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Sawyer T, Yamada N, Umoren R. The difficult neonatal airway. Semin Fetal Neonatal Med 2023; 28:101484. [PMID: 38000927 DOI: 10.1016/j.siny.2023.101484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Airway management is one of the most crucial aspects of neonatal care. The occurrence of a difficult airway is more common in neonates than in any other age group, and any neonatal intubation can develop into a difficult airway scenario. Understanding the intricacies of the difficult neonatal airway is paramount for healthcare professionals involved in the care of newborns. This chapter explores the multifaceted aspects of the difficult neonatal airway. We begin with a review of the definition and incidence of difficult airway in the neonate. Then, we explore factors contributing to a difficult neonatal airway. We next examine diagnostic considerations specific to the difficult neonatal airway, including prenatal imaging. Finally, we review management strategies. The importance of a multidisciplinary team approach and the role of communication and collaboration in achieving optimal outcomes are emphasized.
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Affiliation(s)
- Taylor Sawyer
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
| | - Nicole Yamada
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Rachel Umoren
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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2
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Jha P, Raghu P, Kennedy AM, Sugi M, Morgan TA, Feldstein V, Pōder L, Penna R. Assessment of Amniotic Fluid Volume in Pregnancy. Radiographics 2023; 43:e220146. [PMID: 37200220 DOI: 10.1148/rg.220146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Amniotic fluid (AF) is an integral part of the fetal environment and is essential for fetal growth and development. Pathways of AF recirculation include the fetal lungs, swallowing, absorption through the fetal gastrointestinal tract, excretion through fetal urine production, and movement. In addition to being a marker for fetal health, adequate AF is necessary for fetal lung development, growth, and movement. The role of diagnostic imaging is to provide a detailed fetal survey, placental evaluation, and clinical correlation with maternal conditions to help identify causes of AF abnormalities and thereby enable specific therapy. Oligohydramnios prompts evaluation for fetal growth restriction as well as genitourinary issues, including renal agenesis, multicystic dysplastic kidneys, ureteropelvic junction obstruction, and bladder outlet obstruction. Premature preterm rupture of membranes should also be clinically excluded as a cause of oligohydramnios. Clinical trials evaluating amnioinfusion are underway as a potential intervention for renal causes of oligohydramnios. Most cases of polyhydramnios are idiopathic, with maternal diabetes being a common cause. Polyhydramnios prompts evaluation for fetal gastrointestinal obstruction and oropharyngeal or thoracic masses, as well as neurologic or musculoskeletal anomalies. Amnioreduction is performed only for maternal indications such as symptomatic polyhydramnios causing maternal respiratory distress. Polyhydramnios with fetal growth restriction is paradoxical and can occur with maternal diabetes and hypertension. When these maternal conditions are absent, this raises concern for aneuploidy. The authors describe the pathways of AF production and circulation, US and MRI assessment of AF, disease-specific disruption of AF pathways, and an algorithmic approach to AF abnormalities. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Priyanka Jha
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Preethi Raghu
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Anne M Kennedy
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Mark Sugi
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Tara A Morgan
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Vickie Feldstein
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Liina Pōder
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Rubal Penna
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
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3
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Surgical Emergencies in the Pregnant Patient. Curr Probl Surg 2023; 60:101304. [PMID: 37169419 DOI: 10.1016/j.cpsurg.2023.101304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Hall J, Aly FZ, Comer J, Gebhard MP, Schrepfer T. A Rare Case of Ectopic Colonic Mucosa Presenting With Airway Compromise in a Neonate. Cureus 2022; 14:e27031. [PMID: 35989776 PMCID: PMC9388194 DOI: 10.7759/cureus.27031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2022] [Indexed: 11/05/2022] Open
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Prenatal 2-D and 3-D Ultrasound Characteristics of a Case of Fetal Orofacial Macrocystic Lymphatic Malformation and its Postnatal Management with Intralesional Bleomycin. JOURNAL OF FETAL MEDICINE 2022. [DOI: 10.1007/s40556-022-00339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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Chung W, Lim C. Intraoperative management for ex-utero intrapartum treatment: focusing on the fetus. Anesth Pain Med (Seoul) 2022; 16:329-337. [PMID: 35139613 PMCID: PMC8828620 DOI: 10.17085/apm.21097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022] Open
Abstract
Ex-utero intrapartum treatment (EXIT) is a method of securing the airway of a fetus while maintaining umbilical circulation for newborns who are experiencing life-threatening airway obstruction. Cesarean section is completed only after ensuring the neonate's safety. However, managing the airway of a neonate while maintaining umbilical circulation is a major challenge for anesthesiologists. Anesthesiologists must understand the physiology of both the mother and fetus, and extensive discussions with obstetricians, pediatricians, otolaryngologists, and nursing staff prior to the procedure are essential. This review provides an overview of the EXIT and details of airway management for neonates.
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Affiliation(s)
- Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Chaeseong Lim
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
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Genetic and Molecular Determinants of Lymphatic Malformations: Potential Targets for Therapy. J Dev Biol 2022; 10:jdb10010011. [PMID: 35225964 PMCID: PMC8883961 DOI: 10.3390/jdb10010011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 12/15/2022] Open
Abstract
Lymphatic malformations are fluid-filled congenital defects of lymphatic channels occurring in 1 in 6000 to 16,000 patients. There are various types, and they often exist in conjunction with other congenital anomalies and vascular malformations. Great strides have been made in understanding these malformations in recent years. This review summarize known molecular and embryological precursors for lymphangiogenesis. Gene mutations and dysregulations implicated in pathogenesis of lymphatic malformations are discussed. Finally, we touch on current and developing therapies with special attention on targeted biotherapeutics.
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Prenatal Diagnosis and Outcome of Tracheal Agenesis as Part of Congenital High Airway Obstruction Syndrome. Case Presentation and Literature Review. Medicina (B Aires) 2021; 57:medicina57111253. [PMID: 34833471 PMCID: PMC8619531 DOI: 10.3390/medicina57111253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/24/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022] Open
Abstract
Tracheal atresia is an extremely rare condition whereby a partial or total obstruction of the trachea is seen. It is almost always lethal, with just a handful of cases that ended with a good outcome. In this study we report on a 15-week male fetus, diagnosed with hyperechogenic lungs, midline heart position and inverted diaphragm. Sonographic findings suggest congenital High Airway Obstruction Syndrome (CHAOS) An ultrasound scan and fetal MRI were not able to point out the exact obstruction level. In spite of extensive counselling, the parents opted to carry on with the pregnancy. Fetal demise was noted on a scan at 19 weeks gestation. After the elective termination of pregnancy, a post-mortem examination showed partial tracheal atresia with no other anomalies. Despite technological progress in CHAOS syndrome, a precise diagnosis and accurate prognosis remain elusive.
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Varela MF, Peiro JL. EX-UTERO INTRAPARTUM TREATMENT (EXIT). REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ex utero intrapartum technique (EXIT): Indications, procedure methods and materno-fetal complications - A literature review. J Gynecol Obstet Hum Reprod 2021; 51:102252. [PMID: 34638008 DOI: 10.1016/j.jogoh.2021.102252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/24/2021] [Accepted: 10/06/2021] [Indexed: 12/23/2022]
Abstract
A congenital malformation of the head, neck or thorax can lead to upper airway compression with a risk of asphyxia or neonatal death. To secure and protect the upper airway, the Ex Utero Intrapartum Therapy (EXIT) procedure has been developed. The procedure allows delivery of the fetus via a hysterotomy while relying on the placenta as the organ of respiration for the fetus prior to clamping of the umbilical cord. A high level of expertise is necessary for successful completion of the EXIT procedure, which is not void of maternal and fetal risks. In this literature review, we present the indications, procedure methods and materno-fetal complications associated with the EXIT procedure.
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Jha P, Feldstein VA, Revzin MV, Katz DS, Moshiri M. Role of Imaging in Obstetric Interventions: Criteria, Considerations, and Complications. Radiographics 2021; 41:1243-1264. [PMID: 34115536 DOI: 10.1148/rg.2021200163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
US has an established role in the prenatal detection of congenital and developmental disorders. Many pregnant women undergo US at 18-20 weeks of gestation for assessment of fetal anatomy and detection of structural anomalies. With advances in fetoscopy and minimally invasive procedures, in utero fetal interventions can be offered to address some of the detected structural and physiologic fetal abnormalities. Most interventions are reserved for conditions that, if left untreated, often cause in utero death or a substantially compromised neonatal outcome. US is crucial for preprocedural evaluation and planning, real-time procedural guidance, and monitoring and assessment of postprocedural complications. Percutaneous needle-based interventions include in utero transfusion, thoracentesis and placement of a thoracoamniotic shunt, vesicocentesis and placement of a vesicoamniotic shunt, and aortic valvuloplasty. Fetoscopic interventions include myelomeningocele repair and tracheal balloon occlusion for congenital diaphragmatic hernia. In rare cases, open hysterotomy may be required for repair of a myelomeningocele or resection of a sacrococcygeal teratoma. Monochorionic twin pregnancies involve specific complications such as twin-twin transfusion syndrome, which is treated with fetoscopic laser ablation of vascular connections, and twin reversed arterial perfusion sequence, which is treated with radiofrequency ablation. Finally, when extended placental support is necessary at delivery for repair of congenital high airway obstruction or resection of lung masses, ex utero intrapartum treatment can be planned. Radiologists should be aware of the congenital anomalies that are amenable to in utero interventions and, when necessary, consider referral to centers where such treatments are offered. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ©RSNA, 2021.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Vickie A Feldstein
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Margarita V Revzin
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Douglas S Katz
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Mariam Moshiri
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
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12
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Varela MF, Pinzon-Guzman C, Riddle S, Parikh R, McKinney D, Rutter M, Lim FY, Peiro JL. EXIT-to-airway: Fundamentals, prenatal work-up, and technical aspects. Semin Pediatr Surg 2021; 30:151066. [PMID: 34172204 DOI: 10.1016/j.sempedsurg.2021.151066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Ex-utero intrapartum treatment (EXIT) is a delivery strategy developed to manage a variety of prenatally diagnosed conditions in the transition to newborn life. This procedure allows control and provides time for intervention in otherwise life-threatening malformations, such as congenital upper airway obstructions. EXIT-to-airway has changed the outcome of fetuses with these anomalies. The main purpose of this intervention is to improve the safety of establishing a reliable airway at birth. Maximal but controlled uterine relaxation to maintain feto-maternal perfusion and thus gas exchange, while keeping the fetal and maternal well-being are the paradigms of any type of EXIT. The most important aspect of fetal airway management is to consolidate a highly trained, well-coordinated, multidisciplinary team that is prepared for every contingency. A comprehensive prenatal assessment, including ultrasound, fetal echocardiogram, fetal MRI, and genetic testing is imperative for patient selection. Extensive preoperative planning, ad-hoc team meetings, and surgical simulations for challenging cases are critical strategies to achieve the best outcomes. This article outlines the prenatal work-up, decision making, technical aspects, and principles for a successful EXIT-to-airway procedure.
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Affiliation(s)
- Maria Florencia Varela
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA
| | - Carolina Pinzon-Guzman
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
| | - Stefanie Riddle
- Division of Neonatology, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA.; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rupi Parikh
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David McKinney
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael Rutter
- Division of Pediatric Otolaryngology, Head and Neck Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jose L Peiro
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Fetal MRI assessment of head & neck vascular malformation in predicting outcome of EXIT-to-airway procedure. CASE REPORTS IN PERINATAL MEDICINE 2021. [DOI: 10.1515/crpm-2020-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
The objective of this clinical case report is to highlight the MRI features and staging system which may guide clinicians in determining further management.
Case presentation
Three different cases with fetal head and neck vascular malformation diagnosed during prenatal screening were presented. MRI demonstrates large cystic neck masses which may compromise fetal airway during delivery. Thus, this required multidisciplinary team management among obstetricians, otolaryngologists, pediatricians, anesthesiologists, and radiologists. A decision for complex birth delivery through the cesarean section aided with EXIT-to-airway procedure was made. Each of these procedures demonstrates the different challenges and outcomes of the neonates which correlated with the characterization and staging based on prenatal MRI.
Conclusions
EXIT-to-airway procedure in head and neck malformation may be beneficial in transiting complicated and potentially catastrophic delivery situations to a more controlled environment. However, it also needs to align with prenatal MRI evaluation, which provides a more objective assessment guide for the clinicians.
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Goussard P, Pohunek P, Eber E, Midulla F, Di Mattia G, Merven M, Janson JT. Pediatric bronchoscopy: recent advances and clinical challenges. Expert Rev Respir Med 2021; 15:453-475. [PMID: 33512252 DOI: 10.1080/17476348.2021.1882854] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: During the last 40 years equipment has been improved with smaller instruments and sufficient size working channels. This has ensured that bronchoscopy offers therapeutic and interventional options.Areas covered: We provide a review of recent advances and clinical challenges in pediatric bronchoscopy. This includes single-use bronchoscopes, endobronchial ultrasound, and cryoprobe. Bronchoscopy in persistent preschool wheezing and asthma is included. The indications for interventional bronchoscopy have amplified and included balloon dilatation, endoscopic intubation, the use of airway stents, whole lung lavage, closing of fistulas and air leak, as well as an update on removal of foreign bodies. Others include the use of laser and microdebrider in airway surgery. Experience with bronchoscope during the COVID-19 pandemic has been included in this review. PubMed was searched for articles on pediatric bronchoscopy, including rigid bronchoscopy as well as interventional bronchoscopy with a focus on reviewing literature in the past 5 years.Expert opinion: As the proficiency of pediatric interventional pulmonologists continues to grow more interventions are being performed. There is a scarcity of published evidence in this field. Courses for pediatric interventional bronchoscopy need to be developed. The COVID-19 experience resulted in safer bronchoscopy practice for all involved.
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Affiliation(s)
- P Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - P Pohunek
- Division of Pediatric Respiratory Diseases, Pediatric Department, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - E Eber
- Department of Paediatrics and Adolescent Medicine, Head, Division of Paediatric Pulmonology and Allergology, Medical University of Graz, Graz, Austria
| | - F Midulla
- Department of Maternal Infantile and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - G Di Mattia
- Department of Maternal Infantile and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - M Merven
- Department Otorhinolaryngology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - J T Janson
- Department of Surgical Sciences, Division of Cardio-Thoracic Surgery, Stellenbosch University, and Tygerberg Hospital, Tygerberg, South Africa
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Shamshirsaz AA, Aalipour S, Stewart KA, Nassr AA, Furtun BY, Erfani H, Sundgren NC, Cortes MS, Donepudi RV, Lee TC, Mehta DK, Kravitz ES, Asl NM, Espinoza J, Belfort MA. Perinatal characteristics and early childhood follow up after ex-utero intrapartum treatment for head and neck teratomas by prenatal diagnosis. Prenat Diagn 2021; 41:497-504. [PMID: 33386645 DOI: 10.1002/pd.5894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 11/09/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ex utero intrapartum treatment (EXIT) is utilized for safe delivery when a baby has a compromised airway. The purpose of this retrospective study was to examine the indications and outcomes of 11 children presenting with airway occluding oropharyngeal and cervical teratomas. METHODS Study of all children with an airway occluding teratoma delivered via EXIT (2001-2018) in our unit. Primary outcomes included survival and tracheostomy at discharge. Data are reported using descriptive statistics as median (range) and rate (%). RESULTS We performed 45 EXIT procedure performed between January 2001 and April 2018. Of these, eleven were for cervical and/or upper airway teratoma. Ten (91%) cases had associated polyhydramnios, two (18%) developed nonimmune hydrops, and eight (72%) delivered preterm. Six (45.5%) were performed as an emergency. Estimated blood loss was 1000 ml (500, 1000). The neonatal mortality rate was 18% (2/11) and 33% (3/9) of the survivors were discharged with a tracheostomy. CONCLUSION EXIT is a reasonable option for delivery of babies with an occlusive upper airway mass. Neonatal survival depends on individualized factors but may be as high as 82% in those with teratoma.
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Affiliation(s)
- Alireza A Shamshirsaz
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Soroush Aalipour
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Kelsey A Stewart
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ahmed A Nassr
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Egypt
| | - Betul Y Furtun
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Hadi Erfani
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Nathan C Sundgren
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Magdalena S Cortes
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Roopali V Donepudi
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Timothy C Lee
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Deepak K Mehta
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Elizabeth S Kravitz
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Nazli M Asl
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Jimmy Espinoza
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Michael A Belfort
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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16
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Role of prenatal imaging in the diagnosis and management of fetal facio-cervical masses. Sci Rep 2021; 11:1385. [PMID: 33446872 PMCID: PMC7809128 DOI: 10.1038/s41598-021-80976-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/29/2020] [Indexed: 12/01/2022] Open
Abstract
Congenital facio-cervical masses can be a developmental anomaly of cystic, solid, or vascular origin, and have an inseparable relationship with adverse prognosis. This retrospective cross-sectional study aimed at determining on the prenatal diagnosis of congenital facio-cervical masses, its management and outcome in a large tertiary referral center. We collected information on prenatal clinical data, pregnancy outcomes, survival information, and final diagnosis. Out of 130 cases of facio-cervical masses, a total of 119 cases of lymphatic malformations (LMs), 2 cases of teratoma, 2 cases of thyroglossal duct cyst, 4 cases of hemangioma, 1 case of congenital epulis, and 2 cases of dermoid cyst were reviewed. The accuracy of prenatal ultrasound was 93.85% (122/130). Observations of diameters using prenatal ultrasound revealed that the bigger the initial diameter is, the bigger the relative change during pregnancy. Magnetic resonance imaging (MRI) revealed that 2 cases of masses were associated with airway compression. In conclusion, ultrasound has a high overall diagnostic accuracy of fetal face and neck deformities. Prenatal US can enhance the management of ambulatory monitoring and classification. Furthermore, MRI provided a detailed assessment of fetal congenital malformations, as well as visualization of the trachea, presenting a multi-dimensional anatomical relationship.
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García-Díaz L, Chimenea A, de Agustín JC, Pavón A, Antiñolo G. Ex-Utero Intrapartum Treatment (EXIT): indications and outcome in fetal cervical and oropharyngeal masses. BMC Pregnancy Childbirth 2020; 20:598. [PMID: 33028259 PMCID: PMC7541246 DOI: 10.1186/s12884-020-03304-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022] Open
Abstract
Background The “Ex-Utero Intrapartum Treatment” (EXIT) procedure allows to ensure fetal airway before completion of delivery and umbilical cord clamping while keeping uteroplacental circulation. Airway obstruction in fetal oropharyngeal and cervical masses can be life-threatening at birth. In those situations, controlled access to fetal airway performed by a trained multidisciplinary team allows safe airway management, while feto-maternal circulation is preserved. We aim to review the indications and outcome of the EXIT procedure in a case series of fetal cervical and oropharyngeal masses. Methods We have carried out a retrospective review of all patients with fetal cervical and oropharyngeal masses who underwent an EXIT procedure between 2008 and 2019. Variables evaluated included indication for EXIT, ultrasound and MRI findings, the need of amnioreduction, gestational age at EXIT, birth weight, complications, operative time, survival rate, pathological findings, and postnatal evolution. Five patients are included in this series. One additional case has already been published. Results The diagnosis were cervical teratoma (n = 1), epulis (n = 1) and lymphangioma (n = 3). Polyhydramnios was present in 2 patients, requiring amnioreduction in one of them. Mean gestational age at EXIT was 36–37 weeks (range, 34–38 weeks). Median EXIT time in placental support was 9 min (range, 3–22 min). Access to airway was successfully established in EXIT in all cases. All children born by EXIT are currently healthy and without complications. Conclusion The localization and characteristics of the mass, its relationship to the airway, and the presence of polyhydramnios seem to be major factors determining indications for EXIT and clinical outcome.
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Affiliation(s)
- Lutgardo García-Díaz
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Avda. Manuel Siurot s/n ES-41013, Seville, Spain
| | - Angel Chimenea
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Avda. Manuel Siurot s/n ES-41013, Seville, Spain.,Fetal, IVF and Reproduction Simulation Training Centre (FIRST), Seville, Spain
| | | | - Antonio Pavón
- Department of Neonatology, Hospital Universitario Virgen del Rocio, Seville, Spain
| | - Guillermo Antiñolo
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Avda. Manuel Siurot s/n ES-41013, Seville, Spain. .,Fetal, IVF and Reproduction Simulation Training Centre (FIRST), Seville, Spain. .,Centre for Biomedical Network Research on Rare Diseases (CIBERER), Seville, Spain.
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Cash H, Bly R, Masco V, Dighe M, Cheng E, Delaney S, Ma K, Perkins JA. Prenatal Imaging Findings Predict Obstructive Fetal Airways Requiring EXIT. Laryngoscope 2020; 131:E1357-E1362. [PMID: 32770766 DOI: 10.1002/lary.28959] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/02/2020] [Accepted: 06/30/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Detection of fetal airway compromise through imaging raises the possible need for ex utero intrapartum treatment (EXIT) procedures. Despite EXIT procedures involving massive resource utilization and posing increased risk to the mother, decisions for EXIT are usually based on anecdotal experience. Our objectives were to analyze prenatal consultations with potential fetal airway obstruction for imaging and obstetric findings used to determine management strategy. METHODS Retrospective chart review was performed for prenatal abnormal fetal airway consults between 2004-2019 at a quaternary pediatric facility. Data collected included demographics, imaging characteristics, delivery information, and airway management. Our primary outcome was EXIT performance and the secondary outcome was postnatal airway management. Fisher's exact test was used to compare management decisions, outcomes, and imaging findings. RESULTS Thirty-seven patients met inclusion criteria. The most common diagnoses observed were lymphatic malformation, teratoma, and micrognathia. Of the imaging findings collected, only midline neck mass location was associated with EXIT procedure performance. Factors associated with invasive airway support at birth were mass-induced in-utero neck extension and neck vessel compression, polyhydramnios, and micrognathia. CONCLUSIONS Multidisciplinary input and interpretation of prenatal imaging can guide management of fetal airway-related pathology. EXIT is an overall safe procedure and can decrease risk due to airway obstruction at birth. We identified in-utero neck extension, neck vessel compression, micrognathia, and polyhydramnios as better indicators of a need for invasive airways measures at birth and suggest use of these criteria in combination with clinical judgement when recommending EXIT. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1357-E1362, 2021.
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Affiliation(s)
- Harrison Cash
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Randall Bly
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Vanessa Masco
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Manjiri Dighe
- Department of Radiology, Prenatal Imaging, University of Washington, Seattle, Washington, U.S.A
| | - Edith Cheng
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Shani Delaney
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Kimberly Ma
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Jonathan A Perkins
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
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Chapman MC, Soares BP, Li Y, Shum DJ, Glenn OA, Glastonbury CM, Courtier JL. Congenital Oral Masses: An Anatomic Approach to Diagnosis. Radiographics 2020; 39:1143-1160. [PMID: 31283464 DOI: 10.1148/rg.2019180128] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although congenital oral masses are rare, they are readily detectable during fetal US screening. Most congenital oral masses are benign, but some may cause mechanical airway obstruction, resulting in poor outcomes at delivery. The radiologist's ability to describe these abnormalities and their physiologic sequelae accurately can have a substantial effect on perinatal treatment. Furthermore, despite being rare, congenital oral lesions encountered at screening and at follow up fetal MRI provide the opportunity to make a specific diagnosis by following a simple anatomic approach. This article describes an anatomic algorithm as the framework for accurate diagnosis of congenital oral lesions. The imaging appearance of the most common congenital oral cavity neoplasms is outlined, including vascular anomalies, epulides, choristomas, congenital lingual thyroid anomalies, lingual hamartomas, and epignathi, and other conditions that mimic these at US. Also reviewed are perinatal management of masses that affect the fetal airway and the imaging features key to optimizing delivery outcomes. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Molly C Chapman
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA (M.C.C., Y.L., D.J.S., O.A.G., C.M.G., J.L.C.) and the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD (B.P.S.)
| | - Bruno P Soares
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA (M.C.C., Y.L., D.J.S., O.A.G., C.M.G., J.L.C.) and the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD (B.P.S.)
| | - Yi Li
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA (M.C.C., Y.L., D.J.S., O.A.G., C.M.G., J.L.C.) and the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD (B.P.S.)
| | - Dorothy J Shum
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA (M.C.C., Y.L., D.J.S., O.A.G., C.M.G., J.L.C.) and the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD (B.P.S.)
| | - Orit A Glenn
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA (M.C.C., Y.L., D.J.S., O.A.G., C.M.G., J.L.C.) and the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD (B.P.S.)
| | - Christine M Glastonbury
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA (M.C.C., Y.L., D.J.S., O.A.G., C.M.G., J.L.C.) and the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD (B.P.S.)
| | - Jesse L Courtier
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA (M.C.C., Y.L., D.J.S., O.A.G., C.M.G., J.L.C.) and the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD (B.P.S.)
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Mohammad S, Olutoye OA. Airway management for neonates requiring ex utero intrapartum treatment (EXIT). Paediatr Anaesth 2020; 30:248-256. [PMID: 31898837 DOI: 10.1111/pan.13818] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 12/30/2019] [Indexed: 12/19/2022]
Abstract
In utero congenital malformations in the fetus can occasionally lead to an obstructed airway at birth accompanied by hypoxic injury or peripartum demise, without intervention. Ex utero intrapartum treatment (EXIT) may help reduce morbidity and mortality associated with challenging airways by providing extra time on uteroplacental circulation to secure the airway. Meticulous preparation and planning are crucial for this procedure. Many different types of congenital malformations can result in a difficult airway, but there is no correlation between specific malformations and a required type of airway intervention. Based on our experience and literature review, an airway process flow diagram has been created to help assist teams in decision-making for airway intervention in a neonate during the EXIT procedure. The management of the airway in this scenario involves additional unique considerations that accompany handling a partially delivered newborn in the uterine environment. Extensive preparation and team rehearsal are essential to the success of this procedure.
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Affiliation(s)
- Shazia Mohammad
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Olutoyin A Olutoye
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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21
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Petrikovsky BM. Shoulder Shrug Maneuver to Facilitate Delivery During Shoulder Dystocia. Obstet Gynecol 2019; 134:648. [PMID: 31441810 DOI: 10.1097/aog.0000000000003439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Boris M Petrikovsky
- Department of Obstetrics and Gynecology, New York Institute of Technology, Great Neck, New York
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22
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Ravelli A, Napolitano M, Rustico M, Riccipetitoni G, Di Leo G, Righini A, Sardanelli F. Prenatal MRI of neck masses with special focus on the evaluation of foetal airway. Radiol Med 2019; 124:917-925. [PMID: 31175537 DOI: 10.1007/s11547-019-01049-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 05/24/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prenatal magnetic resonance imaging is the best tool to visualize foetal airway. OBJECTIVE To evaluate the performance of MRI in the assessment of foetal airway status in the presence of a neck mass. MATERIALS AND METHODS Two paediatric radiologists with 12- and 2-year experience in foetal imaging retrospectively analysed 23 foetal MRI examinations, performed between 2001 and 2016, after a second-level ultrasound suspicious for presence of a neck mass. Postnatal imaging, postoperative report, histology, autopsy, and clinical outcomes were the reference standard to calculate sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of prenatal MRI in detecting airway patency. We used the Cohen к statistics to estimate the interobserver agreement. We also assessed MRI performance in the diagnosis of the mass nature. RESULTS We obtained data about postnatal airway status in 19 of 23 patients; prenatal MRI demonstrated a sensitivity of 9/9 [100%, 95% confidence interval (CI) 66-100%], specificity 8/10 (80%, 44-98%), accuracy 17/19 (89%, 67-99%), PPV 9/11 (82%, 48-98%), and NPV 8/8 (100%, 63-100%); the interobserver agreement was perfect. Prenatal MRI correctly identified 21 of 23 masses (к = 0.858); the interobserver agreement was almost perfect (к = 0.851). CONCLUSION Prenatal MRI demonstrated high accuracy in assessing foetal airway status and diagnosing mass nature, allowing proper delivery planning.
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Affiliation(s)
- Anna Ravelli
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital - ASST Fatebenefratelli-Sacco, Via Castelvetro 32, 20154, Milan, Italy.
| | - Marcello Napolitano
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital - ASST Fatebenefratelli-Sacco, Via Castelvetro 32, 20154, Milan, Italy
| | - Mariangela Rustico
- Department of Obstetrics and Gynecology, V. Buzzi Children's Hospital - ASST Fatebenefratelli-Sacco, Via Castelvetro 32, 20154, Milan, Italy
| | - Giovanna Riccipetitoni
- Department of Pediatric Surgery, V. Buzzi Children's Hospital - ASST Fatebenefratelli-Sacco, Via Castelvetro 32, 20154, Milan, Italy
| | - Giovanni Di Leo
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy
| | - Andrea Righini
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital - ASST Fatebenefratelli-Sacco, Via Castelvetro 32, 20154, Milan, Italy
| | - Francesco Sardanelli
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy.,Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy
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Tay SY, Krishnasarma R, Mehta D, Mehollin-Ray A, Chandy B. Predictive Factors for Perinatal Outcomes of Infants Diagnosed With Micrognathia Antenatally. EAR, NOSE & THROAT JOURNAL 2019; 100:NP16-NP20. [PMID: 31159574 DOI: 10.1177/0145561319855641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Advances in fetal imaging have allowed us to identify abnormalities previously not appreciated. With this study, we hope to identify factors predicting a difficult airway at birth and review the perinatal outcomes of these patients. METHODS Sixteen patients with antenatally diagnosed micrognathia were reviewed from a tertiary care hospital database from 2011 to 2016. Jaw index (JI), amniotic fluid index (AFI), glossoptosis, gastric size, and oropharynx obliteration were assessed. The airway support required at birth, specialist team involvement, and outcomes were evaluated. RESULTS Nine (56.3%) of 16 patients had JI <5th percentile, 3 (33.3%) of 9 had difficult intubation, 2 (22.2%) of 9 needed an emergency tracheostomy, and 1 (11.1%) of 9 died. Seven patients had polyhydramnios, 2 (28.6%) of 7 had difficult intubation, 2 (28.6%) of 7 required tracheostomy, and 1 (14.3%) of 7 died. Twelve patients had either JI <5th percentile or abnormal AFI, 5 (41.7%) of 12 had difficult intubation, 2 (16.7%) of 12 required tracheostomy, and 1 (8.33%) of 12 died. For the group without otolaryngology consultation, 8 (50%) of 16, 1 (12.5%) of 8 had difficult intubation and 1 (12.5%) of 8 died because airway was not secured after 45 minutes of resuscitation. CONCLUSION Jaw index <5th percentile or abnormal AFI predicts a difficult airway. A multidisciplinary approach with otolaryngology involvement for airway intervention may be required at birth.
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Affiliation(s)
- Sok Yan Tay
- Department of Pediatric Otolaryngology, 3984Texas Children's Hospital, Houston, TX, USA
| | - Rekha Krishnasarma
- Department of Radiology, 3984Texas Children's Hospital, Houston, TX, USA
| | - Deepak Mehta
- Department of Pediatric Otolaryngology, 3984Texas Children's Hospital, Houston, TX, USA
| | - Amy Mehollin-Ray
- Department of Radiology, 3984Texas Children's Hospital, Houston, TX, USA
| | - Binoy Chandy
- Department of Pediatric Otolaryngology, 3984Texas Children's Hospital, Houston, TX, USA
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Ravindra GL, Madamangalam AS, Seetharamaiah S. Anaesthesia for non-obstetric surgery in obstetric patients. Indian J Anaesth 2018; 62:710-716. [PMID: 30237597 PMCID: PMC6144550 DOI: 10.4103/ija.ija_463_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Anaesthesia for pregnant patients presenting for non-obstetric surgery needs a thorough understanding of the physiological changes and altered pharmacokinetics of pregnancy. Considering the effects of surgery and anaesthesia on the foetus, only essential and emergency surgeries are performed during pregnancy. Surgical procedures in second trimester have the advantage of better foetal outcome. The primary concerns of maternal and foetal safety are achieved by a focused multidisciplinary team-based approach with respect to the surgical condition. Meticulous attention to preoperative patient counselling, airway management, haemodynamic stability, and thromboprophylaxis are the key factors in anaesthetic management. Choice of anaesthesia or anaesthetic drugs has minimal impact on the foetus provided utero-placental perfusion and uterine relaxation are maintained. Foetal monitoring when feasible and when done by a trained person enables to diagnose and treat the factors responsible for foetal heart rate variability. Anaesthetic technique needs to be modified according to the type of surgery.
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Affiliation(s)
- GL Ravindra
- Janani Anaesthesia and Critical Care Services, Shimoga, Karnataka, India
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25
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Perkins JA. New Frontiers in Our Understanding of Lymphatic Malformations of the Head and Neck: Natural History and Basic Research. Otolaryngol Clin North Am 2018; 51:147-158. [PMID: 29217059 DOI: 10.1016/j.otc.2017.09.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The future of head and neck lymphatic malformation (HNLM) evaluation and treatment is changing because of 2 decades of clinical research and recent basic science investigation. Basic science investigation using cellular biology and molecular genetics has revealed the genetic cause of some HNLMs, which has created the possibility of medical treatment specific to HNLM. This article summarizes the clinical and basic science research that will likely influence the future of HNLM assessment and treatment.
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Affiliation(s)
- Jonathan A Perkins
- Otolaryngology/Head and Neck Surgery, University of Washington School of Medicine, 1959 Pacific Avenue NE, Box 366515, Seattle, WA 98195, USA; Vascular Anomalies Program, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA.
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26
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Nagarajan M, Sharbidre KG, Bhabad SH, Byrd SE. MR Imaging of the Fetal Face: Comprehensive Review. Radiographics 2018; 38:962-980. [PMID: 29652578 DOI: 10.1148/rg.2018170142] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The human face is a complex anatomic structure with an equally complex embryologic development. Derangement of the developmental process can result in various structural anomalies, which range from a mainly cosmetic deformity, such as cleft lip, to potentially life-threatening conditions such as arhinia. These anomalies (a) can occur as isolated anomalies; (b) can be associated with intracranial, spinal, or dental anomalies; or (c) can be a part of various syndromes, thus serving as diagnostic clues in such cases. Proper evaluation of fetal facial deformities can help in prognostication, family counseling, and prenatal or early postnatal intervention. Ultrasonography (US) is the first line of investigation in these cases. However, when US does not allow complete evaluation of these anomalies owing to its inherent limitations, magnetic resonance (MR) imaging allows comprehensive evaluation of the anomaly itself and also evaluation of various associations and the treatment approach. The embryology of the fetal facial structures is considered with regard to the MR imaging technique and the MR imaging anatomy. The MR imaging features of various structural anomalies are described and classified into six groups, namely, orofacial clefts, orbital anomalies, nasal anomalies, facial masses, external ear anomalies, and abnormal face shape or profile. Also, the key associations and relevant treatment implications are reviewed. The article provides a "one-stop shop" review of these unique disorders-from basic understanding of the embryology to applying the knowledge in clinical practice, helping the interprofessional team and the patients alike. ©RSNA, 2018.
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Affiliation(s)
- Murali Nagarajan
- From the Department of Neuroradiology, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Kedar G Sharbidre
- From the Department of Neuroradiology, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Sudeep H Bhabad
- From the Department of Neuroradiology, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
| | - Sharon E Byrd
- From the Department of Neuroradiology, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
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Ex utero intrapartum treatment procedure in two fetuses with airway obstruction. Obstet Gynecol Sci 2018; 61:417-420. [PMID: 29780786 PMCID: PMC5956127 DOI: 10.5468/ogs.2018.61.3.417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 07/27/2017] [Accepted: 08/07/2017] [Indexed: 11/08/2022] Open
Abstract
The ex utero intrapartum treatment (EXIT) procedure was introduced to reduce fetal hypoxic damage while establishing an airway in fetuses with upper and lower airway obstruction. Delivery of the fetal head and shoulders while maintaining the uteroplacental circulation offers time to secure the fetal airway. Here, we report two cases of EXIT procedure for fetal airway obstruction, which were successfully managed with extensive preoperative planning by a professional multidisciplinary team.
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Gonzales SK, Goudy S, Prickett K, Ellis J. EXIT (ex utero intrapartum treatment) in a growth restricted fetus with tracheal atresia. Int J Pediatr Otorhinolaryngol 2018; 105:72-74. [PMID: 29447823 DOI: 10.1016/j.ijporl.2017.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/04/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
Congenital high airway obstruction syndrome (CHAOS) encompasses a heterogeneous group of pathologies leading to poor lung development and difficulty oxygenating the newborn after delivery. While previously uniformly fatal, the ex utero intrapartum therapy (EXIT) procedure has provided a method to treat these patients and provide an airway to potentiate survival. We present a patient diagnosed prenatally with CHAOS secondary to tracheal atresia complicated by severe intra-uterine growth restriction (IUGR) who was successfully delivered via an EXIT procedure at 33-weeks. Multidisciplinary care and planning is paramount.
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Affiliation(s)
- S Kyle Gonzales
- Division of Maternal Fetal Medicine, Emory University, Atlanta, GA, USA.
| | - Steven Goudy
- Division of Otolaryngology, Head & Neck Surgery, Emory University, Atlanta, GA, USA
| | - Kara Prickett
- Division of Otolaryngology, Head & Neck Surgery, Emory University, Atlanta, GA, USA
| | - Jane Ellis
- Division of Maternal Fetal Medicine, Emory University, Atlanta, GA, USA
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29
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Takla M, Gratz I, Gourkanti B. Anesthesia for Ex-Utero Intra-Partum Procedures. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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30
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Vascular Malformations. CURRENT OTORHINOLARYNGOLOGY REPORTS 2017. [DOI: 10.1007/s40136-017-0174-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Fetal MRI is a level III diagnostic tool performed subsequently a level II prenatal ultrasound (US), in cases of inconclusive ultrasonographic diagnosis or when a further investigation is required to confirm or improve the diagnosis, to plan an appropriate pregnancy management. Fetal MRI plays an increasingly important role in the prenatal diagnosis of fetal neck, chest and abdominal malformations, even if its role has been amply demonstrated, especially, in the field of fetal CNS anomalies. Due to its multiparametricity and multiplanarity, MRI provides a detailed evaluation of the whole fetal respiratory, gastrointestinal and genitourinary systems, especially on T2-weighted (W) images, with a good tissue contrast resolution. In the evaluation of the digestive tract, T1-W sequences are very important in relation to the typical hyperintensity of the large intestine, due to the presence of meconium. The objective of this review is to focus on the application of fetal MRI in neck, chest and abdominal diseases.
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de Oliveira GH, Svetliza J, Vaz-Oliani DCM, Liedtke H, Oliani AH, Pedreira DAL. Novel multidisciplinary approach to monitor and treat fetuses with gastroschisis using the Svetliza Reducibility Index and the EXIT-like procedure. EINSTEIN-SAO PAULO 2017; 15:395-402. [PMID: 29364360 PMCID: PMC5875150 DOI: 10.1590/s1679-45082017ao3979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 08/15/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To describe our initial experience with a novel approach to follow-up and treat gastroschisis in "zero minute" using the EXITlike procedure. METHODS Eleven fetuses with prenatal diagnosis of gastroschisis were evaluated. The Svetliza Reductibility Index was used to prospectively evaluate five cases, and six cases were used as historical controls. The Svetliza Reductibility Index consisted in dividing the real abdominal wall defect diameter by the larger intestinal loop to be fitted in such space. The EXIT-like procedure consists in planned cesarean section, fetal analgesia and return of the herniated viscera to the abdominal cavity before the baby can fill the intestines with air. No general anesthesia or uterine relaxation is needed. Exteriorized viscera reduction is performed while umbilical cord circulation is maintained. RESULTS Four of the five cases were performed with the EXIT-like procedure. Successful complete closure was achieved in three infants. The other cases were planned deliveries at term and treated by construction of a Silo. The average time to return the viscera in EXIT-like Group was 5.0 minutes, and, in all cases, oximetry was maintained within normal ranges. In the perinatal period, there were significant statistical differences in ventilation days required (p = 0.0169), duration of parenteral nutrition (p=0.0104) and duration of enteral feed (p=0.0294). CONCLUSION The Svetliza Reductibility Index and EXIT-like procedure could be new options to follow and treat gastroschisis, with significantly improved neonatal outcome in our unit. Further randomized studies are needed to evaluate this novel approach.
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Affiliation(s)
| | - Javier Svetliza
- Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | | | - Humberto Liedtke
- Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil
| | - Antonio Helio Oliani
- Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil
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Current and future approaches to large airways imaging in adults and children. Clin Radiol 2017; 72:356-374. [DOI: 10.1016/j.crad.2017.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 01/07/2017] [Accepted: 01/23/2017] [Indexed: 01/04/2023]
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Overcash RT, Marc-Aurele KL, Hull AD, Ramos GA. Maternal Iodine Exposure: A Case of Fetal Goiter and Neonatal Hearing Loss. Pediatrics 2016; 137:peds.2015-3722. [PMID: 27006474 DOI: 10.1542/peds.2015-3722] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2016] [Indexed: 11/24/2022] Open
Abstract
A 27-year-old gravid 1 at 27 weeks 6 days with a history of hypothyroidism had an ultrasound that demonstrated a 3.9 × 3.2 × 3.3-cm well-circumscribed anterior neck mass, an extended fetal head, and polyhydramnios. Further characterization by magnetic resonance imaging (MRI) showed a fetal goiter. During her evaluation for the underlying cause of the fetal goiter, the patient revealed she was taking nutritional iodine supplements for treatment of her hypothyroidism. She was ingesting 62.5 times the recommended amount of daily iodine in pregnancy. The excessive iodine consumption caused suppression of the fetal thyroid hormone production, resulting in hypothyroidism and goiter formation. After the iodine supplement was discontinued, the fetal goiter decreased in size. At delivery, the airway was not compromised. The infant was found to have reversible hypothyroidism and bilateral hearing loss postnatally. This case illustrates the importance of examining for iatrogenic causes for fetal anomalies, especially in unregulated nutritional supplements.
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Affiliation(s)
- Rachael T Overcash
- Division of Maternal-Fetal Medicine, Department of Reproductive Medicine, and Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Krishelle L Marc-Aurele
- Division of Neonatology, Department of Pediatrics, University of California San Diego, San Diego, California; and
| | - Andrew D Hull
- Division of Maternal-Fetal Medicine, Department of Reproductive Medicine, and
| | - Gladys A Ramos
- Division of Maternal-Fetal Medicine, Department of Reproductive Medicine, and
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Diercks GR, Hartnick CJ, Bates SV. Management of the critical airway when an EXIT procedure is not an option: A case report. Int J Pediatr Otorhinolaryngol 2015; 79:2433-7. [PMID: 26429602 DOI: 10.1016/j.ijporl.2015.08.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 11/19/2022]
Abstract
Perinatal imaging facilitates detection of congenital head and neck masses to plan fetal procedures which secure the airway. Ex utero intrapartum therapy (EXIT) procedures are preferred to protect the neonatal airway. Herein we present a case in which a neonate with a large oropharyngeal lymphovascular malformation was delivered and the airway successfully managed without an EXIT procedure using a multidisciplinary approach. Preparations for the non-EXIT delivery and critical airway management are described.
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Affiliation(s)
- Gillian R Diercks
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, United States
| | - Christopher J Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, United States.
| | - Sara V Bates
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, United States; Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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Agarwal Jayagobi P, Chandran S, Sriram B, Chang KTE. Ex-utero intrapartum treatment (EXIT) procedure for giant fetal epignathus. Indian Pediatr 2015; 52:893-5. [DOI: 10.1007/s13312-015-0740-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Fetal magnetic resonance imaging (MRI) is currently offered in a limited number of centers but is predominantly used for suspected fetal central nervous system abnormalities. This article concentrates on the role of the different imaging sequences and their value to clinical practice. It also discusses the future of fetal MRI.
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Affiliation(s)
- Elspeth Whitby
- Academic Unit of Reproductive and Developmental Medicine, Sheffield, UK.
| | - Peter Wright
- Medical Imaging and Medical Physics, Radiology, Royal Hallamshire Hospital, Sheffield, UK
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Zielinski R, Respondek-Liberska M. Retrospective chart review of 44 fetuses with cervicofacial tumors in the sonographic assessment. Int J Pediatr Otorhinolaryngol 2015; 79:363-8. [PMID: 25600283 DOI: 10.1016/j.ijporl.2014.12.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 12/18/2014] [Accepted: 12/22/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this retrospective study was to review and analyze ultrasonography examinations and follow-up of fetuses with cervicofacial tumors to develop bases for counseling specialist involved in perinatal treatment. METHODS The study consisted of case series with chart review of 44 fetuses with cervicofacial tumors diagnosed in utero by ultrasonography. The study was carried in Department of Diagnosis and Prevention of Congenital Malformations, Medical University of Lodz in years 1998-2013. The analysis of the fetuses with cervicofacial tumors included assessment of fetal sonographic features, neonatal survival and in utero as well as perinatal treatments. The obtained data were analyzed by the standard statistical tests and the Pearson's Chi square test, statistical significance at p=0.05. RESULTS Cervicofacial tumors were detected at mean 19±7 weeks of gestation. Eighty-two percent of the fetuses were males. Lymphatic malformations followed by teratomas were the most common fetal tumors in the cervicofacial region. In most cases, fetuses with cervicofacial tumors had other abnormalities. Mortality rate in our case series was 43%. In utero treatment was introduced in 6 fetuses. In 4 neonates prenatal sonographic assessment revealed upper airway patency and EXIT procedure (ex-utero intrapartum treatment) was introduced. CONCLUSION Prenatal sonographic detection of cervicofacial tumor, in case of lymphatic malformations possibly as early as in the first trimester, in case of craniofacial teratomas, cervical teratomas, hemangiomas and thyroid tumors possibly as early as in the second trimester, and in case of epignathi possibly in the third trimester, permits planning further course of pregnancy as well as EXIT procedure before delivery.
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Affiliation(s)
- Rafal Zielinski
- Department of Pediatric Otorhinolaryngology, Medical University of Lodz, Poland.
| | - Maria Respondek-Liberska
- Department of Diagnosis and Prevention of Congenital Malformations, Polish Mother Memorial Hospital, Chair of Morphology and Embryology, Medical University of Lodz, Poland
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George R, Shah R, Bulas D, Kline S, Alexander S, Reilly BK. The delivered promise of prenatal imaging and a challenge to the utility of sildenafil for severe lymphatic malformations. Int J Pediatr Otorhinolaryngol 2015; 79:89-93. [PMID: 25547959 DOI: 10.1016/j.ijporl.2014.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 11/21/2014] [Accepted: 12/02/2014] [Indexed: 11/27/2022]
Abstract
We report the case of an infant with severe lymphatic malformation necessitating ex-utero intrapartum treatment (EXIT) procedure and examine recent advances in high resolution ultrasonography and magnetic resonance imaging, which allow for improved prenatal diagnosis of lesions that cause critical airway obstruction in the neonate. Treatments for lymphatic malformations including surgical resection, sclerotherapy, coblation, and sildenafil are discussed. Our patient did not have any reduction in the size of the lymphatic malformation from sildenafil as suggested in another series.
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Affiliation(s)
- Ryan George
- Walter Reed National Military Medical Center, Bethesda, MD 20889, United States.
| | - Rahul Shah
- Division of Otolaryngology, Children's National Medical Center, 111 Michigan Ave., NW, Washington, DC 20010, United States.
| | - Dorothy Bulas
- Division of Diagnostic Imaging and Radiology, Children's National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010, United States.
| | - Shannon Kline
- Division of Anesthesia, 111 Michigan Ave., NW, Washington, DC 20010, United States.
| | - Sean Alexander
- Division of Anesthesia, 111 Michigan Ave., NW, Washington, DC 20010, United States.
| | - Brian K Reilly
- Division of Otolaryngology, Children's National Medical Center, 111 Michigan Ave., NW, Washington, DC 20010, United States.
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Walz PC, Schroeder JW. Prenatal diagnosis of obstructive head and neck masses and perinatal airway management: the ex utero intrapartum treatment procedure. Otolaryngol Clin North Am 2014; 48:191-207. [PMID: 25442130 DOI: 10.1016/j.otc.2014.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Advances in prenatal imaging in the last 20 years have enabled prenatal diagnosis of obstructive head and neck masses. These advances, coupled with improvements in maternal-fetal anesthesia, have made possible the development of the ex utero intrapartum treatment (EXIT) procedure for management of obstructive head and neck masses, during which the airway is managed in a controlled fashion while maintaining fetal circulation for oxygenation. This review addresses the preoperative and perioperative assessment and management of patients with prenatally diagnosed airway obstruction, indications and contraindications for the EXIT procedure, technical details of the procedure, and outcomes.
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Affiliation(s)
- Patrick C Walz
- Department of Pediatric Otolaryngology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611-2991, USA
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Sweeney K, Spurway J, Mein B, Magotti R, Benzie R, Challis D, Henry G. Congenital Epulis: a clinical case presentation. Australas J Ultrasound Med 2014; 17:85-88. [PMID: 28191214 PMCID: PMC5024936 DOI: 10.1002/j.2205-0140.2014.tb00112.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Congenital Epulis (CE) is a rare, benign tumour of the mucosa of the mouth in a neonate. It presents as an intraoral tumour and is rarely diagnosed prenatally. Complications include neonatal airway compromise, difficulty feeding and aesthetic considerations. Ultrasound is useful in aiding decisions regarding site, age, method of delivery and preparing parents and staff for the appearances of the tumour at birth. We present a case where CE was identified at 35 weeks gestational age during a routine third trimester prenatal ultrasound. The patient was scanned at a rural centre, referred to a tertiary institution for follow up and delivered at a specialist perinatal surgical centre, in preparation for neonatal surgery. The outcome was excellent and this case is a good example of multi-centre cooperation.
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Affiliation(s)
| | | | - Brendan Mein
- Perinatal Ultrasound Nepean Hospital Penrith New South Wales Australia
| | - Robert Magotti
- Perinatal Ultrasound Nepean Hospital Penrith New South Wales Australia
| | - Ron Benzie
- Perinatal Ultrasound Nepean Hospital Penrith New South Wales Australia
| | - Daniel Challis
- Royal Hospital for Women Sydney New South Wales Australia
| | - Guy Henry
- Sydney Children's Hospital Sydney New South Wales Australia
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Liao AY, Levin B, Daniel M, Chan L, Cooper MG, Birman CS. Emergency EXIT: an urgentex uterointrapartum tracheostomy for giant fetal neck mass. ANZ J Surg 2013; 83:684-5. [DOI: 10.1111/ans.12316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Adelene Y. Liao
- Department of ENT Surgery; The Children's Hospital at Westmead; Westmead; New South Wales; Australia
| | - Brett Levin
- Department of ENT Surgery; The Children's Hospital at Westmead; Westmead; New South Wales; Australia
| | - Matija Daniel
- Department of ENT Surgery; The Children's Hospital at Westmead; Westmead; New South Wales; Australia
| | - Lyndon Chan
- Department of ENT Surgery; The Children's Hospital at Westmead; Westmead; New South Wales; Australia
| | - Michael G. Cooper
- Department of ENT Surgery; The Children's Hospital at Westmead; Westmead; New South Wales; Australia
| | - Catherine S. Birman
- Department of ENT Surgery; The Children's Hospital at Westmead; Westmead; New South Wales; Australia
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MacArthur CJ. Prenatal diagnosis of fetal cervicofacial anomalies. Curr Opin Otolaryngol Head Neck Surg 2012; 20:482-90. [DOI: 10.1097/moo.0b013e3283582e21] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fetal magnetic resonance imaging and three-dimensional ultrasound in clinical practice: Applications in prenatal diagnosis. Best Pract Res Clin Obstet Gynaecol 2012; 26:593-624. [DOI: 10.1016/j.bpobgyn.2012.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 06/08/2012] [Indexed: 01/09/2023]
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Abstract
PURPOSE OF REVIEW The ex-utero intrapartum treatment (EXIT procedure) can be life-saving for fetuses with large neck masses. Advances in fetal imaging and access to prenatal care have improved the ability to anticipate and plan for the treatment of these fetuses. This review will highlight advances in imaging techniques, modification of anesthesia and case selection for the EXIT procedure. Long-term maternal and fetal outcomes will also be discussed. RECENT FINDINGS There have been relatively few articles published on this subject in the past 18 months. A better understanding of the effect of inhalational anesthetics on fetal cardiac function and some insight into the pharmacokinetics of narcotics while on uteroplacental support has been gained. Imaging characteristics that may improve patient selection have been proposed. The long-term outcomes of mothers undergoing fetal surgical procedures in general and specifically those undergoing EXIT procedures suggest that the EXIT procedure can be performed with minimal maternal morbidity in skilled hands. Furthermore, long-term neonatal outcomes appear to be improving, but further studies are needed. SUMMARY The EXIT procedure can be performed safely in a skilled multidisciplinary setting with minimal maternal and fetal morbidity and excellent fetal outcomes. Recent reports have helped further identify which fetuses will benefit from the EXIT procedure.
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Current World Literature. Curr Opin Obstet Gynecol 2012; 24:114-7. [DOI: 10.1097/gco.0b013e328351e420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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