title: Congenital high airway obstruction syndrome due to complete tracheal agenesis: an accident of nature with clues for tracheal development and lessons in management.
abstract: Congenital high airway obstruction syndrome (CHAOS) is a life-threatening condition characterized by complete blockage of the fetal airways associated with hydrops. We present a case of CHAOS due to the rare cause of complete tracheal agenesis. The ex utero intrapartum therapy (EXIT) strategy was employed to allow for neck and mediastinal exploration. Thymectomy allowed dissection to the level of the carina demonstrating the confluence of dilated mainstem bronchi but no trachea and no connection to the esophagus. A 2.5 endotracheal tube was inserted into the right mainstem bronchus and secured to the left clavicle. At 3 months of age, the infant succumbed to sepsis from Enterobacter mediastinitis due to friction between the tracheostomy tube and the nasogastric tube resulting in erosion of the esophagus. Complete tracheal agenesis, as seen in this case, is consistent with the failure of normal tracheal elongation as suggested by newer theories of foregut development. This case illustrates the most severe form of tracheal atresia causing CHAOS ever salvaged by the EXIT procedure at birth. The subsequent postnatal course highlights the need for early tracheal replacement in this particularly challenging form of CHAOS.
authors.affiliation: Division of Pediatric General, Thoracic, and Fetal Surgery, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio 45229-3039, USA.
authors.forename: Sachin S
authors.initials: SS
authors.lastname: Vaikunth
authors.forename: Lee M
authors.initials: LM
authors.lastname: Morris
authors.forename: William
authors.initials: W
authors.lastname: Polzin
authors.forename: William
authors.initials: W
authors.lastname: Gottliebson
authors.forename: Foong-Yen
authors.initials: FY
authors.lastname: Lim
authors.forename: Beth
authors.initials: B
authors.lastname: Kline-Faith
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Crombleholme
mesh_terms: D000328:Adult; D000402:Airway Obstruction / Q000151:congenital / Q000000981:diagnostic imaging* / Q000196:embryology / Q000601:surgery; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D011247:Pregnancy; D014132:Trachea / Q000196:embryology*; D014133:Tracheal Diseases / Q000151:congenital / Q000000981:diagnostic imaging* / Q000196:embryology / Q000601:surgery; D014139:Tracheostomy; D016216:Ultrasonography, Prenatal