Tracheal agenesis: a clinical approach

Clinical presentation and airway management of tracheal atresia: A systematic review

OBJECTIVES

Tracheal atresia (TA) is a rare congenital condition that typically requires an unexpected and emergent resuscitation in the delivery room. The mortality rate associated is very high, with only a few long-term survival cases reported. We describe the findings of a systematic review on the clinical presentation and airway management of TA.

METHODS

Using the keywords "tracheal atresia", "tracheal agenesis" and "tracheal hypoplasia" a search through Embase and Pubmed databases was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Articles published from 1950 to 2015 in English, French, Italian, Portuguese and Spanish were included. Exclusion criteria were cases of stillborn, and unclear diagnosis or outcome.

RESULTS

149 cases of TA were identified after reviewing 1125 initial references. There was a male preponderance (65%), and associated malformations were described in 94.2% of patients. Prenatal ultrasound was abnormal in 56.3% of cases, with polyhydramnios being the most common finding. The most frequent type of TA was Faro Type C. 94 (41.3%) patients did not survive beyond the first 24 h of life. Only 13 (8.4%) patients survived more than three months of life, after undergoing a variety of surgical approaches.

CONCLUSION

This review, which to our knowledge is the largest one to date, confirms that TA is a rare malformation, occurs more frequently in males, and has a very high mortality rate. Depending on the presence and type of concomitant malformation, as well of the length of the remaining trachea, different surgical management options are described.

A long-term survival case of tracheal agenesis: management for tracheoesophageal fistula and esophageal reconstruction

Tracheal agenesis is a very rare disorder which leads to severe respiratory disorders immediately after birth. Reports are very limited on long-term survival cases. We report here a long-term survival case with Floyd's type I tracheal agenesis. During the neonatal stage, the patient underwent abdominal esophageal banding to substitute esophagus for trachea and transection at the cervical esophagus with esophagostomy. Subsequently, airway management was difficult due to a fragile tracheoesophageal fistula, but the fistula was conservatively treated and stabilized with the patient's growth. This patient is a very rare case in whom oral feeding was achieved after esophageal reconstruction using a gastric tube. For this case, we describe mainly (1) the management method of the tracheoesophageal fistula and (2) esophageal reconstruction without thoracotomy.

Tracheal agenesis and esophageal atresia with proximal and distal bronchoesophageal fistulas

Tracheal agenesis (TA) is an extremely rare, typically fatal congenital tracheal malformation. Lack of prenatal symptoms and emergent presentation usually lead to a failure to arrive at the correct diagnosis and manage the airway properly before the onset of irreversible cerebral anoxia. Esophageal atresia (EA) encompasses a group of congenital anomalies comprising an interruption of the continuity of the esophagus with or without a persistent communication with the trachea. In 86% of cases, there is a distal tracheoesophageal fistula (TEF); in 7%, there is no fistulous connection, whereas in 4%, there is a TEF without atresia. We report the case of an infant born with TA and EA with proximal and distal bronchoesophageal fistulas. During 3 consecutive antenatal ultrasound examinations, there had been polyhydramniosis, difficulty visualizing the stomach, and dilatation of proximal esophagus, leading to a presumptive diagnosis of EA. The clinical presentation, embryology, classification, and surgical management are discussed.

[Tracheal agenesis. A rare cause of respiratory insufficiency in neonates]

Tracheal agenesis is a very rare congenital anomaly that occurs isolated or in combination with other anomalies. It presents immediately after birth with an absolute respiratory insufficiency and lack of crying. The immediate precise anatomical classification of the anomaly is crucial in order to decide if surgical therapy is possible. This report describes a newborn boy with tracheal agenesis type II. The diagnosis was confirmed by spiral computed tomography and a selection of the pictures is presented. The treatment was discontinued due to a lack of therapeutical options. Based on this case report we discuss the special situation of this rare anomaly. Interesting information on tracheal agenesis was gathered, the differential diagnosis of respiratory insufficiency of the newborn is summarised and a modified algorithm of the current newborn resuscitation guidelines of the American Heart Association is presented.

Tracheal agenesis type B: further evidence to a lethal congenital tracheal malformation

Tracheal agenesis is an extremely rare, typically fatal congenital tracheal malformation. Lack of prenatal symptoms and emergent presentation usually lead to a failure to arrive at the correct diagnosis and manage the airway properly before the onset of irreversible cerebral anoxia. We report the case history of an infant born with immediate respiratory failure who was diagnosed with tracheal agenesis. The clinical presentation, embryology, classification, and surgical management are discussed.

Tracheal agenesis with unique anatomy

A premature infant with a unique form of tracheal agenesis is described. The combination of difficulty in intubation, abnormal course of the nasogastric tube on plain x-ray, and gastric perforation raised the suspicion of an upper airway malformation. Tracheal agenesis is an extremely rare, typically fatal, congenital anomaly with scattered case reports of its successful management. On many occasions, the diagnosis is a retrospective one at postmortem examination. The possibility of surgical correction rests on early diagnosis, anatomy, birth weight, and associated anomalies. Early recognition is mandatory, but in our case, the low birth weight precluded consideration for reconstructive surgery.

Tracheal agenesis with anomalies found in both VACTERL and TACRD associations

Tracheal agenesis (TA) was diagnosed by endoscopy after esophageal intubation in a 34-week newborn. Diagnosis, work-up, and management approach are discussed. Similar to previous reports, this case of tracheal agenesis presented with multiple associated defects found at autopsy. Tracheal agenesis had previously been reported as a part of the VATER (vertebral defects, anal atresia, tracheoesophageal fistula and/or esophageal atresia, radial dysplasia, renal defects) and VACTERL (VATER plus cardiovascular and limb defects) associations/syndromes. More recently, cases of TA have been reported with associated anomalies described as TACRD (tracheal agenesis/atresia, complex congenital cardiac abnormalities, radial ray defects, and duodenal atresia) association/syndrome. We present a case of TA with anomalies found in both VACTERL and TACRD associations, which support the speculation that both are different manifestations of a spectrum of mesodermal dysplasia.

Management of tracheal agenesis

Complete tracheal agenesis is a very rare congenital anomaly that is only compatible with life in some cases with associated tracheo-oesophageal or broncho-oesophageal fistula. In most cases, concomitant congenital anomalies of the heart, digestive tract or genitourinary tract are present. It should be suspected in any neonate with a history of hydramnios, absent crying, respiratory distress and difficulty in intubation. The possibility for surgical correction or palliation rests on the extent of atresia present. We present a case of complete tracheal agenesis without tracheo nor broncho-oesophageal fistula (type II by Floyd's classification) - the diagnosis of which was prenatally suspected - and discuss the important features of the airway management of this condition.

Tracheal agenesis in a child who survived for 6 years

The authors report on a child with tracheal agenesis who survived for 6 years and 10 months. A female infant was born with respiratory distress and an absence of audible cry. With mask ventilation, gastrostomy and division of the esophagus was performed just after birth. She was well ventilated with an endotracheal tube inserted through the cervical esophagostomy after thoracic esophageal banding. An accidental extubation caused her anoxic encephalopathy at 9 months of age. She had been alive without artificial ventilatory support until she died of acute esophageal bleeding.

Tracheal agenesis

Agenesis of the trachea is a rare anomaly. The main signs are respiratory distress and cyanosis, inability to vocalize and impossible tracheal intubation. In most cases concomitant congenital anomalies of the heart, digestive tract or genitourinary tract are present. Endoscopy and X ray studies will confirm the diagnosis. There is no long-term surgical solution because no suitable material for a tracheal prosthesis is available at present, therefore the condition is ultimately fatal. We report a case of tracheal agenesis. After the diagnosis was established the baby's lungs were ventilated for several hours via an oesophageal tube and two broncho-oesophageal fistulae, but she finally died from untreatable respiratory acidosis. Autopsy revealed a Floyd's type III tracheal agenesis and a laryngeal cleft.

Tracheobronchial obstructions in infants and children. Experience with 45 cases

Forty-five infants and children with intrathoracic tracheobronchial obstructions requiring surgical treatment are reported. Segmental stenosis of the trachea is defined as involvement of less than one half the length of the airway, which affected six infants. Elongated stenosis involving more than one half the length of the trachea was seen in 12 infants, and complete annular cartilage rings, along the entire length of the trachea, were present in 11. Severe tracheomalacia occurred in six infants associated with aortic arch anomalies and in nine infants with esophageal atresia. Segmental tracheal resection was performed in 17 cases (two after failure of a rib cartilage graft), and anastomotic stricture developed in three. These three anastomotic strictures were resected, resulting in an excellent airway in two and restricture in one. Rib cartilage grafts were used in five patients: two of three with elongated stenosis with complete tracheal rings required subsequent resection, and one of two infants with tracheomalacia had excellent outcome. Approximately 50% of an infant's trachea can be resected, but rib cartilage grafts should be used for elongated stenosis. Resection of bronchial stenosis in two patients resulted in a widely patent bronchus. From this experience primary segmental tracheobronchial resection and re-resection of recurrent stenosis are highly successful. Anastomotic stricture is due to tension at the suture line and suture material inciting a fibrotic reaction. Rib cartilage grafts amounting to 25% or less of the circumference of the airway readily resurfaces with adjacent epithelium, but when 30% or more of the circumference is rib graft, epithelialization may be impaired.

Tracheal agenesis: an exceptional cause of neonatal respiratory distress

The absence of the trachea is a rare and always lethal congenital malformation. Temporary survival depends on ventilation through the esophagus. We report our experience with a newborn who presented this unusual tracheal abnormality in association with cardiac malformation.

Tracheal agenesis: a case report

Tracheal agenesis is described in a premature infant. Absent cry, failure of tracheal intubation despite adequate ventilation with a face mask, and ventilation of both lungs after oesophageal intubation suggested the diagnosis. The infant's condition deteriorated rapidly because of severe pulmonary hyaline membrane disease 12 h later due to intractable cardiac failure. At post-mortem examination, large bilateral broncho-oesophageal fistulae were found.

Agenesis of the trachea

We report a case of agenesis of the trachea type III of Floyd that survived for 2 days with an esophageal intubation. Surgical treatment consisted of a distal esophageal binding, cervical esophagostomy in double-barrelled shotgun, and gastrostomy. Death occurred on the third day after surgery.

Tracheal agenesis with bronchoesophageal fistulas--a case report

Although tracheal agenesis is presently considered to be a rare and fatal anomaly, an increasing number of institutions have been reporting such cases. Reported herein, is a clinical and necropsy report of a premature infant whose tracheal agenesis was associated with broncho-esophageal fistulas and an imperforate anus. Accidental esophageal intubation enabled a perineal anoplasty to be performed under general anesthesia and allowed him to survive for 14 days.

Tracheal stenosis or agenesis in association with tracheo-oesophageal fistula and oesophageal atresia

Two babies are described with oesophageal atresia, a tracheo-oesophageal fistula and severe subglottic tracheal stenosis. A third baby, who did not survive, had a tracheal agenesis associated with bronchi arising from the oesophagus. A review of the types of tracheal stenosis and agenesis associated with various forms of tracheo-oesophageal fistula is included.

Congenital laryngeal anomalies associated with tracheal agenesis

Forty-eight cases of tracheal agenesis have been reported to date. Previous authors have studied gross postmortem laryngeal specimens. Of 37 cases wherein laryngeal findings were mentioned, only 14 were reported to be abnormal. This report details two more cases of tracheal agenesis and includes a detailed histopathologic study of the laryngeal anomalies by serial horizontal section. Although one of these specimens appeared normal at autopsy, both were found to have several abnormalities when studied microscopically in horizontal section. Both have an elliptical cricoid cartilage, an abnormality originally discovered by one of us (G.F.T.) using the same technique.

Tracheal agenesis

Congenital anomalies of the tracheobronchial tree must be included in the differential diagnosis of children with symptoms of respiratory distress. Tracheal agenesis is a rare major congenital anomaly that has been uniformly fatal. Diagnosis requires a high index of suspicion utilizing roentgenographic and endoscopic examinations.

The embryology of foregut malformations

Developmental disorders in the period of the differentiation of the primitive foregut leads to atresia of the esophagus with tracheoesophageal fistula. Most authors think that this differentiation is caused by lateral foregut folds, which fuse in midline, thus forming the tracheoesophageal septum. In order to gain information about this period of development, we studied the foregut region of chick embryos by scanning electron microscopy (SEM) and light microscopy. In our study no signs of lateral folds or fusing foregut wall components, which were forming a tracheoesophageal septum, were found. Our study suggests that the development of the esophagus and trachea is the result of a simple reduction of the size of the primitive foregut. The consequence for the understanding of the embryology of the foregut malformations is discussed.

Tracheal agenesis and associated malformations: a comparison with tracheoesophageal fistula and the VACTERL association

Tracheal agenesis is a rare malformation of the lower respiratory tract. Investigation of a patient with multiple congenital anomalies and tracheal agenesis prompted a review of the literature which uncovered 42 previously published cases, most of whom had other defects. The presence in our patient of a tracheal abnormality in association with radial hypoplasia, single umbilical artery, tetralogy of Fallot, and left hydroureter initially suggested presence of the VACTERL association. However, numerical classification of malformation patterns in the reported patients with tracheal agenesis and in a series of patients with tracheoesophageal fistula and other components of the VACTERL association suggests that tracheal agenesis does not occur in the VACTERL association and may be part of another pattern of malformations which includes laryngeal atresia, complex congenital heart anomalies, radial ray defects, and duodenal atresia.