{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T07:05:24Z","timestamp":1784099124159,"version":"3.55.0"},"reference-count":21,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T00:00:00Z","timestamp":1784073600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Pediatr."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Laryngo-tracheo-esophageal cleft (LTEC) is a rare congenital anomaly caused by incomplete separation of the foregut. Type IV defects are exceptionally rare and typically carry high mortality and morbidity despite surgical interventions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>We report a preterm neonate born at 34\u2009+\u20091 weeks\u2019 gestation from a monochorionic diamniotic twin pregnancy. Antenatal ultrasound detected a large microcystic congenital pulmonary airway malformation (CPAM) with mediastinal shift, absent gastric bubble, and suspected esophageal pouch. Immediately upon birth, bedside ultrasound identified the affected twin. Direct laryngoscopy and intubation revealed a common tracheoesophageal lumen; flexible bronchoscopy confirmed a Type IV LTEC with absent posterior tracheal wall extending to the carina and communicating with the oesophagus. Selective intubation of the right bronchus provided temporary ventilation. CT thorax demonstrated a wide anomalous aero-digestive tract, intrathoracic stomach, and large CPAM. Surgical repair was deemed very high risk and disproportionately burdensome due to a composite of factors: severity of the type 4 cleft, associated significant pulmonary and gastrointestinal anomalies, low birth weight, and being a high risk ECMO candidate. Following multidisciplinary counselling, care was redirected to palliation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This case highlights limitations of fetal imaging, the importance of early bronchoscopy for airway evaluation and stabilization, and the role of palliative care when extensive surgical correction carries risks of significant harm and may not serve in the best interest of the patient.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fped.2026.1874038","type":"journal-article","created":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T06:10:06Z","timestamp":1784095806000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Type IV laryngo-tracheo-esophageal cleft with CPAM in a preterm twin- a case report"],"prefix":"10.3389","volume":"14","author":[{"given":"Chee Mun","family":"Chan","sequence":"first","affiliation":[{"name":"Department of Neonatology, Khoo Teck Puat National University Children Medical Institute, National University Hospital","place":["Singapore, Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Palaniappan Janaki","family":"Abirami","sequence":"additional","affiliation":[{"name":"Department of Neonatology, Khoo Teck Puat National University Children Medical Institute, National University Hospital","place":["Singapore, Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Agnihotri","family":"Biswas","sequence":"additional","affiliation":[{"name":"Department of Neonatology, Khoo Teck Puat National University Children Medical Institute, National University Hospital","place":["Singapore, Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khadijah Binti Abdul","family":"Kader","sequence":"additional","affiliation":[{"name":"Department of Neonatology, Khoo Teck Puat National University Children Medical Institute, National University Hospital","place":["Singapore, Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,7,15]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"417","DOI":"10.1177\/000348948909800603","article-title":"Minor congenital laryngeal clefts: diagnosis and classification","volume":"98","author":"Benjamin","year":"1989","journal-title":"Ann Otol Rhinol Laryngol"},{"key":"B2","doi-asserted-by":"publisher","first-page":"435","DOI":"10.1097\/MOO.0000000000000669","article-title":"Current management of type III and IV laryngo-tracheal-esophageal clefts: the case for a revised cleft classification","volume":"28","author":"J\u00e1uregui","year":"2020","journal-title":"Curr Opin Otolaryngol Head Neck Surg"},{"key":"B3","doi-asserted-by":"publisher","first-page":"905","DOI":"10.1016\/j.ijporl.2014.03.015","article-title":"Laryngeal cleft: evaluation and management","volume":"78","author":"Johnston","year":"2014","journal-title":"Int J Pediatr Otorhinolaryngol"},{"key":"B4","doi-asserted-by":"publisher","first-page":"1335","DOI":"10.1001\/archotol.132.12.1335","article-title":"The presentation and management of laryngeal cleft: a 10-year experience","volume":"132","author":"Rahbar","year":"2006","journal-title":"Arch Otolaryngol Head Neck Surg"},{"key":"B5","doi-asserted-by":"publisher","first-page":"2073","DOI":"10.1016\/j.ijporl.2006.07.021","article-title":"Type 1 laryngeal cleft: establishing a functional diagnostic and management algorithm","volume":"70","author":"Chien","year":"2006","journal-title":"Int J Pediatr Otorhinolaryngol"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1092753","DOI":"10.3389\/fcell.2023.1092753","article-title":"Development of the foregut and the formation of the trachea and esophagus in rat embryos. 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