A tracheoesophageal fistula (TEF) is a congenital or acquired communication between the trachea and esophagus. TEFs often lead to severe and fatal pulmonary complications.
Acquired TEFs occur secondary to malignant disease, infection, ruptured diverticula, and trauma. Postintubation TEFs uncommonly occur following prolonged mechanical ventilation with an endotracheal or tracheostomy tube.
Acquired nonmalignant TEFs :
Traumatic TEFs occur secondary to either blunt trauma or open avulsion injury to the neck and thorax. In blunt traumatic injuries, the TEF is intrathoracic and is usually located at the carina level. The TEF appears several days later as a result of tracheal wall necrosis. TEFs caused by endotracheal tube intubation depend on several factors, including prolonged intubation, an irritating or abrasive tube, and pressure exerted by the cuff. Pressures exceeding 30 mm Hg can significantly reduce mucosal capillary circulation and result in tracheal necrosis. Cuff pressure is particularly risky when exerted posteriorly against a rigid nasogastric tube in the esophagus. Poor nutrition, infection, and steroid use cause tissue alteration, which predisposes patients to development of TEFs.
Traumatic TEFs occur secondary to either blunt trauma or open avulsion injury to the neck and thorax. In blunt traumatic injuries, the TEF is intrathoracic and is usually located at the carina level. The TEF appears several days later as a result of tracheal wall necrosis. TEFs caused by endotracheal tube intubation depend on several factors, including prolonged intubation, an irritating or abrasive tube, and pressure exerted by the cuff. Pressures exceeding 30 mm Hg can significantly reduce mucosal capillary circulation and result in tracheal necrosis. Cuff pressure is particularly risky when exerted posteriorly against a rigid nasogastric tube in the esophagus. Poor nutrition, infection, and steroid use cause tissue alteration, which predisposes patients to development of TEFs.
TEFs occur uncommonly at the time of tracheostomy or secondary to improper positioning of the tracheal tube because of improper tracheal incision. The malpositioned tracheostomy tube exerts posterior pressure against the esophagus, resulting in tissue damage and a TEF.
Acquired malignant TEFs
This devastating complication results in contamination of the respiratory tract, leading to pulmonary infections and death from sepsis within a few weeks of development. Although the most common tumor site is the esophagus, tumors at other sites, including the lungs, trachea, and metastatic lymph nodes in the larynx, may also result in TEFs. The anatomic site of a TEF is the trachea in more than 50% of cases; approximately 40% occur in the left and right mainstem bronchi, and a smaller number (6%) occur in lung parenchyma. Despite aggressive management, the prognosis is generally poor in these patients.
This devastating complication results in contamination of the respiratory tract, leading to pulmonary infections and death from sepsis within a few weeks of development. Although the most common tumor site is the esophagus, tumors at other sites, including the lungs, trachea, and metastatic lymph nodes in the larynx, may also result in TEFs. The anatomic site of a TEF is the trachea in more than 50% of cases; approximately 40% occur in the left and right mainstem bronchi, and a smaller number (6%) occur in lung parenchyma. Despite aggressive management, the prognosis is generally poor in these patients.
Imaging Studies:
- Diagnosis of acquired TEFs
- Acquired TEFs can be diagnosed by instillation of contrast media into the esophagus or during direct visualization by flexible esophagoscopy or bronchoscopy. Either method can be useful, depending on the individual center's expertise and experience.
- Some clinicians prefer to visualize the fistula and assess its exact location prior to surgery. The diagnosis of a TEF secondary to malignancy is confirmed by contrast radiography, esophagoscopy, bronchoscopy, and clinical testing (methylene blue).
Procedures:
- Flexible esophagoscopy or flexible bronchoscopy may be useful in the diagnosis of acquired TEFs. Either or both of these procedures may be required to evaluate the anatomy of these structures and to exclude an unsuspecting mucosal lesion. The role of endoscopic procedures is especially important in localizing the acquired nonmalignant or malignant TEF
Complications:
The major postoperative complications are tracheal stenosis and recurrent fistula. Tracheal stenosis occurs in patients who have extensive injury to the posterior tracheal wall. Surgical repair of tracheal stenosis may be performed at a later date. Recurrent fistulas develop in patients who require continued postoperative intubation. This generally occurs from breakdown of the repair, and the risk of infection spreading into the soft tissue planes, neck, and mediastinum is high.
The major postoperative complications are tracheal stenosis and recurrent fistula. Tracheal stenosis occurs in patients who have extensive injury to the posterior tracheal wall. Surgical repair of tracheal stenosis may be performed at a later date. Recurrent fistulas develop in patients who require continued postoperative intubation. This generally occurs from breakdown of the repair, and the risk of infection spreading into the soft tissue planes, neck, and mediastinum is high.