The EXIT procedure: when, who, and how

Management of fetal airway obstruction requires a multidisciplinary approach to optimize the safety of the pregnant patient and fetus. For severe cases of fetal airway obstruction, ex-utero intrapartum treatment (EXIT) is recommended. This review highlights indications and rationale for EXIT and presents an approach to fetal airway management from an otolaryngologic perspective.

Approach to the fetus with airway obstruction differs in the literature. Recent studies have sought to identify prenatal risk factors that portend the need for surgical intervention at delivery, with identification of three fetal anomalies that justify delivery modification: micrognathia, congenital high airway obstruction, and head and neck masses. There remains heterogeneity within this cohort, contributing to the varied approach to fetal airway obstruction. What remains consistent is the need for early identification of at-risk fetuses and multidisciplinary input throughout pregnancy to ensure that the appropriate teams are present at delivery.

EXIT is a mainstay in the management of fetal airway obstruction, as it enables airway intervention while preserving uteroplacental circulation. Further research is needed to define indications for EXIT and develop management algorithms starting from identification of airway obstruction on prenatal imaging. Multidisciplinary collaboration is tantamount to a successful procedure.