but none showed skeletal class III. No statistically significant differences were observed in growth pattern, but children treated with TRS showed a tendency towards both maxillary and mandibular prognathism with protruding lower lip. Growth pattern seemed to be not related to molecular subtypes.

CONCLUSIONS

These preliminary data suggest that early TSR does not improve craniofacial growth pattern and dentoskeletal features in BWSp children.

CLINICAL RELEVANCE

Reductive glossectomy may not be justified for preventing or avoiding oro-facial deformities in BWSp; therefore, early monitoring of maxillofacial development of each affected child has a great clinical significance.

Parotid Gland Venolymphatic Malformation Presentation As Macroglossia

Venolymphatic malformations (VLM) are the rare congenital disorders but the parotid gland VLMs are the rarest. Most of the parotid lesions present with unilateral swellings. Aetiology is unknown. Interestingly, this case came in OPD with the macroglossia and only complaint was cosmetic problem. Diagnosis was confirmed on the basis of Magnetic resonance imaging which is gold standard. Doppler ultrasonography showed low flow. Intra lesion electro cautery was done. There is need to focus on malformations and work to find out the causes.

Understanding and Treating Macroglossia

The tongue is a vital human organ that needs to be checked before beginning a dental treatment, especially one in orthodontics or sleep apnea. The size of the tongue is an issue because there is not yet a clear definition of what a normal-sized tongue is. This leads to further problems in defining macroglossia. The current article aims to define macroglossia and bringforth more information about the two different types: pseudo macroglossia and true macroglossia. It further discusses treatment solutions available, such as partial glossectomies, coblation technique, and radiofrequency waves treatment.

Submucosal Minimally Invasive Lingual Excision: An Effective, Novel Surgery for Pediatric Tongue Base Reduction

Objectives:

The aim of this study was to develop an effective single intraoral, minimally invasive technique to reduce the enlarged tongue base in children with obstructive macroglossia.

Methods:

We present the anatomic dissection of fresh cadavers and a representative case series of children who underwent submucosal minimally invasive lingual excision (SMILE) with a plasma-mediated radiofrequency device (coblation) under intraoral ultrasonic and endoscopic guidance. Multiple anatomic dissections determined the relative location of the hypoglossal nerve and lingual neurovascular bundle in relation to removable tongue base musculature. A pediatric case series demonstrates the straightforward SMILE technique.

Results:

Laboratory anatomic dissection and clinical lingual ultrasonography revealed the surgical safety borders for SMILE. The surgical safety and efficacy of SMILE is demonstrated by preoperative and postoperative clinical examinations and polysomnograms in children with obstructive macroglossia (such as Beckwith-Wiedemann and Down syndromes and tongue vascular malformation). Coblation submucosally removes excessive tongue base tissue through a small anterior tongue incision. SMILE was performed without excessive pain, bleeding, edema, infection, or tongue dysfunction.

Conclusions:

SMILE is an effective novel operation that incorporates coblation with ultrasonography and endoscopic guidance for children who need tongue base reduction. Anatomic dissection and clinical cases demonstrate the potential for aggressive yet relatively safe tissue removal by this minimally invasive technique. SMILE also has significant potential for adults with obstructive sleep apnea due to a large tongue base.

A case of symmetrical lipomatosis of the tongue presenting as macroglossia

Lipomas are the most common benign soft tissue mesenchymal tumours composed of mature adipose tissue. They are uncommon in the oral and maxillofacial regions, with 15-20 % of cases involving the head and neck region and less than 5% of all benign oral lesions. Multiple symmetric lipomatosis is rare and characterized by diffuse growth and nonencapsulated lipomas. It is usually found in the posterior neck and upper trunk and they are relatively infrequent on the oral and maxillofacial regions like Madelung disease. In the report, we describe a rare case of symmetrical lipomatosis of tongue with OSAS and Dysartria. This lesions were resected under general anesthesia. Intraoperative findings revealed only adipose tissues with replacement of lingual muscles and no capsulation. The lesion was finally diagnosed as symmetric lipomatosis of the tongue based on clinical radiological and histologic examination. SLT (Symmetrical lipomatosis of the tongue) is an extremely rare case that appears like a macroglossia. Partial glossectomy is the treatment of choice because of the improvement of symptoms and the low rate of recurrence.

KEY WORDS

Macroglossia, Oral lipoma, Tongue lipomatosis.

Long-term orthodontic and surgical treatment and stability of a patient with Beckwith-Wiedemann syndrome

Beckwith-Wiedemann syndrome (BWS) is a congenital growth disorder. Children born with BWS develop enlarged organs, including the tongue, a large body, and other signs. A woman with BWS was treated and followed for 30 years. Treatment consisted of tongue reduction, orthopedic and orthodontic treatment, orthognathic surgery, and retention. The patient was first treated when she was 5 years old. Her original orthodontic problems included macroglossia, anterior open bite, anterior crossbite, and a skeletal Class III jaw relationship caused by significant mandibular protrusion. The jaw-base relationships did not improve in the early preadolescent period after phase 1 of orthodontic treatment with a vertical chincap. With the growth spurt accompanying puberty, she developed a severe skeletal Class III jaw relationship and a constricted maxillary arch. Surgically assisted rapid maxillary expansion was performed at 23 years of age to correct the severe discrepancy between the maxillary and mandibular dental arch widths. Then, at 26 years, a LeFort I osteotomy, a horseshoe osteotomy, a bilateral sagittal split ramus osteotomy, and genioplasty were performed after presurgical orthodontic treatment with extraction of the mandibular first molars. Both the facial profile and the occlusion were stable after 6 years of retention. This case report discusses the result of long-term observation of a patient with BWS who underwent tongue reduction, early orthodontic treatment, and surgical-orthodontic treatment.

[Coblation-channelling for the tongue]

OBJECTIVE

To investigate the efficacy of Coblation-channelling for the tongue(CCT) treatment of tongue hypertrophy.

METHOD

The 31 patients with severe obstructive sleep apnea hypopnea syndrome (OSAHS) combining tongue hypertrophy staged as Friedman ll or N were performed CCT after nasal septum surgery, coblation channelling of bilateral inferior turbinate and coblation-assisted UPPP. While the vertical channelling in the base and the body of the tongue, the tilted one parallel side edge and posterior to the tongue were combined. The intraoperative and postoperative complications such as bleeding were observed. The 12 months postoperative follow-up were done by MRI of the tongue.

RESULT

The retrolingual space were expanded postoperatively. The 2 bleedings occurred immediately after channellings in the tongue body, and they were stopped by local compression. No postoperative tongue paralysis, no tongue hematoma and abscess happened. The tongue sizes changed from preoperative III or IV degree to postoperative I to II degrees. One case received three CCT sessions.

CONCLUSION

CCT treatment tongue hypertrophy is a individually safe, effective and minimally invasive treatment.

Macroglossia associated with brainstem injury

BACKGROUND

Macroglossia has been reported in patients undergoing posterior fossa neurosurgical procedures and is thought to be as a result of venous engorgement from intubation or mechanical positioning during these prolonged procedures.

METHODS

We report three patients who developed macroglossia and dysautonomia of central neurogenic origin following brainstem injury.

RESULTS

The three patients developed macroglossia and dysautonomia with wide hemodynamic fluctuations in the setting of posterior fossa injury of the lower brainstem structures, necessitating tracheostomy placement. Macroglossia was managed with dexamethasone and there was complete resolution of dysautonomia while treated with beta-blockers and gabapentin.

CONCLUSIONS

Neurointensivists should be aware of macroglossia with dysautonomia complicating brainstem injury, which may have perilous consequences in the setting of cerebral edema or intracranial hypertension.

[Perioperative management of tongue reduction surgery for macroglossia associated with Beckwith-Wiedemann syndrome -A retrospective evaluation of 14 patients--]

BACKGROUND

Macroglossia is the commonest symptom of Beckwith-Wiedemann syndrome (BWS) and sometimes requires surgical tongue reduction for cosmetic, feeding, drooling and speech problems.

METHODS

We retrospectively reviewed the perioperative course of 14 BWS patients. The subjects were children who underwent tongue reduction surgery or glossopexy between 1994 and 2008 at Osaka Medical Center for Maternal & Child Health.

RESULTS

The median age was 18 months, and the median weight was 12.2 kg at the time of surgery. One patient had the trachea intubated and another had tracheostomy to keep airway patency. Other 12 patients had no artificial airway and were premedicated with midazolam or diazepam and had the trachea intubated after induction with sevoflurane and nitrous oxide in oxygen. Only one patient developed difficult mask ventilation for which a nasal airway was applied. No patients demonstrated difficult intubation. All without preoperative artificial airway were extubated in the OR after the surgery. One patient demonstrated hypoglycemia. Airway compromise in the two patients who was intubated or had tracheostomy prior to surgery was not alleviated by the surgery.

CONCLUSIONS

Airway disorder was not alleviated by tongue reduction surgery or glossopexy.

A severe open bite case treated with orthodontics and tongue reduction surgery: 13-year followup. A case report

BACKGROUND

The management of open bite malocclusions creates controversy when treatment approach and long-term stability are considered. Tongue size, posture and habits have been associated as aetiologic and compounding factors. Reduction tongue surgery has therefore been advocated as an aid in treatment, especially when the open bite is accompanied by perceived macroglossia.

AIM

The present article describes a clinical case of a 10-year-old girl who started treatment in the mixed dentition with an excessive open bite and speech defects.

METHODS

A combination of orthodontics and a partial glossectomy was necessary to successfully address the open bite associated with an enlarged tongue.

RESULTS

The need for orthognathic surgery treatment was eliminated and the patient was satisfied with the post-treatment aesthetics, function and speech.

CONCLUSION

After 13 years of follow-up, a stable occlusion was maintained with only minor relapse.

Lymphangioma of the tongue with macroglossia: a case report

Lymphangioma are rare benign lesions of the lymphatic vessels, found mainly in the head and neck. Almost all cases of macroglossia in young children are caused by lymphangioma of the tongue. Aesthetic, occlusal, functional and psychosocial problems may arise as a result of this condition. The preferred treatment is surgery but in some cases sclerosant therapy may be used as an adjunct treatment. We report a case of lymphangioma of the tongue with macroglossia that was treated successfully with a Vshaped anterior glossectomy and discuss the surgical considerations.

Orthognathic surgery in a case of infantile facioscapulohumeral muscular dystrophy with macroglossia

INTRODUCTION

Facioscapulohumeral muscular dystrophy (FSHD) is an autosomal dominant disorder with a shortened fragment of a D4Z4 repeat on chromosome 4q35. The infantile form of FSHD is relatively rare.

CASE REPORT

Within this case report, we describe the orthognatic surgery in a patient with infantile FSHD to diminish the functional and esthetic disturbances in the orofacial region. We saw a 20-year-old female patient suffering from infantile FSHD with remarkable macroglossia and frontal open bite. Diagnosis was based on molecular genetic investigations. To improve the functions of the stomatognathic system, we performed a tongue reduction and a segment osteotomy in the frontal aspect of the mandible. The patient was satisfied with the functional and esthetic results. Lip competence and occlusion were significantly improved. Thus, orthognatic surgery can enhance oral function, facial esthetics, and general quality of life.

[Anesthetic management of a pediatric patient with Beckwith-Wiedemann syndrome accompanied by macroglossia]

We report the anesthetic management of an infant with Beckwith-Wiedemann syndrome having massive macroglossia and umbilical hernia. Umbilical hernia repair and tongue reductions were performed under general anesthesia. Although a difficult airway was anticipated, we did not have difficulty in her airway management, even with tracheal intubation. After the operation, mechanical ventilation was required for three days because of airway obstruction by secretions in the mouth and her edematous tongue. She had no complications and the postoperative course was uneventful.

[Partial glossectomy assisted with temperature-controlled radiofrequency for treating macroglossia]

OBJECTIVE

To study the clinical efficacy of partial glossectomy assisted with temperature-controlled radiofrequency for treating macroglossia.

METHODS

There were 4 patients performed this procedure. We took a rhombus shape incision in the middle of the tongue and performed a wedge excision.

RESULTS

The mouth can close entirely in all of patients and there weren' t hemorrhage and obviously swollen; Tongue's sensory function hadn't disturbance. Masticate function were normal. One patient still had the symptom that tongue lied outside the oral cavity occasionally after operation. The symptom was disappeared after Temperature-controlled radiofrequency (TCRF) ablation. All of patients' parent were satisfied with the results.

CONCLUSIONS

Partial glossectomy assisted with temperature-controlled radiofrequency for treating macroglossia is an effective, much safer and less invasive procedure without obvious adverse reactions. There are better prospects for applying.

Long-term outcomes of surgical tongue reduction in Beckwith-Wiedemann syndrome

BACKGROUND

Surgical tongue reduction is often performed in Beckwith-Wiedemann syndrome when macroglossia results in abnormal tongue function or cosmesis; however, no published studies have examined the long-term outcomes of this procedure.

METHODS

Patients older than 18 years with Beckwith-Wiedemann syndrome who had previously undergone surgical tongue reduction at the Royal Children's Hospital in Melbourne underwent assessment of speech and tongue function, mobility, sensation, and cosmesis. These assessments were performed by questionnaire on 11 subjects and by formal medical and speech pathology review in four of these 11 subjects.

RESULTS

Eleven patients aged 19 to 31 years completed responses by means of questionnaire. The most common self-reported abnormalities were continued disproportionate tongue bulk (91 percent), abnormal tongue appearance (82 percent), specific speech sound errors (73 percent), and a short tongue tip (55 percent). Formal assessments investigated speech, swallowing, taste, and tongue mobility in four quite different subjects. One of these four subjects had no detectable deficits in tongue function. All 11 patients were of normal intelligence and did not report significant difficulties in their day-to-day life that were attributable to their macroglossia or tongue reduction surgery.

CONCLUSIONS

Pediatric patients with symptomatic macroglossia requiring surgical tongue reduction may not achieve complete normality in tongue function and appearance in adulthood. It is important that surgical tongue reduction addresses the global nature of the macroglossia and aims to retain a tapered tongue tip with length sufficient to permit normal tongue movements.

Benign symmetric lipomatosis of the tongue in Madelung's disease

INTRODUCTION

Madelung's disease is characterized by benign, non-encapsulated accumulations of fat in a symmetrical manner. Although rare, symmetrical lipomatosis involving the tongue exclusively has been previously reported. Here another case is presented of Madelung's disease involving the tongue.

CASE REPORT

A 57-year-old woman was referred with the diagnosis of Madelung's disease, with slight difficulty in swallowing, dysarthria and dyspnoea while sleeping due to tongue swelling. Clinical examination revealed multiple, large disfiguring soft masses involving neck, upper arms and hips. There was enlargement of the tongue with bilateral protrusions and buccal displacement of the teeth. The masses were soft and non-tender. Bilateral partial glossectomy was performed under general anaesthesia. Histology revealed adipose tissue, interspersed within the lingual musculature.

DISCUSSION

Lipomas in Madelung's disease are characterized by multiplicity, non-encapsulation and invasiveness. Over the years, the fat deposits enlarge significantly, become cosmetically deforming, and cause dyspnoea and dysphagia in advanced cases. The aetiology of benign symmetrical lipomatosis is still unknown. It is often accompanied by liver dysfunction probably due to alcoholism. Treatment is limited to surgical removal of the fatty tissue, in patients with a severe cosmetic deformity causing psychological stress, and in patients with dyspnoea or dysphagia if there is restriction of the aerodigestive tract.

Treatment of macroglossia in Beckwith-Wiedemann syndrome

A case of macroglossia caused by Beckwith Wiedemann syndrome is reported. Beckwith-Wiedemann Syndrome is an overgrowth disorder characterized by a constellation of congenital anomalies. The most common manifestations are omphalocele, macroglossia, gigantism, and visceromegaly. When the tongue reaches a huge dimension, clinical symptoms are represented by dysphagia, alterations in speech, difficulty in chewing, obstruction of the upper airways, and psychologic consequences derived from the patient's physical appearance. The authors describe the surgical strategy performed in the reported case.

Taste after reduction of the tongue in Beckwith-Wiedemann syndrome

We tested the sensitivity of taste after reduction of the tongue in four girls with Beckwith-Wiedemann syndrome. No patient had taste blindness, but the ability to detect salty and bitter tastes declined after reduction of the tongue.

Acute exacerbation of macroglossia leading to necrosis of the anterior third of the tongue

Macroglossia is defined as an enlarged tongue that protrudes beyond the teeth or the alveolar ridge in the resting position. Macroglossia may be classified into generalised and localised based on the extent of tongue involvement. Each of these groups can be subdivided into congenital, inflammatory, traumatic, metabolic and neoplastic lesions [Myer III CM, Hotaling AJ, Reilly JS. The diagnosis and treatment of macroglossia in children. Ear Nose Throat J 1986;65:444-8]. The congenital causes are vascular anomalies such as haemangioma and lymphovenous malformations. We report the case of a large lymphovenous malformation of the tongue in a 17 month old child who developed an acute exacerbation of macroglossia following trauma. This eventually led to necrosis of the anterior third of his tongue requiring a partial glossectomy.

Dermoid cyst of the tongue: an association of dermoid cyst with bronchogenic epithelium

A congenital dermoid together with a bronchogenic cyst of the tongue is extremely rare. The diagnosis made in this case of a 1-year-old boy was "teratoid cyst of the tongue". A surgical exploration was performed under general anaesthesia via a midline sagittal glossotomy. The tumour was completely dissected and excised, the microscopical examination of the surgical specimen revealed multiple cystic cavities lined by a keratinized squamous epithelium with skin appendages and fatty tissue. Others were composed of cylindrical, ciliated epithelial cells of respiratory type. This is the third reported case in the world literature. All cases were reviewed and compared with this case.

[Method of tongue size reduction with maintenance of taste and other types of sensitivity]

All known operations for tongue size reduction in cases of macroglossia foresee end and part of back tongue excision. In this case patient will get rid of gustatory and other types of sensitivity and it is considered inevitable. Method is described to reduce tongue size allowing preserve all types of sensitivity. During the operation of end tongue excision narrow part of its edge is left in the form of mucous-muscle flap on feeding stem. Scheme of the operation is described.

Oral lymphangioma: a case report

Lymphangiomas are congenital malformations of lymphatic vessels filled with a clear protein-rich fluid containing few lymph cells. It can also occur in association with hemangioma. Large lymphangioma extending into the tissue spaces of neck is referred to as cystic hygroma. Herewith, we present a case of cystic hygroma associated with lymphangioma of tongue leading to macroglossia in a 5-year-old boy.

Acute exacerbation of macroglossia

We report the case of a large venous malformation of the tongue, preventing the patient from being able to contain it within the oral cavity. The extent of the malformation precluded a complete surgical excision. The immediate problems were; impending airway compromise, inability to speak, eat or drink, severe discomfort due to exposure-induced dryness and an embarrassing spectacle. This case demonstrates that even malformations considered to be incurable may be managed appropriately.

Cleft palate and Beckwith-Wiedemann syndrome

OBJECTIVE

Patients with Beckwith-Wiedemann syndrome suffer numerous anomalies, which vary somewhat from case to case. Cleft palate in combination with this syndrome has rarely been reported in the literature. Through two cases, this report examines the staging of the surgical repairs and the role of macroglossia in cleft palate and the consequences of the scarred palate on mandibular development.

RESULTS

Of four patients with Beckwith-Wiedemann syndrome, only two had a cleft palate. The timing of the repair in these two children was different. Speech development was satisfactory in the first case but mediocre in the second. This result seemed to be related to a poor social environment. Mandibular prognathism persisted in both cases.

CONCLUSION

The treatment of patients with cleft palate and Beckwith-Wiedemann syndrome remains complex. It is preferable not to operate on a cleft palate before performing a tongue reduction plasty, but rather to combine these two surgical interventions. This would reduce the risks of anesthesia and enable the palate to heal more efficiently. Surgical treatment should be performed after the age of 6 months and before problems in speech development occur. An orthognathic surgery at adolescence could be performed if prognathism persists. While the origin of the cleft palate is still being discussed, we cannot claim that macroglossia is related to the development of cleft palate, nor that the scarred palate has an impact on the mandibular development.

Assessment of obstructive apnea by using polysomnography and surgical treatment in patients with Beckwith-Wiedemann syndrome

PURPOSE

Obstructive apnea is sometimes seen in patients with Beckwith-Wiedemann syndrome. The cause of apnea is not limited to macroglossia, and the surgical indication for obstructive apnea has not yet been established. The authors performed polysomnography for the assessment of apnea.

METHOD

Overnight polysomnograms were obtained in 2 patients who developed obstructive apnea after 1-stage repair for omphalocele. CASE 1: Apnea index (AI), defined as apneic events per hour, indicated 17.3, and SpO2 below 95% occupied 80% of the total sleep time. Computed tomography and magnetic resonance imaging indicated obstruction of the airway between macroglossia and the hypopharynx. Central tongue resection and the division of the frenulum linguae for associated ankyloglossia were performed 97 days after birth. One month after surgery, apneic events disappeared and SpO2 below 95% occupied only 1% of the total sleep time. CASE 2: Obstructive AI indicated 28.1. Division of the frenulum linguae and anterior glossopexy were performed 55 days after birth. Postoperative polysomnogram indicated a marked reduction of AI.

CONCLUSIONS

These results indicated that polysomnography was useful for evaluating obstructive apnea and that advancement of the tongue by division of the frenulum linguae may be recommended for the treatment of obstructive apnea in patients with Beckwith-Wiedemann syndrome.

Siblings with spaced arches treated with and without partial glossectomy

Macroglossia, or enlarged tongue, is thought to be an etiological factor in open bite, bimaxillary protrusion, and dental arch spacing, and it might cause instability after orthodontic treatment. Partial glossectomy to reduce tongue size might be a useful method of solving these problems. In this report, we describe orthodontic treatment of 2 siblings with enlarged tongues and arch-space problems. The sister, whose tongue was larger and spacing problem more severe, was treated with a partial glossectomy; her brother refused surgery and was treated with a tongue-crib appliance. Stability after orthodontic treatment was evaluated.

Surgical management of lymphangiomatous or lymphangiohemangiomatous macroglossia

PURPOSE

The specific aim of this retrospective investigation was to evaluate effects of lymphangiomatous or lymphangiohemangiomatous macroglossia managed by Jian or Dingman glossectomy.

PATIENTS AND METHODS

Between 1992 and 2002, we treated surgically a total of 7 patients (5 males and 2 females) with lymphangiomatous or lymphangiohemangiomatous macroglossia. Of the 7 patients, 3 had lymphangiohemangiomatous macroglossia and 4 had lymphangiomatous macroglossia. Lymphangioma or lymphangiohemangioma, which is localized in the anterior middle two thirds of the tongue, was present in 4 patients who were operated on with Jian glossectomy. Lymphangiomatous macroglossia, which is localized in the anterior and lateral two thirds of the tongue, was present in 3 patients, who were treated with Dingman glossectomy. The complications and recurrences after surgical management were analyzed.

RESULTS

After a follow-up period of 1 to 10 years, cosmesis and function improved after surgery in all 7 patients. The tongue healed well, and the patients had no long-term complications. Postoperatively, tongue protrusion resolved in all the patients. All parents were satisfied with the postoperative appearance and did well with oral feedings. The physiologic functions that benefited most with surgical treatment were respiratory and deglutition. No patient in this investigation had macroglossia recurrence.

CONCLUSIONS

Jian or Dingman glossectomy is an effective surgical technique for lymphangiomatous or lymphangiohemangiomatous macroglossia, but both of these techniques have unique indications. Surgical techniques must be chosen in accordance with the position of lymphangiomas or lymphangiohemangiomas.

Clinical treatment of oral manifestations of Beckwith-Wiedeman syndrome in a child

Orthodontic treatment in a young patient with Beckwith-Wiedeman Syndrome (BWS) is reported and a multidisciplinary approach to the management of this syndrome is reviewed. The patient presented with a tendency to Class III malocclusion, an open-bite and a slight macroglossia, which was treated at an early age by glossotomy. It was decided to monitor growth without treatment and to wait for the best time to begin therapy. It was based only on functional rehabilitation, without any fixed appliances, in which optimum intercuspation of the teeth and the skeletal Class I relationship was achieved and maintained after the retention period of three years. In conclusion the treatment of BWS patients requires a multidisciplinary approach that includes orthodontics, orthopaedics and surgical intervention. It is also necessary to underline the significance of diagnosis at an early age and timely treatment to reduce the development of dento-skeletal alterations.

Implant treatment of macroglossia and edentulous mandible following radiotherapy for nasopharyngeal cancer: a case report

Radiotherapy for the nasopharyngeal cancer patient with poor oral care may lead to severe deterioration of the dentition and may require multiple extractions. Although the use of an implant-retained overdenture can successfully restore the function and esthetics of edentulous patients, its use can be complicated by the tissue changes subsequent to head and neck irradiation. The difficulties in implant treatment planning for an edentulous patient with macroglossia and soft tissue changes following radiotherapy are discussed.

Huge Lymphangioma of the Tongue: A Case Report

Lymphangioma of the tongue is relatively rare and may cause facial structural deformity. Using a combination of a V-shaped and central resection, we successfully treated a 6-year-old girl who had massive lymphangioma of the tongue. Postoperatively, her tongue was located completely within her mouth with good cosmetic results. Sensory and motor nerves to the tongue appeared to be intact. Her speech was also improved.

[Seip Berardinelli: the effect of the partial tongue resection]

The Seip Berardinelli or undiagnosed endocrine metabolic syndrome is a rare autosomal recessive pathology mainly described in families of Portuguese origins. This syndrome presents various metabolic disturbances responsible of various dysmorphies. We report the case of two brothers seen during their childhood for respiratory, speaking and feeding problems related to a class 3 of Angle and macroglossia. The object was to study the interaction between the size of the tongue, the prognathism and the disturbances presented in order to organize early surgery (partial glossectomy).

The role of tongue reduction

Macroglossia may occur as a congenital or acquired condition. The enlarged tongue has both functional and cosmetic deformity, which may affect the oral airway, speech, and the development of the jaws. We discuss the various tongue-reduction procedures and present cases to illustrate the uses of this procedure, its potential complications, and the results.

Surgical management of macroglossia: discussion of 7 cases

OBJECTIVE

We present an overview of international literature concerning macroglossia-related etiology, clinical and instrumental diagnoses, surgical treatments, complications, and recurrences. Moreover, we present a series of cases of patients affected by macroglossia who have been treated surgically at the Department of Maxillofacial Surgery of the University of Rome "La Sapienza".

METHODS

Between 1990 and 1999, only after attempts to solve this pathologic condition with medical and orthodontic treatment, we treated surgically a total of 7 patients (4 male and 3 female). The surgical techniques used were Köle glossectomy and Dingman and Grabb glossectomy. We analyzed the clinical and instrumental study and the surgical treatment, including possible complications and recurrences.

RESULTS

After follow-up of a period from 2 to 9 years, macroglossia recurrences were absent, showing that the Köle and the Dingman and Grabb glossectomies are viable surgical options for treatment of macroglossia.

CONCLUSION

The best therapy for each case macroglossia must be carefully evaluated, with the right medical therapy and orthodontic therapy attempted first and surgical treatment performed only when the first and second therapy fail. Moreover, surgical techniques must be chosen in accordance with the functional results that one wants to achieve and must be the most conservative technique to preserve the vascular-nerve bundle.

A less-invasive approach with orthodontic treatment in Beckwith-Wiedemann patients

The Beckwith-Wiedemann syndrome (BWS) is a rare genetic disorder, linked to an alteration on the short arm of chromosome 11 that comprises multiple congenital anomalies. Macroglossia is the predominant finding, with subsequent protrusion of dentoalveolar structures, which results in a protruding mandible, anterior open bite, abnormally obtuse gonial angle and increased mandibular length. A less-invasive treatment with orthopaedic appliances in a patient with early tongue reduction is presented. This work summarizes the oral signs linked to macroglossia, and highlights the influence of macroglossia on mandibular growth structures. In our opinion, glossotomy could be carried out in the paediatric patient as a preventive measure in that it curbs the tongue's influence on skeletal growth and dramatically reduces the duration and extensiveness of subsequent treatment.

[A neonate with Beckwith-Wiedemann syndrome who developed upper airway obstruction after glossopexy]

We report a case of a female neonate with Beckwith-Wiedemann syndrome who manifested upper airway obstruction soon after birth and suffered from intractable hypoglycemia and abdominal distention caused by nephromegaly. She was delivered at 31 weeks of gestation with 2480 g and was diagnosed as Beckwith-Wiedeman syndrome, manifesting macroglossia, hepatomegaly, nephromegaly and omphalocele. Her trachea was intubated 30 minutes after birth due to upper airway obstruction. At 12 days of life, glossopexy was performed to relieve the airway obstruction. Although tracheal extubation was successfully accomplished 12 days later, 21 days after the glossopexy she manifested apnea and hypoxia and required tracheal intubation and mechanical ventilation again. We suspected hypoglycemia or central apnea to be the cause of apnea and started the administration of somatostatin analog as a treatment for hypoglycemia. In addition to the apnea, abdominal distention caused by nephromegaly exacerbated her respiratory condition. At 69 days of life she died of sepsis complicated with disseminated intravascular coagulation and renal failure. A needle biopsy at autopsy revealed nephroblastomatosis.

Severe dental open bite malocclusion with tongue reduction after orthodontic treatment

We treated a 21-year-old woman with a severe open bite and macroglossia with a standard edgewise appliance and without partial glossectomy. This was followed by retention using a Begg-type plate retainer for the upper dental arch and a fixed canine-to-canine for the lower arch. A crib was added to the upper plate retainer for suppression of a tongue thrust. The lower arch relapsed during the retention period, with a widening of the intermolar distance, flaring of the anterior teeth, and increased mobility of the teeth. We chose tongue reduction to resolve these problems and one-third of the middle dorsal part of the tongue was excised. After the tongue reduction, the patient experienced no functional problem in mastication, swallowing, and gustation, but she complained of mild speech difficulty and slight pain on the dorsal portion of her tongue. These symptoms disappeared 6 months after surgery. At this time, the mandibular dental arch was markedly improved. The flared lower dental arch had returned to an upright position and the tooth mobility reduced to normal. No appliance was used after surgery. Most of the recovery changes occurred within 4 months. This case highlights the importance of the teeth tending to move toward a balance between the tongue pressure from the inside and labio-buccal pressure from the outside.

Tongue lesions in the pediatric population

OBJECTIVE

To describe the spectrum of pediatric tongue lesions treated surgically at Columbia-Presbyterian Medical Center from January 1990 to December 1999.

STUDY DESIGN AND SETTING

Retrospective case-series at the pediatric hospital of a tertiary care, academic medical center.

RESULTS

Seventeen patients were identified. Their ages ranged from 1 to 132 months (median, 7 months). Eight lesions were located anteriorly: mucous cyst (1), polyp (1), chronic inflammatory mass (1), hamartoma (1), squamous papilloma (2), cavernous hemangioma (1), and vascular malformation (1). Four lesions were located posteriorly: teratoma (1), glial choristoma (1), osseous choristoma (1), and benign epithelial cyst (1). Finally, there were 5 diffuse lesions including macroglossia (4) and massively infiltrating congenital lymphatic malformation (1). Symptoms included respiratory distress (3) and dysarthria (3); all other children were asymptomatic.

CONCLUSIONS

This series revealed an interesting spectrum of rare solid tumors; compared with other large series, fewer lymphatic and vascular malformations were seen. Presenting symptoms, differential diagnosis, and surgical approach were differentiated according to lesion location.

Orthodontic-surgical approach in a case of severe open-bite associated with functional macroglossia

This article discusses an orthodontic-surgical approach to a patient with a severe openbite associated with relative macroglossia. Phonoaudiologic therapy had been used for 2 years without success. Glossectomy was used as an aid for orthodontic surgery. Various treatment stages are described, and information is given on diagnosis and macroglossia correction.