Pierre Robin sequence (; abbreviated PRS) is a

congenital defect A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can r ...

observed in humans which is characterized by facial abnormalities. The three main features are micrognathia (abnormally small mandible), which causes

glossoptosis Glossoptosis is a medical condition and abnormality which involves the downward displacement or retraction of the tongue. It may cause non-fusion of the hard palate, causing cleft palate. It is one of the features of Pierre Robin sequence and Down ...

(downwardly displaced or retracted tongue), which in turn causes breathing problems due to obstruction of the

upper airway The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to th ...

. A wide, U-shaped

cleft palate A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate (the roof of the mouth) contains an opening into the nose. The ...

is commonly also present. PRS is not merely a

syndrome A syndrome is a set of medical signs and symptoms which are correlated with each other and often associated with a particular disease or disorder. The word derives from the Greek language, Greek σύνδρομον, meaning "concurrence". When a sy ...

, but rather it is a

sequence In mathematics, a sequence is an enumerated collection of objects in which repetitions are allowed and order matters. Like a set, it contains members (also called ''elements'', or ''terms''). The number of elements (possibly infinite) is called ...

—a series of specific developmental malformations which can be attributed to a single cause.

Signs and symptoms

PRS is characterized by an unusually small

mandible In anatomy, the mandible, lower jaw or jawbone is the largest, strongest and lowest bone in the human facial skeleton. It forms the lower jaw and holds the lower teeth in place. The mandible sits beneath the maxilla. It is the only movable bone ...

, posterior displacement or retraction of the tongue, and upper airway obstruction. Cleft palate (incomplete closure of the roof of the mouth) is present in the majority of patients. Hearing loss and speech difficulty are often associated with PRS.

Causes

Mechanical basis

The physical craniofacial deformities of PRS may be the result of a mechanical problem in which intrauterine growth of certain facial structures is restricted, or mandibular positioning is altered. One theory for the

etiology Etiology (pronounced ; alternatively: aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek (''aitiología'') "giving a reason for" (, ''aitía'', "cause"); and ('' -logía''). More completely, ...

of PRS is that, early in the first trimester of

gestation Gestation is the period of development during the carrying of an embryo, and later fetus, inside viviparous animals (the embryo develops within the parent). It is typical for mammals, but also occurs for some non-mammals. Mammals during pr ...

, some mechanical factor causes the neck to be abnormally flexed such that the tip of the mandible becomes compressed against the

sternoclavicular joint The sternoclavicular joint or sternoclavicular articulation is a synovial saddle joint between the manubrium of the sternum, and the clavicle, as well as the first rib. The joint possesses a joint capsule, and an articular disk, and is reinfo ...

. This compression of the chin interferes with development of the body of the mandible, resulting in micrognathia. The concave space formed by the body of the

hypoplastic Hypoplasia (from Ancient Greek :wikt:ὑπό, ὑπo- ''hypo-'' 'under' + πλάσις ''plasis'' 'formation'; adjective form ''hypoplastic'') is underdevelopment or incomplete development of a tissue or organ.palatal shelves. This in turn may result in failure of the left and right palatal shelves to fuse in the midline to form the

hard palate The hard palate is a thin horizontal bony plate made up of two bones of the facial skeleton, located in the roof of the mouth. The bones are the palatine process of the maxilla and the horizontal plate of palatine bone. The hard palate spans t ...

. This condition manifests as a cleft palate. Later in gestation (at around 12 to 14 weeks), extension of the neck of the fetus releases the pressure on the mandible, allowing it to grow normally from this point forward. At birth, however, the mandible is still much smaller (hypoplastic) than it would have been with normal development. After the child is born, the mandible continues to grow until the child reaches maturity.

Genetic basis

Alternatively, PRS may also be caused by a

genetic disorder A genetic disorder is a health problem caused by one or more abnormalities in the genome. It can be caused by a mutation in a single gene (monogenic) or multiple genes (polygenic) or by a chromosomal abnormality. Although polygenic disorders ...

. In the case of PRS which is due to a genetic disorder, a

hereditary Heredity, also called inheritance or biological inheritance, is the passing on of traits from parents to their offspring; either through asexual reproduction or sexual reproduction, the offspring cells or organisms acquire the genetic informa ...

basis has been postulated, but it usually occurs due to a ''de-novo''

mutation In biology, a mutation is an alteration in the nucleic acid sequence of the genome of an organism, virus, or extrachromosomal DNA. Viral genomes contain either DNA or RNA. Mutations result from errors during DNA or viral replication, m ...

. Specifically, mutations at chromosome 2 (possibly at the

GAD1 Glutamate decarboxylase 1 (brain, 67kDa) (GAD67), also known as GAD1, is a human gene. This gene encodes one of several forms of glutamic acid decarboxylase, identified as a major autoantigen in insulin-dependent diabetes. The enzyme encoded is re ...

gene), chromosome 4, chromosome 11 (possibly at the

PVRL1 Poliovirus receptor-related 1 (PVRL1), also known as nectin-1 and CD111 (formerly herpesvirus entry mediator C, HVEC) is a human protein of the immunoglobulin superfamily (IgSF), also considered a member of the nectins. It is a membrane protein ...

gene), or chromosome 17 (possibly at the

SOX9 Transcription factor SOX-9 is a protein that in humans is encoded by the ''SOX9'' gene. Function SOX-9 recognizes the sequence CCTTGAG along with other members of the HMG-box class DNA-binding proteins. It is expressed by proliferating but n ...

gene or the

KCNJ2 The Kir2.1 inward-rectifier potassium channel is a lipid-gated ion channel encoded by the gene. Clinical significance A defect in this gene is associated with Andersen-Tawil syndrome. A mutation in the KCNJ2 gene has also been shown to c ...

gene) have all been implicated in PRS. Some evidence suggests that genetic dysregulation of the SOX9 gene (which encodes the SOX-9 transcription factor) and/or the KCNJ2 gene (which encodes the

Kir2.1 The Kir2.1 inward-rectifier potassium channel is a lipid-gated ion channel encoded by the gene. Clinical significance A defect in this gene is associated with Andersen-Tawil syndrome. A mutation in the KCNJ2 gene has also been shown to c ...

inward-rectifier potassium channel Inward-rectifier potassium channels (Kir, IRK) are a specific lipid-gated subset of potassium channels. To date, seven subfamilies have been identified in various mammalian cell types, plants, and bacteria. They are activated by phosphatidylino ...

) impairs the development of certain facial structures, which can lead to PRS. PRS may occur in isolation, but it is often part of an underlying disorder or syndrome. Disorders associated with PRS include Stickler syndrome,

DiGeorge syndrome DiGeorge syndrome, also known as 22q11.2 deletion syndrome, is a syndrome caused by a microdeletion on the long arm of chromosome 22. While the symptoms can vary, they often include congenital heart problems, specific facial features, frequent i ...

, fetal alcohol syndrome,

Treacher Collins syndrome Treacher Collins syndrome (TCS) is a genetic disorder characterized by deformities of the ears, eyes, cheekbones, and chin. The degree to which a person is affected, however, may vary from mild to severe. Complications may include breathing prob ...

, and

Patau syndrome Patau syndrome is a syndrome caused by a chromosomal abnormality, in which some or all of the cells of the body contain extra genetic material from chromosome 13. The extra genetic material disrupts normal development, causing multiple and comp ...

Diagnosis

PRS is generally diagnosed clinically shortly after birth. The infant usually has respiratory difficulty, especially when

supine In grammar, a supine is a form of verbal noun used in some languages. The term is most often used for Latin, where it is one of the four principal parts of a verb. The word refers to a position of lying on one's back (as opposed to ' prone', l ...

. The palatal cleft is often U-shaped and wider than that observed in other people with cleft palate.

Management

The goals of treatment in infants with PRS focus upon breathing and feeding, and optimizing growth and nutrition despite the predisposition for breathing difficulties. If there is evidence of airway obstruction (snorty breathing, apnea, difficulty taking a breath, or drops in oxygen), then the infant should be placed in the sidelying or prone position, which helps bring the tongue base forward in many children. One study of 60 infants with PRS found that 63% of infants responded to prone positioning. Fifty-three percent of the infants in this study required some form of feeding assistance, either nasogastric tube or gastrostomy tube feedings (feeding directly into the stomach). In a separate study of 115 children with the clinical diagnosis of PRS managed at two different hospitals in Boston, respiratory distress was managed successfully in 56% without an operation (either by prone positioning, short-term intubation, or placement of a nasopharyngeal airway). In this study, gastrostomy tube feeding were placed in 42% of these infants due to feeding difficulties.

Gastroesophageal reflux Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases where stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/ ...

(GERD) seems to be more prevalent in children with PRS. Because reflux of acidic contents in the posterior pharynx and upper airway can intensify the symptoms of PRS, specifically by worsening airway obstruction, it is important to maximize treatment for GER in children with PRS and reflux symptoms. Treatment may include upright positioning on a wedge (a tucker sling may be needed if the baby is in the prone position), small and frequent feedings (to minimize vomiting), and/or pharmacotherapy (such as proton pump inhibitors). In nasopharyngeal

cannula A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...

tion (or placement of the nasopharyngeal airway or tube), the infant is fitted with a blunt-tipped length of surgical tubing (or an endotracheal tube fitted to the child), which is placed under direct visualization with a laryngoscope, being inserted into the nose and down the pharynx (or throat), ending just above the vocal cords. Surgical threads fitted through holes in the outside end of the tube are attached to the cheek with a special skin-like adhesive material called 'stomahesive', which is also wrapped around the outside end of the tube (but not over the opening at the end) to keep the tube in place. This tube or cannula, which itself acts as an airway, primarily acts as a sort of "splint" which maintains patency of the airway by keeping the tongue from falling back on the posterior pharyngeal wall and occluding the airway, therefore preventing airway obstruction, hypoxia and asphyxia. Nasopharyngeal airways are not available at every center; however, when available, nasopharyngeal cannulation should be favored over the other treatments mentioned in this article, as it is far less invasive; it allows the infant to feed without the further placement of a nasogastric tube. This treatment may be utilized for multiple months, until the jaw has grown enough so that the tongue assumes a more normal position in the mouth and airway (at birth, the jaws of some infants are so underdeveloped that only the tip of the tongue can be seen when viewed in the throat). Some institutions discharge the infant home with a nasopharyngeal tube in place. Distraction osteogenesis (DO), also called a "Mandibular Distraction", can be used to correct abnormal smallness of one or both jaws seen in patients with PRS. Enlargement of the lower jaw brings the tongue forward, preventing it from obstructing the upper airway. The process of DO begins with preoperative assessment. Doctors use three-dimensional imaging to identify the parts of the patient's facial skeleton that need repositioning and determine the magnitude and direction of distraction. They may then select the most appropriate distraction device or sometimes have custom devices fabricated. When possible, intraoral devices are used. DO surgery starts with an osteotomy (surgical division or sectioning of bone) followed by the distraction device being placed under the skin and across the osteotomy. A few days later, the two ends of the bone are very gradually pulled apart through continual adjustments that are made to the device by the parents at home. The adjustments are made by turning a small screw that protrudes through the skin, usually at a rate of 1 mm per day. This gradual distraction leads to formation of new bone between the two ends. After the process is complete, the osteotomy is allowed to heal over a period of six to eight weeks. A small second surgery is then performed to remove the device. The cleft palate is generally repaired between the ages of 6½ months and 2 years by a plastic surgeon, an oromaxillofacial surgeon, or an

otorhinolaryngologist Otorhinolaryngology ( , abbreviated ORL and also known as otolaryngology, otolaryngology–head and neck surgery (ORL–H&N or OHNS), or ear, nose, and throat (ENT)) is a surgical subspeciality within medicine that deals with the surgical a ...

(ENT surgeon). In many centres there is now a cleft lip and palate team comprising these specialties, as well as a coordinator, a speech and language therapist, an orthodontist, sometimes a psychologist or other mental health specialist, an audiologist, and nursing staff. The

and

micrognathism Micrognathism is a condition where the jaw is undersized. It is also sometimes called mandibular hypoplasia. It is common in infants, but is usually self-corrected during growth, due to the jaws' increasing in size. It may be a cause of abnor ...

generally do not require surgery, as they improve to some extent unaided, though the mandibular arch remains significantly smaller than average. In some cases jaw distraction is needed to aid in breathing and feeding. Lip-tongue attachment is performed in some centres, though its efficacy has been recently questioned. A cleft palate (PRS or not) makes it difficult for individuals to articulate speech sounds, which may be due to the physical nature of cleft palate or the hearing loss that is associated with the condition. This is typically why a speech language pathologist and/or audiologist is involved with the patient. Hearing should be checked by an audiologist regularly and can be treated with hearing amplification such as hearing aids. Because middle ear effusion is found in many patients with PRS, tympanostomy (ventilation) tubes are often a treatment option.Handžić-Ćuk, 2007 One study with children showed that patients with PRS displayed a moderate and severe hearing loss most frequently. Planigraphs of temporal bones in these patients displayed an underdeveloped pneumatization of the

mastoid The mastoid part of the temporal bone is the posterior (back) part of the temporal bone, one of the bones of the skull. Its rough surface gives attachment to various muscles (via tendons) and it has openings for blood vessels. From its borders, ...

bone in all PRS patients and in most patients with cleft palate (without PRS). There were no abnormalities of the inner or middle ear anatomy in patients with PRS.

Prognosis

Children affected with PRS usually reach full development and size. However, it has been found internationally that children with PRS are often slightly below average size, raising concerns of incomplete development due to chronic hypoxia related to upper airway obstruction as well as lack of nutrition due to early feeding difficulties or the development of an oral aversion. However, the general prognosis is quite good once the initial breathing and feeding difficulties are overcome in infancy. Most PRS babies grow to lead a healthy and normal adult life. The most important medical problems are difficulties in breathing and feeding. Affected infants very often need assistance with feeding, for example needing to stay in a lateral (on the side) or prone (on the tummy) position which helps bring the tongue forward and opens up the airway. Babies with a cleft palate will need a special cleft feeding device (such as the Haberman Feeder). Infants who are unable to take in enough calories by mouth to ensure growth may need supplementation with a

nasogastric tube Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric tube or NG tube) through the nose, down the oesophagus, and down into the stomach. Orogastric intubation is a similar process involving the inserti ...

. This is related to the difficulty in forming a vacuum in the oral cavity related to the

, as well as to breathing difficulty related to the posterior position of the tongue. Given the breathing difficulties that some babies with PRS face, they may require more calories to grow (as working of breathing is somewhat like exercising for an infant). Infants, when moderately to severely affected, may occasionally need nasopharyngeal

tion, or placement of a nasopharyngeal tube to bypass the airway obstruction at the base of the tongue. in some places, children are discharged home with a nasopharyngeal tube for a period of time, and parents are taught how to maintain the tube. Sometimes endotracheal

intubation Intubation (sometimes entubation) is a medical procedure involving the insertion of a tube into the body. Patients are generally anesthetized beforehand. Examples include tracheal intubation, and the balloon tamponade with a Sengstaken-Blake ...

tracheostomy Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe). The r ...

may be indicated to overcome upper respiratory obstruction. In some centers, a tongue lip adhesion is performed to bring the tongue forward, effectively opening up the airway. Mandibular distraction can be effective by moving the jaw forward to overcome the upper airway obstruction caused by the posterior positioning of the tongue. Given that some children with PRS will have Stickler syndrome, it is important that children with PRS be evaluated by an optometrist or ophthalmologist. Because the retinal detachment that sometimes accompanies Stickler syndrome is a leading cause of blindness in children, it is very important to recognize this diagnosis.

Epidemiology

The prevalence of PRS is estimated to be 1 in 8,500 to 14,000 people. Hearing loss has a higher incidence in those with cleft palate versus non-cleft palate. One study showed hearing loss in PRS at an average of 83%, versus an average of 60% of individuals with cleft without PRS.Handžić et al, 1995 Another study with children showed that hearing loss was found more frequently with PRS (73.3%) compared to those with cleft and no PRS (58.1%). Hearing loss with PRS typically is a bilateral, conductive loss (affecting the outer/middle portion of the ear).

History

The condition is named for the French dental surgeon Pierre Robin. It is thought that

Noel Rosa Noel de Medeiros Rosa (December 11, 1910 – May 4, 1937) was a Brazilian songwriter, singer, and guitar/mandolin player. One of the greatest names in Brazilian popular music, Noel gave a new twist to samba, combining its Afro-Brazilian roots wi ...

, one of the most famous and influential artists in the history of

Brazilian music The music of Brazil encompasses various regional musical styles influenced by European, American, African and Amerindian forms. Brazilian music developed some unique and original styles such as forró, repente, coco de roda, axé, sertanejo, ...

, had PRS, although others claim that his sunken chin was the result of a forceps accident during childbirth.

References

Handžić-Ćuk, J., Ćuk, V., Rišavi, R., Katić, V., Katušić, D., Bagatin, M., ... Gortan, D. (2007, June 29). Pierre Robin syndrome: characteristics of hearing loss, effect of age on hearing level and possibilities in therapy planning: The Journal of Laryngology & Otology. Retrieved from https://www.cambridge.org/core/journals/journal-of-laryngology-and-otology/article/pierre-robin-syndrome-characteristics-of-hearing-loss-effect-of-age-on-hearing-level-and-possibilities-in-therapy-planning/6DD871B7BD583AD124C1EE0A3538FCCD Handzic, J., Bagatin, M., & Subotic, R. (1995, February). Hearing Levels in Pierre Robin Syndrome. Retrieved March 11, 2020, from https://www.researchgate.net/publication/15470673_Hearing_Levels_in_Pierre_Robin_Syndrome Pierre Robin Syndrome - Birth Defect Fact Sheet. (2020, March 11). Retrieved from https://www.birthdefects.org/pierre-robin-syndrome Pierre Robin Sequence (PRS). (2020). Retrieved from http://craniofacialteamtexas.com/pierre-robin-sequence-prs/

External links

* http://www.orpha.net/consor/cgi-bin/OC_Exp.php?Lng=GB&Expert=718 {{DEFAULTSORT:Pierre Robin Syndrome Syndromes affecting the jaw Congenital disorders of musculoskeletal system Syndromes affecting the tongue Medical triads Syndromes with craniofacial abnormalities