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Neurological Rehabilitation

Acquired Retrognathia and Tracheostomy Management Following Severe Traumatic Brain Injury: A Case Report

Thursday, October 23, 2025
12:45 PM - 2:15 PM MT
Location: Kiosk 6

    Primary Author(s)

  • Alexandra Wolfe, DO

    Resident Physician
    McGaw Medical Center of Northwestern University (SRAL) PM&R Program
    Chicago, Illinois

    • Poster Presenter(s)

  • Joseph Monat, DO

    Resident Physician
    McGaw Medical Center of Northwestern University (SRAL) PM&R Program
    Chicago, Illinois

    • Co-Author(s)

  • ER

    Eboni A. Reed, MD

    Attending Physician
    Shirley Ryan AbilityLab
    Chicago, Illinois

Disclosure(s):
Alexandra Wolfe, DO: No financial relationships to disclose
Joseph Monat, DO: No financial relationships to disclose
Case Diagnosis: Acquired retrognathia resulting in airway obstruction and difficult tracheostomy management following severe traumatic brain injury.

Case Description or Program Description: A 36-year-old male with no prior medical history presented to acute inpatient rehabilitation (AIR) after severe traumatic brain injury from a fall, resulting in intracranial bleeds and brainstem herniation requiring posterior fossa decompression. He had a prolonged hospital stay including respiratory failure, requiring tracheostomy, and was discharged to a long-term acute care hospital (LTACH). During his stay, he developed retrognathia due to poor positioning and weakened cervical musculature. At AIR, secretion burden improved, but tracheostomy capping tolerance remained limited. Pulmonology and otolaryngology were consulted. Computed tomography revealed significant upper airway obstruction in the posterior oropharynx, and laryngoscopy showed no airway obstruction, tracheal stenosis or hypergranulation tissue. The cause was determined to be retrognathia. Physical and occupational therapy focused on cervical mobility and strengthening, while speech therapy addressed respiratory muscle training.

Setting: Acute Inpatient Rehabilitation

Assessment/Results: The patient tolerated extended capped tracheostomy during the day but had difficulty with overnight tolerance due to obstructive sleep apnea, with plans to trial continuous positive airway pressure.

Discussion (relevance): Retrognathia is defined as posterior positioning of the mandible relative to the maxilla and cranial base. Incidence of acquired retrognathia due to poor positioning and weak cervical musculature has not been previously reported. Typical causes include temporomandibular disorders, juvenile idiopathic arthritis and rheumatoid arthritis. Complications include sleep-disordered breathing, neck pain and functional impairments.
There are no reports of non-surgical management of daytime airway obstruction secondary to retrognathia. Studies that examine conservative treatment are done in the context of obstructive sleep apnea or post-surgical correction. In this context, therapy and splinting focused on mandibular movement to enhance strength, coordination and positioning.

Conclusions: Patients with acquired retrognathia and difficult tracheostomy management require a comprehensive team-based approach to address their neuromuscular deficits and improve their overall function.