Extensive cervicofacial lymphatic malformations can compromise the neonatal airway. Fetal magnetic resonance imaging (MRI) is useful in airway assessment but it is not known how well the fetal MRI findings correspond to postnatal MRI.

To describe and compare fetal and postnatal MRI findings of patients who required tracheostomy in the neonatal period due to large cervicofacial lymphatic malformations. To examine the usefulness of the tracheoesophageal displacement index (TEDI) in cervicofacial lymphatic malformation patients.

A single-institution, retrospective case series of patients who had been tracheostomized due to cervicofacial lymphatic malformations and had undergone at least one fetal MRI between 2007–2024. The anatomical areas involved and airway effects in fetal and postnatal MRIs were assessed. The TEDI was measured for 40 fetuses imaged for reasons other than a cervical or upper thoracic mass for comparison.

A total of six fetuses were identified. Marked retropharyngeal extension was present in 5/6 cases. Third-trimester fetal MRI corresponded well with postnatal MRI findings. Patients with prenatal intralesional hemorrhage continued to have postnatal intralesional bleeding. TEDI values became abnormally elevated (>12) in the third trimester in fetuses with a tracheostomy requirement postnatally.

Fetal MRI is a valuable tool for anticipating neonatal airway obstruction in cervicofacial lymphatic malformations. Retropharyngeal extension of the malformation and a TEDI >12 in fetal MRI should alert to the possibility of significant airway compromise postnatally.