Conclusion

Management of the child with retrognathia is a clinical challenge. If there is no associated syndrome, the decision for intervention can be based on the results of polysomnography in addition to objective assessment of growth parameters. If there is compromise in either area, intervention is necessary. Positioning and observation may be appropriate on a short-term basis. However, if this fails, placement of a nasopharyngeal airway may be successful. If the child has continued symptoms after 3 weeks, placement of a tracheotomy is indicated. Although I will send patients home with positioning and observation, I am reluctant to send children home with nasopharyngeal airways. In the retrognathic child with a syndrome, I go through a similar thought process, but I am much quicker to place a tracheotomy because of the high morbidity and mortality associated with these conditions. In most circumstances, obstruction improves between 6 and 9 months of age, and one can begin the process of withdrawing airway support.1'2,7,15

Figure 73-1 Algorithm for the management of the retrognathic patient.

REFERENCES

Myer III—CHAPTER 73

1. Olson TS, Kearns DB, Pransky SM, Seid AB. Early home management of patients with Pierre Robin sequence. Int J Pediatr Otorhinolaryngol 1990;20:45-49

2. Shprintzen RJ, Singer L. Upper airway obstruction and the Robin sequence. Anesthesiology Clin 1992;30:109-114

3. Sher AE. Mechanisms of airway obstruction in Robin sequence: implications for treatment. Cleft Palate Craniofac J 1992;29:224-231

4. Bull MJ, Givan DC, Sadove AM, et al. Improved outcome in Pierre Robin Sequence: effect of multidisciplinary evaluation and management. Pediatrics 1990;86:294-301

5. Gilhooly JT, Smith JD, Howell LL, et al. Bedside poly-somnography as an adjunct in the management of infants with Robin sequence. Plast Reconstr Surg 1993;92:23-27

6. Caouette-Laberge L, Bayet B, Larocque Y. The Pierre Robin sequence: review of 125 cases and evolution of treatment modalities. Plast Reconstr Surg 1994;93:934-942

7. Benjamin B, Walker P. Management of airway obstruction in the Pierre Robin sequence. Int J Pediatr Otorhinolaryngol 1991;22:29-37

8. Frohberg U, Lange R. Surgical treatment of Robin sequence and sleep apnea syndrome: case report and review of the literature. J Oral Maxillofac Surg 1993;51:1274-1277

9. Augarten A, Sagy M, Yahav J, Barzilay Z. Management of upper airway obstruction in the Pierre Robin syndrome. Br J Oral Maxillofac Surg 1990;28:105-108

10. Shprintzen RJ. The implications of the diagnosis of Robin sequence. Cleft Palate Craniofac J 1992;29:205-209

11. Argamaso RV. Glossopexy for upper airway obstruction in Robin sequence. Cleft Palate Craniofac J 1992;29:232-238

12. Singer L, Sidoti EJ. Pediatric management of Robin sequence. Cleft Palate Craniofac J 1992;29:220-223

13. Easter B, Wood C, Eppley BL, Sadove AM. Mandibular traction system for adjunctive management of airway insufficiency in infants with Pierre Robin malformation sequence. Am J Occup Ther 1991;45:941-943

14. Myer III CM, Reed JM, Cotton RT, et al. Airway management in Piere Robin sequence. Otolaryngol Head Neck Surg 1998;118:630-635

15. Tomaski SM, Zalzal GH, Saal HM. Airway obstruction in the Pierre Robin sequence. LLarygoscope 1995;105:111-114

As otolaryngologists, we are often requested to evaluate newborns, infants, and children with upper airway obstruction. Nasal pyriform aperture stenosis, posterior choanal stenosis or atresia, Pierre Robin sequence (PRS), craniofacial anomalies, and laryn-gotracheal disorders are among the etiologies of upper airway obstruction. PRS is classically known as a triad of micrognathia, glossoptosis, and cleft palate. In PRS, the mandible may be of normal size, but it is displaced posteriorly. Retrognathia, lack of support of the genioglossus muscle, and negative pharyngeal pressure during inspiration lead to of the compromise upper airway.

Positioning, oropharyngeal airway, nasopharyngeal (NP) airway, tongue-lip adhesion (TLA), glossopexy, prosthesis placement, endotracheal intubation, and tracheotomy are many nonsurgical and surgical airway interventions. Choosing the most effective, reliable, and safe airway intervention for retrog-nathic patients is as challenging as it is controversial.

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