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King A, Bedwell JR, Mehta DK, Stapleton GE, Justino H, Sutton C, Donepudi R, Sanz-Cortes M, Nassr AA, Sun RC, Lee TC, Keswani SG, Cassady CI, Mehollin-Ray A, Belfort MA. Fetoscopic balloon dilation and stent placement of congenital high airway obstruction syndrome leading to successful Caesarian delivery. Fetal Diagn Ther 2022; 49:29-35. [PMID: 34999582 DOI: 10.1159/000521664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 12/22/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Without fetal or perinatal intervention, congenital high airway obstruction syndrome (CHAOS) is a fatal anomaly. The ex utero intrapartum treatment (EXIT) procedure has been used to secure the fetal airway and minimize neonatal hypoxia, but is associated with increased maternal morbidity. CASE PRESENTATION A 16-year-old woman (gravida 1, para 0) was referred to our hospital at 31 weeks gestation with fetal anomalies, including echogenic lungs, tracheobronchial dilation and flattened diaphragms. At 32 weeks, fetoscopic evaluation identified laryngeal stenosis, which was subsequently treated with balloon dilation and stent placement. The patient developed symptomatic and regular preterm contractions at post-operative day 7 with persistent sonographic signs of CHAOS, which prompted a repeat fetoscopy with confirmation of a patent fetal airway followed by Cesarean delivery under neuraxial anesthesia. Attempts to intubate through the tracheal stent were limited and resulted in removal of the stent. A neonatal airway was successfully established with rigid bronchoscopy. Direct laryngoscopy and bronchoscopy confirmed laryngeal stenosis with a small tracheoesophageal fistula immediately inferior to the laryngeal stenosis and significant tracheomalacia. A tracheostomy was then immediately performed for anticipated long term airway and pulmonary management. The procedures were well tolerated by both mom and baby. The baby demonstrated spontaneous healing of the tracheoesophageal fistula by day of life 7 with discharge home with ventilator support at three months of life. CONCLUSION Use of repeated fetoscopy in order to relieve fetal upper airway obstruction offers the potential to minimize neonatal hypoxia, while concurrently decreasing maternal morbidity by avoiding an EXIT procedure. Use of the tracheal stent in CHAOS requires further investigation. The long-term reconstruction and respiratory support of children with CHAOS remain challenging.
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Affiliation(s)
- Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Joshua R Bedwell
- Department of Otolaryngology-Head and Neck 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
| | - Gary E Stapleton
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Henri Justino
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Caitlin Sutton
- Department of Anesthesiology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Roopali Donepudi
- Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Magdalena Sanz-Cortes
- Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Ahmed A Nassr
- Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Raphael C Sun
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Christopher I Cassady
- E. B. Singleton Department of Radiology, Texas Children's Hospital, Houston, Texas, USA
| | - Amy Mehollin-Ray
- E. B. Singleton Department of Radiology, Texas Children's Hospital, Houston, Texas, USA
| | - Michael A Belfort
- Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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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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Bresciani L, Grazioli P, Bosio R, Chirico G, Zambelloni C, Santoro A, Baronchelli C, Redaelli de Zinis LO. Neonatal Respiratory Distress and Airway Emergency: Report of Two Cases. CHILDREN-BASEL 2021; 8:children8040255. [PMID: 33805876 PMCID: PMC8064368 DOI: 10.3390/children8040255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 11/24/2022]
Abstract
We discuss two cases of congenital airway malformations seen in our neonatal intensive care unit (NICU). The aim is to report extremely rare events characterized by immediate respiratory distress after delivery and the impossibility to ventilate and intubate the airway. The first case is a male twin born at 34 weeks by emergency caesarean section. Immediately after delivery, the newborn was cyanotic and showed severe respiratory distress. Bag-valve-mask ventilation did not relieve the respiratory distress but allowed for temporary oxygenation during subsequent unsuccessful oral-tracheal intubation (OTI) attempts. Flexible laryngoscopy revealed complete subglottic obstruction. Postmortem analysis revealed a poly-malformative syndrome, unilateral multicystic renal dysplasia with a complete subglottic diaphragm, and a tracheo-esophageal fistula (TEF). The second case is a male patient that was vaginally born at 35 weeks. Antenatally, an ultrasound (US) arose suspicion for a VACTERL association (vertebral defects, anal atresia, TEF with esophageal atresia and radial or renal dysplasia, plus cardiovascular and limb defects) and a TEF, and thus, fetal magnetic resonance (MRI) was scheduled. Spontaneous labor started shortly thereafter, before imaging could be performed. Respiratory distress, cyanosis, and absence of an audible cry was observed immediately at delivery. Attempts at OTI were unsuccessful, whereas bag-valve-mask ventilation and esophageal intubation allowed for sufficient oxygenation. An emergency tracheostomy was attempted, although no trachea could be found on cervical exploration. Postmortem analysis revealed tracheal agenesis (TA), renal dysplasia, anal atresia, and a single umbilical artery. Clinicians need to be aware of congenital airway malformations and subsequent difficulties upon endotracheal intubation and must plan for multidisciplinary management of the airway at delivery, including emergency esophageal intubation and tracheostomy.
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Affiliation(s)
- Lorenzo Bresciani
- Pediatric Otolaryngology Head Neck Surgery, Children Hospital “ASST Spedali Civili”, 25123 Brescia, Italy; (L.B.); (P.G.); (R.B.)
| | - Paola Grazioli
- Pediatric Otolaryngology Head Neck Surgery, Children Hospital “ASST Spedali Civili”, 25123 Brescia, Italy; (L.B.); (P.G.); (R.B.)
| | - Roberta Bosio
- Pediatric Otolaryngology Head Neck Surgery, Children Hospital “ASST Spedali Civili”, 25123 Brescia, Italy; (L.B.); (P.G.); (R.B.)
| | - Gaetano Chirico
- Department of Neonatology and Neonatal Intensive Care Unit, Children Hospital “ASST Spedali Civili”, 25123 Brescia, Italy; (G.C.); (C.Z.)
| | - Cesare Zambelloni
- Department of Neonatology and Neonatal Intensive Care Unit, Children Hospital “ASST Spedali Civili”, 25123 Brescia, Italy; (G.C.); (C.Z.)
| | - Amerigo Santoro
- Department of Pathology, University of Brescia, 25123 Brescia, Italy; (A.S.); (C.B.)
| | - Carla Baronchelli
- Department of Pathology, University of Brescia, 25123 Brescia, Italy; (A.S.); (C.B.)
| | - Luca O. Redaelli de Zinis
- Pediatric Otolaryngology Head Neck Surgery, Children Hospital “ASST Spedali Civili”, 25123 Brescia, Italy; (L.B.); (P.G.); (R.B.)
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Section of Audiology, University of Brescia, 25123 Brescia, Italy
- Correspondence: ; Tel.: +39-030-399-6236
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Congenital High Airway Obstruction Syndrome (CHAOS): No Intervention, No Survival-A Case Report and Literature Review. Case Rep Radiol 2020; 2020:1036073. [PMID: 32685231 PMCID: PMC7336206 DOI: 10.1155/2020/1036073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 06/15/2020] [Indexed: 11/17/2022] Open
Abstract
Congenital high airway obstruction syndrome (CHAOS) is complete or partial obstruction of the fetal upper airway. CHAOS is a rare and fatal condition if no perinatal intervention is done. Antenatal sonographic imaging has typical findings that can help in an early diagnosis, which is important in deciding elective termination of the pregnancy or successful planning of appropriate perinatal management.
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