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Mandibulofacial dysostosis,

also known as Treacher

Collins syndrome

Treacher Collins
1 in 40,000 to 1 in 70,000 of live
Diminished growth of craniofacial
structures derived from the first and
second pharyngeal arch, groove, and

Physical Exam
The Face is characteristic.
Abnormalities are usually
present bilaterally
and symmetrically.

Malar bones, zygomatic process of frontal
bone, lateral pterygoid plates, paranasal
sinuses, and mandibular condyles are
The mastoids are not pneumatized.
The lateral margins of the orbits may be
defective, and the orbits are hyperteloric.
The cranial base is progressively kyphotic.
The calvaria are essentially normal.

The palpebral fissures are short and
slope laterally downward.
In the outer third of
the lower lid, a
coloboma is
present, and the
cilia (eyelashes)
may be deficient
medially from the

The pinnae are often malformed, crumpled forward, or misplaced
toward the angle of the mandible
Extra ear tags and
blind fistulas may develop
anywhere between the tragus
and the angle of the mouth

Absence of the middle ear and tympanic
spaces are present, resulting in a conductive
hearing loss.
The inner ears are normal

The nose appears
large because of the
lack of malar
development and
supraorbital ridges.

Mouth and throat :

A Cleft palate is found in one third of the

patients, and congenital palatopharyngeal
incompetence (foreshortened, immobile,
or absent soft palate)
o Submucous cleft palate is found in an
additional one third of patients.

The parotid glands are missing or

Pharyngeal hypoplasia is a constant

Other features:
Mental status: Intelligence is usually normal
Developmental delay may be secondary to
undiagnosed hearing loss.
Dysfunctional symptoms: Hypoplasia and a
retropositioned tongue
Difficulties with swallowing and feeding (caused
by musculoskeletal underdevelopment and a
cleft palate)
Conductive hearing loss (caused by
maldevelopment of the auditory canal and
middle ear ossicles)
Impaired vision (caused by under developed
lateral orbit and extraocular muscles)

1. Embryology:
Failure of neural crest cells to migrate into
the first and second branchial arches leads
to dysplasia, hypoplasia, or aplasia of the
arches. Therefore, the abnormalities are
bilateral and symmetrical.

The critical period occurs approximately

between the sixth and seventh week of
embryonal development.


Autosomal dominant
Approximately 60% of cases represent fresh
May be associated with exposure of a
teratogenic dose of vitamin A (animal studies)
Can be caused by mutations in
o TCOF1was mapped to chromosome bands 5q31.333.3.

Nager Syndrome (Preaxial acrofacial dysostosis)
o Facial features nearly identical to those of Treacher Collins Syndrome.
o Cleft palate, mandibular growth (more severe), hypoplastic or
absent thumbs, radioulnar synostosis, lower eyelid colobomas are

Oculoauriculovertebral spectrum, including Goldenhar

o Epibulbar dermoids of the eye, preauricular tags, vertebral defects, and
facial underdevelopment.

X-linked dominant maxillofacial dysostosis

o B/L hypoplasia of malar bones, downward-slanting palpebral fissures
without colobomas, maxillary hypoplasia, open bite, and relative
mandibular prognathism.

Work Up
Midtrimester ultrasonography can
detect facial dysmorphology and,
because of its noninvasive quality, is
preferred to fetoscopy

Work Up
Mutations of theTCOF1gene can be
detected as single-nucleotide
polymorphisms. Thus, prenatal diagnosis
is possible but not yet clinically available.
A prenatal diagnosis requires the
Blood samples from family members
Fetal cells obtained via chorionic villi
sampling (performed at 10-11 weeks'
gestation) or via amniocentesis (performed
at 16-17 weeks' gestation)

Assessment and
monitoring of postnatal

Pulse oximeter
Monitoring of hemoglobin saturation with oxygen
Assessment of feeding efficiency
Audiologic testing
Neuro-ophthalmologic assessment
Full craniofacial CT scan (axial and coronal slices,
from the top of the skull through the cervical
Evaluation and genetic diagnosis by a medical

Radiology (for surgical

Anteroposterior and lateral cephalography
Full craniofacial CT scan (axial and coronal slices
from the top of the skull through the cervical
As follow-up, CT scans from orbits through
Panoramic radiography
Brain MRI for inner auditory canal (IAC) study
preferred (If MRI is not available, CT scan may be
obtained for IAC.)

Treatment of mandibulofacial dysostosis
(Treacher Collins syndrome) is lengthy
and requires a multidisciplinary approach
focused on treatment of symptoms.
In newborns with mandibulofacial
dysostosis, immediate attention to
airway and swallowing inadequacies is

Severe airway inadequacy tracheostomy is performed
o until the lower jaw has sufficiently grown or until alveolar
distraction is performed (May take several years)

Otherwise, special positioning of the infant may be sufficient

Severe swallowing difficulty introduce feeding to
ensure adequate caloric intake and hydration.
Substantial conductive hearing loss Fit hearing
aidshortly after birth
Important for the development of the infant's communication
skills and for the normal bonding process within the family

Family-to-family support has proven to be of great

psychological value


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