Cervical Teratoma Causing Airway Obstruction in a Premature Infant

A 29-week-old infant was born by spontaneous vaginal delivery at an outside facility. The mother received no prenatal care. At the time of birth, the infant was in acute respiratory distress, and a large left-sided neck mass was noted on examination. Direct laryngoscopy was attempted, but laryngeal exposure was difficult, and a 2.0-mm inner diameter (ID) endotracheal tube was secured by blind intubation as a temporizing measure. Computed tomography was obtained to determine the extent and character of the mass. A large, likely solid mass with a well-defined capsule was identified (Figure 1).

Figure 1.

Coronal (A) and axial (B) views on computed tomography (CT) of the left-sided neck mass (asterisk) with airway compression and deviation (arrow).

The patient was taken to the operating room to place a larger caliber endotracheal tube. A rigid Parsons laryngoscope was used to expose the larynx. The airway was significantly displaced, with severe deviation of the larynx to the right. A 3.0-mm ID endotracheal tube placed over a 2.7-mm rigid telescope was inserted into the airway for direct visualization. As the previously placed endotracheal tube was withdrawn, the rigid telescope and new endotracheal tube were inserted into the airway. The telescope was carefully withdrawn leaving the larger tube in place.

At 2 weeks of age, the patient was taken to the operating room again for surgical resection of a 2-cm immature thyroid teratoma (Figures 2 and 3). A serum α-fetoprotein level was found to be greater than 180 000, well above normal limits. No invasive characteristics were noted on histologic examination, and the patient was discharged home on day 21 of life. Follow-up 1 year later with Pediatric Oncology and Otolaryngology has been unremarkable with no sign of recurrence, and serum α-fetoprotein levels have returned to normal levels.

Figure 2.

Preoperative view of the left-sided neck mass.

Figure 3.

Immature thyroid teratoma of the left neck.

Large cervical tumors can cause acute respiratory distress in the newborn. Patients with little or no prenatal care pose a significant clinical challenge, ¹ and risk of morbidity and mortality increases precipitously when surgical intervention is performed emergently. ² Emergency airway management in newborns with airway compromise is challenging. ^3,4 Most recently, Bryson et al published a case series detailing patients requiring immediate airway intervention in the labor and delivery suite. Their conclusions further support the need for prenatal imaging and resulted in the development of a neonatal airway team and availability of instruments for emergent airway intervention on the labor and delivery floor. ⁵ In this patient, a Hopkins rod was used for visualization and as a rigid stylet to follow the previously placed tube to the larynx. We believe that this is an important technique to consider when faced with a challenging airway in the neonatal patient with airway obstruction.