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University of Washington Medical Center, Seattle, WA
INTRODUCTION: Tracheoesophageal fistula (TE fistula) is a well-known complication of penetrating traumas. TE fistulas also have been described as rare complications of prolonged endotracheal intubations and malignancy. We present a case of TE fistula formation after blunt chest trauma.
CASE PRESENTATION: A 24-year-old restrained passenger sustained blunt thoracic trauma in a high-speed motor vehicle collision. He was initially alert and oriented, but his mental status rapidly declined and he was intubated, uneventfully, at the scene. Physical examination upon arrival to the hospital revealed abrasions and contusions on his anterior chest wall in the distribution of a seat belt. Initial radiographs revealed bilateral pneumothoracies, and sternal, clavicular, and rib fractures. A CT angiogram diagnosed an intimal tear of the aorta at the takeoff of the brachiocephalic artery. Bilateral thoracostomy tubes were placed. The dissection was managed by strict blood pressure control. The patient became febrile on the fourth day of hospitalization. A chest radiograph demonstrated new left lower lobe opacity. Bronchoscopy was done for evaluation of ventilator-associated pneumonia. Thorough airway evaluation at that time showed no airway abnormalities. Broad-spectrum antibiotics were started and his fevers abated. On the eighth day of hospitalization the patient again developed high fevers along with hypotension and hypoxemia. Physical exam showed a distended abdomen and gurgling inspiratory sounds in his chest suspicious for an air leak around the cuff of his endotracheal tube. He also had a new and persistent air leak in his left chest tube. Chest radiography showed the endotracheal tube to be in good position and a left pneumothorax. Gastric contents were suctioned from the patient's endotracheal tube. Emergent bronchoscopy revealed a one-centimeter tear at the posterior wall of the proximal left main bronchus. Chest CT confirmed the TE fistula. The patient underwent emergent thoracotomy and a pleural flap was used to repair the TE fistula. The flap failed seven days later and the patient developed another left pneumothorax. An esophageal stent was placed and the fistula was allowed to heal. The patient stabilized and the remainder of his recovery was uneventful.
DISCUSSIONS: TE fistula is rare following blunt thoracic trauma. In this case, it appeared to be a late complication as signs of a TE fistula did not appear until the eighth day of hospitalization, and the patient underwent bronchoscopy early in his course with no evidence of airway injury at that time.We speculate that the initial trauma caused a partial submucosal tear of the bronchus that was not evident at the time of the first bronchoscopy, and it subsequently eroded through to form the TE fistula. Alternatively, a contained esophageal perforation and localized abscess may have eroded into the posterior wall of the bronchus. The gurgling sound suggestive of an air leak around his endotracheal tube was likely air coming from the bronchus into the esophagus and escaping through the mouth.
CONCLUSION: Although rare, TE fistula can occur following blunt thoracic trauma. Early recognition is important for guiding definitive management. In our case, the initial clue of escaping inspired air was mistakenly attributed to endotracheal tube cuff failure. The correct diagnosis was confirmed after recognition of persistent pleural air leak and aspiration of gastric contents from the airway. Trauma and pulmonary and critical care physicians should be aware of TE fistula as a possible complication of blunt trauma and should be familiar with its presenting features.
DISCLOSURE: Ann Chen, None.
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