Severity of Mandibular Dysmorphology in Treacher Collins Syndrome for Stratification of Perioperative Airway Risk

BACKGROUND

Patients with Treacher Collins syndrome (TCS) and attendant airway dysmorphology may be predisposed to airway complications in the perioperative period. However, limited data correlates severity of mandibular hypoplasia and airway status. This study aims to improve risk stratification for perioperative airway insufficiency in TCS by using a previously proposed mandibular severity index.

METHODS

Patient demographics, perioperative airway status, difficulty of intubation, and Cormack Lehane grade were collected and compared using a TCS mandibular hypoplasia severity grading scale in patients with TCS treated between 2000 and 2022.

RESULTS

Twenty-six patients underwent 222 procedures with institutional mandibular severity gradings as follows: 23% Grade I, 31% Grade II, 39% Grade III, 8% Grade IV. Our severity index was associated with intubation difficulty ( P <0.001) and difficult airway status ( P <0.001), with 72% of difficult airways found in grade III and grade IV patients. Mandibular retrusion and ramal hypoplasia subscores were positively correlated with measures of airway severity ( P <0.001), whereas the gonial angle was negatively correlated ( P <0.001). Age was negatively correlated with difficult visualization for endotracheal intubation ( P =0.02) but had no association with difficult airway status ( P =0.2).

CONCLUSIONS

This study found a positive correlation between severity of maxillomandibular dysmorphology and perioperative airway difficulty in TCS patients. Our findings suggest that severely affected patients require heightened vigilance throughout life, as difficult airways may not completely resolve with aging. Given the risk of morbidity and mortality associated with airway complications, proper identification and preparation for challenging airways is critical for TCS patients.

Otodental syndrome: Case report and differential diagnosis with Treacher Collins syndrome

BACKGROUND

Otodental syndrome and Treacher Collins syndrome are rare diseases that have similar clinical features, which can complicate the diagnostic process. These syndromes cause skeletal and dental abnormalities, the differential diagnosis can be based on clinical signs but only the genetic analysis can confirm it. The aim of this case report is to describe and compare clinical signs of these syndromes.

CASE REPORT

A 7-year-old patient came to our department: he presented abnormal tooth shapes and sizes, delayed teeth replacement and micrognathia. After extra- and intra-oral examination and radiographic exams, a clinical diagnosis of otodental syndrome was made, and a genetic testing was requested to confirm the diagnosis.

CONCLUSION

Dental management of patients with otodental syndrome is challenging due to agenesis, teeth malformation, lack of space for permanent dentition. Proper treatment decision is crucial to obtain the best result for the patient.

Ocular and adnexal anomalies in Treacher Collins syndrome: a retrospective multicenter study

BACKGROUND

Treacher Collins syndrome (TCS) is a rare craniofacial disorder characterized by bilateral hypoplasia of facial structures and periorbital, ocular, and adnexal anomalies. The purpose of this multicenter study was to report the prevalence of ocular and adnexal anomalies in TCS and to identify patients at risk for visual impairment.

METHODS

The medical records of patients seen at four craniofacial centers were reviewed retrospectively. The following data were reported: primary and secondary ocular and adnexal anomalies, orthoptic and ophthalmological findings, and severity of TCS based on the facial deformity.

RESULTS

A total of 194 patients were included, of whom 49.5% were examined by an ophthalmologist or optometrist. The mean age at the first visual acuity measurement was 6.96 ± 6.83 years (range, 1.50-47.08); at final measurement, 11.55 ± 10.64 years (range, 1.75-62.58). Primary ocular anomalies were reported in 98.5% of cases, secondary anomalies in 34.5%, strabismus in 27.3%, refractive errors in 49.5%, and visual impairment in 4.6%. We found no association between ocular anomalies and visual impairment or between the severity of TCS and ocular anomalies or visual impairment, except for an increased prevalence of secondary ocular anomalies in patients with more severe manifestations of TCS.

CONCLUSIONS

Ocular anomalies were present in nearly all patients with TCS, even in mild cases.

[Clinical case analysis and literature review of mandibulofacial dysostosis with microcephaly syndrome]

Objective:To explore the clinical diagnosis, otological treatment and molecular etiology in a rare syndromic hearing loss case characterized by mandibulofacial dysostosis with microcephaly（MFDM）. Methods: The proband underwent detailed history collection, systematic physical examination and phenotypic analysis, as well as audiological examination, chest X-ray, temporal bone CT and brain MRI and other imaging examinations. The blood DNA of the proband and his parents was extracted and tested by the whole exom sequencing. The EFTUD2-related-MFDM literatures published by the end of 2020 were searched and sifted in PubMed and CNKI databases,the clinical characteristics of MFDM were summarized. Results:In this study, the patient presented with hypoplasia of auricle, micrognathia, microcephaly, developmental retardation, severe sensorineural hearing loss in both ears, and developmental malformation of middle and inner ear. Genetic analysis revealed a de novo deletion c.623_624delAT in EFTUD2 gene. According to the clinical features and genetic test results, the patient was diagnosed as MFDM. In order to solve the problem of hearing loss, the patient was further performed bilateral cochlear implantation, and part of the electrodes responded well during and after operation. Conclusion:This is the first domestic reported case of MFDM caused by EFTUD2 gene mutation. The key problem of cochlear implantation for this kind of patient is to avoid damaging the malformed facial nerve during the operation.The effect of speech rehabilitation after cochlear implant operation is related to many factors such as intelligence development of the patients.

Double limbal dermoid with Tessier's paramedian facial cleft

We report the case of mandibulofacial dysostosis in a 9-year-old Indian boy presenting with unilateral double limbal dermoid in superotemporal and superonasal quadrants, high arched palate, and paramedian cleft in the right side of the nose with abnormal dentition. A multidisciplinary approach to treatment was advised. The dermoid cysts were excised surgically with a reconstruction of the ocular surface using multilayered amniotic membrane transplantation.

Multidisciplinary treatment approach in Treacher Collins syndrome

Treacher Collins syndrome (TCS) is a common genetic disorder with high penetrance and phenotypic variability. First and second branchial arches are affected in TCS, resulting in craniofacial and intraoral anomalies such as: severe convex facial profile; mid-face hypoplasia; microtia; eyelid colobomas; mandibular retrognathism; cleft palate; dental hypoplasia; heterotopic teeth; maxillary transverse hypoplasia; anterior open bite; and Angle Class II molar relationship. A high incidence of caries is also a typical finding in TCS patients. Nonetheless, even simple dental restorative procedures can be challenging in this patient population due to other associated medical conditions, such as: congenital heart defects; decreased oropharyngeal airways; hearing loss; and anxiety toward treatment. These patients often require a multidisciplinary treatment approach, including: audiology; speech and language pathology; otorhinolaryngology; general dentistry; orthodontics; oral and maxillofacial surgery; and plastic and reconstructive surgeries to improve facial appearance. This paper's purpose was to present a current understanding of Treacher Collins syndrome etiology, phenotype, and current treatment approaches.

[Use of a metal guide in the working channel of a fiberoptic scope to insert a tracheal tube in an infant with Treacher Collins syndrome and choanal atresia]

Neonates with Treacher Collins syndrome can present difficult airways. Ventilation through a face mask and laryngoscopy for tracheal intubation may prove impossible due to the craniofacial malformations that are characteristic of this syndrome. Furthermore, patients with this syndrome are at high risk of airway obstruction, meaning that awake fiberoptic endoscopy provides the best option for tracheal intubation. This technique is especially difficult in children, however, and material required for performing it in neonates is not always available. We report the case of a 5-day-old infant boy with Treacher Collins syndrome and bilateral choanal atresia in whom we used a flexible metal guide inserted into the working channel of a fiberoptic scope. The tracheal tube could then be inserted.

Mandibulofacial syndrome with growth and mental retardation, microcephaly, ear anomalies with skin tags, and cleft palate in a mother and her son: autosomal dominant or X-linked syndrome?

We report on a Brazilian mother and her son affected with mandibulofacial dysostosis, growth and mental retardation, microcephaly, first branchial arch anomalies, and cleft palate. To date only three males and one female, all sporadic cases, with a similar condition have been reported. This article describes the first familial case with this rare condition indicating autosomal dominant or X-linked inheritance.

Orthodontic treatment for a patient with Treacher-Collins syndrome: a case report

AIM

To demonstrate an orthodontic approach for a patient with Treacher-Collins syndrome.

METHODS

After growth observation and eruption of permanent teeth, a multibracket fixed appliance was applied for alignment of the teeth and bite closing. After 4 years 6 months of active treatment, Hawley retainers were used for stabilization.

CONCLUSION

An orthodontic treatment in a patient with Treacher-Collins syndrome was completed with a fairly satisfactory result.

Computer-aided surgical treatment of bilateral choanal atresia

Transnasal surgical treatment of congenital choanal atresia is difficult. A limited view to the surgical field often accounts for poor results. An occurrence of a restenosis is frequently observed requiring difficult revision surgery. Severe complications include bleeding, skull base and intracranial injuries as well as orbital injuries. We describe the use of an optical computed tomography data-based navigation system for surgical planning and intraoperative guidance to improve treatment outcome. Computer-assisted planning and computed tomography data-based navigation was used in the case of a 2-year-old infant with a history of Treacher Collins syndrome associated with bilateral choanal atresia. To reduce target registration error, registration markers were fixed to a maxillary dental splint that was inserted intraorally during image data acquisition and patient registration. A combined technique using navigational guidance and nasal and retropalatal endoscopy was used for instrument navigation successfully removing the bony atretic plates. This clinical report demonstrates the feasibility of a combined approach with surgical navigation. A larger clinical series with long-term follow up will be needed to determine the reproducibility and validation of potential benefits.

Cleft palate, bilateral external auditory canal atresia, and other midline defects associated with Diamond-Blackfan anemia: case report

Diamond-Blackfan anemia (DBA) is associated with congenital anomalies especially of the midline. When present, facial anomalies are reminiscent of Treacher-Collins syndrome, and both DBA and Treacher-Collins syndrome are disorders of ribosomal biogenesis. Herein, we describe a female infant with multiple midline defects associated with DBA and reaffirm the absence of RPS-19 mutations in DBA patients with facial anomalies.

Oral health status of children with treacher Collins syndrome

There is a lack of data on the oral health status of individuals with craniofacial syndromes. A group of 15 children with Treacher Collins syndrome, aged 5 to 15 years old, was examined and evaluated for plaque, caries and gingival problems. The ability of the patients to clean their teeth was also investigated. A high plaque index and poor efficacy of tooth-brushing was recorded. The caries and gingival indexes were not proportionally as high as the plaque accumulation. There was no association between the gingival index and presence of mouth breathing. There was predominance of the D component in both the dmft and DMFT indexes; this was associated with a need for restorative dental treatment in 60% of the patients, which indicated the need for dental care for these patients. Caretakers should be informed of the importance of oral health and oral hygiene and encouraged to take responsibility for the oral care of the children living at home.

Robin sequence: a retrospective review of 115 patients

OBJECTIVES

Review a large series of patients with Robin sequence to document the incidence of (1) associated syndromic diagnoses; (2) co-morbid conditions; (3) frequency and type of operative management for airway compromise and feeding difficulties; and (4) possible differences in treatment between syndromic and nonsyndromic infants.

METHODS

Retrospective case-review of 115 patients with Robin sequence managed between 1962 and 2002 at two tertiary-care teaching hospitals for evaluation of demographic information, clinical findings, and treatment interventions.

RESULTS

Fifty-four percent (N=63) of patients were nonsyndromic. Syndromic patients included: Stickler syndrome (18%), velocardiofacial syndrome (7%), Treacher-Collins (5%), facial and hemifacial microsomia (3%), and other defined (3.5%) and undefined (9%) disorders. There was no statistical difference between the syndromic and nonsyndromic patients with regard to need for operative airway management (Fisher's exact test, p=0.264). Forty-two percent of patients required a feeding gastrostomy tube to correct feeding difficulties. Patients with a syndromic diagnosis were more likely to be developmentally delayed. Fifty-one (44%) patients underwent operative airway management: 61% underwent tongue-lip adhesion and 39% underwent tracheotomy. Fifteen percent of patients initially had tongue-lip adhesion subsequently required tracheotomy. While the preferred treatment for respiratory compromise differed between the two institutions, the percentage of patients requiring operative intervention was similar.

CONCLUSIONS

The pathogenesis of Robin sequence is multifactorial and syndromic in nearly half of the patients. Operative treatment of respiratory failure was required in 44% of infants; the rate was similar in both hospitals. The operative approach differed significantly between the institutions, however, based on the philosophy and training of the managing surgical specialty. Co-morbid factors such as baseline cardiopulmonary and neurologic status did not play a significant role in surgical decision making.

Genioplasty Distraction Osteogenesis and Hyoid Advancement for Correction of Upper Airway Obstruction in Patients with Treacher Collins and Nager Syndromes

BACKGROUND

Treacher Collins and Nager syndromes may present with mandibular hypoplasia that causes posterior collapse of the tongue base and a decreased oropharyngeal airway. Mandibular distraction and orthognathic advancement are effective treatments to correct the airway, but failure may occur despite achieving class I occlusion. For this select population, the authors propose a novel procedure of genioplasty distraction and hyoid advancement to optimize epiglottal positioning.

METHODS

Patients diagnosed with Treacher Collins (n = 5) or Nager syndrome (n = 3) with obstructive sleep apnea or tracheostomy dependency (n = 8) underwent genioplasty distraction and hyoid advancement. Airway outcome was assessed by preoperative and 1-year follow-up comparison of (1) laryngobronchoscopy, (2) sleep studies, and (3) tracheostomy dependency. For genioplasty outcome, three groups were used: group I (distraction genioplasty, syndromic) (n = 8), group II (acute genioplasty, syndromic) (n = 7), and group III (acute genioplasty, nonsyndromic) (n = 10). Lateral cephalogram measurements were used in the preoperative, postoperative, and follow-up periods to assess horizontal and vertical advancement and relapse.

RESULTS

Epiglottal position was optimized by the procedure in all patients based on direct endoscopic assessment. All five patients with obstructive sleep apnea had resolution of symptoms, and two of three patients achieved removal of their tracheostomy. Mean advancement for groups I, II, and III was 25, 14, and 8 mm, respectively. Follow-up horizontal advancement for groups I, II, and III were 18, 4, and 6 mm, respectively. Cephalometric measurements showed a horizontal relapse for groups I, II, and III of 10, 62, and 11 percent, respectively.

CONCLUSIONS

Data suggest that genioplasty distraction allows for a greater advancement and decreased relapse rate than acute procedures alone; and genioplasty distraction with hyoid advancement is a useful technique for resolution of obstructive sleep apnea or to achieve tracheostomy removal in those syndromic patients who have already undergone mandibular advancement into a class I occlusion.

Prevalence of dental anomalies, ectopic eruption and associated oral malformations in subjects with Treacher Collins syndrome

OBJECTIVE

To examine the prevalence of dental anomalies in the deciduous and permanent teeth, ectopic eruption of permanent first molars, and associated oral malformations in individuals with Treacher Collins syndrome.

STUDY DESIGN

Clinical and radiographic examination of 15 patients with Treacher Collins syndrome, from the Hospital for Rehabilitation of Craniofacial Anomalies of the University of São Paulo, not submitted to orthodontic or orthognathic treatment.

RESULTS

Dental anomalies were present in 60% of the sample, with 1-8 anomalies per individual. Hypoplastic dental anomalies were the most common, followed by heterotopic and hyperplastic dental alterations. The most frequent anomalies were tooth agenesis (33.3%), mainly affecting the mandibular second premolars, and enamel opacities (20% of patients). Ectopic eruption of the maxillary first molars was found in 13.3% of subjects. Associated oral malformations, primarily isolated cleft palate, followed by complete cleft lip and palate and macrostomia, were observed in 66.7% of patients.

CONCLUSIONS

Presence of cleft palate associated with the syndrome is in agreement with the literature. The high prevalence of dental anomalies suggests a possible etiologic relationship, not described in the literature so far, between such alterations and the Treacher Collins syndrome. Further investigations on larger samples are required to confirm these results.

Accidental choking in a patient with Treacher Collins syndrome

A 3-year-old boy with Treacher Collins syndrome had undergone tracheostomy and placement of a secured cannula at the age of 4 months. When he was 3 years old, he manually extracted the secured cannula by himself and choked to death. Autopsy revealed upper airway obstruction with posterior deviation and mucosal hyperplasia of the radix linguae, mandibular hyperplasia, and occlusion of the artifical airway owing to intratracheal granuloma due to the long-standing tracheotomy. For safe, long-term use of a tracheostomy to maintain the airway, children with craniofacial abnormalities should be carefully supervised by their families to prevent accidental decannulation.

Treacher Collins Syndrome with choanal atresia: a case report and review of disease features

Treacher Collins Syndrome - or mandibulofacial dysostosis – is a rare condition that presents several craniofacial deformities of different levels. This is a congenital malformation involving the first and second branchial arches. Incidence is estimated to range between 1-40,000 to 1-70,000 of live births. The disorder is characterized by abnormalities of the auricular pinna, hypoplasia of facial bones, antimongoloid slanting palpebral fissures with coloboma of the lower eyelids and cleft palate. Treacher Collins Syndrome is rarely associated with choanal atresia. A multidisciplinary team, including craniofacial surgeon, ophthalmologist, speech therapist, dental surgeon and otorhinolaryngologist, is the most appropriate setting to manage these patients. This study reports a rare case of Treacher Collins Syndrome with choanal atresia, presenting literature review and multidisciplinary intervention.

Mandibular osteomyelitis and fracture successfully treated with vascularised iliac bone graft in a patient with pycnodysostosis

Pycnodysostosis is a rare sclerosing bone disorder. Complications such as osteomyelitis and fracture of the jaws are not uncommon and difficult to treat. Treatment by reconstruction with a reconstruction plate and an iliac bone graft fails in most cases. We report a case of pycnodysostosis with osteomyelitis and fracture of the mandible that was successfully treated with vascularised iliac bone graft. We believe that this procedure is the best method for the treatment of this condition.

Management of the difficult pediatric airway with Shikani Optical Stylet

The airways of children with many craniofacial and mandibulofacial malformations often present unique challenges to the anesthesiologists. We report the application of Shikani Optical Stylet (SOS) in facilitating the tracheal intubation of four children with history of difficult airway management. The SOS combines the benefits of the lightwand and fiberoptic bronchoscope.

Facial nerve palsy: a complication following anaesthesia in a child with Treacher Collins syndrome

We report a case of facial nerve palsy following anaesthesia in a child with Treacher Collins syndrome. Children in whom intubation is difficult may be at increased risk of this complication.

Neonatal Distraction Surgery for Micrognathia Reduces Obstructive Apnea and the Need for Tracheotomy

The objective of the study was to assess the effectiveness of neonatal mandibular distraction in treatment of obstructive sleep apnea in the perinatal period in preventing a tracheotomy. This was a prospective study of 17 infants at two centers with severe micrognathia who demonstrated obstructive sleep apnea refractory to conservative therapy. Age at surgery varied from 5 to 120 days. Distraction was performed at a rate of 2 mm/d. After distraction, callus consolidation was allowed for 4 to 6 weeks, and the device was then removed. Each child underwent a three-dimensional computed tomography scan before surgery and approximately 3 months after surgery. Of the 17 patients, 14 successfully underwent extubation and demonstrated significant improvement in the obstructive sleep apnea. Postoperative horizontal ramus length increased from 23.3 to 34.8 mm after surgery. Mean maxillary mandibular discrepancy was 8.28 mm before surgery and 2.2 mm after surgery. Ten infants who underwent pre- and postoperative polygraphic studies showed improvement in obstructive apnea. Three patients had postoperative polysomnographic studies only; the results were also within the normal range. The mean follow-up interval was 16.5 months (range: 8-48 months). Neonatal distraction is an effective method for treatment of micrognathia with obstructive sleep apnea in the perinatal period in preventing a tracheotomy.

Mandibular Lengthening by Distraction for Airway Obstruction in Treacher-Collins Syndrome: The Long-Term Results

Mandibular lengthening by distraction was performed in a 6-year-old severely affected Treacher-Collins syndrome patient who was tracheostomy dependent. As previously reported, this procedure permitted tracheostomy removal once distraction was complete. Now that the patient is skeletally mature, the long-term results of this intervention are reported with regard to his clinical outcome and an assessment of the anatomical changes in the upper airway during growth. Although the distraction could be considered a success in that it enabled permanent decannulation and improved the minimum cross-sectional area of the upper airway, there was no further increase in the minimum cross-sectional area of the upper airway during childhood growth. It is significant that the abnormal growth pattern of the mandible, which is characteristic of this syndrome, did not alter from its preoperative pattern once distraction was completed.

Fiberoptic Tracheal Intubation Through a Laryngeal Mask Airway in a Child with Treacher Collins Syndrome

Treacher Collins syndrome (TCS) is a rare inherited condition characterized by bilateral and symmetric abnormalities of structures within the first and second bronchial arches. The mechanism of inheritance is autosomal dominant with variable expressivity. Because of this variability in expression, some affected individuals exhibit virtually no overt clinical manifestations. However, most children with TCS present with the following classic facial features: down-sloping palpebral fissures, colobomata of the lower eyelid, scanty lower eyelashes, malar hypoplasia, and micro- or retrognathia. Cleft palate is present in up to 35% of patients and an additional 30-40% have congenital palatopharyngeal incompetence. Abnormalities of the ear are very common and vary from minor malformations to severe microtia and hearing loss. Hearing loss may be due to atresia of the auditory canals or ossicular malformation of the middle ear. Despite these many development abnormalities, TCS patients are usually of normal intelligence. We report the case of a 3 1/2-yr-old patient with TCS undergoing cleft palate repair and discuss fiberoptic intubation through a laryngeal mask airway using two endotracheal (ETT) tubes secured via an ETT connector.

Percutaneous Bone-Anchored Hearing Aid

Patients born with severe dysmorphology involving the ears usually have hearing derangements as well as other areas of the craniofacial skeleton affected. To correct the functional problem, the usual and customary treatment is augmentation of the hearing with a bone conducting hearing device. The patients have to wear these devices with an external band. The new advances in osseointegrated implant allowed us today to utilize the same technology in the patient with the application of a bone anchored hearing device. The advantages are related to the obviation of the need to use a hearing band across the head, that most children object to, and the new device is much smaller than the large and cumbersome banded device. There is also an added advantage in the improvement of the hearing as the units are anchored internally in the bone. The device utilizes digital technology and can be calibrated easily. The patient can apply the device in the morning by a simple application click. The disadvantage to the patient is that the area requires consistent maintenance and care, however, this operation can be done very easily. A sleeper osseointegrated unit is kept as a spare that can be utilized if any osseo-integrated functional problem appears. The functional changes in the hearing and the audiological improvements are well documented.

Hearing loss in the Treacher-Collins syndrome

About 50% of patients with the TCS have conductive hearing loss, caused by characteristic major and/or minor ear anomalies. It is also common for these patients to have microtia or severe malformation of the pinna. The results of [figure: see text] reconstructive surgery to improve hearing are usually moderate to poor, because of combinations of anomalies. In general, it is recommended to start hearing rehabilitation at the earliest possible stage. Owing to the above-described anomalies, rehabilitation usually involves fitting a BAHA, whether or not in combination with a pinna epithesis.

A profile of the features and speech in patients with mandibulofacial dysostosis

PURPOSE

To present a profile of the features and speech in patients with mandibulofacial dysostosis (MFD). Data were collected on occlusion, palatal condition, hearing, resonance, voice, and articulation.

PATIENTS

Thirty patients with MFD ranging in age from 1.6 to 21.0 years.

STUDY DESIGN

Retrospective and prospective cross-sectional designs.

SETTING

Pediatric tertiary care hospital.

RESULTS

Sixty percent of the patients had an open bite. Isolated cleft palate was found in 37% with other types of cleft conditions occurring less frequently. Twenty-three percent underwent tracheostomy. All patients demonstrated hearing loss, 93% were conductive and 7% were mixed. Resonance, voice, and articulation were also affected. Seventy-seven percent had aberrant resonance including hypernasality, hyponasality, mixed hyper- and hyponasality or muffled resonance, which was found in 40% of the patients. Voice quality was abnormal in 63%. All patients had articulation errors. Although overlap between categories occurred, results showed that 60% had errors related to malocclusion, 30% demonstrated errors usually associated with velopharyngeal inadequacy and 50% had general articulatory or phonological errors that could be attributed to other causes.

CONCLUSIONS

The features and speech of patients with MFD are complex. The speech disorders may have multiple overlapping etiologies that require careful differential diagnosis. This is imperative to establish appropriate treatment regimens and evaluate clinical outcomes.

Difficult paediatric intubation when fibreoptic laryngoscopy fails

We report an unusual problem with fibreoptic bronchoscopy in an 8-year-old girl with Negar syndrome. She had a history of difficult airway since birth, and had undergone mandibular distraction for severe obstructive sleep apnoea when she was aged 2 years. Nagar syndrome is a Treacher-Collins like syndrome with normal intelligence, conductive bone deafness and problems with articulation. The patients have malar hypoplasia with down slanting palpebral fissures, high nasal bridge, micrognathia, absence of lower eyelashes, low set posteriorly rotated ears, preauricular tags, atresia of external ear canal, cleft palate, hypoplasia of thumb, with or without radius, and limited elbow extension. Protracted attempts with a fibreoptic bronchoscope failed to visualize the glottis, and this was only possible when the tube was guided to the larynx by blind nasal intubation. Apparently, the healing of the wounds for the mandibular distraction in the mandibular space on the inside of the rami of the mandible had caused differential fibrosis on either side of the hyoid, leading to a triplane distortion of the larynx with a left shift, clockwise rotation to a 2-8 o'clock direction and a slight tilt towards the left pharyngeal wall. The large epiglottis overlying this had precluded a view of the larynx. Finally, the older technique of breathguided intubation facilitated fibreoptic bronchoscopy to achieve tracheal intubation.

Anaesthetic implications of Nager syndrome

Nager acrofacial dysostosis is an oromandibular hypogenesis syndrome with associated limb abnormalities. Although it shares some phenotypic features with Treacher-Collins syndrome, it is recognized as a separate disorder. The physical features of Nager syndrome include down slanted palpebral fissures, malar hypoplasia, a high nasal bridge, atretic external auditory canals, cleft palate and micrognathia. Preaxial limb malformations include absent or hypoplastic thumbs, hypoplasia of the radius and shortened humeral bones. Of primary concern to the anaesthetist are the midface and mandibular manifestations which may complicate perioperative airway management. These problems may also manifest in the postoperative period with airway obstruction. Associated defects have included vertebral malformations with reports of cervical spine involvement, congenital cardiac defects and upper limb defects affecting the preaxial or radial side. We describe a 7-year-old boy with Nager syndrome who required anaesthetic care during placement of a syringopleural shunt for drainage of a spinal cord syrinx. The perioperative implications of this disorder are reviewed.

Airway management of the severely retrognathic child: use of the laryngeal mask airway

Successful airway management of an infant or child with moderate to severe retrognathia first requires recognition of a potential problem. If the child cannot be intubated in a standard fashion, the use of a laryngeal mask airway (LMA) should be considered. We describe two cases wherein a toddler and an infant with severe retrognathia failed multiple attempts at traditional intubation. Both had an anterior larynx and hypoplasia of the mandible. In both cases, a subsequent LMA was successfully placed. The severely retrognathic newborn or child presents to the physician a unique challenge in airway management. Techniques to manage this difficult pediatric airway are different from those used in the adult. Otolaryngologists should be aware of this intubation technique and include it in their armamentarium of airway-management strategies. The LMA is not recommended as the technique of choice for securing a difficult airway, but it is an effective alternative when indicated, and it might be life-saving.

[Hemifacial microsomia treated with mandibular lengthening using intraoral distractors. On precise indications]

Mandibular hypoplasia in the hemifacial microsomia have largely benefited from distraction techniques especially intraoral. In fact, these techniques are possible in the child, replacing him in a better morphological, psychological and functional configuration. They can redynamise growth and, in any case, diminish secondary distant effects. The authors, from precise criteria, propose a surgical classification to facilitate the therapeutic decision. Intraoral and sometimes bidirectional distraction, whose results are equivalent to external distraction, present numerous advantages that, in the majority of cases, make it preferred now to external distraction. Its three-dimensional (3D) effect on bone and soft tissues and the long term follow-up must be evaluated more objectively, as pre and post-distraction stereolithographic or 3D photogrammetric may get. It must be considered in the child as the first step of skeletic surgery preparing to a facilitated second step orthopedic, orthodontic or orthognathic after puberty. In the young adult, it is in competition with conventional surgery but the slow progressive process, kind with the temporo-mandibular joints, allows in mandibular asymmetries an adaptation having avoided the need for controlateral osteotomy or a bone graft.