5, 6 In recent years, there have been an increasing number of reports on the results of MDO as an alternative to tracheotomy. There is also potential long-term morbidity related to peristomal scarring and tracheal erosion in addition to the need for long-term maintenance and home care. 4 Tracheotomy offers a definitive treatment for upper airway obstruction but has associated risks of accidental decannulation or mucous plugging. In addition, tongue-lip adhesion can lead to dysphagia and feeding difficulties. Tongue-lip adhesion has been shown to significantly improve obstructive sleep apnea due to micrognathia 3 but has generally been less effective than MDO at normalizing obstructive symptoms, particularly in severely symptomatic patients. 2 In the event that such conservative treatments are unsuccessful or for more severe symptoms, options for surgical intervention include tongue-lip adhesion, tracheotomy, and mandibular distraction osteogenesis (MDO). Conservative measures for less severe symptoms include prone positioning and use of a nasopharyngeal airway. Interventions aimed at relieving such symptoms vary depending on the severity of the symptoms. Long-term sequelae of severe airway obstruction can lead to cor pulmonale and cardiorespiratory arrest. Gasping or aspiration while feeding is frequently encountered, and this in combination with chronic airway obstruction can cause failure to thrive. Symptoms of airway obstruction may range from snoring and stertor while asleep to frank obstruction and retractions when awake. 1 Though not classically described as part of its definition, cleft palate is a commonly associated finding that occurs in up to 90% of children with Pierre Robin sequence. Pierre Robin sequence is characterized by the triad of micrognathia, glossoptosis, and resultant airway obstruction owing to constriction of the retrolingual space. Patients with Goldenhar syndrome have a decreased likelihood of surgical success. However, these patients also had a higher rate of syndromic diagnoses and associated comorbidities. Patients who required a tracheotomy before MDO had a lower success rate in achieving decannulation and a higher rate of complications. Poorer odds of success were associated with the need for 2 or more other airway procedures (odds ratio, 0.14 ) in the MDO-first subgroup and craniofacial microsomia or Goldenhar syndrome (OR, 0.07 ) in the tracheotomy-first subgroup.Ĭonclusions and Relevance Mandibular distraction osteogenesis has a high rate of success in avoiding tracheotomy. Tracheotomy-first patients were more likely to have a syndromic diagnosis (66.0% vs 43.0% P = .009) and were older at the time of MDO (median age, 30 months vs 5.1 months P < .001). Surgical success and complication rates were 83.6% and 14.8% in the MDO-first subgroup and 67.7% and 38.7% in the tracheotomy-first subgroup. Median age at time of distraction was 21 months (range, 7 days–24 years). Results A total of 123 patients (61 in MDO-first subgroup, 62 in tracheotomy-first subgroup) underwent MDO during the study period. Potential predictors included demographics, syndrome presence, follow-up time, and surgical history. Main Outcomes and Measures Rates of surgical success (defined as either tracheotomy avoidance or decannulation) and complications. Multivariable regression analysis was used to assess for predictors of outcome. Interventions Electronic medical records were reviewed.
Objective To assess the rate and predictors of surgical success and complications among (1) patients who underwent MDO prior to other airway procedures (MDO first), and (2) patients who required an initial tracheotomy and were subsequently treated with MDO (tracheotomy first).ĭesign, Setting, and Participants Retrospective cohort study at a tertiary care pediatric medical center of patients diagnosed as having micrognathia resulting in symptomatic airway obstruction (Pierre Robin sequence) and who underwent MDO from September 1995 to December 2009. This study presents outcomes from one of the largest cohorts reported. Mandibular distraction osteogenesis (MDO) is an alternative to tracheotomy that lengthens the mandible in order to improve the retrolingual airway. Importance Patients with severe micrognathia are predisposed to airway obstruction. Shared Decision Making and Communication.Scientific Discovery and the Future of Medicine.Health Care Economics, Insurance, Payment.Clinical Implications of Basic Neuroscience.Challenges in Clinical Electrocardiography.
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