Algorithm for Airway Management in Patients With Pierre Robin Sequence.

PURPOSE: Airway management in neonates with Pierre Robin sequence (PRS) can be challenging. The goal was to describe the algorithm developed by the authors over the past 8 years. METHODS: A retrospective case series analyzing airway management in neonates with PRS admitted to the neonatal intensive care unit at a tertiary care pediatric hospital was performed. The utility of the proposed algorithm for airway management incorporating more consistent use of polysomnography (PSG), and airway assessment was assessed. RESULTS: A total of 31 neonates with PRS (12 men, 19 women) with a mean gestational age of 38.2 weeks were analyzed. Thirteen (41.9%) patients had a named syndrome, chromosomal abnormality, or global delay. Twenty (64.5%) patients had pre-intervention PSG, and severe obstructive sleep apnea with an apnea-hypopnea index (AHI) ≥ 10 events/hour was identified in 19 (95.0%). Mandibular distraction osteogenesis was performed in 18 (58.1%) patients, and improved the AHI on post-operative PSGs. Direct assessment of the upper and lower airways was performed in 19 patients, and 13 (68.4%) were found to have secondary airway pathology. Presence of a concomitant syndrome was significantly associated with need for tracheostomy. CONCLUSION: The algorithm differs from previous ones in that it relies on rigorous pre- and post-intervention PSG (including with a nasopharyngeal airway), as well as that it allows flexibility between treatment options given the whole-patient clinical scenario and endoscopic findings. Results from these studies may be integrated to stratify patients into those who are most likely to benefit from conservative interventions or surgical procedures.

Cervical oesophageal perforation secondary to food consumption in a well-appearing patient.

A 71-year-old woman presented to the emergency department 8 days after ingesting fish with mild neck pain but otherwise demonstrated no signs of infection. X-rays were negative but CT imaging demonstrated a curvilinear radiodense object extending from the posterior cervical oesophagus through the right thyroid lobe terminating in the neck just a few millimetres from the external carotid artery. Rigid oesophagoscopy and direct laryngoscopy were negative and the neck was explored for the foreign body, which ultimately was encountered after a painstaking dissection of the right neck that included skeletonisation of the recurrent laryngeal nerve. Her postoperative recovery was uneventful and after a 3-day course of intravenous antibiotics she was discharged on oral antibiotics, in good condition and tolerating a soft diet.

Characterization of facial paresis in hemifacial microsomia.

OBJECTIVE: To provide an overview of the incidence, characteristics, and proposed etiologic mechanisms of facial paresis in patients with manifestations of hemifacial microsomia. DATA SOURCES: PubMed database for English-language studies with no date restrictions. REVIEW METHODS: A comprehensive literature review was performed identifying all studies that discussed incidence, characterization, or etiologic mechanisms for facial paresis in hemifacial microsomia/oculo-auriculo-vertebral spectrum. CONCLUSIONS: This review supports that the prevalence of facial weakness in the spectrum of hemifacial microsomia/oculo-auriculo-vertebral spectrum ranges from 10% to 45%. Most of these patients have involvement of all facial nerve branches or lower branches only. The most commonly involved single nerve branch has yet to be described. The 2 most common associated anomalies involve the mandible and auricle. Dysmorphogeneisis of the temporal bone and its effects on the facial nerve are most likely implicated in the cause of facial weakness. IMPLICATIONS FOR PRACTICE: There is a wide variety of facial nerve presentations seen within oculo-auriculo-vertebral spectrum for which the exact etiologic mechanism is unclear. Through a better understanding of the presentation and etiology surrounding facial paresis in hemifacial microsomia, improved treatment options may be offered in the management of the facial weakness.