Correction of Upper Airway Obstruction in the Newborn With Internal Mandibular Distraction Osteogenesis

Abstract

Tracheostomy for management of neonatal airway obstruction may be life saving but is associated with complications and developmental problems. As an alternative, the effectiveness of internal mandibular distraction osteogenesis was investigated in select neonatal patients with micrognathia and upper airway obstruction. Preoperative tests (sleep study, direct laryngobronchoscopy, and "milk scan" for GI reflux) were used to select appropriate candidates for the procedure. Excluded were patients with 1) central apnea, 2) severe reflux, 3) other airway lesions, and 4) mild to moderate obstruction controlled by positioning. Of 44 newborns (aged <3 weeks) with upper airway obstruction and micrognathia seen in the neonatal intensive care unit, 19 underwent tracheostomy, 10 were discharged with home monitoring and positional instructions, and 15 underwent bilateral mandibular lengthening with microdistractors. Of those who underwent mandibular distraction, a tracheostomy was avoided in 14 of 15 patients. Relative improvement in the posterior airway space was seen on 3D CT scans, cephalograms, and laryngobronchoscopies obtained preoperatively, postoperatively, and during follow-up evaluation. One of these 15 patients required a tracheostomy for postoperative central apnea. In an average of just 4.5 days following completion of distraction, patients were discharged home with improved oral feeding and no feeding tube. This study suggests that for selected newborns, the use of internal microdistractors allows for avoidance of a tracheostomy and improved oral feeding.

A clinical narrative review of mandibular distraction osteogenesis in neonates with Pierre Robin sequence

“…Several recent case series have demonstrated the effectiveness of treating upper airway obstruction in neonates with PRS [14,[17][18][19]31]. Majority of patients were able to avoid tracheostomies and those who already had tracheostomies were decannulated successfully.…”

“…A careful assessment of gastroesophageal reflux and swallowing with a pH-probe, swallow study, and feeding evaluation can help determine candidacy for distraction osteogenesis, as some children with significant reflux and associated feeding issues can have poor postoperative outcomes [14,33]. However, some authors report feeding and swallowing problems, along with reflux, all tend to improve post-distraction, and therefore these gastrointestinal problems should not be considered a contraindication for distraction osteogenesis [17].…”

“…laryngomalacia) and bronchoscopy to ensure a normal lower airway (e.g. tracheomalacia) [4][5][6]12,14,19]. For those patients with multilevel obstructions, additional airway procedures may be required prior to decannulation [7].…”

“…There is tremendous variability reported in the literature (24 h to 7 days) regarding the appropriate amount of time that should be elapsed during the latency phase [14,40]. In general, however, the tendency is to use shorter latency periods in the very young patient to avoid premature consolidation of the bony regenerate, while longer latency phase is used for older patients.…”

“…The process of gradually lengthening the mandible can lead to correcting the posterior tongue base position, which can relieve the pharyngeal airway obstruction. Initially, reports of mandibular advancement during the first few days of life were limited [13,14] but many more studies can be found in the recent literature [6,[15][16][17][18][19][20]. The objective of this clinical narrative review is to discuss the efficacy of distraction osteogenesis in the neonatal patient.…”