1. 60 yof with recurrent pneumonia, regurgitation, and dysphagia
Luis Goity
DR Elective

2. 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

5. 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

6. 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

7. 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

8. 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

9. Sources https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700431/
fistula-1