Acquired Tracheoesophageal Fistulas: A Case Report and Review of Diagnostic and Management Challenges

Abstract

Acquired, nonmalignant tracheoesophageal fistulas (TEFs) often occur in the setting of prolonged use of endotracheal or tracheostomy tubes due to trauma and erosion of the tracheal wall inflicted by tube cuffs or direct tracheal contact. In this report, we present a patient with a tracheostomy who presented with recurrent aspiration pneumonia and was found to have a large TEF that was difficult to treat. We also discuss the diagnostic and management challenges concerning TEFs. TEFs, especially if large, lead to recurrent aspiration pneumonia and can be challenging to manage. Definitive management of TEFs involves surgical repair; meanwhile, endoscopic or bronchoscopic stenting to bypass the fistula can be performed. The fistula location, size, and concurrent positive pressure ventilation make its treatment challenging in those with chronic ventilatory dependence. Early recognition and multidisciplinary management involving gastroenterologists, interventional pulmonologists, and thoracic surgeons are necessary to decide on the best treatment strategy.

Keywords: dual stenting; esophageal stenting; tracheal stenting; tracheoesophageal fistula; tracheostomy.

Figure 1. Tracheoesophageal fistula on chest CT.

CT scan of the chest reveals tracheoesophageal fistula (blue arrow: trachea, black arrow: esophagus). CT: computed tomography.

Figure 2. Tracheoesophageal fistula on upper endoscopy.

Upper endoscopy demonstrating a tracheostomy balloon in the upper esophagus 20 mm from the incisors just below the upper esophageal sphincter. There is a widely patent tracheoesophageal fistula large enough to allow passage of the tracheostomy balloon.