Neonatal Distraction Research Articles

Pre-Operative Characteristics Helping to Avoid Gastrostomy Tube After Mandibular Distraction in Neonates With Pierre-Robin Sequence: A Institutional Case-Series and Review of the Literature.

to investigate the ability of mandibular distraction osteogenesis (MDO) to avoid gastrostomy tube (G-tube). PubMed, EBSCOhost, Cochrane, and Embase. We retrospectively reviewed the number of MDO cases performed at our institution for patients with Robin Sequence (RS) over the past 10 years. In our institutional review, patients were excluded if they had a G-tube already placed at the time of surgery. We also performed a systematic review of the literature. Articles were excluded if they did not detail feeding outcomes after MDO, or if MDO was performed on patients that did not have RS. In our systematic review, 12 articles were included that comprised a total of 209 neonates with RS that underwent MDO. A total of 174 (83.3%) patients avoided a G-tube once MDO was performed. A total of 14 patients met the inclusion criteria at our institution. Of the 14 RS patients, 9 (64%) avoided having a G-tube placed and all (14/14) avoided tracheostomy. The average birth weight of patients avoiding a G-tube was 3.11 kg compared to 2.25 kg (P = .045) in the group requiring a G-tube. In the group avoiding a G-tube, the average weight at time of operation was 3.46 kg compared to 2.83 kg (P = .037) in the group requiring a G-tube. MDO may be considered as a surgical option to prevent G-tube placement for neonates with non-syndromic RS who have difficulty with PO feeding but whose airway obstruction is not severe enough to require respiratory support. Based on our institutional experience, a minimum weight of 3.00 kg correlated with higher success rates of PO intake and avoiding a G-tube.

Neonatal Mandibular Distraction Osteogenesis in Infants With Pierre Robin Sequence.

Pierre Robin sequence is the constellation of micrognathia, glossoptosis, and tongue-based airway obstruction. When airway obstruction is severe, feeding, growth, and respiratory demise are at risk. Neonatal mandibular distraction osteogenesis is a technique which improves tongue-based airway obstruction and avoids tracheostomy in patients with severe expressions of Pierre Robin sequence. Its efficacy in relieving airway obstruction is well documented, and it has become the surgical intervention of choice at many craniofacial centers. However, this is an uncommon procedure which can be performed within the first weeks of life, offering little space for a learning curve. The success of neonatal distraction and avoidance of complications is highly dependent on proper surgical technique. This report provides a brief overview of the disease, details the technique of the senior surgeon with captioned videos, describes the protocol used at our institution and reports long-term outcomes with a case description.

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BACKGROUND In newborns with micrognathia and severe upper airway obstruction, understanding potential airway lesions is important for determining appropriate treatment: observation, mandibular distraction, or tracheostomy. When concomitant airway anomalies are present, mandibular distraction is often unsuccessful at alleviating causes of obstruction, mandating the need for tracheostomy. The first part of this study evaluates 10-year results using the University of California, Los Angeles, algorithm for surgical candidacy to identify patients who will benefit from neonatal mandibular distraction. The second part describes the concomitant airway abnormalities found at the time of diagnostic laryngoscopy/bronchoscopy and how these anomalies affect neonatal distraction candidacy of these patients. METHODS Newborns admitted to the neonatal intensive care unit with micrognathia and upper airway obstruction (n = 133) were subjected to a decision tree model protocol formulated by a multidisciplinary team at the University of California, Los Angeles, to decide on appropriate treatment. Concomitant airway abnormalities were recorded and outcomes were documented for the first 5 years of life. RESULTS Fifty-five percent of patients underwent internal mandibular distraction with 97 percent success. Home observation with a nasopharyngeal tube was chosen in 11 percent of patients, and 34 percent had tracheostomies. On endoscopic examination, 51.7 percent of the nondistracted patients had concomitant airway anomalies: laryngomalacia (53.3 percent), tracheal web (20.0 percent), vocal cord paralysis (13.3 percent), epiglottal collapse (6.7 percent), and infraglottal narrowing (6.7 percent). CONCLUSIONS For the management of neonatal upper airway obstruction with micrognathia, a decision tree algorithm is useful to determine candidates for mandibular distraction. Diagnostic laryngoscopy/bronchoscopy is an important component of this algorithm because a multitude of airway anomalies may be present. CLINICAL QUESTION/LEVEL OF EVIDENCE : Therapeutic, IV.

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

In newborns with micrognathia and severe upper airway obstruction, understanding potential airway lesions is important for determining appropriate treatment: observation, mandibular distraction, or tracheostomy. When concomitant airway anomalies are present, mandibular distraction is often unsuccessful at alleviating causes of obstruction, mandating the need for tracheostomy. The first part of this study evaluates 10-year results using the University of California, Los Angeles, algorithm for surgical candidacy to identify patients who will benefit from neonatal mandibular distraction. The second part describes the concomitant airway abnormalities found at the time of diagnostic laryngoscopy/bronchoscopy and how these anomalies affect neonatal distraction candidacy of these patients. Newborns admitted to the neonatal intensive care unit with micrognathia and upper airway obstruction (n = 133) were subjected to a decision tree model protocol formulated by a multidisciplinary team at the University of California, Los Angeles, to decide on appropriate treatment. Concomitant airway abnormalities were recorded and outcomes were documented for the first 5 years of life. Fifty-five percent of patients underwent internal mandibular distraction with 97 percent success. Home observation with a nasopharyngeal tube was chosen in 11 percent of patients, and 34 percent had tracheostomies. On endoscopic examination, 51.7 percent of the nondistracted patients had concomitant airway anomalies: laryngomalacia (53.3 percent), tracheal web (20.0 percent), vocal cord paralysis (13.3 percent), epiglottal collapse (6.7 percent), and infraglottal narrowing (6.7 percent). For the management of neonatal upper airway obstruction with micrognathia, a decision tree algorithm is useful to determine candidates for mandibular distraction. Diagnostic laryngoscopy/bronchoscopy is an important component of this algorithm because a multitude of airway anomalies may be present. : Therapeutic, IV.

Protection of the Temporomandibular Joint during Syndromic Neonatal Mandibular Distraction using Condylar Unloading

Neonatal distraction in severe micrognathia patients may alleviate the need for tracheostomy. The authors' objectives in evaluating syndromic neonatal distraction cases were to: (1) document preoperative temporomandibular joint pathology, (2) compare the incidence of postoperative temporomandibular joint ankylosis, and (3) determine whether "unloading" the condyle tended to prevent temporomandibular joint pathology. Syndromic versus nonsyndromic micrognathic (and normal) patient temporomandibular joint abnormalities were compared preoperatively based on computed tomography scans and incisor opening (n = 110). Patient temporomandibular joint outcomes after neonatal mandibular distraction were compared with regard to ankylosis (n = 59). Condylar-loaded versus condylar-unloaded (with class II intermaxillary elastics) temporomandibular joint outcomes were compared based on imaging and the need for joint reconstruction (n = 25). Preoperative abnormalities of neonatal temporomandibular joint pathology on computed tomography scans were not significant: syndromic, 15 percent; nonsyndromic, 5.9 percent; and normal joints, 4.2 percent. Syndromic patients had a significantly greater interincisor distance decrease postoperatively (48 percent; p < 0.05) and at 1-year follow-up (28 percent; p < 0.05) compared with nonsyndromic patients. Also, computed tomography scans revealed that 28 percent of syndromic patients developed temporomandibular joint abnormalities, whereas nonsyndromic patients were unchanged. Condylar-loaded patients had worse clinical outcomes compared with condylar-unloaded patients (80 percent versus 7 percent) and required temporomandibular joint reconstruction for bony ankylosis (40 percent versus 0 percent) after distraction. Neonatal syndromic, micrognathia patients have increased temporomandibular joint pathology preoperatively and bony ankylosis after distraction but are protected with partial unloading of the condyle during distraction. Risk, II; Therapeutic, III.

Mandibular distraction in neonates: indications, technique, results

BackgroundThe Pierre Robin Sequence features were first described by Robin in 1923 and include micrognathia, glossoptosis and respiratory distress with an incidence estimated as 1:8,500 to 1:20,000 newborns. Upper airway obstruction and feeding difficulties are the main concerns related to the pathology. Mandibular distraction should be considered a treatment option (when other treatments result inadequate).Patiants and methodsTen patients between the ages of 1 month and 2 years with severe micrognathia and airway obstruction were treated with Mandibular Distraction Osteogenesis (MDO).All patients underwent fibroscopic examination of the upper airway and a radiographic imaging and/or computed tomography scans to detect malformations and to confirm that the obstruction was caused by posterior tongue displacement. All patients were evaluated by a multidisciplinary team. Indications for surgery included frequent apneic episodes with severe desaturation (70%). Gavage therapy was employed in all patients since oral feeding was not possible. The two tracheotomy patients were 5 months and 2 years old respectively, and the distraction procedure was performed to remove the tracheotomy tube. All patients were treated with bilateral mandibular distraction: two cases with an external multivector distraction device, six cases with an internal non-resorbable device and two cases with an internal resorbable device. In one case, the patient with Goldenhar's Syndrome, the procedure was repeated.ResultsThe resolution of symptoms was obtained in all patients, and, when present, tracheotomy was removed without complications. Of the two patients with pre-existing tracheotomies, in the younger patient (5 months old) the tracheotomy was removed 7 days postoperatively. In the Goldenhar's syndrome case (2 years old) a Montgomery device was necessary for 6 months due to the presence of tracheotomy-inducted tracheomalacia. Patients were discharged when the endpoint was obtained: symptoms and signs of airway obstruction were resolved, PAS and maxillomandibular relationship improved, and tracheotomy, when present, removed. During the follow-up, no injury to the inferior alveolar nerve was noted and scarring was significant in only the two cases treated with external devices.ConclusionMandibular Distraction Osteogenesis is a good solution in solving respiratory distress when other procedures are failed in paediatric patients with severe micrognatia.

Neonatal distraction in Pierre Robin sequence

Pierre Robin sequence is a pathology derived from alterations in the first and second branchial arches. Patients have breathing problems due to micrognathia and glossoptosis, causing severe upper airway obstruction and frequently requiring mechanical ventilator assistance.

Mandibular Distraction Using Bone Morphogenic Protein and Rapid Distraction in Neonates With Pierre Robin Syndrome

Mandibular distraction is recognized as a treatment of respiratory distress in neonates with microretrognathia as seen in the Pierre Robin syndrome. However, mandibular distraction is a complex and lengthy treatment involving 2 to 4 weeks of distraction and another 4 to 12 weeks for bone consolidation. This study was performed to establish the safety and effectiveness of rapid protocol distraction osteogenesis with recombinant human bone morphogenetic protein 2 (rhBMP-2) in neonates with the Pierre Robin syndrome. A retrospective review of all patients treated in our department between February 2003 and February 2008 was performed. Three patients with the Pierre Robin syndrome who underwent distraction osteogenesis with rhBMP-2 were identified. Inpatient and outpatient charts were reviewed for time to completion of distraction, age at distraction, need for tracheostomy, and complications of the mandibular distraction. Three patients (6 hemimandibles) with Pierre Robin syndrome underwent rapid protocol distraction with rhBMP-2. Mean age at initial distraction was 17.3 days. Mean time from device placement to removal was 89.3 days. The complication rate was 16%, with 1 case of nonunion that required subsequent operative intervention. No patient required tracheostomy. Rapid protocol distraction with rhBMP-2 allows distraction of the hypoplastic mandible to class III occlusion during the initial operation and avoids the latency and distraction phases of standard mandibular distraction. This case series demonstrates the safety and effectiveness of rapid distraction in neonates with Pierre Robin syndrome. Larger studies and long-term follow-up are necessary; however, this study suggests that rapid protocol distraction with rhBMP-2 is effective in neonates with Pierre Robin syndrome.

Mandibular Distraction Osteogenesis to Relieve Pierre Robin Severe Airway Obstruction in Neonates

Airway management in neonates with Pierre Robin sequence is often challenging. Advancement of the tongue base using mandibular distraction in neonates can avoid tracheotomy and is increasingly propagated. The surgical indication is very important. We establish indication. The result of the preoperative peripheral oxygen saturation of about 40% in the prone position is considered as indication. The distance from postpharyngeal wall to lingual root of more than 5 mm is considered as contraindication; however, distance of less than 2 mm is considered needing performing mandibular distraction in preoperative lateral cephalometric radiograph. A three-dimensional computed tomographic demonstrating severity of retrognathia was generated preoperatively in the computed tomography room. The osteotomies can be performed by extraoral approaches. Nowadays, for precise bone cutting, Surgybone (Silfradent Co., Sofia, Italy) devices have been introduced in maxillofacial surgery, which we used for extraoral-approach osteotomies in 6 patients presented in this study. Distraction was performed after bilateral oblique osteotomy and removed after 1-month fixation in the second stage. A follow-up examination after removal of the distractors was performed. Normal appearance and no apnea were observed at 6 months' follow-up.

Intraoral osteotomies using piezosurgery for distraction in an infant with Pierre–Robin sequence

Airway management in infants with Pierre Robin sequence (PRS) is often challenging. Advancement of the tongue base using mandibular distraction in neonates can avoid tracheotomy and is increasingly propagated. The osteotomies can be performed via intra- and extraoral approaches. Nowadays, for precise bone cutting, piezosurgical devices have been introduced in maxillofacial surgery, which we used for osteotomies via the intraoral approach in the 7-week-old patient presented in this study. Instead of a preoperative CT scan, a 3D data set was generated preoperatively in the operating theatre using a 3D C-arm system. After bilateral transcutaneous pin placement and osteotomies, a second 3D data set was acquired. Primary and secondary reconstructions clearly visualized the patient's bone despite the low level of ossification in newborns and the presence of a large amount of metal implants. In view of the low level of radiation exposure going along with the 3D C-arm imaging, a follow-up examination after removal of the distractors was performed. With this report of a 7-week-old female infant with the diagnosis of PRS, we want to extend the surgical and diagnostic armamentarium for the treatment of infants with PRS.

To Distract or Not to Distract: An Algorithm for Airway Management in Isolated Pierre Robin Sequence

Approaches advocated for treatment of airway obstruction among neonates with Pierre Robin sequence include positioning, tongue-lip adhesion, mandibular distraction, and tracheostomy, with no established guidelines regarding which modality is appropriate for a specific patient. This report proposes an algorithm for the management of neonatal upper airway obstruction among patients with isolated Pierre Robin sequence. Data for 21 patients with isolated Pierre Robin sequence who were treated by one surgeon during a 9-year period were reviewed. Eighteen patients presented during the first 1 week of life and three patients presented late, between 12 and 33 months of age. Follow-up periods ranged from 9 to 70 months (median, 33 months). Successful airway management was achieved with positioning alone for 10 patients, with tongue-lip adhesion for seven of nine patients, with tracheostomy for two patients, and with mandibular distraction for three patients. Changes in the maxillary-mandibular discrepancy were significant with natural mandibular growth during the first 1 year of life (p < 0.0001). Oromotor studies performed 3 months or more after tongue-lip adhesion reversal (n = 9) demonstrated no appreciable deficits in tongue function, relative to other children with cleft lips/palates. A multidisciplinary team should evaluate all patients with isolated Pierre Robin sequence, to fully assess the maxillary-mandibular relationship, anatomically define the site of airway obstruction, and identify feeding difficulties. Patients should be evaluated for episodes of desaturation occurring spontaneously, during feeding, or during sleeping. Patients with desaturation should be further evaluated with double endoscopy (nasoendoscopy and bronchoscopy). If the airway obstruction is localized to the tongue base alone and cannot be controlled with positioning, then tongue-lip adhesion is the initial treatment of choice, because such patients demonstrate significant mandibular growth during the first 1 year of life. Mandibular distraction among neonates is reserved for failures of tongue-lip adhesion in which isolated tongue-base airway obstruction is documented. Neither of the patients who experienced failure of tongue-lip adhesion in this series would have been a candidate for distraction with the algorithm presented. Avoiding routine neonatal distraction serves to avoid facial scarring, nerve and tooth bud injury, and potential disturbances of intrinsic mandibular growth. Patients with persistent respiratory difficulties beyond age 9 months require reevaluation for multiple sites of airway obstruction. Mandibular distraction may be one of several modalities required to avoid tracheostomy for such patients.

A New Strategy to Avoid Tracheostomy in Neonates with Pierre Robin Sequence

Plastic Surgery| November 01 2002 A New Strategy to Avoid Tracheostomy in Neonates with Pierre Robin Sequence AAP Grand Rounds (2002) 8 (5): 57. https://doi.org/10.1542/gr.8-5-57 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation A New Strategy to Avoid Tracheostomy in Neonates with Pierre Robin Sequence. AAP Grand Rounds November 2002; 8 (5): 57. https://doi.org/10.1542/gr.8-5-57 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: pierre robin syndrome, tracheostomy Source: Denny A, Kalantarian B. Mandibular distraction in neonates: a strategy to avoid tracheostomy. Plast Reconstr Surg. 2002;109:896–904. The authors from the Medical College of Wisconsin report on their experience with mandibular distraction in 5 neonates with Pierre Robin sequence (mean age 14.5 days). Mandibular distraction employs surgically placed pins, wires and orthopedic devices to allow advancement of the mandible by 1–2 mm per day. All patients had retrognathia, glossoptosis, incomplete cleft palate, inability to control the airway during feeding, and resting oxygen saturations in the 70–80% range. Subjects underwent a multispecialty evaluation. Multimodal objective measurements of airway obstruction included weight gain, oral intake, computerized tomography, direct laryngoscopy, and flexible fiber optic bronchoscopy. A pediatric intensivist, pediatric anesthesiologist, pediatric otolaryngologist, and the authors reached a consensus that each patient would require a tracheostomy if mandibular distraction was not performed promptly. After a linear, external mandibular distraction device was applied at surgery, distraction rates of 2 mm per day were employed for the first 3 days and then decreased to 1 mm per day. All patients were extubated by distraction day 5, and bottle-feeding was initiated within 24 hours of the procedure. All patients experienced complete elimination of airway symptoms, gained a minimum of 500 g per month following the procedure, and avoided tracheostomy. Routine palatoplasty was performed without incident at a later date in all patients. Mandibular hypoplasia with resultant airway obstruction can be a life-threatening problem, often requiring prolonged or permanent tracheostomy.1 Tracheostomy has an associated mortality rate of from 1 to 5% and may result in speech and developmental problems.2 Pierre Robin sequence has been reported to occur as frequently as 1 in 2,000 births with varying degrees of airway and feeding impairment.3 Mandibular distraction has been shown to be effective in lengthening the mandible allowing for decannulation in older children. There have been many reports on techniques and devices designed to improve the airway and avoid tracheostomy, which have had variable success. These include suturing the tongue to the lip, prolonged use of a nasopharyngeal airway, bonnets attached to the mandible to thrust it forward, and infant positioning devices. The authors are among the first to report the application of distraction in the neonatal period to avoid tracheostomy. The multidisciplinary evaluation with multimodal measurements advocated by the authors should be considered essential to successful diagnosis and treatment of neonates with Pierre Robin sequence. You do not currently have access to this content.

Mandibular Distraction in Neonates: A Strategy to Avoid Tracheostomy

Mandibular Distraction in Neonates: A Strategy to Avoid Tracheostomy

Mandibular distraction in neonates: a strategy to avoid tracheostomy.

Over the past 5 years, the authors developed an application of mandibular distraction osteogenesis to eliminate existing tracheostomy. That experience led the authors to attempt mandibular distraction osteogenesis in neonates as an alternative before tracheostomy. Success with this approach using supporting objective airway measurements has been reported previously. This report includes six neonates diagnosed with Pierre Robin sequence. Of the six, five neonates ranging in age from 6 to 26 days (mean, 14.5 days) were treated by the authors with mandibular distraction over a 22-month period. The sixth neonate was treated with tracheostomy, because of other airway abnormalities. Findings included retrognathia, glossoptosis, incomplete cleft palate, and airway obstruction in each patient. Birth weights ranged from 2.8 to 3.2 kg. All patients were unable to control their airway during feeding, as evidenced by repeated episodes of choking and obstruction. Resting oxygen saturations were in the 70 to 80 percent range in all patients, with further deterioration during attempted feeding. Bronchoscopy was performed in all patients under anesthesia before distraction. Recurrent near-complete and intermittent complete airway obstruction were present in all patients at the level of the tongue base. There was a consensus by a pediatric intensivist, a pediatric anesthesiologist, and a pediatric otolaryngologist in all cases. Each patient met all criteria requiring ventilation for life support. Tracheostomy would be required if mandibular distraction osteogenesis was not performed, or if it failed. Patients with other airway abnormalities were not considered for treatment. Maxillomandibular disharmony measured at the midline ranged from 8 to 15 mm (mean, 11.2 mm). Active distraction was performed at the rate of 1 to 2 mm a day, with a consolidation period of 4 weeks. Total time of treatment was less than 6 weeks in all cases. All patients were extubated by the completion of active distraction. Distraction distance ranged from 8 to 15 mm (mean, 12.4 mm). All patients were discharged to home on apnea monitors, the use of which was discontinued after 90 days with no further apneic events. Weight gains met or exceeded the average 500 g a month after distraction. Bronchoscopy at the time of distractor removal showed correction of airway obstruction at the tongue base. Radiographs showed bilateral ossification of the distraction sites. Tracheostomy was avoided in all cases selected for treatment by distraction. Patient follow-up range was 9 to 22 months. In selected Pierre Robin sequence patients with tongue base airway obstruction, mandibular distraction osteogenesis can successfully avoid the need for and the associated mortality and morbidity of indwelling tracheostomy.