Retrognathia patients may have isolated PRS or PRS with Stickler syndrome, unique pattern of malformation, or other named syndromes (i.e., Nager, Treacher Collins, VCF, and fetal alcohol syndromes). PRS patients with associated syndromes or malformations tend to have other factors that complicate the upper airway obstruction: skull base anomalies, nasal stenosis, neuromuscular hypotonia, and cardiac and CNS defects. While patients are closely monitored in the NICU, a systematic airway management should include thorough history and physical examination, evaluation of the airway to determine the site(s) of obstruction (i.e., airway radiographs, endoscopy), objective measurement of the severity of obstruction (i.e., PSG), and other associated congenital disorders. In general, isolated PRS and Stickler patients should benefit from conservative airway intervention (positioning, NP airway). Those patients with named syndromes or unique pattern of malformation are at higher risk of more severe obstruction and tracheotomy because of associated airway anomalies or neurologic deficits, or both. Decannulation is expected as the mandibular growth occurs.


Zalzal and Tran—CHAPTER 74

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Airway Management of the Retrognathic Patient

Eve Bluestein


Retrognathia, or posterior positioning of the mandible relative to the cranial base, is a complex condition that may have various etiologies and effects on patients of all age groups. The range of those affected spans from neonates born with congenital conditions or syndromes to adults who suffer from growth abnormalities, systemic disease, or posttraumatic deformities. The consequences of retrognathia are many and vary in severity from mild aesthetic abnormalities to emergent airway obstruction. Within this range of consequences exist an entire spectrum of effects on the upper airway.

The airway compromise, regardless of the degree, may result in part, entirely, or not at all from the retrognathia itself. Discerning the precise role played by posterior mandibular positioning in a particular case of airway obstruction is both challenging and controversial. Accurate determination of the contribution of the ret-rognathia to the airway compromise is paramount to appropriate treatment planning. Once the diagnostic challenge is surmounted, even greater controversies and challenges present in determining the optimum short-term and long-term strategies for managing the patient's airway. This paper presents a general approach to airway management in the retrognathic patient (Fig. 75-1).

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