Evolution of Airway Obstruction in Infants with Robin Sequence (RS): Non-Surgical Vs. Surgical Treatment

PURPOSE

Infants with RS have airway obstruction of varying severity that dictate their management (non-surgical vs. surgical). In our centre, all infants with RS and significant airway obstruction have sequencial evaluation with oximetry in addition to timed polysomnography. The purpose of the study was to caracterize, for the different treatment strategies, the evolution during the first year of life and post palatal closure.

 

METHODS

We reviewed all oximetry and polysomnography data accumulated in infants who presented with significant airway obstruction. Treatment consisted either of prone position (prone, n=11); use of nasopharyngeal airway (NPA, n=4); tongue-lip adhesion (TLA, n=6); or mandibular distraction osteogenesis (MDO, n=5). Desaturation index (drops in SpO₂≥4%, DI4%; normal ≤8 events/h) and % time <90% (normal ≤0.2%) were used as parameters for airway obstruction on oximetry. Central apnea-hypopnea and mixed obstructive apnea-hypopnea index (MOAHI) were used from PSG.

 

RESULTS

On the initial oximetry (pre-treatment), DI4% and % time < 90% was higher in TLA, MDO and NPA groups than in the prone group (p<0.001). In the first week post-surgery, 3 neonates had persistence of high DI4% due to frequent brief central apnea. All infants improved over time, however, improvement was faster for infants undergoing surgery and much slower for NPA. By 3 months, there was no longer a difference between the two surgical groups and the prone group.

In infants with persistently elevated DI4% on oximetry (DI4% >10 ev/h, 4 prone, 3 TLA, 2 MDO), PSG showed predominance of brief central apnea with drops in oxygenation; MOAHI was < 5 events/h (normal or mild obstruction).

Before palatal closure, all infants except one in the NPA group (needed MDO) had normal or near-normal oximetry and polysomnography. Post palatal closure, 4 infants (36%) who had surgery in the neonatal period deteriorated; in the TLA group, 2 needed adenoidectomy, with one eventually needing MDO. In the MDO group, 1 infant needed adenoidectomy and one prolonged CPAP treatment. In that group that deteriorated post palatal closure, the MOAHI went from 4.4 events/hour (mild obstruction) to 35.8 events/h (severe obstruction).

 

Table. % time < 90% (average)

 

Treatment    1-week       1-month     3-months     10-12-months     Post palatal closure

Prone              2,0              0,7             0,1                0,06                       0,08

NPA                12,9            10,3            2,2                0,3                         0,4

TLA                 2,9              0,5             0,3                 0,1                        0,2

MDO                3,1             0,3              0,2                 0,1                        2,3

 

CONCLUSION

TLA and MDO both resulted in the most rapid improvement in obstruction parameters, and the use of NPA was associated with the longest time to improve. Brief central apnea is a frequent occurrence and PSG was needed for the diagnosis. Infants treated surgically for obstruction in the neonatal period had less favorable outcome post palatal closure, likely reflecting more severe initial obstruction due to narrow retropharyngeal space or associated airway anomalies.