Ex-utero intrapartum treatment procedure for giant neck masses—fetal and maternal outcomes

Lazar, David A.; Olutoye, Oluyinka O.; Moise, Kenneth J.; Ivey, Richard; Johnson, Anthony; Ayres, Nancy A.; Rodríguez, M. Acosta; Cass, Darrell L.

doi:10.1016/j.jpedsurg.2011.02.006

Cited by 93 publications

(66 citation statements)

References 22 publications

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“…A proportion of cases still show difficulties and failure to intubate the trachea by using careful direct neonatal laryngoscopy or rigid bronchoscopes, and sometimes a cricothyroidotomy, tracheostomy or even an emergency surgical excision of the tumor has been required to identify the airway [10,11,12]. In addition, emergency surgical access may cause bleeding or trauma to the airway or adjacent neck and chest structures [8,13]. Thus, in the presence of a large vascular neck mass, the clinical algorithm to obtain a neonatal airway during an EXIT procedure can be quite challenging [4,12], even with the most experienced team [13].…”

Section: Discussionmentioning

confidence: 99%

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

Cruz‐Martínez

Moreno-Álvarez²,

Garcia³

et al. 2014

Fetal Diagn Ther

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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.

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Section: Discussionmentioning

confidence: 99%

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

Cruz‐Martínez

Moreno-Álvarez²,

Garcia³

et al. 2014

Fetal Diagn Ther

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“…20,21 Cervicofacial LMs may obstruct the airway and require support perinatally, ranging from intubation to ex utero intrapartum treatment procedures, 22 which entail potential fetomaternal risks. 23,24 Maternal treatment with propranolol could be considered in such patients. However, neonatal LMs can also regress spontaneously, 25 and maternal propranolol may be associated with intrauterine growth restriction.…”

Section: Discussionmentioning

confidence: 99%

Initial Experience With Propranolol Treatment of Lymphatic Anomalies: A Case Series

Wu¹,

Hooper²,

Laifer-Narin

et al. 2016

Pediatrics

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Lymphatic malformations (LMs) are congenital lymphatic lesions that impose significant and costly morbidities on affected patients. Treatment options are limited due to incomplete understanding of LM pathobiology. Expression of an activated β2-adrenergic receptor has been described in LM tissue, suggesting that this pathway may contribute to the clinical manifestations of LM. We hypothesized that propranolol, a β-adrenergic receptor antagonist, might improve symptoms of patients with LMs and lymphatic anomalies. A retrospective chart review of patients treated with propranolol as an adjunct therapy was conducted; analyses included demographic characteristics, clinical features, and response to propranolol. Three patients with cystic and noncystic LMs displayed clinical improvement at a minimum dose of 0.7 mg/kg/d, whereas symptomatic relapses were observed when propranolol doses dropped below this threshold. Two patients with Klippel-Trenaunay syndrome demonstrated partial clinical responses with reduced edema. The fetus of a mother treated with propranolol from a gestational age of 35 weeks through delivery displayed arrested growth of a cervicofacial LM. Our retrospective review suggests that propranolol improved symptoms in a subset of patients with lymphatic anomalies. Propranolol treatment may also limit the growth of congenital LMs in utero.

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“…They reported that the airway of a fetus can be viewed by this technique. A large series (12 cases) on EXIT procedure in fetal neck masses showed that EXIT can be performed safely for both the mother and child (7). There are a few cases reporting unsuccessful EXIT procedures (8).…”

Section: Discussionmentioning

confidence: 99%

Fetal Oropharyngeal and Neck Tumors: Determination of the Need for Ex-Utero Intrapartum Treatment Procedure

Özgünen¹,

Güleç²,

Evrüke³

et al. 2015

Balkan Med J

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Oropharyngeal and neck tumors are rarely seen in fetal life. The lesions located in the area involve cystic hygroma, teratoma, ranula, epulis, hemangioma, congenital goiter, solid thyroid tumor, thyroid cyst or thyroglossal duct cyst, branchial cleft cyst, neuroblastoma and hamartoma. The most common types are cervical teratoma and cystic hygroma (1). These tumors have the potential to obstruct the airway, which can be life threatening, and endotracheal intubation can be difficult or impossible due to anatomic distortion.The aim of the ex-utero intrapartum therapy (EXIT) procedure is to maintain the newborn's airway open during placental circulation after the partial delivery of a fetus, and, in this way, to protect the fetus from hypoxia until providing an open airway (2). As fetoplacental circulation continues, endotracheal intubation is implemented for opening the airway of the fetus. If this is not possible, other interventions such as bronchoscopy or tracheostomy and excision of the mass can be applied (1-3). However, the EXIT procedure is not a treat- Background:The aim of this study was to assess the ex-utero intrapartum therapy (EXIT) applied to 3 of the 7 cases with oropharyngeal or neck masses and review the indicators of the need for an EXIT procedure. Case Report: Prenatal presentation, size and localization of the masses, existence of fetal hydrops and associated findings such as polyhydramnios, intraoperative managements, complications, and maternal and neonatal outcomes were evaluated through a retrospective analysis. Four cases had neck masses and three cases had oropharyngeal masses. Prenatal sonography was used as the main diagnostic tool for all patients. The median gestational age was 34.5 weeks at the time of diagnosis and 36 weeks at delivery. Polyhydramnios was observed in three of the seven cases and they were delivered prematurely. Interventions such as endotracheal intubation or tracheostomy were performed to provide patency of the airway during delivery by the EXIT procedure in three cases. Hemangioma was found in two cases, teratoma in two cases, lymphangioma in two cases and hamartoma in one case following pathological examination of the masses. Conclusion: The localization of mass, its characteristics, invasion (if it exists), and relation to the airway are the main factors used to determine the need for EXIT. The presence of polyhydramnios may be an important indicator to predict both the need for EXIT and fetal outcomes.

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Ex-utero intrapartum treatment procedure for giant neck masses—fetal and maternal outcomes

Cited by 93 publications

References 22 publications

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

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

Initial Experience With Propranolol Treatment of Lymphatic Anomalies: A Case Series

Fetal Oropharyngeal and Neck Tumors: Determination of the Need for Ex-Utero Intrapartum Treatment Procedure

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