A 76‐year‐old white man presented with a1‐year history of abdominal fullness, bloating, episodic choking spells, and wheezing. These episodes worsened with food, usually to liquids, but had become more frequent over the last month. His medical history included treated laryngeal cancer with laryngectomy and mediastinal tracheostomy in 1975 and mild chronic obstructive pulmonary disease maintained on short‐acting bronchodilators. Given his recurrent symptoms and clinical presentation, a bronchoscopy was performed, which confirmed the presence of a 1.5‐mm tracheo‐esophageal fistula (TEF) with active bubbling seen 2 cm distal to the mediastinal tracheostomy stoma. He underwent repair of the TEF with primary closure of the esophagus and trachea with sternocleidomastoid interposition muscle flap via low collar incision. A postoperative esophagram found no evidence of TEF at the repair site. The tissue biopsy confirmed benign squamous epithelium and scar without evidence of malignant features. Here we describe a patient with a spontaneous tracheoesophageal fistula with a cuffless tracheostomy tube.
TEF can be congenital or acquired. Acquired TEFs are usually malignant and rarely benign. The latter is usually a complication of trauma, prior esophageal, or tracheal surgeries, but the greatest risk is largely from cuff overinflation in patients with endotracheal intubation. TEFs are life threatening, as they cause pulmonary compromise and inadequate nutrition. In intubated patients, high‐pressure cuffs can lead to decreased perfusion of the trachea and fistula formation. With the introduction of low‐pressure cuffs, the incidence of TEF is as low as 0.5%. TEF may present with a sudden increase in tracheal secretions, violent coughing, recurrent pulmonary infections, and sudden onset of abdominal distention or suctioning of gastric content from trachea. Coughing while swallowing (Ono's sign) may also be present. Diagnosis is usually confirmed by cineesophagram, CT scan, or direct visualization with bronchoscopy or esophagoscopy. Management of TEF is primarily surgical or rarely by airway stenting, as spontaneous closure is rare. It is important to rule out malignancy (esophageal cancer), as treatment is usually different with a guarded prognosis. Complications from surgery include infections, respiratory failure, esophageal leak, bleeding, recurrent TEFs, and tracheal dehiscence. Most patients also require parenteral nutritional in the perioperative period.
It is important for clinicians to recognize TEFs as an early complication of tracheostomy, as hospitalists frequently care for patients with prolonged mechanical ventilation and tracheostomy. Once recognized, the cuff should be inflated distal to the fistula to prevent tracheobronchial soilage. Overall, prognosis is determined by the pre‐morbid patient condition, with early recognition and treatment favoring better outcomes.
K. Malhotra ‐ none; N. R. Kalva ‐ none
To cite this abstract:Malhotra K, Kalva N. Spontaneous Acquired Benign Tracheoesophageal Fistula in a Patient with Mediastinal Tracheostomy. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 332. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/spontaneous-acquired-benign-tracheoesophageal-fistula-in-a-patient-with-mediastinal-tracheostomy/. Accessed March 30, 2020.