60 yof with recurrent pneumonia, regurgitation, and dysphagia Luis Goity DR Elective

Clinical Data 60 yof s/p CABG with hospital course c/b occlusion of grafts, respiratory failure requiring trach/peg, mucus plugging, and recurrent emesis and coughing Barium swallow performed to assess for mechanical/physical impediments to swallowing and possible aspiration

Findings Contrast material visualized passing from anterior wall of esophagus to trachea 1 cm below vocal cords No laryngeal penetration of contrast into trachea above fistula Scalloped filling defect of trachea at level of fistula, favored to be mass-like lesion

Acquired Tracheo-Esophageal Fistula Commonly caused by malignancy, iatrogenic damage Infrequently caused by trauma, chronic esophagitis, TB, histoplasmosis Best study to assess is endoscopy, VFSS is best imaging exam CT can miss tract if it is collapsed – better assessment is CT with oral contrast Benefit is added visualization of lung disease d/t fistula such as aspiration

Risk Factors in This Patient Prolonged hospitalization with intubation High cuff pressures can lead to fistulization 2/2 tracheal mucosal necrosis Poor nutrition Secretions managed by suctioning with possible associated trauma Tracheostomy with cuffed trach tube, tracheostomy instrumentation However unlikely that trach cuff caused damage (fistula location higher than cuff location) Diabetes

Course for This Patient ENT and pulm consulted, decided to allow TEF to heal with conservative measures Mass in trachea at anterior ostium of fistula tract favored to be granulation tissue by ENT, which portends favorable prognosis and healing Anti-emetics to avoid vomiting which can delay fistula closure Optimization of nutrition

Sources https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700431/ https://radiopaedia.org/articles/acquired-tracheo-oesophageal- fistula-1 https://www.ncbi.nlm.nih.gov/pmc/articles https://radiopaedia.org/articles/barium-swallow