Fetal Endoscopic Tracheal Intubation: A New Fetoscopic Procedure to Ensure Extrauterine Tracheal Permeability in a Case with Congenital Cervical Teratoma

Abstract

Congenital neck masses are associated with high perinatal mortality and morbidity secondary to airway obstruction due to a mass effect of the tumor with subsequent neonatal asphyxia and/or neonatal death. Currently, the only technique designed to establish a secure neonatal airway is the ex utero intrapartum treatment (EXIT) procedure, which involves neonatal tracheal intubation while fetal oxygenation is maintained by the uteroplacental circulation in a partial fetal delivery under maternal general anesthesia. We present a case with a giant cervical teratoma and huge displacement and compression of the fetal trachea that was treated successfully at 35 weeks of gestation with a novel fetoscopic procedure to ensure extrauterine tracheal permeability by means of a fetal endoscopic tracheal intubation (FETI) before delivery. The procedure consisted of a percutaneous fetal tracheoscopy under maternal epidural anesthesia using an 11-Fr exchange catheter covering the fetoscope that allowed a conduit to introduce a 3.0-mm intrauterine orotracheal cannula under ultrasound guidance. After FETI, a conventional cesarean section was performed uneventfully with no need for an EXIT procedure. This report is the first to illustrate that in cases with large neck tumors involving fetal airways, FETI is feasible and could potentially replace an EXIT procedure by allowing prenatal airway control.

Fetal neck tumors – antenatal and intrapartum management

“…This can be achieved with an ultrasound, MRI or even directly by fetoscopy [16][17][18]. The proposed predictors of a fetal airways obstruction are: polyhydramnios, bigger size of the mass, and a presence of teratoma [16].…”

“…The innovative, alternative method to EXIT may be fetal endoscopic tracheal intubation (FETI) [17]. The procedure consists of fetal tracheoscopy with subsequent insertion of intrauterine orotracheal cannula under ultrasound guidance.…”

“…This complicated procedure ensures fetal tracheal permeability before delivery. The above procedure was described by Cruz-Martinez et al for giant neck teratoma [17].…”

Congenital cervical teratoma in association with neuronal migration disorder

“…Determining the optimal timing of the EXIT procedure is challenging as the risk of preterm labor in a center without necessary expertise should be weighed against the socio-economic and financial costs of relocating family to a quaternary center (25). More recently, novel therapeutic techniques such as fetal endoscopic tracheal intubation (26) and fetal airway reconstruction (14) have been proposed as potential future treatment options in management of fetal neck mass but are not yet part of routine clinical practice.…”

In utero Fetal Intubation for a Large Neck Mass: A Minimally Invasive EXIT Option

“…Furthermore, although an EXIT procedure can provide up to 2 h on uteroplacental support, the significantly distorted fetal anatomy in combination with potentially limited time on placental circulation can create circumstances in which endotracheal intubation is not technically possible, leading to potential respiratory failure and death or other morbid methods of securing the airway such as tracheotomy or neck mass resection [5,6]. In order to circumvent such technical issues, fetal endoscopic intubation under maternal regional anesthesia has been proposed as an alternative delivery method [7]. We report a case of fetal endoscopic tracheal intubation in a fetus with a large anterior neck mass.…”