Treacher-Collins syndrome is a congenital disorder of craniofacial development characterized by bilateral symmetrical oto-mandibular dysplasia without abnormalities of the extremities, associated with several head and neck defects. Annual incidence at birth is estimated at 1/50,000 live births. Children present with characteristic facial dysmorphism with bilateral and symmetrical hypoplasia of the malar bones and infra-orbital rim (80% of cases) and of the mandible (78%) (retrognathia, retrogenia), which results in dental malocclusion, often characterized by an anterior apertognathia. Predominant hypoplasia of soft tissues is observed in the malar, inferior orbital rim and cheek. Features also observed include abnormalities in the temporo-mandibular joint leading to a limitation of mouth opening of varying severity, anti-mongoloid obliquity of palpebral fissures (89%) and a coloboma of the lower eyelids between the external and middle thirds (69%) with absence of eyelashes on the outer third of the lower eyelid. There is a palpable bony notch next to the lateral canthus. The palate is ogival and cleft palate is occasionally observed (28%). External ear abnormalities, such as microtia or anotia, atresia of the external auditory canal and anomalies of the ossicular chain are often present (60%) and lead to conductive hearing loss. Intelligence is usually normal. Breathing and nutrition difficulties may arise during the early years because of the narrowness of the upper respiratory tract and limited mouth opening. Less common signs include enchondromas and/or pretragal fistulas, spinal and cardiac anomalies, and commissural clefts. The syndrome is caused by mutations in the TCOF1 gene (5q32-q33.1) encoding the nucleolar phosphoprotein Treacle. Transmission is autosomal dominant with 90% penetrance and variable expressivity, even among affected patients within the same family. Diagnosis is based on clinical findings and complementary examinations. Molecular tests confirm the diagnosis. Differential diagnoses include Nager and Miller syndromes (see these terms). The syndrome can be revealed on antenatal ultrasound showing typical facial dysmorphism with bilateral ear abnormalities. Antenatal diagnosis is possible by molecular analysis of chorionic villus samples (CVS). Genetic counseling is complicated by the variable expression of the disease and should be discussed by a multidisciplinary antenatal diagnosis team. Management is multidisciplinary. In cases with respiratory distress, tracheostomy, Non-Invasive Ventilation (NIV) or mandibular distraction should be discussed. Maxillofacial and plastic surgery can correct the soft tissue hypoplasia (lipostructure), bone hypoplasia (distraction, bone grafts), eyelid coloboma and cleft palate. The treatment of the limited opening of the mouth is very difficult. Specialist ENT surgery is required for the abnormalities of the middle ear (functional surgery) and the external ear (reconstruction of the auricles). Management of hearing impairment should be early (hearing aids and functional surgery) to aid normal development. The prognosis for milder forms of the disease is favorable with adequate treatment.
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