Massive mature cystic teratoma of the head and neck, masquerading as a glial choristoma, causing respiratory compromise of a neonate

Glial choristoma of the head and neck is a rare, benign congenital malformation consisting of a mass of heterotopic glial cells. In cases involving the upper aerodigestive tract, this can present with upper airway obstruction. In the acute setting, this can lead to diagnostic challenges due to the broad differential, as well as the additional difficulties in obtaining appropriate imaging and tissue samples due to the potential risk of airway compromise. We present a case of a neonate born with a large heterogenous mass involving the upper aerodigestive tract and multiple deep neck spaces which resulted in upper airway compromise requiring emergency surgical intervention in the form of a paediatric tracheostomy. We will discuss the histological findings which initially suggested a glial choristoma, work-up and treatment of this patient with the aim of supplementing the limited existing clinical knowledge of this congenital anomaly and understanding the implications of a paediatric tracheostomy in our setting.

[EXIT: Experiences from Karolinska University Hopsital]

The main, but not sole, indication for an Ex-utero Intrapartum Treatment (EXIT) delivery is an airway obstruction due to either laryngeal atresia or tumors in the head and neck region. Here we present our Institution's experience with eleven cases: three teratomas, four lymphatic malformations, two laryngeal atresias and two dermoid cysts. The EXIT procedure was used to secure the fetal airway while maintaining uteroplacental gas exchange and fetal hemodynamic stability through the umbilical circulation. Five fetuses required tracheostomy. Only one fetal death occurred due to extensive growth of a teratoma preventing us from establishing an airway. No other fetal or major maternal complication occurred. The EXIT procedure is a complex procedure and these rare cases should be referred to a center with a dedicated and experienced multidisciplinary team.

Congenital high airway obstruction with tracheoesophageal fistula: A case report

RATIONALE

Congenital high airway obstruction syndrome (CHAOS) is defined as complete or partial obstruction of the fetal upper airways. Laryngeal atresia is the most frequent cause.

PATIENT CONCERN

A male neonate born with poor reactions, weakly spontaneous breathing and cyanosis of the limbs was referred to our hospital.

DIAGNOSIS

CHAOS with tracheoesophageal fistula.

INTERVENTION

A tracheostomy was performed and a 3.0-mm internal diameter tracheostomy tube was inserted.

OUTCOMES

Neonatal survival depended on our immediate postnatal intervention.

LESSONS

In summary, a multidisciplinary team including otolaryngologists, radiologists, obstetricians, and anesthesiologists must be present during the whole diagnosis and treatment process.

Fetal Evaluation and Airway Management

Congenital causes of airway obstruction once noted at birth are now diagnosed prenatally. The adoption of ex utero intrapartum treatment has allowed for planned airway stabilization on placental support, dramatically decreasing the incidence of hypoxic injury or peripartum demise related to neonatal airway obstruction. Airway access is gained either through laryngoscopy, bronchoscopy, or a surgical airway. In complete airway obstruction, primary resection of the obstructing lesion may be performed before completion of delivery. This article reviews the current and emerging methods of fetal evaluation, indications for ex utero intrapartum treatment, and provides a detailed description of the procedure and necessary personnel.

Congenital high airway obstruction syndrome (CHAOS) associated with cervical myelomeningocele

Congenital high airway obstruction syndrome (CHAOS) is a rare and potentially fatal entity resulting from complete or near complete developmental airway obstruction. Although most reported cases of CHAOS are sporadic, the condition may also be associated with certain syndromes and a variety of cervical masses. Meningocele and myelomeningocele have not yet been reported in association with CHAOS. We describe the typical constellation of sonographic findings in a case of early diagnosis of CHAOS associated with cervical myelomeningocele. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:507-510, 2017.

CHAOS: Prenatal imaging findings with post mortem contrast radiographic correlation

Congenital high airway obstruction syndrome is a rare fetal anomaly with characteristic constellation of prenatal findings on ultrasound and MRI. The typical triad of imaging features are enlarged and echogenic lungs, flattening or inversion of diaphragm and fetal hydrops. Early prenatal recognition of congenital high airway obstruction syndrome by ultrasound and/or MRI is mandatory for the appropriate perinatal management. We report a case of a male fetus with typical imaging findings of congenital high airway obstruction syndrome on ultrasound and MRI at 19 weeks of gestation. The role of contrast radiographs of fetal airways, including retrograde laryngogram, in confirming the postnatal diagnosis of this fetal condition is demonstrated. The prenatal imaging findings were correlated with contrast radiographs of upper airways, sonography of aborted fetus and fetal autopsy findings.

Management of tracheobronchial obstruction in infants using metallic stents: long-term outcome

INTRODUCTION

Tracheobronchial obstruction, although uncommon in the pediatric age group, remains a challenging problem. We review the long-term outcome of endoscopic metallic stenting in infants with tracheobronchial obstruction.

MATERIALS AND METHODS

Medical records of all pediatric surgical patients who underwent tracheobronchial metallic stenting in our center were reviewed retrospectively from 1996 to 2014. Patients' demographic data, including etiology, associated anomalies and nature of obstruction were reviewed. Outcome measures include complications such as re-stenosis, granulation tissue, stent migration, fractured stent, maximal tracheal diameter achieved, weaning of ventilator and growth at interval follow-up.

RESULTS

Twelve balloon-expandable metallic stents were placed in the trachea (n = 10) and/or bronchi (n = 2) of 5 patients with a median age of 13 months (range 5-30 months). Etiology of the airway obstruction included congenital tracheal stenosis (n = 4), giant cervical and superior mediastinal lymphatic malformation with tracheobronchomalacia (n = 1). Seven complications were reported (3 patients developed granulation tissue, 2 patients had re-stenosis, 1 stent migrated, 1 stent fractured). All patients survived and were in good condition with a median follow-up of 16 years (range 11-18 years). Three patients weaned off ventilator and oxygen.

CONCLUSIONS

Endoscopic stenting with metallic stent has satisfactory long-term outcome in treating infants with tracheobronchial obstruction.

Prenatal diagnosis of congenital high airway obstruction syndrome (CHAOS). Five case report

Congenital high airway obstruction syndrome (CHAOS) is an extremely rare life-threatening condition. Laryngeal atresia appears to be the most frequent cause. Generally the diagnosis is made with severely enlarged and highly echogenic lungs and additional ultrasound findings. The prognosis of the affected infants is often poor. Five cases are reported here that were diagnosed in a tertiary center between 2008 and 2014.

Cesarean section plus delayed cord clamping approach in the perinatal management of congenital high airway obstruction syndrome (CHAOS): a case report

In this case, we describe a newborn with prenatal diagnosis of congenital high airway obstruction syndrome (CHAOS), successfully managed with a cesarean section with delayed cord clamping 180 seconds. In case of prenatal diagnosis of CHAOS, prompt airway intervention at delivery allows survival of this otherwise fatal condition. Ex utero intrapartum treatment (EXIT) is considered the elective procedure to secure the fetal airway before the baby is completely separated from the maternal circulation. In cases where the EXIT procedure is not possible for maternal reasons (Ballantyne's syndrome), delayed cord clamping may serve as an alternative method to manage CHAOS.

Congenital High Airway Obstruction Syndrome (CHAOS) as part of Fraser syndrome: ultrasound and autopsy findings

Congenital High Airway Obstruction Syndrome (CHAOS) is a potential lethal condition. We describe a case report of CHAOS, with additional malformations diagnosed at 20 weeks. Autopsy findings are suggestive for Fraser syndrome (cryptophthalmos-syndactyly syndrome; OMIM 219000). The diagnosis was confirmed by mutation analysis of FRAS1.

Ex utero intrapartum treatment in the management of giant cervical teratomas

PURPOSE

The purpose of this study is to present the outcome and technical details of the Ex Utero Intrapartum Treatment (EXIT) procedure performed in the management of the fetus with a giant cervical teratoma.

METHODS

A retrospective review of the medical records of patients undergoing the EXIT procedure between September 1995 and September 2010 was performed.

RESULTS

Eighty-seven EXIT procedures were performed. In 20% of cases (17/87), the indication was giant cervical teratoma. There were 10 females and 7 males. Polyhydramnios was present in 82%. Median gestational age at EXIT was 35 weeks (range, 30-39 weeks). Median birth weight was 2.5 kg (range, 1.7-3.7 kg). Access to the airway under placental support was established in all cases via direct laryngoscopy/bronchoscopy in 8 patients (47%) and via surgical exploration (tracheostomy or retrograde intubation) in 9 patients (53%). The mortality rate under placental support was zero. Seven patients had the tumors resected immediately after the EXIT, 6 patients had the resection later, and 4 patients died before resection. The neonatal mortality rate was 23% (4/17 patients). Patients who died had severe pulmonary hypoplasia that resulted from the upward traction by the giant cervical mass on the airway and compression of the lungs against the thoracic apex.

CONCLUSIONS

We conclude that the EXIT procedure continues to be the optimal delivery strategy for patients with prenatally diagnosed giant cervical teratomas and potential airway obstruction at birth. A thorough evaluation of the prenatal images and an experienced multidisciplinary team are key factors for an effective approach to the obstructed fetal airway.

Congenital high airway obstruction syndrome

Congenital high airway obstruction syndrome (CHAOS) is a very rare fetal malformation caused by obstruction of fetal airway because of laryngeal or tracheal atresia, subglottic stenosis, laryngeal cyst or laryngeal web. The prenatal diagnosis is inferred from secondary changes such as enlarged, hyperechogenic lungs, ascites and/or hydrops, flattened or everted diaphragms, dilated distal airways and mediastinal compression. There are only few cases of long-term survival described in literature. We present the case of fetus with such secondary changes diagnosed during routine ultrasound evaluation in 20 weeks' gestation. There were no other abnormalities and the kariotype was normal. In 26 weeks' gestation fetal hydrops appeared and subsequent polyhydramnios occurred in 28 weeks' gestation. The patient was planned for EXIT procedure during labor in experienced in CHAOS cases center. In 29 weeks' gestation the premature rupture of membranes and regular uterine contractions occurred and we've performed cesarean section. A multidisciplinary team of neonatologists, laryngologists and pediatric surgeons made their efforts to save the newborn, but there was complete laryngeal atresia and tracheal agenesia and immediate tracheostomy was impossible. The most important about CHAOS are early diagnosis, detailed fetal assessment and an adequate postnatal intervention for establishing fetal airways.

Congenital high airway obstruction syndrome: MR/US findings, effect on management, and outcome

BACKGROUND

Congenital high airway obstruction syndrome (CHAOS) is a rare disorder defined as any fetal abnormality that obstructs the larynx or trachea. Prompt airway intervention at delivery after accurate prenatal diagnosis may allow survival of this otherwise fatal condition.

OBJECTIVE

To identify prenatal MRI findings in CHAOS, to compare these findings with those of fetal US, to determine if imaging alters diagnosis and management decisions, and to correlate prenatal with postnatal imaging findings.

MATERIALS AND METHODS

Records and MRI scans of ten fetuses with CHAOS were reviewed, and the findings correlated with outside and same-day fetal US and postnatal imaging findings. Fetal lung volumes were measured on MRI scans.

RESULTS

Large lung volumes were found in 90% of the fetuses. Increased lung signal intensity, inverted diaphragm, and a dilated, fluid-filled lower airway were identified in all. The obstruction level was identified in 90%. MRI changed screening US diagnosis in 70%, but was concordant with the tertiary care US imaging in 90%. Seven fetuses were terminated or died in utero, and three fetuses survived after ex utero intrapartum tracheostomy placement. Autopsy or bronchoscopy performed in 60% confirmed CHAOS. Postnatal chest radiographs and CT showed hyperinflation, while US and fluoroscopy showed diminished diaphragmatic motion.

CONCLUSION

MRI demonstrates large lung volumes, increased lung signal intensity, inverted diaphragm, and dilated fluid-filled lower airway, and usually identifies the obstruction level. The degree of correlation between MRI and tertiary prenatal US is high, but CHAOS is frequently misdiagnosed on screening US. Correct diagnosis may enable planned airway management. Voluminous lungs and diaphragmatic abnormalities persist on postnatal imaging.

Ex utero intrapartum treatment (EXIT), a resuscitation option for intra-thoracic foetal pathologies

The ex utero intrapartum treatment (EXIT) procedure is designed to guarantee sufficient oxygenation for a foetus at risk of airway obstruction. This is achieved by improving lung ventilation, usually by establishing an airway during caesarean delivery whilst preserving the foetal-placental circulation temporarily. Indications for the EXIT procedure have extended from its original use in reversing iatrogenic tracheal obstruction in congenital diaphragmatic hernia to naturally occurring upper airway obstructions. We report our experience with a new and rarely mentioned indication for the EXIT procedure, intra-thoracic volume expansions. The elaboration of lowest risk scenarios through balancing risks with alternative options, foetal or neonatal intervention and coordination between professionals from various disciplines are the most important conditions for a successful EXIT procedure. The EXIT procedure requires a caesarean section that specifically differs from the traditional caesarean section during which uterine tone is maintained to minimize maternal bleeding. To guarantee foetal oxygenation during the EXIT procedure, profound uterine relaxation is desired. To gain time with optimal placental oxygenation in order to safely perform an airway intervention in a baby at risk of hypoxia may require deep inhalation anaesthesia and/or tocolytic agents. We review the EXIT procedure and present a case series from the University Hospital of Geneva that contrasts with the common indication for the EXIT procedure usually based on upper airway obstruction by its exclusive indication for intra-thoracic malformations/diseases.

Perioperative extracorporeal membrane oxygenation support for critical pediatric airway surgery

Extracorporeal membrane oxygenation (ECMO) has been used for cardiopulmonary support in neonates, infants, and adults. We report the application of ECMO for critical airway surgery when mechanical ventilation cannot provide adequate gas exchange. Three pediatric patients underwent emergency ECMO establishment because of hypercapnia that could not be managed by conventional mechanical ventilation. The pathology included: (1) left pulmonary artery sling with long-segment tracheal stenosis; (2) absence of the right intermediate bronchus and abnormal origin of the right lower bronchus arising from the left main bronchus; (3) right-lung agenesis with long-segment tracheobronchial stenosis. Venoarterial ECMO was established. Before ECMO, the arterial pH values were 7.28, 7.0, and 7.08, and the PaCO2 values were 111.8, 112.0, and 208.7 mmHg for each patient, respectively. After ECMO support, respiratory acidosis was reversed. The patients then underwent surgical intervention. The surgical procedures included: (1) slide tracheoplasty and reimplantation of the left pulmonary artery; (2) resection of the stenotic tracheal segment and reconstruction of the bronchial tree; (3) tracheal dilatation and stent implantation. The ECMO durations were 11, 5, and 16 h, respectively. All patients were successfully weaned off ECMO without complications. In conclusion, ECMO provided adequate ventilation support for patients undergoing critical tracheobronchial reconstruction when conventional mechanical ventilation could not maintain adequate gas exchange.

Parapharyngeal neuroglial heterotopia extending through the skull base in a neonate with airway obstruction

We present a neonate with heterotopic nasopharyngeal brain tissue causing airway obstruction. Preoperative imaging showed extension of the mass along major neurovascular pathways into the cranial vault. Preoperative identification of intracranial extension is essential for planning surgery to prevent postoperative cerebrospinal fluid leaks or possible meningitis.

More or less CHAOS: case report and literature review suggesting the existence of a distinct subtype of congenital high airway obstruction syndrome

Congenital obstruction of the upper airway (CHAOS) is a rare, usually lethal abnormality. A literature review of 36 prenatally diagnosed cases of CHAOS and the analysis of our own case suggest the existence of a distinct subtype of CHAOS, raising important implications for diagnosis and management. Serial fetal ultrasound examinations at 17-23 weeks' gestation showed hyperechoic and enlarged lungs, mediastinal shift, flattened diaphragm, polyhydramnios and apparently fluid-filled esophagus, findings interpreted as bilateral cystic adenomatoid malformation Type III. Ultrasound findings normalized around 32 weeks. The diagnosis of CHAOS was made after birth at term by direct laryngoscopy prompted by ventilatory difficulties and failed attempts at intubation. A pinhole opening posterior to the cricoid cartilage allowed the passage of an endotracheal tube. Based on observations in our case and those of five similar cases in the literature, we describe for the first time a subtype of CHAOS that is characterized by minor pharyngotracheal or laryngotracheal communications and associated with a less severe natural history and even resolution of ultrasound findings. In spite of this, a high index of awareness should be maintained because resolution of ultrasound findings does not necessarily indicate resolution of underlying pathology.

Case series: Combined spinal epidural anesthesia for Cesarean delivery and ex utero intrapartum treatment procedure

PURPOSE

To report the use of regional anesthesia and iv nitroglycerin to provide anesthesia and uterine relaxation for three Cesarean deliveries (CD) involving ex utero intrapartum treatment (EXIT) of potentially life-threatening airway obstruction in the newborn.

CLINICAL FEATURES

Case 1--a 36-yr-old woman at 38 weeks' gestation was scheduled for an elective CD for fetal skeletal dysplasia and micrognathia. Case 2--a 34-yr-old woman at 35 weeks gestation had a fetal ultrasound revealing fixed neck flexion and micrognathia consistent with fetal arthrogryposis. Case 3--a 27-yr-old woman presented at 38 weeks gestation for CD for severe fetal micrognathia, with mandibular growth below the fifth percentile. For each case, a combined spinal epidural anesthetic was performed with 0.75% bupivacaine, fentanyl and morphine intrathecally followed by placement of a multiorifice epidural catheter. Prior to uterine incision patients received a loading dose followed by an iv infusion of nitroglycerin. Uterine relaxation was sufficient in all cases for delivery of the fetus, and allowed for evaluation by direct laryngoscopy and intubation while maintaining fetal-placental circulation. The surgical procedures were completed without incident.

CONCLUSIONS

Anesthesia and uterine relaxation for CD and EXIT procedures can be safely provided with regional anesthesia and iv nitroglycerin.

A case of congenital high airway obstruction syndrome managed by ex utero intrapartum treatment: case report and review of the literature

Congenital high airway obstruction syndrome (CHAOS) has been reported to be fatal. Ten cases of CHAOS that underwent ex utero intrapartum treatment (EXIT) procedure to secure the fetal airway have been reported. A 36-year-old woman (gravida 3, para 2) was referred to our hospital at 22 weeks of gestation. Sonography revealed large echogenic lungs, flattened diaphragm, and marked hydrops. Magnetic resonance imaging confirmed the diagnosis of CHAOS. Polyhydramnios and fetal skin edema were improved and the fetal ascitic fluid was regressed gradually. At 36 weeks of gestation, an EXIT procedure was undertaken. Fetal laryngoscopy and bronchoscopy showed complete laryngeal obstruction, and a tracheostomy was performed immediately. The infant was discharged from hospital at 6 weeks of age. Thereafter, he developed well both physically and mentally. A laryngoplasty was performed at 20 months of age using silicon sheet as a patent airway. The child has a tracheostomy, is able to phonate but does not speak, and is awaiting decannulation. Use of the EXIT procedure in CHAOS cases offers the potential for salvage and excellent long-term outcome of these fetuses that otherwise would not survive. However, management of the airway, particularly with regard to long-term reconstruction in children with CHAOS, remains challenging.

[Two cases of congenital airway obstruction managed with ex utero intrapartum treatment procedures: anesthetic implications]

An ex utero intrapartum treatment (EXIT) procedure provides sufficient time to gain control of the potentially obstructed fetal upper airway while uterine placental circulation is maintained during cesarean section. We report 2 cases in which fetal congenital upper airway obstruction was managed without complications during EXIT procedures. We also discuss general considerations concerning the obstetric patient and the performance of intramuscular fetal anesthesia. Before the hysterotomy, sevoflurane at 1.5 minimum alveolar concentration was administered to assure sufficient uterine relaxation during EXIT. The 2 parturients remained hemodynamically stable during the procedure and uterine and placental perfusion was adequate. Nasotracheal intubation was possible in 1 fetus after a cervical mass was dissected. In the other, a tracheostomy was created. After the umbilical cord was clamped, the concentration of sevoflurane anesthetic gas was reduced and oxytocin and methylergometrine were administered to induce adequate uterine contractions within a few minutes. Both neonates survived the EXIT procedure with no complications.

Congenital pyriform aperture stenosis

Nasal airway obstruction is a potentially life-threatening condition in the newborn. Neonates are obligatory nasal breathers. The pyriform aperture is the narrowest, most anterior bony portion of the nasal airway, and a decrease in its cross-sectional area will significantly increase nasal airway resistance. Congenital nasal pyriform aperture stenosis (CNPAS) is a rare, unusual form of nasal obstruction. It should be considered in the differential diagnosis of any neonate or infant with signs and symptoms of upper airway compromise. It is important to differentiate this level of obstruction from the more common posterior choanal stenosis or atresia. CNPAS presents with symptoms of nasal airway obstruction, which are often characterized by episodic apnea and cyclical cyanosis.

Congenital bilateral vocal cord paralysis

Congenital upper airway obstruction is a relatively rare but important cause of major respiratory problems in the neonatal period. Vocal cord paralysis is the second most common cause of congenital airway obstruction presenting with neonatal stridor. It is often the reason for the failure of neonates to wean from the respiratory support. A retrospective analysis of medical record review was conducted. There were seven paediatric patients diagnosed with bilateral vocal fold paralysis in the past three years, of which five were recently diagnosed. All patients underwent flexible with/without rigid bronchoscopes to confirm the diagnosis. This case series highlight our experience in managing the problem of bilateral vocal cord paralysis in the paediatric population, with particular emphasis on their clinical presentations, associated complications and both upper and lower airway abnormalities. The management options and outcome of these patients will also be discussed.

Evidence for autosomal dominant inheritance in prenatally diagnosed CHAOS

Congenital high airway obstruction syndrome (CHAOS) is a rare prenatal diagnosis consisting of a typical fetal triad of large hyperechogenic lungs, flattened or inverted diaphragms and ascites. Most cases are sporadic with unknown incidence. Before attempts of fetoscopic fetal salvage or ex utero intrapartum treatment (EXIT) are considered, additional malformations must be carefully excluded as CHAOS may be part of various monogenic conditions or chromosomal disorders. We report an unique family with autosomal dominant inheritance of CHAOS and variable expression in the affected father and two affected children. It is concluded that minor expression in one of the parents may be an important indicator for genetic counseling in CHAOS and management of future pregnancies.

Ex-utero intrapartum treatment: a controlled approach to the management of anticipated airway problems in the newborn

Airway problems in an unborn foetus that may cause obstruction can be safely managed using an ex-utero intrapartum technique. Advanced technology now allows many congenital airway problems to be diagnosed in the prenatal period. Careful prenatal planning of an ex-utero intrapartum treatment allows safe airway control while the foetus remains on uteroplacental support. It avoids the need for emergent intervention of an acutely obstructed airway in a neonate that often has disastrous consequences.

Successful ex utero intrapartum treatment (EXIT) procedure for congenital high airway obstruction syndrome (CHAOS) owing to a large oropharyngeal teratoma

Large fetal neck masses can present a major challenge to securing an airway at birth, with associated risks of hypoxia, brain injury and death. The authors report a case of a giant oropharyngeal teratoma diagnosed in a fetus of 19 weeks gestation. The fetus was delivered by the ex utero intrapartum treatment procedure allowing sufficient time on placental support for bronchoscopy and tracheostomy to secure the airway. A multidisciplinary team approach combined with an accurate prenatal diagnosis obtained through fetal ultrasound was the key to a successful outcome. Unfortunately due to the large size of tumour and intracranial extension, the lesion was unresectable and the baby died 6 days after birth.

Congenital bronchopulmonary foregut malformations: concepts and controversies

This article addresses the scope, etiology, important associations and imaging features of congenital bronchopulmonary foregut malformations. Etiologic concepts, including airway obstruction and vascular anomalies, are highlighted. Technical imaging advances, especially CT and MR, have greatly enhanced our diagnostic abilities in evaluating these lesions; however, thorough and careful assessment of all aspects of the malformation is still necessary. Several specific lesions are discussed in more detail, particularly regarding controversial issues in classification, understanding, imaging and management.

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.

Tracheal atresia as part of an exceptional combination of malformations

A case of a premature infant with tracheal atresia together with an exceptional combination of congenital abnormalities that partially corresponds to the TACRD and VACTERL associations is presented. Tracheal atresia was not detectable in the prenatal ultrasound due to lacking of the typical diaphragmatic and pulmonary findings because of the esophago-tracheal fistula, and therefore the resuscitation team was not prepared for this severe airway complication. After prolonged resuscitation efforts were terminated and the newborn expired after birth. Even without typical warning signs physicians have to be aware of tracheal atresia and airway obstruction if VACTERL or TACRD associations are diagnosed.

Tracheotomy in the first year of life: outcomes in term infants, the Vanderbilt experience

OBJECTIVE

In an era emphasizing critical care of preterm infants, we characterize the indications and outcomes of tracheotomies performed in the first year of life in term infants compared to preterm infants.

METHODS

Retrospective study of 127 tracheotomies performed in the first year of life at a tertiary-care children's hospital between 1988-2004.

RESULTS

Mean gestational ages of the term and preterm groups were 38.97 and 29.71 weeks, respectively (P < 0.001). Indications for tracheotomy were upper airway abnormalities in 53% for the term group. The number of subsequent airway procedures required was 1.39 in the term group, achieving decannulation in 36.3%, with a 20.5% mortality rate.

CONCLUSION

Compared to preterm infants, the term decannulation rate was favorable, as chronic lung disease was uncommon. However, non-tracheotomy-related mortalities remained high.

SIGNIFICANCE

Tracheotomies are often performed for relief of upper airway obstruction, and congenital and acquired comorbidities not related to tracheotomy are associated with adverse outcomes in term infants.

EBM RATING

C-4.

Dosisreduzierte 16-Schicht-Multidetektor-Spiralcomputertomographie bei Säuglingen und Kleinkindern mit bronchoskopischem Verdacht auf vaskulär bedingte Trachealstenosen - erste klinische Ergebnisse

PURPOSE

To evaluate the diagnostic accuracy of contrast-enhanced dose-reduced 16-slice multidetector-row CT (MDCT) in newborns and infants with fiberoptic bronchoscopically suspected vascular-induced tracheal stenosis.

MATERIALS AND METHODS

12 children (4 days to 3 years, 1.2 - 13.5 kg body weight) were examined using i. v. contrast-enhanced 16-slice MDCT (SOMATOM Sensation 16, Forchheim, Germany) without breath-hold and under sedation (11/12). All MDCTs were performed with a dose reduction. The beam collimation was 16 x 0.75 mm, except in the case of one child. MPRs along the tracheal axis in the x-, y- and z-directions and volume-rendering-reconstructions (VRTs) were calculated based on a secondary raw data set in addition to conventional axial slices. 2 radiologists used a three-point grade scale to evaluate the image quality, motion, and contrast media artifacts as well as the usefulness of the 2D- and 3D-reconstructions for determining the diagnosis. Statistical analysis was performed on the basis of a Kappa test.

RESULTS

In all cases the cause of the fiberoptic bronchoscopically suspected tracheal stenosis was revealed: compression due to the brachiocephalic trunk (n = 7), double aortic arch (n = 2), lusorian artery (n = 1), vascular compression of the left main bronchus (n = 2). In 3 patients further thoracic anomalies, such as tracheobronchial (n = 2), and vascular (n = 2) and vertebral (n = 1) anomalies were found. The attenuation in the anomalous vessels was 307 +/- 140 HU. The image noise was 9.8 +/- 1.9 HU. The mean dose reduction was 82.7 +/- 3.2 % compared to a standard adult thoracic CT. All examinations were rated as diagnostically good (median 1, range 1, k = 1). 3D images did not show any stair artifacts (median 2, range 1 - 2, k = 1). The image noise was minor to moderate and hardly any motion artifacts were seen (median 1, range 1 - 2, k = 0.8). Contrast media artifacts were rated zero to minor (median 1.5, range 1 - 2, k = 0.676). MPRs (median 1, range 1, k = 1) and VRTs (median 1, range 1, k = 1) were found to be useful for diagnosis. Subsequent vascular surgery was performed on 8 patients.

CONCLUSION

Contrast-enhanced dose-reduced 16-slice MDCT is effective for demonstrating the cause of fiberoptic bronchoscopically suspected vascular-induced tracheal stenosis even in very small and severely ill children despite the small contrast media amount and free breathing.

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.

Fetal laryngeal stenosis/atresia and congenital high airway obstructive syndrome (CHAOS): a case report

Congenital high airway obstructive syndrome (CHAOS) is a rare but fatal disease with predictably characteristic features including stenotic or atretic upper airway, hyperplastic lungs, elevated diaphragm, massive fetal ascites and fetal hydrops. Diagnosis of CHAOS by ultrasound scan is possible and clinically important since advanced intrauterine surgery to correct the defect is possible. We report a case of fetus of CHAOS with massive ascites, pulmonary hyperplasia and laryngeal stenosis/atresia. We feel that it is important to recognize the entity both by ultrasound scan and by the pathologist so that some cases can be corrected by intrauterine fetal surgery.

[Anesthetic management of the ex-utero intrapartum treatment (EXIT) procedure for congenital high airway obstruction syndrome (CHAOS)]

We report an experience of anesthetic management of the ex-utero intrapartum treatment (EXIT) procedure performed in a fetus with congenital high airway obstruction syndrome (CHAOS) due to laryngeal atresia at 30 weeks' gestation. Anesthesia of the mother was induced with rapid sequence, and maintained with 3.5% sevoflurane in 100% oxygen and fentanyl before delivery. Two minimum alveolar concentration (MAC) sevoflurane provided excellent uterine relaxation without maternal hypotension. After hysterotomy, a sterile pulse oxymeter was placed on the fetus hand for monitoring fetal SpO2 and pulse rate, and a Doppler ultrasound transducer was applied to monitor fetal heart rate. Fentanyl (5 microg x dl(-1)) and pancuronium (0.2 mg x dl(-1)) were injected into the fetal upper arm in addition to transplacental anesthetic agents. The fetal heart rate and SpO2 were stable throughout the fetal manipulations, but the rise in SpO2 after initiating ventilation via tracheostomy was very slow. The uterine tone improved soon after discontinuing sevoflurane and oxytocin infusion was started after delivery. Surfactant administration before first ventilation is recommended in preterm babies undergoing EXIT procedure, and capnometer may be useful to confirm the adequate ventilation before cutting the umbilical cord.

Treatment of tracheomalacia with Palmaz stent: a case report

Tracheomalacia is a potentially life-threatening clinical problem. The expandable Palmaz stent can be used for the treatment of tracheomalacia. We describe a female infant with tracheomalacia who showed respiratory distress the day after birth. Tracheomalacia was diagnosed by bronchoscopic examination, computed tomography and bronchography. At 75 days of age, an expandable metallic stent (Palmaz stent) was inserted into the trachea under fluoroscopic control. The patient's respiratory status improved rapidly. Bronchoscopic examination 6 months after the insertion did not show any granulation tissue. However, in bronchoscopic examination carried out two years later, we detected invasion of the Palmaz stent to the trachea and development of granulation tissue. We think that expandable metallic stent placement should be considered in patients who show intractable respiratory symptoms caused by tracheomalacia in the earlier stages of the treatment. But long-term complications of this procedure are crucial.