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Summary
Acquired tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus caused by another condition (e.g., malignancy, trauma). Acquired TEF typically manifests with cough, dysphagia, dyspnea, and/or recurrent lung infections. Barium esophagogram and/or endoscopy confirm the diagnosis. Treatment involves a multidisciplinary team focusing on preventing aspiration, managing the underlying cause, and closing the fistula via surgery or endoscopy.
See also “Congenital tracheoesophageal fistula.”
Etiology
-
Malignancy [1]
- Esophageal cancer (most common malignant cause) [1]
- Lung cancer
- Prolonged endotracheal intubation or tracheostomy
- Excessive cuff pressure of tracheostomy or endotracheal tube
- Mediastinal surgery (e.g., esophagectomy)
- Esophageal or airway stent erosion
- Trauma (e.g., penetrating neck injury)
- Infection (e.g., tuberculosis, histoplasmosis, actinomycosis) [2]
- Ingestion (e.g., foreign body ingestion, caustic ingestion)
- Inflammatory diseases (e.g., rheumatoid arthritis, inflammatory bowel disease) [2]
Clinical features
Clinical features vary based on size, location, and rate of formation of the fistula. [1]
- Nonventilated patients [2]
-
Ventilated patients [1]
- Air leak despite inflated cuff
- Inability to wean off ventilator
- Gastric distention
- Symptoms of underlying cause
-
Symptoms of complications [2]
- Recurrent aspiration pneumonia
- Malnutrition
Diagnosis
- Confirm the diagnosis with barium esophagram and/or endoscopy (i.e., esophagoscopy, bronchoscopy). [1]
- Obtain additional diagnostics under expert guidance to guide treatment, e.g.: [1]
- CT chest
- Esophagoscopy
- Bronchoscopy
Treatment
Treatment is guided by a multidisciplinary team, including gastroenterology, pulmonology, thoracic surgery, and oncology. [1]
Initial management [1][2][3]
- Prevent aspiration in acquired TEF.
- Remove nasogastric tubes and orogastric tubes to minimize further injury.
- Provide nutritional support via jejunostomy tube or parenteral feeding.
- Manage underlying cause (e.g., malignancy, infection).
- Determine definitive management in consultation with multidisciplinary team.
Acute respiratory distress
In patients with known acquired TEF presenting with respiratory distress signs or clinical features of airway obstruction:
- Consider intubation past the level of the TEF if airway compromise is present.
- Patients with tracheostomy: See “Tracheostomy complications.”
- Consider repeat diagnostics (e.g., endoscopy, CT chest) to assess for evolution of the TEF.
- Start treatment of pulmonary aspiration.
Aspiration prevention in acquired TEF [1][2]
- Establish NPO status.
- Elevate head of bed ≥ 45 degrees.
- Perform frequent oral suctioning.
- Administer acid suppression medications.
- Consider gastrostomy tube for gastric decompression.
- In ventilated patients, advance ETT below TEF.
Definitive management [1][2]
Spontaneous closure of acquired tracheoesophageal fistula is rare, and intervention is typically required. [2]
Complications
- Aspiration pneumonia [2]
- Malnutrition [2]
We list the most important complications. The selection is not exhaustive.