Robert J. Tibesar

Mandibular Distraction Osteogenesis in Infants Younger Than 3 Months

OBJECTIVES To examine the long-term outcomes and complications in infants with upper airway obstruction and feeding difficulty who underwent bilateral mandibular distraction osteogenesis (MDO) within the first 3 months of life and to identify any preoperative characteristics that may predict the long-term outcome following early MDO intervention for airway obstruction. METHODS An institutional, retrospective medical chart review was performed. Inclusion criteria were bilateral MDO performed at an age younger than 3 months, with a minimum follow-up of 3 years. A quantitative outcome measures scale was developed, and patients were scored based on long-term postoperative complications as well as airway and feeding goals. Factors such as need for an additional surgical procedure were also considered. RESULTS Nineteen children were identified as having undergone MDO before 3 months of age and having more than 3 years of follow-up data. The mean age at distraction was 4.8 weeks (range, 5 days-12 weeks); the mean length of follow-up was 5.6 years (range, 37-122 months). Of these 19 patients, 14 had isolated Pierre Robin sequence (PRS) and 5 had syndromic PRS. All patients with isolated PRS had a good or intermediate long-term result. Infants with comorbidities such as developmental delay, seizures, or arthrogryposis had the poorest outcomes. CONCLUSIONS Bilateral MDO is a relatively safe and effective means of treating airway obstruction and feeding difficulty in infants with PRS. The effects of this procedure, which carries a relatively low morbidity, persist through early childhood in most patients.

Pierre Robin Sequence: Evaluation, Management, Indications for Surgery, and Pitfalls

This article reviews the various treatment methods for airway obstruction and feeding difficulty in infants with Pierre Robin Sequence (PRS), and highlights the benefits and limitations of early mandibular distraction osteogenesis in particular as a way of managing both airway obstruction and feeding difficulty in these children.

Distraction osteogenesis of the mandible for airway obstruction in children: Long-term results

Objective: To determine the long-term results of distraction osteogenesis of the mandible for upper airway obstruction in children with micrognathia. Study Design: Case series with chart review. Setting: Tertiary care childrens hospital. Subjects and Methods: The records of a pediatric otolaryngology practice and tertiary childrens hospital were searched for patients treated with bilateral mandibular distraction osteogenesis for upper airway obstruction. Patients were selected if greater than three years of follow-up data were available. Data were analyzed for airway and feeding outcomes, and long-term surgical complications were identified. Results: Thirty-two patients met study criteria. Of the 11 patients who had tracheotomy prior to distraction, seven were decannulated after the procedure. Seventeen patients needed perioperative gastrostomy. Seven are now able to feed orally. Fifteen patients treated with mandibular distraction were able to avoid gastrostomy tube placement altogether. The complication of open bite deformity was experienced by nine patients (28%). Five of 32 patients (16%) had tooth malformation, tooth loss, or dentigerous cyst formation while an additional three patients (9%) had long-term facial nerve injury. Nineteen patients (59%) were under three months old at the time of their distraction. Only one of these patients (5.2%) required an additional distraction procedure. Conclusion: Long-term follow-up data on patients treated with mandibular distraction for upper airway obstruction show sustained airway improvement. Additionally, micrognathic children treated with distraction have improved outcomes in oral feeding with a relatively low rate of long-term complications. It remains important to follow these patients to monitor the need for secondary reconstructive procedures.

Prevalence of Positional Plagiocephaly in Teens Born after the "Back to Sleep" Campaign

Objectives. To determine the prevalence of positional plagiocephaly and brachycephaly in teenagers born after the “Back to Sleep” campaign but before orthotic helmet treatment became widely available and to provide long-term outcomes data on those children with plagiocephaly who were not treated with remolding therapy. Study Design. Cross-sectional analysis. Setting. Local high schools in the Minneapolis–St Paul Metro area. Subjects and Methods. Subjects were selected if they attended participating high schools and were born after the Back to Sleep campaign began. Skull measurements, including transcranial diameter, length, and width, were taken. Overall facial appearance was inspected for any apparent abnormal characteristics. Cranial vault asymmetry and cephalic index were calculated for each participant. Plagiocephaly was diagnosed if cranial vault asymmetry was >1 cm. Brachycephaly was diagnosed if the cephalic index was >0.90. Results. There were 1045 participants, ranging from 12 to 17 years old, with an average age of 15.7 years. The prevalence of plagiocephaly was 1.1%. The prevalence of brachycephaly was 1.0%. The overall prevalence of a deformational cranial abnormality was 2.0%. Of those who met diagnostic criteria of plagiocephaly or brachycephaly, 38.1% were noted to have abnormal facial characteristics. Conclusions. The prevalence of plagiocephaly and brachycephaly in teenagers is significantly lower than the 20% to 48% prevalence found in infants in previous studies, suggesting most children will outgrow the condition without intervention. Additional studies are needed to determine which patients might benefit from treatment and which will likely have resolution without intervention, since treating all infants who meet criteria results in significant overtreatment.

Airway management for intubation in newborns with Pierre Robin sequence.

To review airway management in Pierre Robin sequence (PRS) newborns undergoing general anesthesia and to determine if endotracheal intubation is safe in this population.

Sialendoscopy in children

BACKGROUND The definitive cause of most cases of recurrent salivary gland inflammation in children remains unknown. Relatively little has been written about the use of sialendoscopy as a diagnostic and therapeutic tool in children. OBJECTIVE To evaluate the safety and efficacy of sialendoscopy as a diagnostic and therapeutic tool for recurrent salivary gland inflammation in children. STUDY DESIGN Retrospective case series. METHODS Medical records of all patients who underwent sialendoscopy for recurrent salivary gland inflammation from a single tertiary-care pediatric otolaryngology practice were reviewed. Comparison of pre-procedure vs. post-procedure frequency and severity of disease was reviewed. Operative reports, images, and video were analyzed for causes of inflammation. RESULTS Six patients (aged 3-16 years old) underwent sialendoscopy (3/6 bilateral parotid, 2/6 unilateral parotid, 1/6 unilateral submandibular). There were no complications. No post-operative recurrence was noted in 3/6 patients; decreased frequency of recurrence was noted in 2/6 patients; repeat sialendoscopy was required in 1/6. Operative findings from sialendoscopy from 10 parotid glands showed fibrinous debris (7/10), mucoid debris (1/10), purulent debris (1/10), or duct stenosis (1/10). No stones were noted. CONCLUSIONS Sialendoscopy is a safe, minimally invasive procedure that may decrease the frequency of recurrences for salivary gland inflammation in children. In contrast to previously published work, the most common cause of salivary gland obstruction in this series was debris, rather than stones. Increased use of sialendoscopy as a diagnostic and therapeutic tool will allow for improved understanding of the causes of and management for recurrent salivary gland inflammation in children.

Apnea spells in an infant with vallecular cyst.

Vallecular cyst is a rare cause of respiratory distress in newborns and infants. It is typically considered a ductal cyst, otherwise known as a mucous retention cyst. The cyst originates from obstructed submucosal glands and expands in response to glandular secretions. As this occurs, the infant may experience episodic inspiratory stridor, periodic spells of apnea, and cyanosis. Frequent coughing, choking, gagging, difficulty feeding, poor weight gain, and failure to thrive are other likely presenting signs. The differential diagnosis for such nonspecific signs is broad, and diagnosing vallecular cyst can be challenging. We describe a case of vallecular cyst in an infant and highlight the unique magnetic resonance imaging (MRI) characteristics that aid in diagnosis.

Mandibular distraction osteogenesis in the pediatric patient.

Purpose of reviewTo provide a concise review of recent advances in mandibular distraction osteogenesis as it applies to the field of pediatric otolaryngology. Recent findingsThe successful use of mandibular distraction osteogenesis is becoming well established in the literature. Large case series with long-term follow-up are lending strong evidence in support of mandibular distraction osteogenesis in the management of airway obstruction and craniofacial deformities resulting from mandibular deficiency. These recent publications offer refinements in patient selection as well as expanding indications for this surgical intervention. At the same time, an emphasis on reduction of complications and better patient compliance has led to a search for improved device technology. Additionally, there has been an increased interest in understanding of the basic science of distraction osteogenesis at a molecular level. Numerous researchers are investigating the cellular mechanisms involved in distraction osteogenesis bone healing and are attempting to manipulate these factors to improve patient outcomes. SummaryThe field of pediatric distraction osteogenesis continues to advance with active research and study. As clinical experience increases, new models of device design and molecular manipulation have emerged on the scene, promising improved patient outcomes and fewer complications.

Tracheopathia osteoplastica: effective long-term management.

CASE REPORT A 46-year-old woman presented in 1961 with a chief complaint of chronic productive cough. Direct laryngoscopy and rigid bronchoscopy at that time showed an inflamed, erythematous larynx. The trachea and mainstem bronchi appeared to be normal. The diagnosis was asthma and allergic bronchitis, which were managed with short courses of anti-inflammatory medications. In 1980, the patient presented again to the Department of Otorhinolaryngology (Mayo Clinic, Rochester, MN) at 65 years of age, with hoarseness, dysphonia, and a worsening of her asthma. The findings from a laryngeal examination were normal, and she was followed closely. By 1989, the patient’s symptoms were significantly worse, and she was experiencing dyspnea and biphasic stridor. Diagnostic flexible laryngoscopy and bronchoscopy revealed a normal larynx but marked tracheal narrowing caused by several cartilaginous and bony spicules projecting into the airway lumen. The entire tracheal lumen to the main carina was involved, but the posterior pars membranacea was spared. Therapeutic rigid bronchoscopy was subsequently performed with a number 6 Wolf bronchoscope (Richard Wolf GmbH, Knittlingen, Germany). The bronchoscope was passed through the upper trachea with considerable resistance. An Nd:YAG laser was used unsuccessfully to break some of the bony spicules. Several of the bony and cartilaginous spurs were then removed with sharp cup forceps. When the procedure was completed, the narrowest diameter of the airway had been increased from 4 mm to 7 mm. A pathologic inspection revealed mature bone in the submucosa; amyloid staining of the specimens was negative. This dilation and debulking procedure completely relieved the stridor. The patient has had no further airway interventions. In 2002, the patient underwent follow-up flexible fiberoptic laryngoscopy and bronchoscopy. This examination demonstrated a normal larynx with partially obstructing calcifications in the trachea, as previously described (Fig 1). The luminal diameter was approximately 6 mm. No dilation or debulking procedure was performed. The patient is free of significant airway symptoms and is followed up regularly.

Surgical management of distal tracheal stenosis in children

The objective of this study was to describe the long‐term outcomes of tracheoplasty for distal tracheal stenosis, demonstrate the utility of cardiopulmonary bypass for intraoperative airway management, and compare perioperative morbidity and mortality of slide tracheoplasty for distal tracheal stenosis to costochondral graft, and resection with end‐to‐end anastomosis.