Severe Micrognathia: Indications for EXIT-to-Airway

Abstract

The ex utero intrapartum treatment (EXIT) procedure has become an important management option in cases of fetal airway obstruction. Select cases of severe micrognathia may be candidates for EXIT-to-Airway due to high-risk of airway obstruction at birth. Here we present three successful EXIT-to-Airway procedures for the management of congenital micrognathia in its most severe manifestations. Case 1: A 23-year-old G3P1011 with a pregnancy complicated by severe micorgnathia, jaw index <5th percentile, as well as polyhydramnios. At 36 weeks EXIT-to-Airway was performed utilizing a bronchoscopically positioned laryngeal mask airway (LMA) during 23 min of uteroplacental support followed by tracheostomy. Case 2: A 26-year-old G4P0120 with a pregnancy complicated by severe micrognathia, jaw index <5th percentile, and an obstructed oropharynx associated with polyhydramnios. At 37 weeks EXIT-to-Airway was performed with placement of tracheostomy. Case 3: A 36-year-old G6P3023 with fetal magnetic resonance imaging (MRI) revealing esophageal atresia, polyhydramnios, and severe micrognathia with a jaw index <5th percentile. At 35 weeks the patient underwent EXIT-to-Airway with formal tracheostomy during 35 min of uteroplacental bypass. In the most severe cases of fetal micrognathia, EXIT-to-Airway provides time to evaluate and secure the fetal airway prior to delivery. We propose indications for EXIT-to-Airway in micrognathia to include a jaw index <5%, with indirect evidence of aerodigestive tract obstruction such as polyhydramnios, glossoptosis or an absent stomach bubble.

EXIT procedure for fetal neck masses

“…The EXIT procedure has since been applied to other conditions in which advanced perinatal resuscitation is required. It is being used for controlled airway access in fetuses with large neck masses [2,3 && ], congenital high airway obstruction [4][5][6] or severe micrognathia (EXIT for airway) [7], as a bridge for fetuses with anticipated immediate need for extracorporeal support (EXIT-to-ECMO) [8,9], or for resection of large intrathoracic masses that may impair fetal resuscitation (EXIT-to-resection) [10,11 & ]. This article reviews indications, technique and outcomes following EXIT procedure for fetal neck masses.…”

Determining risk factors for early airway intervention in newborns with micrognathia

“…Time, proficiency, and familiarity with the EXIT procedure have led to the expansion of its applications 1. Based on a series of three patients, Morris et al have suggested that micrognathic infants with a jaw index <5 percentile and evidence of aerodigestive tract obstruction are indications for performing an EXIT procedure 2, 3. In an effort to further our knowledge regarding prenatal counseling for optimal and appropriate airway management of micrognathic fetuses, this study examines the rate of airway intervention within the first 24 hours of life in 123 newborns with micrognathia, and identifies prenatal characteristics that represent risk factors for intervention.…”

Current Approach for Prenatally Diagnosed Congenital Anomalies That Requires Surgery

“…[14][15][16] Bu hastaların erken bulgusu, USG esnasında saptanan polihidramniyostur. Hastaların doğum sonrası erken entübasyonunun riskli olduğu durumlarda EXIT prosedürü uygulanmaktadır.…”