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Certain medical and surgical conditions presenting at delivery or during the neonatal period require prompt diagnosis and timely treatment to effect a good outcome. Recent advances in prenatal diagnostic technology, including ultrasound techniques, fetal echocardiography, and fetal MRI imaging, can facilitate prenatal counseling as well as plans for delivery room and neonatal management. However, these techniques do not substitute for a careful newborn assessment and postnatal imaging to confirm and expand upon any prenatal diagnostic studies. Coordination of care is essential, because these conditions typically require the involvement of surgical and medical subspecialty providers. The neonatologist or pediatrician should ensure intervention is timely and in the patient’s best interest, and should facilitate appropriate communication with family.


The successful transition to extrauterine life depends upon patent, structurally intact airways and specific physiologic shifts in pulmonary vascular resistance and parenchymal water transport. Upper airway obstruction is usually evident at or shortly after birth by increased work of breathing, diminished air entry, poor perfusion, and in extreme cases, cyanosis. Craniofacial anomalies can affect nasopharyngeal patency. Choanal atresia usually involves the posterior nasal septum of one or both choanae and can be anticipated by inability to pass a 5-Fr. catheter into the posterior pharynx. Micrognathia associated with conditions such as Pierre Robin syndrome may be sufficiently severe to cause posterior displacement of the tongue and airway obstruction. Similarly, severe macroglossia seen in association with Beckwith-Wiedemann syndrome or subglossal cysts such as cannulae can cause functional obstruction of the proximal airway. In many instances of proximal airway obstruction, prone positioning and placement of an oral airway may relieve symptoms until surgical correction is possible. Severe cases may require tracheostomy. Antenatal diagnostic studies may facilitate delivery room management. Several centers report successful treatment of upper airway obstruction prior to delivery with the infant still attached to the placental circulation.1,2


Anomalous development of the larynx and proximal trachea may present with symptoms ranging from subtle stridor to acute catastrophic respiratory distress. Inspiratory stridor is most often associated with laryngomalacia due to redundant aryepiglottic folds or an enlarged, floppy epiglottis. Despite the stridor, respiratory compromise is less common. If feeding problems or respiratory distress persist, surgical laryngoplasty often yields good results. Unilateral vocal cord paralysis usually presents with stridor, while bilateral cord paralysis often presents as acute airway obstruction with severe respiratory distress requiring urgent intervention.


Unusual anomalies of the upper airway include laryngeal cysts, tracheal stenosis, and laryngotracheal clefts. The extent of symptoms and extent of intervention are functions of the severity of the defect. Tracheal atresia with complete high airway obstruction syndrome (CHAOS) is not compatible with survival unless diagnosed during the prenatal period. Extended survival beyond the delivery room has been reported in patients treated with tracheostomy at the time of delivery.3


Extrinsic compression of conducting airways can occur with congenital tumors of the neck or mediastinum. Cystic hygromas and cervical teratomas are most often implicated. ...

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