Management of the critical airway when an EXIT procedure is not an option: A case report

Taking the Natural Exit: Opportunities for Treatment Rightsizing in Fetal Head and Neck Mass

Fetal head and neck masses, when present, may cause neonatal airway obstruction at birth and associated morbidity and mortality. Escalated maternal treatment intensity such as surgical laryngoscopist/airway surgeon attended delivery and ex utero intrapartum treatment can mitigate the neonatal risk, however, increase maternal risk for complications. Accordingly, accurate prediction of the potential neonatal benefit and maternal risk is essential. Serial third-trimester sonographic features suggestive of more severe airway obstruction may justify more aggressive intervention in the right patient. This case study presents a 23-year-old G1P0 with a fetus predicted to have reduced perinatal airway risk based upon serial third-trimester ultrasound findings. Treatment was de-escalated, and the patient was successfully managed. Collaborative data collection aimed at treatment rightsizing across neonatal, maternal, and systematic domains will support ideal allocation.

International Pediatric Otolaryngology Group (IPOG): Consensus recommendations on the prenatal and perinatal management of anticipated airway obstruction

OBJECTIVE

To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery.

METHODS

Recommendations are based on expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was distributed to all members of the IPOG and responses recorded. The respondents were given the opportunity to comment on the content and format of the survey, which was modified for the second round. "Consensus" was defined by >80% respondent affirmative responses, "agreement" by 51-80% affirmative responses, and "no agreement" by 50% or less affirmative responses.

RESULTS

Recommendations are provided regarding etiologies of perinatal airway obstruction, imaging evaluation, adjunct evaluation, multidisciplinary team and decision factors, micrognathia management, congenital high airway obstruction syndrome management, head and neck mass management, attended delivery procedure, and delivery on placental support procedure.

CONCLUSIONS

Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits.

Ankyloglossum Superius Syndrome compromising a neonatal airway: Considerations in congenital oral airway obstructions

We report the case of a 37-week old newborn presenting on day 1 of life with an apparent congenital fusion of the tongue to the hard palate, consistent with Ankyloglossum Superius syndrome. Physical exam along with endoscopy showed apparent fusion of the floor of the mouth to the anterior hard palate displacing the tongue into the nasal cavity and obstructing the oral airway. The child was nasotracheally intubated and brought to the operating room for lysis of the fusion under binocular microscopy. We review the literature on this rare condition and provide an algorithm for evaluating the neonatal airway in the setting of congenital oral abnormalities.

Perinatal Care of Infants with Congenital Birth Defects

Prenatal diagnosis has changed perinatal medicine dramatically, allowing for additional fetal monitoring, referral and counseling, delivery planning, the option of fetal intervention, and targeted postnatal management. Teams participating in the delivery room care of infants with known anomalies should be knowledgeable about specific needs and expectations but also ready for unexpected complications. A small number of neonates will need rapid access to postnatal interventions, such as surgery, but most can be stabilized with appropriate neonatal care. These targeted perinatal interventions have been shown to improve outcome in selected diagnoses.