Manuscript:
A 52-year-old female with a history of tongue squamous carcinoma treated with surgery and radiotherapy 6-years prior. Recent work-up for dysphagia revealed an ulcerated friable mass at the post-cricoid region that extended 8.5 cm distally. Flexible bronchoscopy showed posterior mid-tracheal wall asymmetry. Biopsies confirmed cervical esophageal squamous carcinoma (T2N2M0). The patient presented with hematemesis complicated by asphyxiation and cardiopulmonary arrest. She was resuscitated with return of circulation within 4-minutes. Intubation was difficult; bougie and video laryngoscopy were used to place a size-6 endotracheal tube (ETT). Two days later, the patient developed acute respiratory failure. Computed tomography imaging showed bilateral consolidation and abnormally placed ETT which traversed from esophagus to trachea resulting in tracheoesophageal fistula (TEF). There was pneumomediastinum, or pneumothorax (figure 1-4). Antibiotics started, and enteral-feedings held. Three days later, gastrostomy-tube placement, tracheostomy, and ETT removal in the operating theater were done. Radiotherapy and chemotherapy followed.
TEF is rarely iatrogenic, and usually due to posterior tracheal wall perforation during intubation or posterior wall erosion from pressure by an overinflated endotracheal cuff1. This case is unusual as TEF was due to an errantly placed ETT. Maintaining the airway through TEF until tracheostomy and supportive measures resulted in a satisfactory outcome.
1. Mooty RC, Rath P, Self M, Dunn E, Mangram A. Review of Tracheo-Esophageal Fistula Associated with Endotracheal Intubation.J Surg Educ . 2007;64(4):237-240. doi:10.1016/j.jsurg.2007.05.004
List of figures legend
  1. Figure 1: Endotracheal tube in the esophagus
  2. Figure 2: Endotracheal tube traversing the esophagus
  3. Figure 3: Endotracheal tube in the trachea
  4. Figure 4: Endotracheal tube traversing the esophagus into the trachea