Shoulder Dystocia, Laryngeal Tear, Mediastinal Intubation, and Extracorporeal Membrane Oxygenation in a Neonate

A 5.6-KG term neonate was born via spontaneous vaginal delivery complicated by shoulder dystocia; Apgar scores were 5 and 7 at 1 and 5 min. The neonate received continuous positive airway pre ssure for respiratory distress, developed cervical emphy sema, and then was intubated because of hypoxemia. Although capnography appeared to indicate a successful intubation, breath sounds were undetectable by auscultation. Chest tubes were placed after a radiograph showed bilateral pneumothoraces.

The neonate arrived at our institution in extremis (heart rate, 59 beats/min; mean arterial pressure, 50 mmHg; Spo₂, 62%). Venoarterial extracorporeal membrane oxygenation was initiated via the right internal jugular vein and the right internal carotid artery. Computed tomography showed absent lung aeration, the arterial cannula (fig. 1A, ac), subcutaneous emphysema (fig. 1A, white arrows), and the endotracheal tube diverging from the midline (fig. 1A, black arrows). Bronchoscopy by the otorhinolaryngologist confirmed a laryngeal tear with a ruptured anterior commissure (fig. 1B, asterisks) through which the endotracheal tube traveled into the mediastinum. The otorhinolaryngologist repositioned the endotracheal tube into the native trachea (fig. 1B). Support was withdrawn 6 days later after progression of hypoxic ischemic injury. Autopsy findings included a hypoplastic thyroid cartilage that likely resulted in an inherent weakness of the anterior tracheal wall.

Traumatic delivery and endotracheal intubation can cause life-threatening tracheal and laryngeal injuries in neonates.¹  Development of cervical emphysema before intubation suggests that this child’s laryngeal rupture was caused by a difficult delivery rather than traumatic intubation. Fiberoptic endoscopy should be used to investigate potential airway rupture, with emergent otorhinolaryngology consultation and deferral of endotracheal intubation until direct airway visualization has been accomplished.²  Extracorporeal membrane oxygenation should be considered early if direct airway visualization cannot be performed.³