Genetic counseling: Oculo-Auriculo-Vertebral Spectrum

Oculo-Auriculo-Vertebral Spectrum

(a.k.a. Goldenhar Syndrome, Oculoauriculovertebral Dysplasia, OAV Syndrome, Facio-Auriculo-Vertebral Spectrum, First & Second Branchial Arch Syndrome)

Overview

 * a condition that affects the growth of the face
 * predominantly unilateral and involves the ear, mouth, and mandible (jaw)
 * about 15% have bilateral involvement though
 * extremely variable with many transitional forms affecting different systems
 * term Goldenhar syndrome used when the spine and the eye (epibulbar dermoids which are benign tumors located just inside the opening of the eye or the eyeballs and can cause vision problems) are involved

Etiology

 * unknown etiology, but is usually sporadic
 * However, a few cases have had a positive family history suggesting autosomal dominant, autosomal recessive, or multifactorial inheritance
 * thought to be caused by abnormal changes in blood vessels and the disruption of the blood supply during embryonic development (early vascular disruption) at about 30-45 days of gestation
 * results in the destruction of differentiating tissue in the first and second branchial arches, from which certain ligaments and bones of the face, parts of the skull, and the middle ear develop
 * amount of damage depends on timing of vascular disruption and degree of tissue destruction
 * No DNA abnormality has been identified
 * However, it has also been noted that certain teratogens (Thalidomide, Primidone, and Accutane) have produced birth defect patterns that are similar to the HFM spectrum.
 * rate of Goldenhar Syndrome found in the children of Gulf War veterans was 4 X's as high as in general population (ABDC collected data) 15 cases when 4 were expected (http://www.widesmiles.org/syndrom/hmsgold/gulfwar.html)

Recurrance Risks
(Unless autosomal dominant pattern found which can be in Goldenhar)
 * chances of having another child with Hemifacial Microsomia or Goldenhar are less than 1%
 * affected person has an approximately 3% chance of passing it on to their children

Incidence

 * The frequency of occurrence is estimated to be 1 in 3000 to 1 in 5000, and there is a slight male predominance (3:2).

Clinical Features

 * Key features:
 * Facial - asymmetry (90%). . .right side predominance (62%)
 * hypoplasia of malar, maxillary, and/or mandibular region
 * macrostomia (lateral cleft-like extension of the corner of the mouth)
 * hypoplasia of the facial musculature
 * frontal bossing
 * Ear - microtia (malformation of the external ear from complete aplasia to a crumpled, distorted
 * pinna which is displaced anteriorly and inferiorly) (65%)
 * accessory preauricular tags and/or pits
 * middle ear anomaly with variable deafness
 * Eye - palpebral fissure is somewhat lowered on the affected side
 * Oral - diminished to absent parotid secretion
 * anomalies in function or structure of the tongue
 * malfunction of the soft palate
 * Associated findings:
 * prenatal growth deficiency, feeding difficulties
 * Vertebral - hemivertebrae or hypoplasia of vertebrae, usually cervical (40-60%)
 * Eye - epibulbar dermoid and/or lipodermoid
 * strabismus
 * unilateral coloboma of the superior lid
 * microphthalmia
 * Oral - cleft lip, cleft palate (7%)
 * Cardiac - various forms of heart disease (45-55%)
 * ventricular septal defect
 * patent ductus arteriosus
 * tetralogy of Fallot
 * coarctation of the descending aorta
 * Lung - pulmonary agenesis or hypoplasia of the lung
 * Renal - ectopic and/or fused kidneys
 * renal agenesis
 * double ureter
 * Nervous - mental retardation (10%)
 * occipital encephalocele
 * hydrocephalus
 * agensis of corpus callosum

Natural History

 * Hemifacial Microsomia is congenital and most of the physical characteristics are apparent at birth.
 * However, the facial asymmetry may not become apparent until the child grows (usually by four years of age).

Potential Medical Concerns

 * lack of the development of the upper and lower jaws can cause breathing problems as well as a dental malocclusion which will need to be addressed surgically and orthodontically

Testing

 * Diagnosis is clinical due to lack of understanding exact cause and probably usually more due to environmental factors
 * Prenatal diagnosis by ultrasound may be possible if there is severe hypoplasia of the mandible or severe abnormality of the ear

Development and Learning

 * Most of these patients have normal intelligence

Management

 * Deafness should be tested for at an early age, and speech therapy is often necessary
 * Help may be required for feeding problems and encouraging weight gain in early infancy
 * Any congenital heart defects may require surgery
 * Plastic surgery may be used to reconstruct the ear, and bone distraction techniques are available to artificially lengthen the jaw bone to improve growth on the face.
 * Children may also need ongoing orthodontic treatment.

Differential Diagnoses

 * Treacher-Collins Syndrome-AD inheritance characterized by facial cleft, hypoplasia of the cheeks and mandible bilaterally, colobomas (or congenital scar) of the eyelids, downward-sloping palpebral fissures, poorly developed supraorbital rims and cheek, receding chin, malformation of the ear
 * CHARGE Association
 * VACTERL Association
 * Townes-Brocks Syndrome
 * Branchio-Oto-Renal (BOR) Syndrome
 * Chromosomal disorders (including Trisomy 9 Mosaicism, Trisomy 18, Ring 21 Chromosome, and Trisomy 22)
 * Teratogen exposure

Psychosocial Issues

 * Assess development.
 * Feeding problems?
 * Are they seeking a diagnosis?
 * Why would a diagnosis be helpful to them?
 * How do other people react is there any teasing by others?
 * How do they feel about the public's response to the facial abnormalities?
 * Would they like to talk with other families going through the same thing?
 * How can we be helpful to them?

Resources

 * Hemifacial Microsomia/Goldenhar Syndrome Family Support Network
 * c/o Kayci Rush
 * 3619 Chicago Avenue
 * Minneapolis, MN 55407-2603
 * (612) 823-3529
 * http://www.widesmiles.org/syndrom/hmsgold/ contains patient information


 * Association of Birth Defect Children (ABDC)
 * 1-800-313-2232
 * http://www.birthdefects.org