Congenital cervical teratoma: airway management and complications

Surgical Management and Outcomes of Pediatric Congenital Head and Neck Teratomas: A Scoping Review

Objective

To perform a scoping review to characterize postoperative outcomes of pediatric patients (ages 0-18) with a history of congenital head and neck teratomas.

Data Sources

PubMed, EMBASE, Web of Science, Cochrane, Clinicaltrails.gov.

Review Methods

A search of multiple databases was performed. Studies were included if they detailed the surgical management and outcomes of pediatric patients with a history of congenital head and neck teratomas.

Results

One hundred and eight studies totaling 137 patients were identified. The median gestational age at birth was 37 weeks. Respiratory distress, prompting emergent endotracheal intubation or tracheostomy, was present in most patients (58%). The ex utero intrapartum treatment (EXIT) procedure was utilized for 21 (15%) patients. The teratomas were resected after a median duration of 4 days from birth. The most common postsurgical complications were vocal cord paralysis (3%), hemorrhage (2%), and tracheomalacia (2%). Death occurred perioperatively in 2 patients (2%). Twenty-six patients (19%) required additional surgery, and 5 patients (4%) needed adjuvant chemotherapy. Patients were monitored for a median duration of 24 months with a recurrence rate of 6%. Four recurrent cases (50%) had intracranial extension, and 88% of the recurrent cases were mature teratomas at initial histopathological diagnosis.

Conclusion

Most patients with congenital head and neck teratomas require emergent airway management perinatally. Excisional and surgical complications are rare, and most patients are cured of their disease with a single operation. Recurrent teratomas tend to have an intracranial extension and are likely to be of mature pathology at the time of initial diagnosis.

Superior Vena Cava Syndrome and Hypoxic Ischemic Encephalopathy Secondary to a Massive, Right-Sided Immature Cervical Teratoma

Cervical teratomas are a rare form of fetal teratoma that can grow to massive size. Generally, these masses can be surgically excised after birth with excellent physical and functional prognosis because the benign variants respect anatomical borders. The primary complications of these masses are associated with compromise of the trachea and esophagus: upper airway obstruction and polyhydramnios. We report the first documented occurrence of superior vena cava syndrome and hypoxic ischemic encephalopathy associated with a massive, right-sided cervical teratoma. This case highlights that when cervical teratomas are right-sided and sufficiently large, they can extend inferiorly and compromise central venous return to the heart. This unique presentation would likely have required fetal surgical excision to avoid catastrophic cerebral injury.

Long-term outcome of pre- and perinatal management of congenital head and neck tumors and malformations

INTRODUCTION

Congenital head and neck pathology may cause direct postnatal airway obstruction. Prenatal diagnosis facilitates safe delivery with pre- and perinatal airway assessment and management and Ex-Utero-Intrapartum-Treatment (EXIT) if necessary. Fetoscopic airway evaluation can optimize the selection of patients in need of an EXIT procedure.

METHODS

Description of 11 consecutive fetuses, born with a potential airway obstruction between 1999 and 2011 and treated at the University Hospitals Leuven, with a long-term follow-up until 2018. An algorithm including fetoscopic airway evaluation is presented.

RESULTS

In utero imaging revealed seven teratomas, one fourth branchial pouch cyst, one thymopharyngeal duct remnant, one lymphatic malformation and one laryngeal atresia. A multidisciplinary team could avoid EXIT in eight patients by ultrasonographic (n = 2) or fetoscopic (n = 6) documentation of accessible airways. Three patients needed an EXIT-to-airway-procedure. Neonatal surgery included tracheostomy during EXIT (n = 2) and resection of teratoma (n = 7) or branchiogenic pathology (n = 3). All patients do well at long-term (minimum 54 months) follow-up.

CONCLUSIONS

Combining prenatal imaging and perinatal fetoscopy, EXIT-procedure and neonatal surgery yields an optimal long-term outcome in these complex patients. Fetoscopy can dramatically reduce the number of EXIT-procedures.

Teratoma cervical congênito gigante: relato de caso e revisão quanto às opções terapêuticas

OBJETIVO: Relatar um caso de teratoma cervical congênito, destacando a gravidade e as dificuldades terapêuticas associadas. DESCRIÇÃO DO CASO: Mãe de 30 anos, com gestação por fertilização assistida. Com 23 semanas, diagnosticada malformação cervical fetal à direita. Parto cesáreo por indicação fetal com 31 semanas. Recém-nascido masculino, peso ao nascer de 1800g, Apgar 4 e 9, com volumoso processo expansivo à direita, ocupando toda a região cervical, comprometendo a mandíbula e estendendo-se para o terço superior do tórax. Com 40 horas de vida, apresentou insuficiência cardíaca congestiva de alto débito por roubo de fluxo pelo tumor. A partir de 54 horas de vida, houve progressiva deterioração hemodinâmica e respiratória, com hipotensão, anúria e labilidade de oxigenação, refratárias às aminas vasoativas, reposição de volume e aumento do suporte ventilatório. Indicada abordagem cirúrgica para ressecção tumoral, todavia o paciente não apresentou estabilidade clínica que permitisse seu transporte ao centro cirúrgico e faleceu com 70 horas de vida. COMENTÁRIOS: O caso demonstra as dificuldades relacionadas à abordagem pós-natal dos teratomas cervicais volumosos. Apesar do diagnóstico pré-natal, o paciente evoluiu com obstrução de vias aéreas, complicada por um choque cardiogênico refratário, que culminou no óbito. A abordagem intraparto é fundamental nesses pacientes, consistindo em exérese tumoral, enquanto a manutenção da circulação materno-fetal permite a oxigenação fetal contínua. A evolução neonatal no caso descrito é condizente com a literatura que mostra prognóstico reservado quando não é realizada a abordagem cirúrgica intraparto.

Comprehensive Airway Management of Neonatal Head and Neck Teratomas

Objectives. To determine the success of initial airway management and to characterize late airway-related complications in patients with airway obstruction due to congenital head and neck teratomas

Study Design. Case series with chart review.

Setting. Tertiary airway referral institution.

Subjects and Methods. Review of consecutive patients with congenital head and neck teratomas from 1988 to 2010. Variables examined include initial airway stabilization at time of birth and perinatal airway management. Outcomes include short- and long-term complications.

Results. Fourteen cases were reviewed. In 12 patients, initial airway management was accomplished on placental support with either intubation or tracheotomy. Two vaginal births required subsequent uncomplicated oral intubation within 24 hours. Nine patients required tracheotomy (3 within the delivery suite, 2 during mass excision on day of life 6 and 24, and the remaining 4 occurred at days 29, 32, 92, and 100). Five deaths occurred, 4 within several days of birth due to complications related to the cervical teratomas and 1 on day of life 32 due to an airway-related complication. Follow-up for surviving patients ranged from 1 month to 18 years. Long-term airway complications ranged from vocal cord paralysis to stenosis requiring laryngotracheoplasty.

Conclusion. This study demonstrates that a multidisciplinary team and a standardized approach in the operating suite have led to successful initial airway stabilization. Furthermore, this study demonstrates the need for continued airway management after delivery. Reassessment of the airway after delivery and an airway management planning meeting with the multidisciplinary team may help decrease morbidity and mortality.

Airway management of three cases of congenital cervical teratoma

Cervical teratomas are rare congenital tumors derived from all three germ cell layers. The vast majority are histologically benign, but the significant size they may attain can potentiate life-threatening upper airway obstruction. All cases require the specialist airway skills of the pediatric anesthetist. This may be planned, in the case of antenatally diagnosed lesions, when the pediatric anesthetist is part of a multidisciplinary team involved in an EX utero Intrapartum Treatment (EXIT) or Operation On Placental Support (OOPS) procedure, or when a neonate is undergoing elective excision in the early neonatal period as definitive treatment. Alternatively the anesthetist may be called upon urgently to secure a compromised airway immediately postpartum when no antenatal diagnosis has been made. Furthermore, after elective surgical excision, airway compromise is possible, which may again require anesthetic intervention. The aim of this study is to report the authors' experience in managing the airway in three cases of congenital cervical teratoma in the study institution over the last 24 months. These cases highlight the possible airway scenarios that may confront the anesthetist in the immediate postpartum, elective surgery and postoperative stages and the variety of techniques that may be employed in order to overcome the potential difficulties encountered.

Prenatal diagnosis of a large fetal cervical teratoma by three-dimensional ultrasonography: a case report

CONTEXT

The cervical teratomas are rare, benign tumors, they are formed by the three embryonic layers, and they represent only 6% of teratomas. The prognosis depends mainly on the size and location of the lesion, on the tumor growth rate, and on the level of tracheal compression. Prenatal diagnosis is usually reached with the aid of a two-dimensional ultrasonography (2DUS) after the 15th week of gestation, which shows a large heterogeneous mass in the cervical region, plus a polyhydramnios, on the Doppler mode which also shows the vascularization of the tumor.

CASE REPORT

We report a case of cervical teratoma diagnosed on the 31st week of gestation with the aid of a 2DUS and color Doppler mode. We focus on the main findings obtained with the three-dimensional ultrasonography in surface mode, and we highlight the importance of this methodology for the indirect evaluation of the neonatal prognosis.

Congenital cervical teratomas: diagnostic, management and postoperative variability

OBJECTIVE

To review the diagnosis, management and outcomes of congenital cervical teratomas presenting to a tertiary referral centre.

METHODS

Retrospective chart review of three cases presenting within an 18-month period.

RESULTS

Of the three patients in this series, one was diagnosed antenatally. The remaining cases were diagnosed at birth. The antenatally diagnosed patient underwent an EXIT procedure whereby the airway was secured by tracheostomy. This patient subsequently died 30 min after separation from the materno-foetal circulation. Neither of the other two cases had any neonatal respiratory distress, despite having large tumours. Both patients had neonatal surgical excision of the teratomas performed. Both patients had postoperative respiratory distress, requiring intervention. Both patients made a full recovery. No recurrence has been reported.

CONCLUSION

The antenatal diagnosis of large congenital cervical teratomas allows for planned intervention by experienced personnel. A successful outcome may not be obtained. All patients that undergo surgical excision of these tumours must be closely observed for post-operative respiratory distress, even in the absence of pre-operative symptoms.

Management of antenatally detected fetal airway obstruction

Five cases of antenatally diagnosed fetal airway obstruction have been cared for at the John Hunter Children's Hospital, Newcastle, Australia. A multidisciplinary team manages them during the perinatal period. We present our technique at the time of delivery, which aims to afford us the greatest flexibility in managing both the mother, her child's airway, and the underlying lesion. We begin with an ex utero intrapartum technique (EXIT) and favor routine rigid bronchoscopy to secure the neonate's airway without preliminary attempts at endotracheal intubation.

Malignant cervical teratoma: report of a case in a newborn

Malignant cervical teratoma (MCT) usually appears in newborns as an enlarging mass of the neck that causes respiratory distress, requiring prompt airway control. We report a case of MCT in an infant electively delivered at 32 weeks to prevent airway impairment. At first, the preoperative diagnosis was hygroma of the neck, and a surgical excision was performed when the newborn was 9 days old. Diagnosis was benign extragonadic immature teratoma, but it was changed in MCT when cervical metastases appeared and the alpha-fetoprotein (AFP) level increased. Subsequent surgical procedures and chemotherapy were necessary. The child has been free from disease and healthy for 7 years since the last surgery. The preoperative diagnosis of MCT is difficult because of its rarity and non-specific clinical findings. Surgical excision is required for an adequate cure and airway repair; a long-term follow-up is mandatory to promptly treat any recurrence.

Strategy for management of newborns with cervical teratoma

BACKGROUND

Cervical teratomas are extremely rare tumors with high perinatal mortality and morbidity rates.

OBJECTIVE

To compare our experience and outcome in newborns with cervical teratoma with similar reports from the literature, in order to propose a structured approach.

METHODS

A retrospective review of seven patients treated between 1986 and 2000 was performed. The results of these seven patients were compared with and added to a series of 44 well-documented patients retrieved from the literature.

RESULTS

In four of the seven patients, the diagnosis was not suspected antenatally. Three of the patients survived, one died. In the other three, the diagnosis was made antenatally. Two were born using the ex-utero intrapartum treatment (EXIT) procedure, one by planned cesarean section. Only one of these three survived. Mortality in the total series of 51 patients was 33% overall, and 46% in the group in which the diagnosis had been made antenatally. Peri- and post-operative complications were reported in 27%. Although larger tumors caused polyhydramnios more frequently than smaller tumors, and were associated with more severe respiratory distress, the relationship between tumor volume at birth and final outcome could not be established. This makes difficult the identification of fetuses with a disastrous prognosis.

CONCLUSION

Although mostly benign, cervical teratomas are still associated with high mortality rates. Timely antenatal diagnosis is indispensable in reducing morbidity and mortality caused by upper airway obstruction. A structured approach to the management of cervical teratoma is proposed.

Ultrasonographic guidance for location of the trachea during the EXIT procedure for cervical teratoma

Cervical teratomas are rare tumors of infancy that are associated with a high mortality rate caused by compression and distortion of the infant's airway. Recent attempts at managing the fetal airway before delivery have focused on the EXIT (ex-utero intrapartum treatment) procedure, in which time to secure an airway is provided while preserving uteroplacental gas exchange. The authors report the use of intraoperative ultrasound guidance during an EXIT procedure for an infant with massive cervical teratoma to aid in identification of the trachea.