eMedicine Specialties > Pediatrics: Surgery > Otolaryngology
Pierre Robin Malformation: Treatment & Medication
Updated: Mar 25, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
The newborn affected with Robin sequence (RS) is of serious concern to neonatologists, pediatricians, and other health care providers.
Pierre Robin sequence has 3 essential components: micrognathia/retrognathia, cleft palate, and relative glossoptosis. Immediately after delivery, because of the micrognathia and, therefore, relative glossoptosis, many children have airway distress. This can require emergency treatment. As the body will always prioritize breathing over eating, many infants have difficulty in achieving adequate caloric intake. A cleft palate further adds to the feeding difficulties.
Neonatal Care
The primary concern in airway compromise is its life-threatening aspect. Most neonates have an isolated defect that is not part of a syndrome, for which the airway and feeding complications are usually greater. The great majority of neonates can be treated in the prone position (face down). Devices or procedures such as oral airways, palatal prostheses, continuous positive airway pressure or endotracheal intubation, mechanical ventilation, and tracheostomy can be avoided.
These neonates also need to be fed in a prone position, but they can be fed by mouth. Again, very few infants need long-term gavage feeding tubes or other devices. Multidisciplinary care that includes a neonatologist, a neonatal nurse specialist, members of the craniofacial team, and the parents is the best approach in the complex care of neonates affected with Robin sequence and Robin complexes.
The vast majority of nonsyndromic neonates, those who are breathing without assistance and orally feeding while in a prone position, can be discharged home after a few days in the hospital. The mandible is expected to eventually grow; hence, the severe airway obstruction and the feeding issues are expected to decrease. The infant continues to need feeding and speech assessments, and breathing capacity needs to be monitored. Eventually, the cleft palate needs closure, and a long-term orthodontic care is required; however, some neonates have much more severe immediate or long-term medical problems.
Postneonatal Care
Airway
Secondary to the micrognathia/retrognathia, airway obstruction may be mild or severe. Severe obstruction may require immediate intervention with a very difficult intubation. In many infants, airway difficulties may seem mild at birth but progress during the first 4-8 weeks. This may be because of the relatively small respiratory needs of a newborn. As an infant grows, the requirements increase, making the obstruction more severe.
A mild obstruction can normally be handled in a very conservative manner with positional changes. Obstruction of airway results from a small mandible and a normal-sized tongue. By putting a baby in the prone position, gravity pulls the tongue forward and results in a larger airway passage. Infants with a nonsyndromic etiology will often outgrow this type of obstruction.
If the obstruction does not resolve through positional changes, many practitioners advocate use of the nasopharyngeal airway. The nasopharyngeal airway bypasses the oral pharynx and the obstruction caused by the relative glossoptosis. In the neonatal ICU, this can be a very effective temporary form of management of the airway obstruction. Most centers do not feel comfortable sending patients home with a nasopharyngeal airway, as its dislodgement can result in an acute airway obstruction.
In patients who consistently maintain CO2 levels above 50, a surgical procedure is appropriate. Three surgical procedures are used to treat Robin sequence: tongue-lip adhesion/glossopexy, tracheotomy, and distraction osteogenesis of the mandible.34
The tongue-lip adhesion/glossopexy is a controversial method to improve the airway obstruction. In this technique, the tongue is sutured to the lower lip, thereby pulling the tongue forward, providing a larger airway. Later, presumably after the child has demonstrated catch-up growth, this bond between the tongue and lip is separated. This results in a very mild cosmetic deformity to the lip and tongue. With a glossopexy, many surgeons try to pull the base of the tongue forward by attaching it to the mandible. Because the mandible is relatively soft, placing a suture that permanently holds the base of the tongue forward is very difficult; consequently, the tongue-lip adhesion/glossopexy has been a relatively controversial technique. Nevertheless, it does have its isolated advocates among maxillofacial surgeons.
A tracheotomy tube effectively bypasses the obstruction in the oral pharynx and hypopharynx. When and if the infant's airway obstruction is resolved, the tracheotomy tube can be removed. Unfortunately, tracheotomy tubes require close monitoring. If the tracheotomy tube becomes occluded or dislodged, the patient could have an acute respiratory arrest. However, a tracheotomy tube rarely remains in place less than a year after being placed in a newborn. Despite the hardship for the family of taking care of a tracheotomy tube, methods of teaching families how to care for it are well established. Tracheotomy remains a criterion standard for children with severe airway obstruction.
Distraction osteogenesis is a relatively new technique for treating airway obstruction in Robin sequence. Distraction osteogenesis has been popularized by Jim Sidman, who has the world's widest experience in treating patients with Pierre Robin sequence with distraction osteogenesis.35
Many centers have developed expertise in this area. In this technique, the mandible is cut near the angle of the mandible on both sides. A mechanical device distracts the 2 portions of the mandible approximately 1.5-2 mm a day. As the portions of the mandible are separated, new bone is formed, and the mandible gradually elongates over a period of 2-3 weeks. Distraction can be performed in the newborn to prevent a tracheotomy or can be performed later to remove a tracheotomy tube. Because this new technique has been popularized only during the last 5-10 years, the long-term sequelae on mandibular growth and tooth development is not known at this time; nevertheless, it remains a very promising technique that has been gaining in popularity (see Media file 12-13).
Child with Pierre Robin Sequence prior to distraction osteogenesis.
Distraction osteogenesis is completed, and the bone is consolidating.
Even if the results of distraction osteogenesis are promising, one must keep in mind that, in nonsyndromic Robin sequence, the mandible grows very fast after birth and that "catch-up growth" improves the airway passage. Mandibular distraction should be reserved only for very severe isolated Robin sequence cases and for syndromic Robin sequence cases in which mandibular catch-up growth does not occur.36
Feeding
Many children with Pierre Robin sequence have feeding difficulties. This is because the body preferentially chooses to breathe rather than eat; therefore, a patient with airway difficulties is expected to have feeding difficulties. If the infant demonstrates catch-up growth, feeding may be handled through special techniques, which consist of keeping the child's head more elevated and using special cleft nursing bottles (for more details, see Cleft Lip and Palate). If this is not satisfactory, gavage or feeding tubes can temporarily provide adequate nutrition. If feeding does not improve over a period of months, many infants require gastrostomy tubes. After the child develops the ability to orally feed, these tubes can be removed.
Cleft palate
In the United States, cleft palates are typically repaired in infants aged 10-18 months; however, if airway concerns are expressed, often the palate surgery is delayed until the child is aged approximately 18 months. Current belief is that, generally, the earlier the surgery is performed, the better the chance that the child will have a completely normal function of the palate and, consequently, normal speech. If a child has a tracheotomy tube in place, the palate repair can be performed at any time.
Micrognathia/retrognathia
Micrognathia may be managed during the perinatal period if airway obstruction is significant and the family chooses to proceed with distraction osteogenesis of the mandible. Otherwise, most centers wait until the infant achieves full growth of the facial bones before dealing with the functional and aesthetic abnormalities caused by micrognathia. In infants who have retrognathia, surgery for the defective dental occlusion is rarely indicated. However, infants with either micrognathia or retrognathia may benefit from some sort of chin enhancement procedure for esthetic reasons.
An extensive description of treatment choices can be found in the review by St-Hilaire and Buchbinder.37
Because different types of obstruction, positioning, and traction devices are not always successful, they may not be recommended in most patients with syndromic Robin sequence and Robin complexes. Thus, nasopharyngeal airway, tongue-lip adhesion, and other glossopexy procedures, as well as tracheostomy, are more common in syndromic patients with Robin sequence than in those with isolated deformational Robin sequence.
A multidisciplinary approach is always necessary for choosing the best treatment protocol for each patient. In patients with syndromic as well as nonsyndromic Robin sequence, postponement of palatal closure may be beneficial for the final treatment outcome. One must carefully consider the individual timing and choice of procedures based on a precise diagnosis and the particulars of the individual case, particularly since variability is great both between syndromes and within each clinical condition.
The major problem is airway compromise or obstruction. As mentioned previously in Etiology and pathogenesis, different causes of airway obstruction are noted in Robin sequence and Robin complexes. Therefore, one must accurately diagnose a baby with Robin sequence as soon as possible in order to successfully manage this serious condition.
The vast majority of infants with nonsyndromic Robin sequence and normal tongue size experience airway obstruction due to micrognathia of different degrees. If the baby is in the prone position (face down), gravity pulls the tongue forward and keeps the airway open. In severe cases, this may not be sufficient, and tongue-lip adhesion or glossopexy may be necessary.
Placement of a nasopharyngeal airway can help to avoid airway blockage. Consider it especially when hypotonia is also present (eg, deletion of chromosome band 22q11.2 syndrome), as well as in Robin complexes with neurological symptoms. Some patients still require a tracheostomy to maintain an open airway.
In extensive studies dealing with airway problems in Robin sequence, Shprintzen demonstrated that different mechanisms of obstruction can occur within the same syndrome and noted that in some patients, glossoptosis is frequently not the cause of the upper airway obstruction.26,4
Infants with Robin sequence also have difficulties with feeding. A cleft palate prevents production of the negative pressure necessary for sucking during breastfeeding. In addition, because of an abnormal jaw position, a baby with a small mandible usually has difficulties contracting its orbicularis oris muscle and squeezing the mother's nipple. In cleft palate, a wide communication between the oral and nasal cavities creates a risk of choking and other feeding problems. Consultation with a feeding specialist is advised. In many cases, when carefully instructed, a mother is able to manage bottle feeding while her baby is in a semisitting position. In patients with severe problems, gavage feeding may be necessary in the beginning of the baby's life.
In deformational Robin sequence, the mandible undergoes catch-up growth (see Media files 3-4) that starts after birth when intrauterine constraint disappears and thus eases airway and feeding problems.
Patient from Media file 2 at age 4 years. The profile is almost normal because of catch-up growth.
Patient from Media file 2.
Usually, improvement is observed after the first 3 months. Even with partial catch-up growth, a child's profile is almost normal at age 4-6 years without any treatment (see Media file 3). When, as in some patients, the mandible still lags behind, orthodontic treatment of malocclusion may be required (see Surgical Care).
In Robin sequence that is part of a syndrome or in Robin complexes, initial problems during the neonatal period and early stages of life are similar to those in deformational Robin sequence.
Numerous syndromes occur with Robin sequence.32,18 Because postnatal development is different for each of them, a precise diagnosis based on a genetic workup is essential.
A careful analysis of the type of airway obstruction is fundamental. Sher et al studied the mechanism of airway obstruction using flexible fiberoptic nasolaryngoscopy and developed a classification scheme based on 4 different processes.20 Identifying a type of airway obstruction and understanding its mechanism is essential for correct management and treatment.
One thing is common for nondeformational Robin sequence: no catch-up growth of the mandible occurs. Because growth is altered in the mandible but may not be altered in other parts of the face, a dysmorphism of the features may progress and become more prominent with age if not treated.
Although treatment in the beginning of an infant's life is similar for all patients with Robin sequences, management of airway obstruction may require a more invasive approach in syndromic Robin sequence and in Robin complexes.
Surgical Care
An extensive description of treatment choices can be found in the review by St-Hilaire and Buchbinder.37 Because of different types of obstruction, positioning and traction devices are not always successful and may not be sufficient for airway management in patients with syndromic Robin sequence and Robin complexes. Thus, nasopharyngeal airway, tongue-lip adhesion, and other glossopexy procedures, as well as tracheostomy, are more common than in patients with deformational Robin sequence.The vast majority of infants with nonsyndromic Robin sequence and normal tongue size experience airway obstruction due to micrognathia of different degrees. If the baby is in the prone position, gravity pulls the tongue forward and keeps the airway open. Placement of a nasopharyngeal airway can help to avoid airway blockage. Consider it especially when hypotonia is also present (eg, deletion of chromosome band 22q11.2 syndrome) as well as in Robin complexes with neurological symptoms. Some cases require a tracheostomy to maintain an open airway in the baby.
One should pay special attention to the timing of cleft palate surgery. Usually, the palatal cleft is shaped like a wide U, with a wide and shallow palate. At the time when surgery is recommended for most children with cleft palate (9-18 mo), the lower jaw is still small, and the child may not be gaining weight and thriving properly because of feeding and airway problems. Furthermore, because of the micrognathic jaw and the normal tongue size, an infant may use his or her cleft palate as an airway. Closing of the cleft may significantly compromise airway function; therefore, a multidisciplinary team of specialists should carefully evaluate the timing of cleft palate closure. Lehman reported a detailed retrospective analysis of cleft palate repair in 34 patients with Robin sequence.38 Approximately 24% of patients suffered from complications related to airway management at the time of palatoplasty.
Mandibular distractional osteogenesis offers a definitive structural resolution of micrognathia. After the first cases of mandibular distractional osteogenesis were published,39 numerous patients underwent this procedure; various modifications of the original technique are now used.
Cohen et al reported performing mandibular distractional osteogenesis in patients aged 14 weeks to 12 years with obstructive sleep apnea caused by craniofacial anomalies.40 In all patients, significant relief from airway obstruction was observed.
Medication
Drug therapy currently is not a component of standard care for Robin sequence (RS). See Treatment.
More on Pierre Robin Malformation |
| Overview: Pierre Robin Malformation |
| Differential Diagnoses & Workup: Pierre Robin Malformation |
 Treatment & Medication: Pierre Robin Malformation |
| Follow-up: Pierre Robin Malformation |
| Multimedia: Pierre Robin Malformation |
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Further Reading
Keywords
Pierre Robin malformation, Pierre Robin syndrome, Robin sequence, Pierre Robin anomalad, Robin complexes, Pierre Robin malformation complex, syndromic Robin sequence, nonsyndromic Robin sequence, Velocardiofacial syndrome, Stickler syndrome, Stickler's syndrome, autosomal dominant Stickler syndrome, Treacher Collins syndrome, Nager syndrome, spondyloepiphyseal dysplasia congenita, spondyloepiphyseal dysplasia congenita, SED, cleft palate, CP, connective tissue dysplasia, 22q11.2 deletion syndrome, spondyloepiphyseal dysplasia congenita, respiratory distress, micrognathia, glossoptosis, oligohydramnios, treatment, diagnosis, orofacial cleft, hypoxia, cor pulmonale, failure to thrive, cerebral impairment
