Introduction

Cervical teratomas are uncommon congenital tumours made of tissues from the ectoderm, mesoderm, and endoderm layers of the embryonic germ layer.¹ They develop from pluripotent germ cells. These tumours affect the area of the neck in newborns and infants, and they have a variety of histological and structural features, frequently including solid, calcified, and cystic elements. The main goal of this article is to raise clinical awareness about the early signs and symptoms of this rare but potentially fatal disorder and to help in its early detection in newborns and infants. In order to help healthcare practitioners differentiate between cervical teratomas from other congenital neck masses, this article highlights the most important clinical signs and symptoms of cervical teratomas.²

Epidemiology

According to certain data from previous reports, the incidence of cervical teratomas is 1 in 20,000 to 40,000 live births, making it up to 3-5 per cent of all paediatric teratomas.¹ Although they can occasionally be linked to syndromic diseases or other congenital abnormalities, they are often seen as standalone defects and are more frequently observed in babies assigned female at birth (AFAB).

Clinical presentation

The clinical presentation of cervical teratomas in newborns and infants depends upon the size, location, and impact of the tumour on nearby structures. These tumours usually affect the oesophagus and airways. Early detection of these tumours is essential because they can lead to life-threatening consequences. The presentation of cervical teratomas might happen during pregnancy, delivery, or in the early neonatal period.

Appearance and physical findings

Cervical teratomas are frequently identified by unilateral neck tumours. The typical cervical shape is noticeably distorted by the tumour, which is often well-circumscribed. On examination:

• Usually multiloculated, the mass has solid, cystic, and sometimes calcified components that can be felt or seen on imaging 
• Tumour mass may cause the neck to seem hyperextended, and facial asymmetry or distortion may be seen
• There may be superficial venous distention in big tumours, and the skin above may be stiff or strained

Respiratory signs and symptoms

The most serious issue is airway compromise, which frequently determines how urgently intervention is needed. Early indications of partial airway obstruction and noisy breathing. After the delivery, respiratory distress symptoms such as cyanosis, retractions, and dyspnea may appear quickly and can also cause serious breathing problems. In extreme circumstances, tracheostomy, ventilatory support, or even intubation must be performed right away at delivery. Imaging or bronchoscopy may show deviation or compression of the trachea due to the mass.³

Feeding and swallowing issues

Compression of the oesophagus by the tumour leads to:

• Feeding issues like choking, gagging, or poor sucking
• Risk of aspiration pneumonia in situations when breathing and swallowing coordination are compromised
• Presentations that are less severe or occur later may reveal feeding resistance and failure to thrive⁴

Other related signs and complications

Pregnancy-related indicators

Sometimes, prenatal screening may reveal polyhydramnios that is observed as a result of poor fetal swallowing during pregnancy. Tumours can also induce venous blockage or high-output cardiac failure, which can cause fetal hydrops (fluid buildup in fetal compartments).⁵

Cardiovascular compromise

An infant may have haemodynamic instability due to vascular compression or arteriovenous shunting inside the tumour, but this happens rarely.

Tumour rupture or infection

In the postnatal period, different signs such as fever, erythema, and symptoms resembling sepsis may be the first signs of a secondary infection or spontaneous rupture of the tumour.⁶

Diagnostic workup

Antenatal ultrasound

Cervical teratomas can frequently be found using a prenatal ultrasound. Usually, the mass appears as a complicated, heterogeneous neck lesion that has both solid and cystic sections. It is easier to distinguish calcifications from other neck lumps if they are visible. Additionally, fetal hydrops or polyhydramnios may be discovered by ultrasound, which would need an early referral to specialised facilities.⁷

Magnetic resonance imaging (MRI)

Fetal or postnatal MRI enables a thorough assessment of the tumour's size, the involvement of nearby structures, and the patency of the airways because it has superior soft tissue contrast and spatial resolution. MRI machines play an important role in surgery planning and help in distinguishing teratomas from other types of congenital neck tumours.⁸

Computed tomography (CT) scans

The internal anatomy of the tumour, which includes calcifications, its connection to nearby blood arteries and airway structures, can all be seen using CT imaging - it provides all necessary details related to the tumour. When MRI imaging can not be used after delivery, CT scans come in handy.

Laboratory evaluation

Infants or newborns who have teratomas may have high serum alpha-fetoprotein (AFP) levels in their blood. Raised levels of AFP can then be used as a tumour marker and to track the response to therapy and the recurrence of tumour.

Airway assessment

If the infant exhibits respiratory distress or some airway blockage, a direct laryngoscopy or bronchoscopy may be necessary in some situations. 

Summary

Cervical teratomas in newborns and infants are rare, but they are a serious clinical risk because they can quickly impair airways and result in serious life-threatening complications. They can be seen as neck masses - these tumours can grow in size and put pressure on nearby structures, particularly the oesophagus and trachea. It is important to identify their clinical signs and symptoms for early diagnosis and to avoid potentially fatal consequences. A substantial, sometimes unilateral cervical swelling made up of a combination of solid and cystic components is one of the common clinical findings. This swelling typically results in respiratory discomfort due to airway compression, which can be observed as dyspnoea and hypoxia. Additionally, some common problems are feeding issues brought on by oesophageal displacement or obstruction. Fetal hydrops and polyhydramnios may be signs of severe fetal impairment throughout pregnancy, which should lead to careful fetal assessment.

Secondary problems can exacerbate the prognosis in addition to the primary symptoms, which include infection, lung hypoplasia, tumour rupture, and occasionally related congenital abnormalities. Therefore, it is important to enhance outcomes in the susceptible population to detect signs early and perform multidisciplinary intervention on time. Most newborns with cervical teratomas can have a good prognosis with early detection of the tumour and coordinated perinatal care, especially in situations when prenatal imaging and airway stabilisation techniques are available. All doctors working in neonatal and perinatal care must have a high index of suspicion and knowledge about the distinctive characteristics of this uncommon illness.