PATHOGENESIS
Iatrogenic
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Following esophageal resection
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Anastomotic leakage
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Following dilatation of esophagogastric anastomosis
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With devascularization of trachea
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Laryngectomy
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Esophageal dilation for benign stricture
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Esophageal/tracheal stenting
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Secondary to erosion
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Following difficult removal of existing esophageal or tracheal stent
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Following radiation therapy of esophageal or lung carcinomas
Infectious
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Histoplasmosis/broncholiths
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Tuberculosis/granulomatous disease
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Often limited to the membranous wall of the trachea
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Immunodeficiency syndromes
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Can lead to devastating necrotizing infections of the esophagus
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Malignancy
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Direct invasion by esophageal carcinoma
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78% of cases of malignant TEF secondary to esophageal carcinoma
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Located in the upper third of esophagus
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Primarily squamous cell carcinoma
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Direct invasion by bronchogenic carcinoma or thyroid carcinoma
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Mediastinal Hodgkin’s and non-Hodgkin’s lymphoma
Mechanical
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Prolonged ventilation
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Pressure across membranous tracheal wall and esophagus secondary to cuff of endotracheal tube/tracheostomy and nasogastric tube
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Circumferential damage to the trachea secondary to cuff injury
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Often minimal contamination of the mediastinum as chronic process
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Esophageal foreign body
Trauma
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Often with extensive mediastinal contamination
CLINICAL FEATURES
Symptoms and Signs
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Wide variety of signs and symptoms
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In patients on ventilator:
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Significant increase in pulmonary secretions
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Return of gastric feeds with suctioning of airway
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Difficulty maintaining seal with cuff of endotracheal/tracheostomy tube
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Development of pulmonary infiltrates and pneumonia
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Distended abdomen on physical examination. This reflects gas insufflation of the entire gut due to positive pressure gas delivery by the ventilator ( Fig. 12-1 )
Figure 12-1
Computed tomography (CT) scout film of chest and abdomen/pelvis ( left panel ) and representative axial CT slices at varying levels ( right 3 panels ), showing gas dilated bowel throughout the gastrointestinal tract, in a patient with a tracheoesophageal fistula on mechanical ventilation.
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Patients taking oral intake
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In patients who are swallowing, violent coughing following oral intake is suggestive of fistula
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Patients may expectorate food with cough
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Occasionally hemoptysis
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Fever and recurrent pneumonia
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Important to distinguish direct communication (fistula) from aspiration
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DIAGNOSTIC WORKUP
Radiographic Evaluation
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Chest radiograph
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Initially normal in majority of cases but will develop a spectrum of findings associated with fistula
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In patients on ventilator, chest radiograph often with dilatation of stomach and esophagus distal to fistula
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Pulmonary infiltrates
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Aspiration pneumonia
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Adult respiratory distress syndrome
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Barium swallow
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Preferable to use thin, dilute barium rather than hyperosmolar, water-soluble agents that can cause a severe pneumonitis ( Fig. 12-2 )
Figure 12-2
Barium swallow demonstrating a tracheoesophageal fistula with contrast filling both the esophagus and outlining the tracheobronchial tree.
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Barium swallow also useful in evaluating esophageal pathology
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Helical computed tomography scan
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Seldom useful in the diagnosis of tracheoesophageal fistula
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More helpful in characterizing and staging a underlying malignancy
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Endoscopy (Bronchoscopy and Esophagoscopy)
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Essential in the diagnosis and management of tracheoesophageal fistula
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Bronchoscopy most valuable to locate fistula and determine extent
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In ventilated patients, flexible bronchoscopy can be performed through endotracheal tube (tube pulled back under direct vision) ( Fig. 12-3 )
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