Current Trends in Surgical Airway Management of Neonates with Robin Sequence

Abstract

Background:Robin sequence is defined by the clinical triad of micrognathia, glossoptosis, and upper airway obstruction, and is frequently associated with cleft palate and failure to thrive. Though the efficacy of certain surgical interventions to relieve airway obstruction has been well established, algorithms dictating decision making and perioperative protocols are poorly defined.Methods:A 22-question survey was sent via e-mail to members of the American Cleft Palate-Craniofacial Association and International Society of Craniofacial Surgeons. Questions were related to surgeon experience in treating neonates with Robin sequence, and specific perioperative protocols.Results:One hundred fifty-one responses were collected. Most respondents were surgeons practicing in North America(82.8%), in a university hospital setting (81.5%) and had completed a fellowship in pediatric plastic surgery or craniofacial surgery (76.2%). Preoperative protocols varied widely by years in training and location of practice. Although 78.8% of respondents always performed direct laryngoscopy, only 49.7% of respondents routinely obtained preoperative polysomnography. Mandibular distraction osteogenesis was the most common primary surgical airway intervention reported by 74.2%, with only 12.6% primarily utilizing tongue-lip adhesion. Slightly less than half of respondents ever performed tongue-lip adhesion. Operative selection was influenced by surgeon experience, with 80% of those in practice 0–5 years primarily utilizing mandibular distraction, compared with 56% of respondents in practice >15 years.Conclusions:This study documents wide variations in preoperative, operative, and postoperative protocols for the surgical airway management of neonates with severe Robin sequence. These results underscore the need to acquire more objective data, to compare different protocols and outcome measures.

Neurocognitive development in isolated Robin sequence treated with the Tuebingen palatal plate

“…There is still a lack of consensus, however, regarding the best treatment options for UAO, partly due to a lack of high-level evidence on treatment results [ 3 , 7 ]. Numerous options are described in the literature, ranging from prone positioning, nasopharyngeal tube, and continuous positive airway pressure (CPAP) to more invasive procedures such as tongue-lip adhesion, mandibular distraction osteogenesis, or tracheotomy [ 3 , 7 , 16 , 21 ]. However, TPP yet represents the only therapeutic option for UAO whose efficacy has been demonstrated in a prospective randomized clinical trial [ 8 ].…”

Defining Age-related OSA Features in Robin Sequence Using Polysomnographic-based Analyses of Respiratory Arousal Responses and Gas-exchange Parameters

“…AHI has been the main metric by which surgeons make treatment decisions. Threshold AHIs for surgical management vary, but a recent survey showed that most practicing surgeons use a cutoff between 10 and 30 events per hour (Fan et al, 2018). Several authors have proposed algorithms for management of infants with RS and OSA, though again these are largely based on expert opinion rather than objective data (Myer 3rd, et al, 1998; Rogers et al, 2011; Abramowicz et al, 2012; Fan et al, 2018).…”

Outcomes of Airway Management in Micrognathia and Retrognathia Patients Born at Fetal versus Nonfetal Centers

“…Currently, there is limited literature on the management of patients presenting with micrognathia and retrognathia at birth. In a recent survey of craniofacial surgeons, there was noted heterogeneity in the surgical management of the airways of patients with micrognathia and PRS among providers [12]. Present studies recommend consideration of cesarean section and an EXIT-to-airway procedure for airway management of severely micrognathic patients [4].…”