2015 HSC Section 1 Book of Articles

Pediatric otolaryngology

Tongue–lip adhesion has been a mainstay of treatment for airway obstruction in children with Robin Sequence. In this procedure, the undersurface of the tongue is secured to the mucosa and muscle of the lower lip, often with a retention sure to remove tension on the wound while healing. In general, it seems to be more effective in the child without a syndrome. Sedaghat et al. [8] reviewed a small num- ber of children with tongue–lip adhesion and found that most were benefited, but that only 38% had complete resolution based on polysomnography. Abramowicz et al. [9] felt that one could more accu- rately predict the success of tongue–lip adhesion with using a GILLS score of less than 2. This takes into consideration gastroesophageal reflux, pre- operative intubation, low birth weight, syndromic diagnosis and late surgical intervention. Certainly, not all are benefited by this particular intervention as some would promote but may be considered in the decision for treatment. Much attention has been focused on bilateral mandibular osteotomy with distraction osteogen- esis for children with micrognathia with or without Robin Sequence [6 && ]. It makes sense that as the jaw is distracted anteriorly, the tongue will also be pulled forward, opening the posterior airway. It is usually very successful for improving the airway as well as feeding. This has been done both with internal and external distraction devices. Internal devices usually offer only linear distraction that may leave the child with an open bite. The multivector external distractors have the advantage of allowing differential distraction based on the observed relation to the maxillary alveolus. This may include the closure of the open bite with a rotational dis- traction as well decreasing the resistance in linear distraction with varus–valgus adjustments. Scott et al. [6 && ] looked at 18 children under 3 months with early distraction and felt the procedure to be both well tolerated and effective as seen from a 3-year follow-up. Though this procedure seems effective for airway and feeding, there are significant risks including facial nerve injury (9%), tooth loss (16%) and a 5.2% need for additional distraction as the child aged. Tonsillectomy and partial adenoidectomy For most otolaryngologists, the understanding of the benefit of tonsillectomy and adenoidectomy in children with sleep apnea is apparent. The cleft population is a concern because of the risk of exacer- bating VPI if the adenoids are removed. Some even refuse the use of adenoidectomy in children with cleft palate. Shapiro [10] initially discussed partial (superior) adenoidectomy as a way to reduce this

risk. Since then, there have been a number of reports on techniques to improve the partial adenoidec- tomy. It has been promoted for all children with palatal abnormalities undergoing adenoidectomy. Removing the superior and leaving the inferior rim of adenoid tissue should improve airway but allow the palate to contact the residual adenoid tissue for speech. Some also promote this for chil- dren with Down syndrome. In a study by Muntz et al. [2], tonsillectomy and partial adenoidectomy were the initial intervention for most of the cleft children with obstructive sleep apnea. Though there was a significant overall improvement in the sleep, many of the children continued to have sleep apnea. It is very important to follow these children to make certain there is not a significant obstructive sleep issue even after ton- sillectomy and partial adenoidectomy. Midface hypoplasia Midface hypoplasia is often associated with cranio- facial syndromes and cleft palate. Though often blamed on early hard palate repair, this is frequently seen regardless of the timing of palatal repair. The bony hypoplasia sets back the hard palate pushing the soft tissue of the soft palate posterior as well. This results in a decreased airway and as such can increase the likelihood of obstructive sleep apnea. Occasionally, we also see midface hypoplasia as a result of chronic CPAP use. Smatt and Ferri [11] and Ronchi et al. [12] both suggest there is a significant improvement in obstructive sleep apnea with man- dibular and maxillary advancement. This has also been documented in children with craniofacial syn- dromes such as achondroplasia [13]. As many of the children will need the distraction or advancement for occlusion and aesthetics, the more important issue of airway may be corrected at that same time. Midface advancement may result in VPI if the upper jaw is displaced forward interfering with the closure of the child’s velopharyngeal port. The treatment of VPI includes surgical management either with further palatal surgery or the creation of a velopharyngeal obstruction to allow appropriate oral pressure for speech. Classically, pharyngeal flap and sphincter pharyngoplasty have been used to correct the VPI. Additionally, multiple methods of velopharyngeal augmentation have been used. If a surgery has been done to improve the speech and sleep apnea results, one must balance the issues of airway and speech production [14,15]. Many of Obstruction postsurgical correction of velopharyngeal insufficiency

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