Management of fetal head and neck masses: Evaluation of prenatal factors associated with airway obstruction and decision for definitive airway and ex‐utero intrapartum treatment at birth

Objective Fetal head and neck masses can result in critical airway obstruction. Our study aimed to evaluate prenatal factors associated with the decision for a definitive airway, including ex‐utero intrapartum treatment (EXIT), at birth among at‐risk fetuses. Methods A single‐institution retrospective review evaluated all fetal head and neck masses prenatally diagnosed from 2005 to 2023. The primary outcome was the decision for a definitive airway at birth, including intubation, tracheostomy, or EXIT. Results Thirty four patients were included, with 23 deliveries occurring at our institution. 8/23 (35%) patients received a definitive airway at birth, six underwent an EXIT procedure, and two required intubation only. Patients who received a definitive airway had higher rates of polyhydramnios (50% vs. 7%, p = 0.03), tracheal narrowing on ultrasound (US) (50% vs. 0%, p = 0.01), tracheal displacement on US (63% vs. 0%, p < 0.01), abnormal fetal breathing on US (50% vs. 0%, p = 0.01), tracheal narrowing or displacement on magnetic resonance imaging (MRI) (75% vs. 7%, p < 0.01), and larger mass maximum diameter (7.9 vs. 4.3 cm, p = 0.02). In our series, 100% of patients with polyhydramnios, tracheal narrowing or displacement on either US or MRI, and abnormal fetal breathing on US received a definitive airway at birth. Conclusion Prenatal findings of tracheal narrowing or displacement, polyhydramnios, and abnormal fetal breathing are strongly associated with the decision for a definitive airway at birth and warrant mobilization of appropriate resources.