Treatment of a Fetal Tracheal Obstruction by Fetoscopy and Laser

Abstract

We report below a case of in utero tracheoscopy with laser collapse of a bronchogenic cyst obstructing the fetal trachea. The patient was referred for ultrasonography at 24 weeks of gestation because of fetal hydrops. Tracheoscopy was performed via fetoscopic approach using a single trocar under local anesthesia with lidocaine and ultrasound guidance. This revealed an image suggestive of a cyst obstructing the middle third at the anterior base of the trachea. Coagulation using a diode laser enabled us to collapse this fluid-filled cyst with three 10-watt bursts (3 times 3 s) and to visualize a completely unobstructed tracheobronchial tree with significant pulmonary fluid reflux on removal of the obstacle. The fetal condition improved markedly within 48 h after the procedure. To the best of our knowledge, this is the first described case of in utero treatment of a tracheal obstruction by tracheoscopy and laser. In severe cases of obstruction of the fetal airways, whether the obstacle is situated in a high or low position, fetal endoscopy is of diagnostic and potentially therapeutic utility.

In utero Treatment of Congenital High Airway Obstruction Syndrome via Fetal Laryngoscopy and EXIT Procedure

“…While the aforementioned case reports have described instances such as fetal intubation to avoid EXIT procedure in the setting of an unstable fetal airway or the ability to secure a definitive fetal airway at the time of fetal laryngoscopy and intervention for prenatally diagnosed CHAOS [5, 12, 19, 21], given the nature of this patient’s airway malformation, it was not felt that additional fetoscopic intervention would have yielded any benefit to secure a definitive airway and avert an EXIT procedure. This was confirmed at the time of near-term delivery, when an oral airway was unable to be secured by ENT services, and tracheostomy was ultimately performed.…”

“…The benefit of the fetoscopic airway evaluation, aside from being a minimally invasive approach, is that this procedure can prove to be both diagnostic and therapeutic, whereby surgical recanalization of the airway may ameliorate the risk for abnormal pulmonary development and allow for increased latency of the pregnancy with subsequent delivery near or at term. While surgical recanalization of the airway has been shown to be effective, published works are limited to case reports and series, limiting the degree to which one can estimate the chances for procedural success or intact survival [2, 6, 16, 19, 22, 23]. These published reports on successful prenatal fetoscopic intervention suggest the risk for subsequent premature delivery and need for EXIT at the time of delivery remain high, the latter of which may be dictated more so by the nature of the obstruction characterized at the time of fetoscopy.…”

“…Fetoscopic evaluation of the fetal airway with subsequent intervention has been described for a variety of indications including: (1) fetal intubation attempt prior to delivery for prenatally diagnosed airway obstruction in lieu of the more invasive outright EXIT procedure [5,12], (2) fetal endoscopic tracheal balloon occlusion in the setting of moderate or severe congenital diaphragmatic hernia [13][14][15], and (3) surgical recanalization or decom-pression of the fetal airway in the setting of CHAOS, tracheal cyst or bronchia atresia [16][17][18][19][20][21].…”

Congenital high airway obstruction syndrome in mid‐trachea: endotracheal bronchogenic cyst

“…Among bronchogenic cysts, the endotracheal variant is exceptionally rare, with only one reported case in which intrauterine treatment was successfully performed 4 . In our case, due to the coexistence of CHD and additional malformations in the spine, kidney and ear, the parents opted to terminate the pregnancy, so intrauterine treatment was not considered.…”

“…If a mid-tracheal obstruction is suspected in the setting of CHAOS, an endotracheal bronchogenic cyst should be considered, and a primary differential diagnosis should involve vascular rings, such as double aortic arch, which can have potential pseudo-CHAOS presentation 5 . Prenatal identification of the tracheal cyst could guide appropriate management, including fetoscopic treatment 4,5 .…”