IS Case 394: Tracheoesophageal Fistula
2009 URMC Imaging Sciences
Publication Date: 2010-03-09
Patient is a 57-year-old male with history of Stage IIIB squamous cell carcinoma of the lung. This was diagnosed six months ago; he had a large right-sided lung mass causing compression of the right mainstem bronchus and of the esophagus. He was treated with radiation therapy after which he developed a right lung abscess, and had subsequent bouts of pneumonia.
He now presents with progressive difficulty swallowing, stating that it feels like the 'food is going into my lungs', all attempts at eating or drinking are followed with coughing up the material. Exam is requested to evaluate for tracheoesophageal fistula.
Multiple fluoroscopic images are obtained in the AP view as the patient swallows thin barium. Contrast is seen entering the trachea at the level of the bifurcation and descends primarily into the right mainstem bronchus although a smaller amount of contrast is seen in the left mainstem bronchus as well. Findings are consistent with a tracheoesophageal fistula.
A tracheoesophageal fistula is an abnormal connection between the trachea and the esophagus. These can be congenital or acquired. Congenital TEF can be associated with a variety of other abnormalities and is generally diagnosed shortly after birth, and is corrected surgically.
Acquired TEF can occur at any age, and are secondary to a number of things including ingested/trapped foreign body, prolonged airway intubation, malignancy, radiation therapy or chemotherapy to name some of the more common causes. Patients with TEF usually present with a sensation of choking or aspirating when they eat, as material enters the bronchi and the lungs. TEF can lead to frequent aspiration pneumonias, ARDS, abscesses, respiratory failure and even death. Diagnosis is most often made with a barium study, although some TEF can be seen on CT. Further investigation into the exact size and location of the TEF can be done with bronchoscopy or esophagoscopy.
Due to the erosive nature of the processes that lead to acquired TEF, they can more difficult to treat than congenital TEF. Depending on the size and extent of the defect, treatment options range from surgical resection and closure to placement of a covered stent in the esophagus to palliation. Prognosis is generally poor.
- Sharma S, Duerksen D. Tracheoesophageal Fistula. e-Medicine, Jan 12, 2010. http://emedicine.medscape.com/article/186735-overview