Congenital tracheoesophageal fistulas presenting in adults: Presentation of two cases and a synopsis of the literature

A Cautionary Tale: Undetected H-type Tracheoesophageal Fistula in an Adolescent Male

An H-type tracheoesophageal fistula is a rare congenital anomaly consisting of an abnormal passageway between the esophagus and the trachea without the presence of esophageal atresia. This condition is usually detected early in infancy; however, some patients may receive a delayed diagnosis. Symptoms experienced by people affected with an H-type tracheoesophageal fistula vary greatly and may consist of bouts of coughing when swallowing liquids and recurring lower respiratory infections. The most commonly used initial diagnostic tests can produce falsely negative results. The treatment of choice for the majority of H-type tracheoesophageal fistulas is an open surgical procedure; however, the thoracoscopic approach has proven effective in cases where the fistula is located below the thoracic outlet. In this case report, we describe a patient whose diagnosis of H-type tracheoesophageal fistula was delayed by 13 years and who was successfully treated using thoracoscopic surgery.

Management of Adults With Esophageal Atresia

Esophageal atresia (EA) with or without trachea-esophageal fistula is relatively common congenital malformation with most patients living into adulthood. As a result, care of the adult patient with EA is becoming more common. Although surgical repair has changed EA from a fatal to a livable condition, the residual effects of the anomaly may lead to a lifetime of complications. These include effects related to the underlying deformity such as atonicity of the esophageal segment, fistula recurrence, and esophageal cancer to complications of the surgery including anastomotic stricture, gastroesophageal reflux, and coping with an organ transposition. This review discusses the occurrence and management of these conditions in adulthood and the role of an effective transition from pediatric to adult care to optimize adult care treatment.

Thoracoscopic Repair of Adult-Onset Congenital Tracheoesophageal Fistula Using a Polyglycolic Acid Sheet-Buttressed Stapler

Congenital tracheoesophageal fistula (TEF) without esophageal atresia is usually diagnosed and treated in the neonatal period. It is uncommon to occur in adulthood. Conventional treatment of adult-onset TEF involves repair by either cervicotomy or thoracotomy. We reported the case of a 31-year-old male patient with clinical and radiographic evidence of congenital H-type TEF. Although this fistula was located at the level of the second thoracic vertebra, the repair of the anomaly was performed successfully using a thoracoscopic approach with the novel use of a polyglycolic acid sheet reinforcement.

Surgery Complicated by Self-Expandable Metallic Stents (SEMS) Tracheal Stent in a Congenital H-type Tracheo-Esophageal Fistula

A congenital tracheo-esophageal fistula of the H-type is a rare variant. The diagnosis is usually missed because of mild symptoms. A long history of coughing during liquid intake and nocturnal cough may aid in the diagnosis. A delay in the diagnosis may have a deleterious effect on the lung because of recurrent infections. Surgery is the cornerstone of management. Self-expandable metallic stents (SEMS) do not have a role in the management of these fistulae. We report a case of a missed diagnosis of a congenital H-type fistula managed as an acquired tracheo-esophageal fistula with two attempts at conservative management with a tracheal self-expandable metallic stent. The difficulties and disadvantages of using self-expandable metallic stents for the management of benign tracheo-esophageal fistulae are also discussed.

Identification of acquired tracheoesophageal fistula after tracheostomy decannulation by videofluoroscopic swallowing study: A case report

RATIONALE

Videofluoroscopic swallowing study (VFSS) is a noninvasive radiographic procedure that examines the oral, pharyngeal, and cervical esophageal stages of swallowing. Tracheoesophageal fistula (TEF) is difficult to diagnose depending on its size and location. However, how VFSS can be of benefit in the diagnosis of TEF has not been reported yet.

PATIENT CONCERNS

A 64-year-old man who had been tracheostomized post spinal tumor resection surgery at the cervical level 1 to 2, had his tracheostomy tube removed approximately 25 years ago. After decannulation, he reported coughing while swallowing food, foreign sensation in the neck and repeated bouts of pneumonia ever since.

DIAGNOSIS

VFSS revealed, for the first time, acquired TEF after tracheostomy decannulation as the cause of repetitive aspiration pneumonia.

INTERVENTION

VFSS was performed in this case.

OUTCOMES

In the background of suspected TEF based on VFSS results, the patient underwent a computed tomography scan of the chest and airway in the prone position, followed by bronchoscopy, which confirmed the existence of a TEF. He then underwent primary closure of the fistula. The patient had an uneventful recovery and is currently symptom-free 10 months after the surgery.

LESSONS

This case alerts clinicians to the possibility of TEF as a diagnosis when the aspirate leaks from the upper esophagus and through the posterior wall of trachea in the esophageal phase of VFSS.

Presentation of an H-type tracheoesophageal fistula in an adolescent male with cystic fibrosis: A case report and review of literature

Congenital TEFs without esophageal atresia are rare but may occur more frequently than previously documented in literature. Careful history is required to suspect the diagnoses, as most patients will present with coughing associated with solid or liquids, recurrent unexplained pulmonary infections and complaints with eating. Some patients may show signs of chronic airway changes from recurrent aspiration pneumonia at the time of presentation. Diagnosis is challenging, with multiple imaging modalities including x ray, CT scan and esophogram able to identify a fistula. Surgery is required to improve quality of life and prevent chronic airway changes, and most cases repaired have no complications.

Prevalence of Laryngeal Cleft in Pediatric Patients With Esophageal Atresia

Importance

Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), and laryngeal cleft are rare congenital anomalies that often occur together. Previous reports have established a link between EA/TEF and laryngeal cleft, but there have been no large case series to further characterize this relationship.

Objectives

To assess the prevalence of laryngeal cleft among patients with EA/TEF, identify associations between types of laryngeal cleft and EA/TEF, and identify factors associated with the timing of diagnosis for both conditions.

Design, Setting, and Participants

Retrospective analysis of 270 patients. The Esophageal Atresia database was used to identify patients seen at the Esophageal and Airway Treatment (EAT) Center at Boston Children's Hospital, Boston, Massachusetts, a tertiary referral hospital, from August 1, 2009, to August 1, 2016. Patients were included if they were younger than 18 years at the time they were diagnosed with EA, TEF, or both and had undergone a procedure or examination by a surgeon from the EAT Center. Patients with acquired airway or esophageal problems were excluded.

Main Outcomes and Measures

Data regarding patient demographics, primary diagnoses, dates of diagnosis, comorbidities, and airway/esophageal surgical interventions were collected and analyzed. Association between type of EA/TEF and laryngeal cleft type was evaluated. Secondary outcomes were age at diagnosis between patients who resided in Massachusetts and those who resided outside the state.

Results

Of 270 patients diagnosed with EA/TEF during the 7-year period, 138 (51.1%) were male, and the median age at diagnosis of EA/TEF was 1.0 years (IQR, 0.4-2.0) and at diagnosis of laryngeal cleft was 1.1 years (interquartile range [IQR], 0.6-2.8). Laryngeal cleft was diagnosed in 53 of the 270 patients (19.6%) (95% CI, 14.9%-24.4%). No apparent difference was found in the distribution of types of laryngeal cleft by type of EA/TEF. Among patients with EA/TEF type A or B, 9 patients (56%) had a type I cleft, 6 (38%) had a type II cleft, and 1 (6%) had a type III cleft. Among those with EA/TEF type C or D, 20 (57%) had a type I cleft, 11 (31%) had a type II cleft, and 3 (9%) had a type III cleft. Out-of-state patients were more likely to be diagnosed with EA/TEF at an older age than in-state patients (mean difference, 1.5 years; 95% CI, 0-2.9 years).

Conclusions and Relevance

Pediatric patients with EA/TEF have a much greater prevalence of laryngeal cleft than the general population. Multidisciplinary esophageal and airway programs serve as an ideal clinical setting for management of EA/TEF.

Congenital H-type tracheoesophageal fistula in adults

Congenital tracheoesophageal fistulas (TEFs) in the adults are uncommonly reported but they are serious conditions that can cause severe morbidities and mortality. Three cases were identified in the last 16 years. The diagnosis was not easy but they were all successfully surgically repaired with good results. A detailed history and meticulous examination of the radiological studies will help diagnose this condition. Surgical repair should be performed once diagnosed.

A rare case of congenital bronchoesophageal fistula in an adult

INTRODUCTION

When congenital bronchoesophageal fistulas exist without atresia of the esophagus, the diagnosis can be delayed, although symptoms may occur early following fistula development. Therefore, while they are usually found in infants, they can be extremely rarely found in adults. We herein report a rare case of bronchoesophageal fistula without atresia in an adult.

CASE

An 69-year-old male presented to the outpatient clinic with a decades-long history of cough with expectoration immediately after taking food, especially liquids. Computed tomograph, esophagoscopy, and esophagography revealed the fistulous communication between the mid-esophagus and right lower lobe bronchus, with consolidation in the right lower lobe. We performed right lower lobectomy with the closure and excision of the fistula. The histopathology of the fistula revealed the mucosa to be lined by stratified squamous epithelium. There was no evidence of inflammation, granuloma, or carcinoma.

CONCLUSION

In conclusion, despite the benign nature of this malformation, if left untreated, it can cause long-term debilitating respiratory symptoms associated with the fistula. Therefore, the diagnosis should be considered in the evaluation of recurrent lung infection.

Imaging of Large Airways Disorders

OBJECTIVE

Recent technical advances, including the routine use of CT thin sections and techniques such as 2D minimum-intensity-projection and 3D volume images, have increased our ability to detect large airways diseases. Furthermore, dedicated CT protocols allow the evaluation of dynamic airway dysfunction.

CONCLUSION

With diseases of the large airways more commonly seen in daily practice, it is important that radiologists be familiar with the appearances, differential diagnosis, and clinical implications of these entities.

Congenital tracheoesophageal fistula: A rare and late presentation in adult patient

Congenital H-type tracheoesophageal fistula (TEF) in adults is a rare presentation and can test the diagnostic acumen of a surgeon, endoscopist, and the radiologist. These undetected fistulas may present as chronic lung disease of unknown origin because repeated aspirations can lead to recurrent lung infections and bronchiectasis. Congenital TEFs should be considered in the diagnosis of infants and young adults with recurrent respiratory distress and/or infections. Here, we present the successful management of this rare case in an adult patient.

[Tracheobronchial and pulmonary parenchymatous congenital abnormalities requiring surgical treatment in adults]

Most tracheobronchial and parenchymatous congenital abnormalities of the respiratory system are diagnosed in early life. However, some lesions may be initially silent and diagnosed only in adulthood. These cases included congenital abnormalies of the tracheobronchial tract (tracheal and/or bronchial stenosis, bronchogenic cysts, bronchial atresia, oesotracheal fistula, oesobronchial fistula, and tracheal diverticulum), and lung parenchyma itself (pulmonary sequestration, congenital cystic adenomatoïd malformation, lobar emphysema, lobar or lung hypoplasia). To avoid dreadful complications, these rare cases deserve surgical management, and must be known by chest physicians and surgeons.

Late presentation of congenital H-type tracheoesophageal fistula in an immunocompromised patient

Congenital tracheoesophageal fistulas without esophageal atresia - H-type tracheoesophageal fistula - accounts for approximately 4% of esophageal malformations. This term refers to a connection at an oblique course between the posterior wall of the trachea and the anterior wall of the esophagus, presenting as an 'H' form. Typically, the diagnosis is made before the third year of life; however, some reports have been made of late presentation in adults who present chronic cough and frequent respiratory infections. Traditionally, surgery has been considered as the best treatment, depending on the level of the fistula. We present the case of an immunocompromised patient who was diagnosed as having a congenital tracheoesophageal fistula of the upper third of the trachea.

Isolated tracheoesophageal fistula in a 10-year-old girl

Isolated tracheoesophageal fistula (H-TOF) is a rare type of tracheoesophageal anomaly and is in most cases diagnosed in the neonatal period because of choking and cyanosis during feeding. Diagnosis may be delayed even until adulthood because of nonspecific and sometimes intermittent symptoms, and because false-negative results of all diagnostic tools are not uncommon. We report a 10-year-old child with H-TOF, whose symptoms had nearly disappeared completely between the ages of 4 and 10 years. Diagnosis was only possible after the recurrence of the symptoms at the time of an episode of bronchitis, profound interrogation of the child's medical history, and questioning of the results of a former diagnostic work-up. In this article, we discuss the potential pitfalls in both clinical diagnosis and diagnostic work-up.

Thoracoscopic Repair of Tracheoesophageal Fistula in a Septuagenarian

We report the case of a 79-year-old female with clinical and radiographic evidence of congenital H-type tracheoesophageal fistula. Past medical history included recurrent pneumonia and episodic cough with food or fluid intake. She exhibited Ohno's sign during the dysphagia evaluation. A video swallow study demonstrated evidence of aspiration. Esophagogram and bronchoscopy identified the fistulous tract. Repair of the anomaly was performed using a minimally invasive thoracoscopic approach. In our experience, excellent visualization and magnification of the anatomic field with use of thoracoscopy allowed for relative ease of dissection and resection of the tract with minimal postoperative morbidity.