Predictors of residual obstructive sleep apnea after mandibular distraction osteogenesis in infants with Pierre Robin sequence: Insight on syndromic stratification.

BACKGROUND

Mandibular distraction osteogenesis (MDO) improves obstructive sleep apnea (OSA) in infants with Pierre Robin sequence (PRS), but residual disease is common. We sought to identify predictors of residual severe OSA after MDO.

METHODS

We performed a retrospective cohort study of infants with PRS who underwent MDO and postoperative polysomnography (PSG) at a tertiary pediatric center between 2019 and 2025. Residual severe OSA was defined a priori as postoperative obstructive apnea-hypopnea index (oAHI) > 10 events/hour or postoperative need for a tracheostomy. Candidate predictors were evaluated using univariate logistic regression. Stickler syndrome was analyzed both within and excluded from the syndromic category based on its tongue-base airway physiology resembling isolated PRS.

RESULTS

Thirty-three infants met inclusion criteria, of whom 11 (33.3%) had residual severe OSA; one required tracheostomy. Syndromic diagnosis excluding Stickler syndrome (odds ratio [OR] 5.95, 95% confidence interval [CI] 1.22-28.95, p = 0.03), neurologic hypotonia (OR = 5.40, 95%CI 1.08-26.93, p = 0.04) and higher preoperative oAHI (OR = 1.04 per event/hour, 95%CI 1.01-1.07, p = 0.02) were associated with residual severe OSA. Exploratory receiver operating characteristic analysis demonstrated modest discrimination (AUC = 0.70, 95%CI 0.43-0.97) with an optimal preoperative oAHI cutoff of 96 events/hour (50% sensitivity, 95% specificity). Among 25 infants with paired PSGs, median oAHI reduction was similar between the non-syndromic/Stickler and syndromic groups (90.5% vs 87.6%, p = 0.3).

CONCLUSIONS

One-third of infants had residual severe OSA after MDO. Higher preoperative oAHI, neurologic hypotonia, and syndromic diagnosis excluding Stickler syndrome were associated with residual disease and may help identify infants who warrant closer postoperative PSG surveillance.