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Original Investigation |

Outcomes of Mandibular Distraction Osteogenesis in the Treatment of Severe Micrognathia

Derek J. Lam, MD, MPH1,2; Meredith E. Tabangin, MPH3; Tasneem A. Shikary, MD2; Armando Uribe-Rivera, DDS4; Jareen K. Meinzen-Derr, PhD3; Alessandro de Alarcon, MD, MPH2; David A. Billmire, MD4; Christopher B. Gordon, MD4
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland
2Division of Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
3Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
4Division of Plastic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
JAMA Otolaryngol Head Neck Surg. 2014;140(4):338-345. doi:10.1001/jamaoto.2014.16.
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Importance  Patients with severe micrognathia are predisposed to airway obstruction. Mandibular distraction osteogenesis (MDO) is an alternative to tracheotomy that lengthens the mandible in order to improve the retrolingual airway. This study presents outcomes from one of the largest cohorts reported.

Objective  To assess the rate and predictors of surgical success and complications among (1) patients who underwent MDO prior to other airway procedures (MDO first), and (2) patients who required an initial tracheotomy and were subsequently treated with MDO (tracheotomy first).

Design, Setting, and Participants  Retrospective cohort study at a tertiary care pediatric medical center of patients diagnosed as having micrognathia resulting in symptomatic airway obstruction (Pierre Robin sequence) and who underwent MDO from September 1995 to December 2009.

Interventions  Electronic medical records were reviewed. Multivariable regression analysis was used to assess for predictors of outcome.

Main Outcomes and Measures  Rates of surgical success (defined as either tracheotomy avoidance or decannulation) and complications. Potential predictors included demographics, syndrome presence, follow-up time, and surgical history.

Results  A total of 123 patients (61 in MDO-first subgroup, 62 in tracheotomy-first subgroup) underwent MDO during the study period. Median age at time of distraction was 21 months (range, 7 days–24 years). Surgical success and complication rates were 83.6% and 14.8% in the MDO-first subgroup and 67.7% and 38.7% in the tracheotomy-first subgroup. Tracheotomy-first patients were more likely to have a syndromic diagnosis (66.0% vs 43.0%; P = .009) and were older at the time of MDO (median age, 30 months vs 5.1 months; P < .001). Poorer odds of success were associated with the need for 2 or more other airway procedures (odds ratio [OR], 0.14 [95% CI, 0.02-0.82]) in the MDO-first subgroup and craniofacial microsomia or Goldenhar syndrome (OR, 0.07 [95% CI, 0.009-0.52]) in the tracheotomy-first subgroup.

Conclusions and Relevance  Mandibular distraction osteogenesis has a high rate of success in avoiding tracheotomy. Patients who required a tracheotomy before MDO had a lower success rate in achieving decannulation and a higher rate of complications. However, these patients also had a higher rate of syndromic diagnoses and associated comorbidities. Patients with Goldenhar syndrome have a decreased likelihood of surgical success.

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Figure 1.
Predicted Probabilities for Surgical Success (Tracheotomy-First Subgroup)

Predicted probabilities of surgical success among patients who had a tracheotomy prior to mandibular distraction osteogenesis. A, Females; B, males. The colored dotted lines indicate differences in the probability of success for each diagnosis. Open circles represent the observed values.

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Figure 2.
Predicted Probabilities for Complications Stratified by Initial Treatment Subgroup

The predicted probabilities of complications stratified by the initial surgical intervention. A, Mandibular distraction osteogenesis (MDO) first; B, tracheotomy first. The colored lines indicate the differences in the probability of success for patients who had less than 2 vs 2 or more other airway procedures. The shaded areas represent the 95% CIs for these probabilities. Open circles represent the observed values.

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Figure 3.
Proposed Treatment Algorithm for Pediatric Patients With Symptomatic Micrognathia

The flowchart demonstrates our current algorithm for workup and decision making regarding the choice of mandibular distraction osteogenesis (MDO) vs tracheotomy for symptomatic micrognathia. CFM indicates craniofacial microsomia.

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