Unexpected Presentation of Tracheoesophageal Fistula During Intubation in a Pediatric Patient

Abstract

Tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus. This report presents a rare case of a pediatric patient who developed a TEF due to battery ingestion, which was diagnosed during intubation and resulted in cardiac arrest. A 4-year-old child with a two-year history of battery ingestion presented with severe dehydration, weight loss, and recurrent respiratory tract infections. Chest X-ray revealed a radiopaque foreign body in the esophagus. During general anesthesia for central venous line insertion and after endotracheal intubation, some difficulties in ventilation occurred, characterized by the inability to reach tidal volume, absence of capnography, and stomach distention which led to hypoxia and ultimately to cardiac arrest. Prompt resuscitation (CPR) was initiated, and selective right bronchial intubation during CPR improved the patient's condition. Subsequent bronchofibroscopy performed in the ICU confirmed the TEF, which was surgically corrected during the hospital stay. TEF poses challenges in anesthesia and airway management, particularly when positive pressure ventilation is used. In this case, the TEF was diagnosed during intubation, highlighting the critical role of clinical expertise and prompt intervention in managing this unexpected pediatric critical event.

Keywords: acquired tracheoesophageal fistula; button battery ingestion; critical airway; one lung ventilation; pediatric anesthesiology.

Figure 1. Chest X-ray at admission (anterior-posterior view)

Chest radiograph at admission showing the button battery lodged at the esophagus (blue arrow) with the characteristic Halo sign.

Figure 2. Chest X-ray after intubation

Chest radiograph taken after selective right intubation. The blue arrow points to the endotracheal tube in the right bronchus.

Figure 3. Axial CT scan of the chest after intubation

CT scan with a foreign body impacted in the medium third of the esophagus, signs of chronic mediastinitis, chronic left lung atelectasis, and bronchiectasis.

Figure 4. Diagnostic bronchofibroscopy performed in the ICU

(A) Left main bronchus with 40% lumen reduction by internal compression. The TEF site was not directly visualized, although there was granulation at this point. (B) The presence of methylene blue in the endotracheal tube, carina, and both bronchus, after injection through the nasogastric tube (25 mL), confirmed the presence of TEF.