Information on the following diseases can be found in the Related Disorders section of this report:

• Nager Syndrome
• Treacher Collins Syndrome
• Maxillofacial Dysostosis
• Osteodysplastic Bird-Headed Dwarfism Type II
• .

The typical clinical characteristics of EPS noted above, small ears, kneecap abnormalities and short stature may be apparent at birth (congenital). The physical characteristics and symptoms of EPS vary from case to case; affected children will not have all the symptoms listed below.

Infants with EPS exhibit abnormally underdeveloped (hypoplastic) or absent outer ears (microtia) and external ear canals (acoustic meatus). Furthermore, the ears may be low set and/or malformed (dysplastic).

Affected infants may also have various skeletal malformations. As mentioned earlier, the most distinctive of these may be the absent or small knee caps (patellae). Other skeletal malformations may include unusually slender ribs and long bones (e.g., the bones of the arms and legs), missing or deformed ribs, dislocation of the elbows, hook-shaped collar bones (clavicles), and/or an abnormal flattening of the end portion (or head) of the long bones (epiphyses). In some cases an absent or abnormally shallow depression on the upper arm bone (humerus) where the bone meets the shoulder (abnormal glenoid fossa), detachment of cartilage and bone tissue from the surface of a bone (osteochondritis dissecans), abnormally extended joints (hyperextensibility), abnormally stiff joints that may lock in position (joint contractures), and/or degeneration of the rounded projections on the sides of the head of the thigh bone (aseptic necrosis of the lateral femoral condyles) have been found.

In most cases of EPS, abnormally slow growth may have occurred during fetal development (prenatal growth retardation). As a result, most affected infants exhibit low birth weights, have feeding difficulties, and fail to thrive leading to unusually slow physical development (postnatal growth retardation and delayed bone age), potentially resulting in short stature. Other physical characteristics may include a slight build and/or a narrow torso.

In addition to the typical facial features already noted, some individuals present with a triangular face, and/or a highly arched roof of the mouth (palate) and/or premature closure of the fibrous joints (sutures) between the bones of an infant's skull (craniosynostosis) as well as the soft, membrane-covered space near an infant's forehead where two of the sutures meet (anterior fontanelle). The anterior fontanelle usually closes at about 18 months of age. Addition features include an abnormally small jaw (micrognathia), small mouth, droopy eyelids (ptosis), and microcephaly, a condition in which the head circumference is smaller than would be expected for age and sex.

Some individuals with EPS show abnormalities of the hands and feet. The fifth finger may be abnormally bent (clinodactyly), and/or one or more fingers may be permanently flexed (camptodactyly).

Most individuals with EPS have normal intelligence. The acquisition of skills requiring mental and motor coordination (psychomotor development) is normal or borderline normal. Some affected children show delays in attaining developmental milestones.

Some boys with EPS may experience failure of the testes to descend into the scrotum (cryptorchidism) or abnormal placement of the urinary opening on the underside of the penis (hypospadias). Some girls with EPS may have underdeveloped (hypoplastic) breasts after reaching puberty.

EPS is thought to be inherited as an autosomal recessive trait. Genetic diseases are determined by two genes, one received from the father and one from the mother.

Recessive genetic disorders occur when an individual inherits the same abnormal gene for the same trait from each parent. If an individual receives one normal gene and one gene for the disease, the person will be a carrier for the disease, but usually will not show symptoms. The risk for two carrier parents to both pass the defective gene and, therefore, have an affected child is 25% with each pregnancy. The risk to have a child who is a carrier like the parents is 50% with each pregnancy. The chance for a child to receive normal genes from both parents and be genetically normal for that particular trait is 25%.

Parents of two affected individuals reported in the medical literature were closely related by blood (consanguineous). If both parents carry the same disease gene, there is a higher than normal risk that their children may inherit the two genes believed to be necessary for the development of the disease.

Since EPS was first described in 1959 only about thirty-five cases have been reported in the medical literature (June, 2005). Researchers believe the disorder is under-diagnosed making it difficult to determine its true frequency in the general population. EPS is believed to affect males and females in equal numbers.

Symptoms of the following disorders can be similar to those of EPS. Comparisons may be useful for a differential diagnosis:

Some researchers include eat-patella-short stature syndrome in a group of disorders known as primordial dwarfism. These disorders share similar characteristics including skeletal malformation (dysplasia), growth deficiency before birth (intrauterine growth retardation) and during infancy and childhood, ultimately resulting in varying degrees of short stature. This group of disorders currently includes five disorders: ear-patella-short stature (Meier-Gorlin) syndrome; Seckel syndrome; Russell-Silver syndrome; Majewski osteodysplastic bird-head dwarfism type I/III; and Majewski osteodysplastic bird-headed dwarfism type II.

Russell-Silver syndrome is a rare genetic disorder characterized by growth delays before birth (prenatal or intrauterine growth retardation); overgrowth of one side of the body (hemihypertrophy or asymmetry); unusual characteristic facial features; and other physical abnormalities. The range and severity of symptoms associated with Russell-Silver syndrome vary greatly from case to case. Growth delays before birth affect both weight and linear growth. As a result, although carried to full term (normal gestational age), affected infants may be abnormally small and have low birth weight. In addition, growth delays and immature bone development (growth retardation and delayed bone age) continue after birth (postnatally). As a result, affected children may exhibit short stature and may be unusually small and thin for their age. In most cases (65 to 80 percent), asymmetry or overgrowth of one side of the body is obvious at birth. Asymmetry may affect the head, trunk, arms, and/or legs. The extent and severity of asymmetry vary greatly among affected children. Characteristic facial features may include a triangular-shaped face with a small, pointed chin; an abnormally prominent forehead (frontal bossing); bluish discoloration of the tough, outer membranes covering the eyeballs (blue sclera); an unusually small, wide mouth; downturned corners of the mouth; and/or an abnormally small jaw (micrognathia). Most cases of Russell-Silver Syndrome are the result of new genetic changes (mutations) that occur randomly for no apparent reason (sporadic). (For more information, choose “Russell Silver” as your search term in the Rare Disease Database.)

Majewski osteodysplastic bird-headed dwarfism type II, also known as MOPD II or osteodysplastic primordial dwarfism type II, is an extremely rare genetic disorder characterized by short stature, low birth weight, an abnormally small head (microcephaly), and/or skeletal abnormalities. Other physical findings may include large eyes, a beaklike protrusion of the nose, a receding jaw, and/or a narrow face. Severe growth deficiency before birth (intrauterine growth deficiency) commonly occurs. Mental retardation may be present in some cases. A variety of additional symptoms may also occur. Specific symptoms and severity varies from case to case. Majewski osteodysplastic bird-headed dwarfism type II is thought to be inherited as an autosomal recessive trait.

Three M syndrome is an extremely rare genetic disorder characterized by low birth weight, short stature (dwarfism), characteristic abnormalities of the head and facial (craniofacial) area, distinctive skeletal malformations, and/or other physical abnormalities. The name "three M" refers to the last initials of three researchers (J.D. Miller, V.A. McKusick, P. Malvaux) who were among the first to identify the disorder. Characteristic craniofacial malformations typically include a long, narrow head (dolichocephaly), an unusually prominent forehead (frontal bossing), and a triangular-shaped face with a prominent, pointed chin, large ears, and/or abnormally flat cheeks. In addition, in some affected children, the teeth may be abnormally crowded together; as a result, the upper and lower teeth may not meet properly (malocclusion). Skeletal abnormalities associated with the disorder include unusually thin bones, particularly the shafts of the long bones of the arms and legs (diaphyses); abnormally long, thin bones of the spinal column (vertebrae); and/or distinctive malformations of the ribs and shoulder blades (scapulae). Affected individuals may also have additional abnormalities including permanent fixation of certain fingers in a bent position (clinodactyly), unusually short fifth fingers, and/or increased flexibility (hyperextensibility) of the joints. The range and severity of symptoms and physicial features may vary from case to case. Intelligence appears to be normal. Three M syndrome is thought to be inherited as an autosomal recessive genetic trait. (For more information choose, "Three M" as your search term in the Rare Disease Database.)

Diagnosis
EPS may be diagnosed at birth, based on detailed medical history, physical examination, and other testing modalities, including ultrasonography of the kneecaps.

The association of microtia and very small or absent kneecaps is essential for the clinical diagnosis of EPS. Characteristic abnormalities of the ears (microtia) are present at birth. Further bone development and subsequent abnormalities (e.g., craniosynostosis) may be diagnosed through careful examination of the entire bone system (skeletal survey) using ultrasonography or x-ray methods.

Treatment
The treatment of EPS is directed towards specific symptoms or complaints. Treatment may require the coordinated efforts of a team of specialists. Pediatricians, surgeons, specialists who assess and treat hearing problems (audiologists), those who specialize in diagnosing and treating skeletal abnormalities (orthopedists), and other health care professionals may be needed to systematically and comprehensively plan an affected child's treatment.

For example, maxillofacial surgery may be used to correct malformation of the jaw after jaw growth is complete.

In addition, pediatricians may closely monitor an affected child's feeding, growth patterns, and respiratory problems since poor weight gain and recurrent respiratory tract infections are the most serious complications of EPS during early infancy and childhood. Early intervention is important in ensuring that children with EPS reach their potential. Services that may be beneficial may include special remedial education, physical therapy, and other medical, social, and/or vocational services.

Genetic counseling will be of benefit for affected individuals, their siblings and parents.

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government website.

For information about clinical trials being conducted at the National Institutes of Health (NIH) Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov

McKusick VA, ed. Online Mendelian Inheritance in Man (OMIM). Baltimore. MD: The Johns Hopkins University; Entry No:224690; Last Update: 6/27/02. Available at: www3.ncbi.nlm.nih.gov/htbin-post/Omim/dispmim?224690

TEXTBOOKS
Nezarati MM, Teebi AS. Ear-Patella-Short Stature Syndrome. In: NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:189.

Gorlin RJ, Cohen MMJr, Hennekam RCM, eds. Syndromes of the Head and Neck. 4th ed. Oxford University Press, New York, NY; 2001:691-2.

Buyse ML, ed. Birth Defects Encyclopedia. Dover, MA: Blackwell Scientific Publications; For: The Center for Birth Defects Information Services Inc; 1990:591-92.

JOURNAL ARTICLES
Faqeih E, Sakati N, Teebi AS. Meier-Gorlin (ear-patella-short stature) syndrome: growth hormone deficiency and previously unrecognized findings. Am J Med Genet A. 2005;137:339-41.

Shalev SA, Hall JG. Another adult with Meier-Gorlin syndrome--insights into the natural history. Clin Dysmorphol. 2003;12:167-9.

Cohen A, Mulas R, Seri M, et al. Meier-Gorlin syndrome (ear, patella, short stature syndrome) in an Italian patient: Clinical evaluation and analysis of possible candidate genes. Am J Med Genet. 2002;107:48-51.

Bongers EM, Opitz JM, Fryer A, et al. Meier-Gorlin syndrome: report of eight additional cases and review. Am J Med Genet. 2001;102:115-24.

Loeys BL, Lemmerling MM, Van Mol CE, et al. The Meier-Gorlin syndrome, or ear-patella-short stature syndrome, in sibs. Am J Med Genet. 1999;84:61-67.

Teebi AS, Gorlin RJ. Not a new Seckel-like syndrome but ear-patella-short stature syndrome. Am J Med Genet. 1997;70:454.

Boles RG, Teebi AS, Schwartz D, et al. Further delineation of the ear, patella, short stature syndrome (Meier-Gorlin syndrome). Clin Dysmorphol. 1994;3:207-14.

Cohen B, Temple IK, Symons JC, et al. Microtia and short stature: a new syndrome. J Med Genet. 1991;28:786-790.

Hurst JA, Winter RM, Baraitser M. Distinctive syndrome of short stature, craniosynostosis, skeletal changes, and malformed ears. Am J Med Genet. 1988;29:107-15.