ANZ J. Surg.

(2001)

71

, 772–773

CASE REPORT

PCASE REPORT

TRACHEO-OESOPHAGEAL FISTULA FOLLOWING A FALL

M

ICHAEL

E

LLIOTT

, P

ETER

B

RADY

AND

R

OSS

S

MITH

Royal North Shore Hospital, Sydney, New South Wales, Australia

Key words:

parenteral nutrition, radiology, surgery, tracheo-oesophageal fistula, trauma.

INTRODUCTION

Tracheo-oesophageal fistula (TOF) is an uncommon event fol-lowing blunt chest trauma. The first case was reported by Vinsonin 1936.

1

Most previously reported traumatic cases are associatedwith motor vehicle accidents and impact with the steering wheelor airbag. We report on a case of tracheo-oesophageal formationfollowing a fall.

CASE REPORT

A previously healthy 22-year-old man was admitted to hospitalafter falling 3 m from a balcony onto concrete while intoxicated.There was no reported loss of consciousness but the patient wasamnesic of the event.

On examination in the emergency department his Glasgowcoma score (GCS) was initially 12/15 and was agitated. He washaemodynamically stable. Examination revealed subcutaneousemphysema of his neck. He had a graze across the interscapularregion of the back. The remainder of the examination was unre-markable. Due to agitation and decreased level of consciousnesshe was intubated.

A computed tomography (CT) scan of the chest revealed pneu-momediastinum, a haematoma to the right side of the oesophagusin the superior mediastinum and a small left sided pneumothorax.CT of the head and abdomen were normal. The patient’s injuriesat the time were assessed as (i) closed head injury (ii) smallleft-sided pneumothorax and (iii) suspicion of oesophageal and/ortrachea perforation.

The patient was admitted to the intensive care unit and intu-bated for 24 h. Post-extubation he was neurologically stable. Onday 2 a barium swallow was performed and showed extraluminalcontrast to the left of the oesophagus just above the carina, con-sistent with an oesophageal rupture. Swallowing the bariumcaused him to have a coughing attack. Total parenteral nutrition(TPN) was commenced and the patient was advised to notswallow his saliva. Prophylactic intravenous ampicillin, gen-tamicin and metronidazole were started. On day 4 the patientdeveloped a cough producing yellowish, blood-stained sputum.A chest X-ray performed on day 6 revealed bilateral pleuraleffusions. A repeat CT of the chest on day 8 revealed persistingbilateral pleural effusions with a reduction in mediastinal gas.

A non-ionic contrast swallow was performed on day 13 andshowed passage of contrast from the upper oesophagus into the

right main bronchus which showed the presence of a tracheo-oesophageal fistula (see Fig. 1). A bronchoscopy was performedon day 15 and this showed a 3-cm laceration in the posteriormembranous trachea with excessive saliva freely entering thetracheal lumen.

The patient underwent repair of the TOF on day 18. Through aright thoracotomy incision in the fourth intercostal space a 3-cmtear in the anterior oesophagus was found. This was communi-cating with a 5-mm perforation in the posterior membranoustrachea 2 cm above the carina. Primary repair of both holeswas undertaken. A pericardial flap was interposed between thetrachea and oesophagus and then fibrin glue was applied.

Antibiotics were ceased 24 h postoperatively. A repeat gastro-graffin swallow performed on day 6 after operation showedcontrast passing freely between a persisting TOF into the rightbronchus. This was managed conservatively by maintaining him

Correspondence: Dr M. Elliott, 236 Eastern Valley Way, Willoughby, NewSouth Wales 2068, Australia.Email: mselliott@eisa.net.au

Accepted for publication 5 January 2001.

Fig. 1.

Contrast swallow image showing a tracheo-oesophageal fistula(arrow).

TRACHEO-OESOPHAGEAL FISTULA 773

nil by mouth and continuing TPN. A further contrast swallow per-formed on day 11 after operation showed contrast passing throughthe persisting TOF. This was repeated again on day 20 after opera-tion and showed a small blind sinus. Sips of fluids was commencedwhich caused occasional coughing. A final oral contrast swallowperformed on day 25 after operation showed no evidence of thetracheo-oesophageal fistula. The patient’s diet was built up to anormal regimen and no further problems were encountered.

DISCUSSION

Tracheo-oesophageal fistula formation following blunt chesttrauma is an uncommon event. The first reported case was byVinson in 1936.

1

Other causes of traumatic TOF are secondary tooesophagoscopy or bronchoscopy, following tracheostomy, pene-trating injuries to the neck and ingestion of foreign bodies.

2,3

Early recognition of the possibility of a tracheo-oesophagealfistula and its diagnosis is important due to the morbidity andmortality associated with late diagnosis.

4

Most reported cases ofTOF formation following blunt trauma have occurred after motorvehicle accidents with impact of the chest wall with the steeringwheel or, more recently reported, air bags. Most of these casesoccur in men.

The pathogenesis of the formation of traumatic TOF is thoughtto be due to the oesophagus and the trachea being crushedbetween the sternum anteriorly and the vertebral column posteri-orly.

5–8

High intrathoracic pressure with a closed glottis causesthe weakest structural part of the trachea, the posterior membra-nous part, to perforate. Most commonly this occurs at or justabove the carina.

4

This tends to seal and heal rapidly. Necrosisoccurs in the oesophagus at the site of injury due to disruption ofthe blood supply. With the processes of haematoma formation,inflammation, infection and repair, a TOF is formed. This occursaround 3–10 days post injury.

4,7

As in our case, the most commonsite of TOF formation is at or just above the carina.

Diagnosis can be suspected historically by the classic swallow–cough complex, or Ono’s sign.

4,8

This is usually seen 3–5 daysafter injury.

9

Swallowing of fluid or food is followed by a coughingattack as the food leaks into and irritates the trachea. In our patient,suspicion of oesophageal or trachea rupture was made early and thepatient was then made nil by mouth and instructed not to swallowhis saliva post injury; thus the swallow–cough complex was notobserved. However, it is interesting to note that swallowing thecontrast on day 2 caused the patient to have a coughing attackdespite no tracheo-oesophageal fistula being demonstrated in thestudy. Other historical features include neck, chest or abdominalpain, a history of haemoptysis or haematemesis, dyspnoea, dys-phagia, hoarseness of voice, odynophagia and abdominal disten-sion. Examination findings consistent with a TOF are subcutaneousemphysema of the chest and/or neck and signs of a pneumothoraxor pneumomediastinum.

9

Chest X-rays may reveal pneumothorax,pneumomediastinum, rib fractures, sternal fractures and subcutane-ous emphysema.

7

Clinical suspicion is confirmed radiologically

with a non-ionic contrast swallow demonstrating passage of con-trast into the trachea.

4,5

Bronchoscopy and oesophagoscopy areundertaken to define the site and size of the TOF.

6

Other diagnostictools include CT in selected cases.

6

Diagnosis was confirmed inour patient on day 13. Once diagnosis is established the oesopha-gus is rested with the use of enteral or parenteral feeding. Broadspectrum antibiotics are given.

Prompt surgical repair is advised; non-operative mortality is80% while operative mortality is 9.3%.

4

Closure of the membra-nous trachea in one layer and closure of the oesophagus in twolayers is undertaken.

10

Structural interposition between thetrachea and oesophagus is advised to decrease the recurrence ofTOF. This is achieved either with a muscle (sternothyroid, inter-costal) or with a pericardial/pleural flap to separate the suturelines.

2,4,6,7,11

In our case a pericardial flap was used and then fibringlue was applied. The recurrence of the tracheo-oesophagealfistula was an unexpected event in our patient. At the time ofrepair there were no obvious signs of infection, the patient wasnot systemically unwell postoperatively and the oesophagus wasrested with nutrition given via TPN.

The case reported here demonstrates the need for early clinicalsuspicion of oesophageal and/or trachea rupture and subsequenttracheo-oesophageal formation in patients with blunt chesttrauma. Despite all precautions taken to avoid recurrence, itdoes occur and can be successfully managed with conservativemeasures.

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