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Distraction osteogenesis can be very effective in improving upper airway obstruction in children with micrognathia, said a pediatric otolaryngologist during the session focused on sleep medicine, held at the Triological Society Combined Sections Meeting. The session also included a review of oral appliances designed to help with obstructive sleep apnea (OSA) and surgical options other than uvulopalatopharyngoplasty.
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March 2016Distraction Osteogenesis
Micrognathia comes in three forms—“isolated” and not associated with a syndrome; “syndromic,” caused by a syndrome such as Trisomy 13; and Pierre Robin Sequence, a combination of micrognathia, glossoptosis, and cleft palate, said Andrew Scott, MD, assistant professor, pediatric otolaryngologist, and pediatric facial plastic surgeon at Tufts University School of Medicine in Boston.
In distraction osteogenesis, a mandiblular osteotomy is made and a distractor device is attached to either side of the gap. The bone is allowed to heal for several days, after which the bone segments are pulled apart by approximately 1 mm to 2 mm a day as new bone grows in the gap. Typically, only one out of three children with Pierre Robin Sequence needs the surgery.
The procedure might seem “barbaric,” Dr. Scott added, “but the outcomes are incredible once you’ve seen it.” After 14 days in the hospital, patients generally spend four to six weeks at home with the device. When it is removed, the patient generally experiences dramatic improvements in breathing, feeding, and overall facial structure. There is some puckering at the incisions when an external device is used, but these scars tend to fade with time, said Dr. Scott.
An internal, curvilinear device can be used in older children, and even performed trans-orally in adolescents. One 11-year-old patient with Treacher Collins syndrome had severe sleep apnea for more than 10 years and was taking three psychiatric medications because of problems with attention and emotional instability at school. After distraction osteogenesis, her OSA was completely resolved, with an apnea-hypopnea index (AHI) down to 0.0. “She was able to come off all her psych meds, her grades and school performance have improved, and she is thriving socially,” Dr. Scott said. “Her parents think it’s a miracle.”
Oral Appliances
M. Boyd Gillespie, MD, MSc, professor and director of the Snoring Clinic at the Medical University of South Carolina in Charleston and ENTtoday editorial board member, said that oral appliances (OA) are worth considering for OSA, particularly as part of combination therapy.