The effectiveness of mandibular distraction in improving airway obstruction: the florentine center experience.

Abstract

Sir: We read with interest the article by Tahiri entitled “The Effectiveness of Mandibular Distraction in Improving Airway Obstruction in the Pediatric Population,” published in the March issue of Plastic and Reconstructive Surgery.1 We would like to further comment on the article and to congratulate the authors for this review investigating the effectiveness of distraction osteogenesis of the mandible in the pediatric population suffering head and neck malformations with respiratory insufficiency. The topic is, socially, of elevated impact and affects the quality of life of not only children but also parents, and thus the successful resolution of the problem assumes great importance. With regard to invasive procedures, tracheotomy, tongue lip adhesion, and mandibular distraction osteogenesis are commonly performed and widely accepted. For the severely compromised airway obstruction, tracheostomy immediately solves the problem. However, this surgical solution is frequently characterized by perioperative (e.g., hypotension, cardiac arrhythmias, pneumothorax, bleeding, and peritracheal insertion) and postoperative complications/sequelae (e.g., tube occlusion/displacement, vocal cord paralysis, tracheoesophageal fistula, subcutaneous emphysema, scarring and granuloma formation, tracheomalacia, and tracheal stenosis).2,3 We would like to use this occasion to present our experience with mandibular distraction osteogenesis performed in syndromic pediatric patients suffering respiratory insufficiency to further discuss the topic. Seven patients suffering mandibular hypoplasia and respiratory distress underwent mandibular distraction osteogenesis between February of 2011 and July of 2013 as shown in Table 1. The mean patient age was 4.7 years (range, 8 months to 7 years). Five patients presented with tracheostomy at the time of surgery performed in other centers to control respiratory airways and two patients avoided tracheostomy. The presence of obstructive apnea was documented by sleep studies, followed by nasoendoscopy to rule any other causes of the obstructive apnea. A three-dimensional computed tomographic scan was obtained to document the anatomy and help plan a vector of distraction. Bilateral external distractors were used in all cases and fixed as follows: the mandibular angle (n = 2), body (n = 3), and ramus (n = 2). The average linear advancement was 19.8 mm (range, 16 to 25 mm). External distractors allowed multiplanar distraction vectors, thereby improving the outcome, although they are cumbersome and sometimes socially unacceptable. The mean consolidation period was 8 weeks (range, 6 to 12 weeks). Volume and surface area increased by an average of 517.9 and 91.1 percent, respectively. We did not record complications such as device failures, scarring, pin loosening/infection, premature bone consolidation, nerve or tooth buds injuries, joint ankylosis, or pneumonitis. We report one failure of decannulation in a patient suffering a complex craniofacial malformation who even experienced a decreased volume and surface area of the upper airway following mandibular distraction. External devices were removed following volume and surface area increase of the upper airway in all cases through three-dimensional computed tomographic assessment. The overall success rate of the procedure performed is 85.7 percent, and this is in line with the current literature.1Table 1: The Florentine Experience with Mandibular Distraction Osteogenesis in Syndromic Pediatric PatientsTommaso Agostini, M.D. Department of Maxillofacial Surgery CTO-AOUC Florence, Italy Francesco Arcuri, M.D. Department of Maxillofacial Surgery CTO-AOUC Florence, Italy Giuseppe Spinelli, M.D. Department of Maxillofacial Surgery CTO-AOUC Florence, Italy