In the span of just a few months last year, experts at Texas Children’s Pavilion for Women delivered two babies with extremely large and rare cervical teratomas. The cases represent a growing collaboration between Otolaryngology and the Fetal Center. They also demonstrate the high quality care and expertise Texas Children’s provides patients and families across the globe.
“We tend to take it for granted that a case like this just rolls through the door, and we are able to handle it,” Fetal Center Surgeon Dr. Timothy Lee said about the November 10, 2015, birth of Keisy Cruz Carbajal. “It’s a testament to Texas Children’s and the Fetal Center that we have this team of experts – from the ultrasound technician to the MFM to the radiologists, surgeons and pediatric and adult anesthesiologists – assembled and ready to deploy at any given moment.”
Otolaryngologist Dr. Binoy Chandy agreed and said, “It’s so beneficial to have the exact right type of specialist on hand not just for the delivery, but for the earliest stages of planning and the follow-up care as well.”
The cases of Arya Hill and Keisy are outlined below and have inspired other families like themselves to come to Texas Children’s for medical care.
At 28 weeks, Maggie Dozler went into early labor due to a build-up of amniotic fluid. She was referred to Texas Children’s Pavilion for Women, where Arya’s teratoma was diagnosed. A multidisciplinary team of experts from Texas Children’s Fetal Center monitored mother and baby closely for the next two months. At 36 weeks, on August 12, 2015, Arya was born with a 180 g tumor blocking her airway internally and protruding from her mouth and nose. A medical team delivered Arya via an EXIT procedure, a cesarean section that leaves the placenta and umbilical cord intact, buying time before the baby has to breathe on its own.
Fetal Center Co-Director Dr. Darrell Cass and Chandy led the procedure, examining the mass, attempting to intubate, and eventually performing a tracheostomy on an airway approximately 3.5 mm wide. Arya was sedated and stabilized while the surgical team planned their approach. When they went in to remove the tumor 16 days later, they found that it was attached to Arya in just one small spot in her throat.
Chandy was able to remove it entirely by endoscope, avoiding external scars. Since then, Arya has recovered almost fully without any additional surgeries or procedures. Her nostrils and lips, once badly misshapen and unable to close, have reverted to normal shape. Arya is being transitioned off her tracheostomy and is working on swallowing normally and transitioning off her g-tube.
Shortly after Arya was discharged, the Fetal Center team received a referral for an even larger and rarer type of teratoma. Yesenia Carbajal was 32 weeks along when her daughter Keisy was diagnosed with a cervical “fetus in fetu” teratoma, a condition so rare that only four cases have been identified in medical literature. Maternal fetal medicine specialist Dr. Jimmy Espinoza performed an immediate amnio reduction to stop her from going into labor. Lee was called in to lead the case, and he called in otolaryngologist Dr. Deepak Mehta.
As it turned out, they did not need to deploy right away. Carbajal was able to make it to her scheduled EXIT procedure at 36 weeks, giving Keisy important time for her lungs to develop. During the delivery, Mehta was able to locate Keisy’s tiny airway, avoiding the need for a tracheostomy. Keisy was intubated and sedated for a week while the surgical team carefully studied the teratoma that was attached to the inside and outside of Keisy’s throat and mouth. Composed of different types of tissue, bone and body parts, teratomas of the head and neck are rarer than sacrococcygeal teratomas located near a baby’s tailbone, and removing them is considerably more complex.
“You can’t just go in and remove the tumor right away,” Mehta said. “You need to know exactly where it is and where all the other important structures are, because a teratoma like this moves everything around. You have to make sure there aren’t any surprise elements.”
Keisy’s teratoma went from the base of her throat to the base of her skull, coming through the floor of her mouth and wrapping precariously around her carotid artery. On November 17, Mehta and Lee successfully removed it in a three and a half hour procedure. There was no way to avoid making an incision in Keisy’s throat, but all important structures were preserved and blood loss was minimal. Before closing, Mehta was able to repair the defect in Keisy’s mouth and throat. Today, she is doing extremely well. As was expected, she had difficulty swallowing and feeding and needed a g-tube, but she is in therapy to improve her swallowing and is expected to make a full recovery soon.
“This is a great example of where medicine is heading, and that’s using everyone’s individual expertise, but ultimately working as a unified team,” Mehta said. “This is not something we were able to do because we’ve got one amazing surgeon,” echoed Lee. “It’s a full integrated system of care that has to work in concert.”