Introduction

The term ‘cervical teratoma’ can be broken down to its meanings of cervical being the neck region, and teratoma being a type of tumour (which are mostly benign). This then allows for the complete understanding of the term ‘cervical teratoma’ being a rare congenital tumour which stems from the neck region. These tumours can be the origin for airway obstructions of the severe variety due to the mass effect they can have on the neck - these airway obstructions can occur at birth as they can be congenital in nature.

Due to the fact that cervical teratomas pose such a severe airway obstruction during the birth process, the early recognition thereof is key to the survival of a neonate. This early detection then allows for careful planning and coordinated perinatal management to commence, which also increases the potential of positive outcomes for neonates.

Understanding cervical teratoma in neonates

As cervical teratomas arise from the neck region, they may compress the trachea (or windpipe) and oesophagus (or food pipe) if they grow rapidly, and once they get to a certain size, this is particularly important in neonates due to their already small anatomy. The majority of teratomas are benign. However, there is a small percentage of teratomas that are malignant, so testing may be needed to give a definitive answer for this.

The diagnosis of cervical teratoma is likely to be made in the prenatal phase (during pregnancy), during ultrasound scans or through foetal magnetic resonance imaging (MRI). It is of high importance that this condition is picked up before birth as the level of airway obstruction is at a life-threatening level of life threatening, and this concept is at a very high risk immediately after birth. An indication that this condition may be a possibility is the presence of polyhydramnios, which is when there is an excess of amniotic fluid, or fluid in the womb, surrounding the baby, during pregnancy, which occurs due to a difficulty with the foetal being able to swallow correctly (due to the cervical teratoma impacting their physical ability to swallow).¹

Challenges in airway management at birth

The reason why immediate airway obstruction is of such high concern after birth is generally due to the fact that airway obstructions prevent ventilation and oxygenation of the brain from being carried out effectively.

In order to try and prevent the negative side effects that can occur due to an obstruction of the airway, intubation methods (using a tube to help keep the airway open) will be used. The most traditional and conventional method of intubation is where a tube is put down someone’s throat through their mouth; however, in children with cervical teratomas, this may be impossible due to the abnormal physical anatomy of their airway. Alike to any supportive procedure, there are risks to intubation of which include the risk of complete airway collapse whilst attempts to secure the airways are pursued.² Luckily, there are more advanced strategies that can be used in order to attempt to secure the airway further. These can include, but are not limited to:

• Tracheostomy (a surgical procedure where an opening is created in the neck to allow for direct access to the trachea, or windpipe - where a certain type of breathing tube is then inserted to allow for air to reach the lungs).
• Fibreoptic intubation (where a breathing tube is inserted into the trachea - or windpipe - using a flexible camera to allow for visualisation of the airway in real time).
• Extracorporeal support (by definition, this is where medical support is given outside of the body, so in this context, it could possibly mean using machines to help an individual breathe, but this overall term can include a plethora of interventions).

Anaesthetic challenges

As is the underlying theme with this condition, planning must begin during the pregnancy stage (antenatally) and include a multidisciplinary team of medical and clinical professionals. This multidisciplinary team may include professionals such as radiologists, anaesthetists, neonatologists and surgeons; however, this is not an exhaustive list.

The primary concern in terms of challenges with anaesthesia is that there is a difficulty in the ability to oxygenate the neonate due to the physical mass, causing a child to experience hypoxia and the potential of having severe negative side effects from this lack of oxygen. In addition to this, due to the instability of the veins within neonates, securing intravenous access can prove difficult and complicated. During the induction process of birth, there is a high risk of hypoxia (lack of oxygen), bradycardia (slow heart rate) and cardiac arrest (where the heart stops beating) for the neonate due to the stress of birth and airway compromise. In order to establish and maintain the airway whilst the neonate is still connected to the placenta and receiving blood flow (or circulation), Ex Utero Intrapartum Treatment (EXIT) procedures may be required. EXIT procedures are a special and particular technique for how a baby is delivered in order to establish a functioning airway prior to the neonate’s detachment from the placenta.³

Surgical challenges

Surgery of any nature includes risks like nerve injury, bleeding, and incomplete excision (removal) of the tumour, if it involves critical blood vessels. The surgery to remove cervical teratomas can become more complex if the tumour is large in size. If the distorted neck anatomy is too complex, this will also cause a rise to the complexity of the overall surgery, and in a similar vein, if the proximity of the tumour is too close to vital structures, then the level of complexity also rises.⁴

The complete surgical excision of a cervical teratoma is often required soon after birth in order to establish a secure long-term airway for the neonate. After the operation, the possible complications that may occur can include: infection, instability of the airway, or even recurrence of the tumour may occur. To ensure positive outcomes remain, long-term monitoring is needed in order to continually assess the consistent access to the airway, as well as tumour regrowth, so then interventions and management methods can be carried out early for the individual.

Summary

Any neonate that is diagnosed with a cervical teratoma faces a high risk of airway obstruction, which is life-threatening, particularly just after birth. There are interventions which can be pursued in order to try and improve the possibility of positive outcomes. The success of these positive outcomes relies upon extremely detailed antenatal planning as well as both fast postnatal intervention and effective teamwork with the multidisciplinary medical and clinical teams. 

The management of cervical teratomas, when looking specifically at the medical specialities of anaesthetics and surgery, is a highly challenging task due to the abnormal physical anatomy of the airway and general neck region, as well as general physiological structural instability. Follow-up within these specialities, in addition to other medical specialities, will be of both the long- and short-term variety in order to allow for the assessment of the stability of the neonate’s airway and to help monitor the possibility of recurrence of the cervical teratoma.

FAQs

What are the earliest signs of a cervical teratoma in pregnancy?

Cervical teratomas are likely to be picked up upon during prenatal scans (scans conducted during pregnancy), such as ultrasound scans or foetal magnetic resonance imaging (MRI). However, it is also possible that the presence of polyhydramnios (too much amniotic fluid surrounds the baby within the womb) can be an indicator that the foetus has a cervical teratoma - this may be a sign that occurs due to the foetus being unable to swallow properly due to the obstruction pressing upon the oesophagus (or food pipe).

How does a cervical teratoma cause airway obstruction in newborns?

Within neonates, cervical teratomas can cause severe airway obstruction due to few reasons. The first one being that, by definition, these are tumours that stem from the neck region, which is where the trachea, or windpipe, lives within the body that enabling us to breathe. The other reasons are that the anatomy of neonates is naturally small, so any obstruction has the possibility of impacting them quite severely. Teratomas may also grow rapidly, which can be another cause of the increased risk posed to a neonate’s airway.

Can cervical teratomas recur after surgery?

Surgery in order to allow for the removal of cervical teratomas is carried out quite soon after birth; however, yes, it is possible for them to reoccur after they have been removed. Although this is a known possibility, neonates who have had cervical teratomas removed will have regular follow-ups with medical professionals throughout their lives to ensure any regrowth is picked up upon early to allow for early interventions to be carried out, which in turn increases the probability of positive outcomes.