Mandibular Distraction Osteogenesis for Tongue-Based Airway Obstruction Without Micrognathia

Abstract

Purpose: Mandibular distraction osteogenesis (MDO) effectively treats tongue-based airway obstruction (TBAO) in micrognathic patients with Robin Sequence. Mandibular distraction osteogenesis may also address TBAO in certain nonmicrognathic patients who have severe obstructive apnea, although there is no current literature to guide MDO use in these atypical patients. This study describes outcomes of MDO in a series of patients with TBAO without micrognathia. Methods: Patients who underwent MDO for TBAO from 2013-20 were reviewed, and patients with micrognathia were excluded. Study subjects received baseline/ follow up polysomnography. Polysomnography variables, including Obstructive Apnea Hypopnea Index, oxyhemoglobin saturation nadir (SpO 2 nadir), percent sleep time end tidal CO 2 greater than 50 mm Hg (%ETCO 2 > 50), and respiratoryrelated arousals were compared before and after MDO. Demographics, syndromic/cleft palate status, airway anomalies, respiratory support, and feeding outcomes were collected. Results: One hundred and twenty-four patients underwent MDO during this study period; 5 were nonmicrognathic and included in analysis. Sixty percent (n = 3) of the cohort was syndromic: 1 patient each had Trisomy 9, Beckwith Wiedemann syndrome, and duplicated pituitary gland plus syndrome. Forty percent (n = 2) of patients had a cleft palate, 60% (n = 3) had laryngomalacia, and 40% had tracheomalacia. Median (range) age at MDO was 53 days (47-167 days), and median length of distraction was 16 mm (14-20 mm). After MDO, median Obstructive Apnea Hypopnea Index decreased from x̃= 60.7/h (11.6-109.4) to x̃= 5.3/h (3.5-19.3) (P = 0.034). SpO 2 nadir increased (69% [58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74] to 85% [80-88], P = 0.011), and median %ETCO 2 > 50 mm Hg decreased (5.8% [5.2-30.1] to 0.0% [0.0-1.3], P ≤ 0.043). Continuous positive airway pressure was used by all patients immediately after MDO, and at 6 months postoperatively, 1 patient remained on continuous positive airway pressure and 1 patient required supplemental oxygen. At last follow up, no patients had significant residual airway obstruction or required a tracheostomy. Conclusions: Mandibular distraction osteogenesis can effectively treat severe TBAO in some patients without micrognathia that would otherwise be candidates for tracheostomy. When used in select patients, MDO significantly improves obstructive sleep apnea and reduces need for ventilatory support, although feeding support is still needed in most patients at 6 months. Further study in a larger cohort will help identify appropriate candidates for MDO and characterize outcomes of unique patient populations.

Treated Pierre Robin Sequence Using Placed Allogenic Acellular Bone Matrix and Mandibular Distraction Osteogenesis in the Neonate

“…Decannulation or extubation was performed postoperatively in all cases. Similarly, numerous studies have verified the successfulness of DO for relieving upper airway obstruction in the management of patients with micrognathia ( 14 , 15 ). Zhang et al ( 16 ) think cases with PRS and preoperative smaller gonial angle or postoperative pulmonary infection may be more likely to undergo prolonged mechanical ventilation after MDO.…”

A Non-Syndromic, Non-Micrognathic Neonate Presenting With Persistent Glossoptosis Who was Successfully Treated With Mandibular Distraction Osteogenesis

“…Past reviews have acknowledged the difficulty of reaching a distraction endpoint, though it has been proposed that the end point in non-micrognathic patients should be 5 mm of negative overjet. 19 In cases such as our patient, where he was not dependent on a tracheostomy, the surgical team was able to continuously reevaluate whether the patient was distracted far enough throughout the entirety of the activation phase. This also allowed esthetics to be taken into consideration by not distracting past a point where the patient would have an overtly class III.…”

“…3,30 The consolidation period observed in this case was in line with what has been reported in the literature for other cases of MDO used to treat non-micrognathic patients. 19…”

“…Given that MDO is usually performed in cases of micrognathia, it makes sense that the distraction end-point of 8.5 mm was less than the reported range in the literature of total distraction in patients with Pierre Robin Sequence of 18 to 27.5 mm. 19 With regards to the consolidation period, the literature reports suggested ranges from 2 days of consolidation for every 1 day of distraction up to 12 weeks. 3,30 The consolidation period observed in this case was in line with what has been reported in the literature for other cases of MDO used to treat non-micrognathic patients.…”

Global trends and current status of distraction osteogenesis: Bibliometric analysis of publications from 1980 to 2021

“…From 1980 to 2021, more and more publications have reported the clinical application of DO in orthopaedics, oral and maxillofacial surgery and neurosurgery around the world ( Sandhaus and Johnson, 2021 ; Shevtsov and Leonchuk, 2021 ; Kosyk et al, 2022 ). However, the bibliometric analysis on the global trend and status of DO is relatively rare.…”