Heller Justin B, Gabbay Joubin S, Kwan Daniel, O'Hara Catherine M, Garri J I, Urrego Andrès, Wilson Libby S, Kawamoto Henry K, Bradley James P
Division of Plastic and Reconstructive Surgery, University of California, Los Angeles 90095, USA.
Plast Reconstr Surg. 2006 Jun;117(7):2389-98. doi: 10.1097/01.prs.0000218796.87243.6d.
Treacher Collins and Nager syndromes may present with mandibular hypoplasia that causes posterior collapse of the tongue base and a decreased oropharyngeal airway. Mandibular distraction and orthognathic advancement are effective treatments to correct the airway, but failure may occur despite achieving class I occlusion. For this select population, the authors propose a novel procedure of genioplasty distraction and hyoid advancement to optimize epiglottal positioning.
Patients diagnosed with Treacher Collins (n = 5) or Nager syndrome (n = 3) with obstructive sleep apnea or tracheostomy dependency (n = 8) underwent genioplasty distraction and hyoid advancement. Airway outcome was assessed by preoperative and 1-year follow-up comparison of (1) laryngobronchoscopy, (2) sleep studies, and (3) tracheostomy dependency. For genioplasty outcome, three groups were used: group I (distraction genioplasty, syndromic) (n = 8), group II (acute genioplasty, syndromic) (n = 7), and group III (acute genioplasty, nonsyndromic) (n = 10). Lateral cephalogram measurements were used in the preoperative, postoperative, and follow-up periods to assess horizontal and vertical advancement and relapse.
Epiglottal position was optimized by the procedure in all patients based on direct endoscopic assessment. All five patients with obstructive sleep apnea had resolution of symptoms, and two of three patients achieved removal of their tracheostomy. Mean advancement for groups I, II, and III was 25, 14, and 8 mm, respectively. Follow-up horizontal advancement for groups I, II, and III were 18, 4, and 6 mm, respectively. Cephalometric measurements showed a horizontal relapse for groups I, II, and III of 10, 62, and 11 percent, respectively.
Data suggest that genioplasty distraction allows for a greater advancement and decreased relapse rate than acute procedures alone; and genioplasty distraction with hyoid advancement is a useful technique for resolution of obstructive sleep apnea or to achieve tracheostomy removal in those syndromic patients who have already undergone mandibular advancement into a class I occlusion.
特雷彻·柯林斯综合征和纳杰尔综合征可能表现为下颌骨发育不全，导致舌根后塌和口咽气道变窄。下颌骨牵张成骨术和正颌前徙术是纠正气道的有效治疗方法，但即便实现了Ⅰ类咬合关系仍可能失败。对于这一特定人群，作者提出一种颏成形术牵张成骨联合舌骨前徙的新术式，以优化会厌位置。
8例诊断为特雷彻·柯林斯综合征（5例）或纳杰尔综合征（3例）且患有阻塞性睡眠呼吸暂停或依赖气管切开术的患者接受了颏成形术牵张成骨联合舌骨前徙术。通过术前及1年随访时对比（1）喉镜检查、（2）睡眠研究和（3）气管切开术依赖情况来评估气道结局。对于颏成形术的结果，分为三组：Ⅰ组（牵张成骨颏成形术，综合征型）（8例），Ⅱ组（急性颏成形术，综合征型）（7例），Ⅲ组（急性颏成形术，非综合征型）（10例）。术前、术后及随访期采用头颅侧位片测量来评估水平和垂直向的前徙及复发情况。
根据直接内镜评估，所有患者的会厌位置均通过该手术得到优化。5例阻塞性睡眠呼吸暂停患者的症状均得到缓解，3例患者中有2例成功拔除气管切开导管。Ⅰ组、Ⅱ组和Ⅲ组的平均前徙量分别为25、14和8mm。Ⅰ组、Ⅱ组和Ⅲ组随访时的水平前徙量分别为18、4和6mm。头影测量显示，Ⅰ组、Ⅱ组和Ⅲ组的水平复发率分别为10%、62%和11%。
数据表明，与单纯急性手术相比，颏成形术牵张成骨能实现更大程度的前徙且复发率更低；对于那些已经接受下颌骨前徙至Ⅰ类咬合关系的综合征患者，颏成形术牵张成骨联合舌骨前徙术是解决阻塞性睡眠呼吸暂停或实现气管切开导管拔除的有效技术。
