Neonatal airway lesions: our experience and a review of the literature V RANGACHARI 1 , R AGGARWAL 1 , A JAIN 1 , M C KAPOOR 2 Departments of 1 Otorhinolaryngology and 2 Anesthesiology, Pushpanjali Crosslay Hospital, Ghaziabad, Uttar Pradesh, India Abstract Objectives: This paper reports on two rare cases of neonatal airway lesions with differing aetiology that were successfully managed by surgery, and provides a review of the literature on neonatal stridor and airway lesions. Case reports: In the first case report, a newborn presented with a nasopharyngeal teratoma. In the second case report, a newborn presented with a congenital laryngeal saccular cyst. Difficulties in the diagnosis of these lesions, and surgical and anaesthetic challenges in their management are discussed. Conclusion: Every case of neonatal airway distress must be evaluated and the cause of stridor needs to be established. It is important that rare lesions such asteratomas and laryngeal cysts are not overlooked; a high index of suspicion for these congenital anomalies is necessary. These airway lesions should be managed in an institutional setting by a multidisciplinary team. Key words: Stridor; Infant; Larynx; Nasopharynx; Pathology; Cyst; Teratoma Introduction Stridor in a neonate potentially implies a compromised airway and therefore requires urgent medical attention. The stridor may be mild, with no respiratory distress and good feeding, or it may be associated with severe airway compromise, which requires immediate inter- vention. 1 We present two cases of severe airway compro- mise in neonates necessitating emergency airway and surgical intervention. Case report one A 5-day-old pre-term male baby, born at 36 weeks, was referred for repeated failure of extubation because of apnoeic spells and intermittent stridor. The neonate’s airway was maintained using a 2.5 mm internal diameter, plain nasotracheal tube. Congenital choanal atresia was ruled out as a size 4 transnasal feeding tube could be passed through either nostril. A bedside examination revealed features of laryngomalacia. A computed tomogra- phy scan of the neck revealed diffuse opacification of the nasopharynx, oropharynx and posterior aspect of the nasal cavities, which were suggestive of mucosal hypertrophy and thick secretions. Repeated trials of tracheal extubation were futile. During tracheal re-intubation on the 11th day of life, the neonate was noticed to have a pearly white, solid swelling protruding from the nasopharynx from behind the soft palate, which pushed the uvula and soft palate anteriorly. Magnetic resonance imaging (MRI) revealed a 32 × 22 × 19 mm multiloculated cystic lesion, with predominantly fat and fluid components in the nasopharynx, which extended superiorly to the posterior choana and markedly obliterated the air passage (Figure 1). No dehiscence was seen in the skull base, thereby ruling out a meningoencephalocoele. Nasal endoscopy was performed under general anaesthe- sia. Anaesthesia was induced by inhalation of 4 per cent sevoflurane in 100 per cent oxygen, and intravenous admin- istration of fentanyl 5 μg. After neuromuscular blockade with atracurium 1 mg was administered intravenously, the naso- tracheal tube was removed and a 2.5 mm oral endotracheal tube was inserted. Anaesthesia was maintained with an inha- lational mixture of oxygen 50 per cent and nitrous oxide 50 per cent, and sevoflurane 1 –2 per cent. Pressure controlled ventilation was delivered, with the peak inspiratory pressure set at 12 cm H 2 O and a respiratory rate of 50 breaths per minute. Endoscopy revealed a multiloculated solid lesion originat- ing from the lateral wall of the nasopharynx on the left side, which extended into the whole nasopharynx and partially into the oropharynx. Transnasal endoscopic excision of the lesion was performed and the specimen was delivered through the oral cavity (Figure 2). After surgery, the neonate was shifted to the neo- natal intensive care unit and mechanically ventilated. Histopathological examination was suggestive of nasophar- yngeal teratoma. Tracheal extubation was achieved after 48 hours. The neonate received oxygen supplementation with a hood for 24 hours, and was discharged after 2 days. Repeat nasal endoscopy was carried out a month later and showed no residual lesion. The neonate was observed to be doing well at the four-month follow up. Accepted for publication 23 March 2012 First published online 21 November 2012 The Journal of Laryngology & Otology (2013), 127, 80–83. CLINICAL RECORD © JLO (1984) Limited, 2012 doi:10.1017/S002221511200254X