Incidence of Concomitant Airway Anomalies When Using the University of California, Los Angeles, Protocol for Neonatal Mandibular Distraction

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Sir: We read with great interest Dr. Andrews and colleagues’ article entitled “Incidence of Concomitant Airway Anomalies When Using the University of California, Los Angeles, Protocol for Neonatal Mandibular Distraction.”1 Their report represents the largest study to date on the use of mandibular distraction for the treatment of infants with Pierre Robin sequence and severe airway obstruction. Based on their experience, which includes an impressive success rate of 97 percent, an algorithm is proposed for the management of these patients. Our experience with mandibular distraction in this same patient population, also published in the Journal,2 supports some of the recommendations from the University of California, Los Angeles. In 50 consecutive patients, we demonstrate that gastroesophageal reflux disease and the need for Nissen fundoplication was statistically associated with failure of distraction. However, the study by Andrews et al. makes clear recommendations not to perform mandibular distraction on patients with laryngomalacia, a suggestion not arising from evidence-based medicine.1,3 Many years ago, we initiated mandibular distraction on patients with Pierre Robin sequence and select airway anomalies. Our published experience demonstrates no statistical association of airway abnormalities with failure of distraction in appropriately selected patients. In our study population, 13 of 50 patients had associated airway abnormalities and 11 of 50 had laryngomalacia. There have been many algorithms published in the Journal based on successful treatment plans instituted by high-volume centers. Evidence of positive results are provided, but often without proof that deviation from the proposed algorithm is indeed detrimental. This assumption of a negative effect can prevent the application of useful techniques to the benefit of our patients. Mandibular distraction is effective and can alleviate airway obstruction secondary to micrognathia. We believe the indications can be extended to select patients with airway abnormalities, including laryngomalacia. Our study provides statistical support for this proposal. We hope that the craniofacial team and the University of California, Los Angeles and other institutions may consider application of distraction in this patient population as, in our experience, it can be a safe and effective intervention. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Roberto L. Flores, M.D. Kariuki Murage, M.D. Sunil S. Tholpady, M.D., Ph.D. Division of Plastic Surgery Riley Hospital for Children Indiana University Medical Center Indianapolis, Ind.