Mandibular Distraction in Neonates: A Strategy to Avoid Tracheostomy

Abstract

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.

The successful use of the nasopharyngeal airway in Pierre Robin sequence: an 11-year experience

“…Various studies have reported on mandibular distraction for the treatment of airway obstruction and possibly avoiding tracheostomy 16–18. Mandibular distraction can help correct micrognathia; by pulling the jaw forward, the tongue is pulled anteriorly via its anterior attachment to the mandible, thereby relieving the airway obstruction.…”

Bioresorbable distraction device for the treatment of airway problems for infants with Robin sequence

“…However, we were able to decannulate her at 7 months of age. Since literature demonstrates that the average age of decannulation for children with Robin sequence is 3.1 years, it is possible that the distraction did shorten her tracheotomy time [25]. …”

New Therapeutics in Promoting and Modulating Mandibular Growth in Cases with Mandibular Hypoplasia

“…When the airway is compromised because of severe mandible underdevelopment, jaw-positioning appliances [9], nasopharyngeal airway [10], orthodontic plates with velar extension [11], intubation [12], tongue-lip adhesion [13], continuous positive airway pressure (CPAP) [14], tracheostomy [15], mandibular advancement with orthognathic surgery/distraction osteogenesis [16, 17], or an anterior mandibular positioning device is used to manage the airway obstruction [18, 19]. …”

“…To avoid tracheostomies, distraction osteogenesis of the mandible (surgical lengthening of the mandible) has recently been recommended as a viable option for pediatric patients with upper airway obstruction due to mandibular deficiency [16]. This technique has been described as an alternative to tracheostomy in neonates (6 to 26 days of age) to improve airway and breathing [17]. …”