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Ann Thorac Surg 1995;59:1251-1256
© 1995 The Society of Thoracic Surgeons

Current Review

Tracheoesophageal Fistula After Blunt Chest Trauma

William J. Reed, MD, Shannon E. Doyle, MD, Charles Aprahamian, MD

The Medical College of Wisconsin, Milwaukee, Wisconsin


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Case Report
 Comment
 References
 
Tracheoesophageal fistula is a very rare but potentially life-threatening complication of blunt chest trauma. Prior reviews have revealed that the victims were all young men involved in deceleration or crush injuries. Of those involved in motor vehicle accidents, most were thrown against the steering wheel. Herein, we review the world literature on this injury and include our own report of 1 of the few cases of traumatic tracheoesophageal fistula involving a female victim. In this case, the victim was an unrestrained driver thrown against an air bag.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Case Report
 Comment
 References
 
Tracheoesophageal fistula (TEF) after blunt chest trauma is a rare but serious complication that all physicians involved in the management of trauma patients should be aware of. Fifty-nine cases have been reported in the world literature since Vinson's [1] first case reported in 1936. There have been 18 new cases reported since the last comprehensive review published by Layton [2], and we have found 7 new cases, including 1 female victim, not previously reported. Prompt recognition of TEF is important, as a delay in diagnosis and treatment can result in increased morbidity and mortality. Following is the report of 1 of only 3 cases of TEF discussed in the world literature that occurred in female patients. The victim was an unrestrained driver thrown against an air bag. The management and outcome of other cases described in the world literature are reviewed and discussed.


   Case Report
Top
 Footnotes
 Abstract
 Introduction
 Case Report
Comment
 References
 
A 41-year-old woman was the unrestrained driver of an automobile that struck a tree at high speed. An air bag inflated unremarkably. At a local hospital before transport to our regional medical center, the patient's condition was stabilized, and she was nasally intubated for the management of dyspnea and had a left chest tube placed for the treatment of a pneumothorax.

On arrival at our facility, the patient was alert and had a Glasgow coma score of 14. Vital signs included a pulse of 80 beats/min, a systolic blood pressure of 78 mm Hg, and a respiratory rate of 20 breaths/min. Except for swelling around the right eye, there were no signs of head trauma. The patient had a 4 x 8–cm midsternal abrasion, and diffuse crackles were heard in both lungs. Gross hematuria was visible in the Foley catheter. She had an obvious deformity of her right pelvis, a right knee laceration, and an open fracture of the right ankle.

Chest radiograms revealed a widened mediastinum, bilateral pneumothoraces, a left pulmonary contusion, several rib fractures, and extensive bilateral subcutaneous air. Other radiograms revealed a right acetabular fracture, a right inferior pubic ramus fracture, and numerous fractures of the right lower extremity. Thoracic aortography was performed and revealed an acute leak with pseudoaneurysm involving the innominate artery and possibly involving the origin of the left common carotid. The aorta was otherwise normal. Based on the patient's injuries, her injury severity score was 20 and her survival probability was 89%.

The patient underwent emergent bronchoscopy and median sternotomy. Bronchoscopy did not reveal any abnormalities. A 10-mm Dacron graft was placed between the aorta and the right carotid artery, and the distal innominate artery was ligated. Several orthopedic procedures were also performed. A follow-up computed tomographic scan showed air within the mediastinum between the bronchus and the esophagus. The day after the accident, the patient underwent esophagogastroduodenoscopy, which showed several linear esophageal lacerations believed to be limited to the mucosa.

Postoperatively, the patient suffered a coagulase-positive staphylococcal pneumonia and was started on antibiotic therapy. She was extubated on postinjury day 7 and begun on clear liquids, which she tolerated well for 2 to 3 days. Subsequently, she began complaining of difficulty swallowing and a cough productive of pulmonary mucus developed.

Because of the patient's symptoms and nonresolving pneumonia, she underwent esophagography on postinjury day 14, which revealed a TEF (Fig 1Go). The next day, the patient underwent rigid esophagoscopy and flexible bronchoscopy, which confirmed the presence of the fistula immediately above the carina. Anesthetic management was achieved with a double-lumen endotracheal tube, and the chest was entered through a right posterolateral thoracotomy by means of the fourth intercostal space. The fistula measured 1 x 0.5 cm. The fistulous tract was ligated, and a pericardial patch was sewn over the defect in the trachea using 4-0 Vicryl suture (Ethicon, Somerville, NJ). The esophageal defect was repaired using an inverting mucosal technique with a two-layer closure using interrupted silk suture. An intercostal muscle flap was then placed in the area of the repair and sewn in place with interrupted 5-0 Prolene suture (Ethicon).



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  		Fig 1. . Esophagogram showing tracheoesophageal fistula.

 
Less than 24 hours after the operation, chest films showed the left lower lobe consolidation had abated. A follow-up esophagogram showed normal findings. She was extubated 6 days after the TEF repair and began to eat 11 days after the repair. Two other orthopedic procedures were performed on postinjury day 6 and 20. She began intensive inpatient rehabilitation on postinjury day 34 and was discharged home from the rehabilitation unit on postinjury day 74.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Case Report
 Comment
References
 
The world literature on TEF after blunt chest trauma was reviewed using the Medline computer database. Blunt thoracic trauma is a rare cause of TEF. Vinson [1] reported the first case in 1936, and, in the ensuing 56 years, only 59 additional cases have been reported. These previously reported patients with TEFs have been predominantly male and ranged in age from 12 to 51 years. Of these previously reported cases, 2 were female patients. The clinical presentations and outcomes of these patients are summarized in Table 1Go.


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  		Table 1. . Review of Literature
 
The exact incidence of TEF is unknown. However, in a recent review of 3,606 trauma patients conducted by Beal and associates [53], 2,560 (71%) sustained blunt trauma and only 3 of them (0.001%) had esophageal perforations. One could postulate, therefore, that the incidence of TEF probably constitutes less than 0.001% of all blunt trauma cases.

The most common site of fistula formation is at or immediately above the carina; this occurred in 45 (73.8%) of the 61 cases. In most of these (86.7%), the mechanism of injury was related to motor vehicle trauma. The fistula was located in the cervical esophagus in 8 (13.1%) of the cases and in the thoracic esophagus in 5 (8.2%) of the cases. The site was unknown in 3 (4.9%) of the cases. Only 50% of the cervical TEFs were the result of motor vehicle trauma. Layton and associates [2] reported a similar frequency of distribution in their review. In 5 cases (Nos. 27, 33, 38, 52, and 60), the fistula extended down the left, right, or both mainstem bronchi.

Regarding the various mechanisms of injury resulting in TEF, and in concurrence with the findings in previous reviews [2, 31], motor vehicle accidents account for most TEFs (n = 46; 75.4%). Most of these victims, including the present case, were drivers thrown against the steering wheel. A crush injury accounted for 6.6% (n = 4), other causes were responsible in 16.4% (n = 10), and the cause was unknown in 1.6% (n = 1). The proposed mechanism of TEF formation is compression of the trachea and esophagus between the sternum and vertebral bodies [31]. Subsequently, a partial laceration occurs in the posterior membranous trachea that apparently seals rapidly. At the same time, the anterior esophageal wall is damaged, with impairment of the mucosal blood supply. Esophageal necrosis then occurs, followed by TEF formation. This delayed formation of the TEF could account for the majority (59.0%) of patients who exhibited symptoms 3 to 10 days after blunt trauma. Stothert and associates [39], however, propose another mechanism of TEF formation involving immediate tracheal and esophageal rupture with subsequent fistula formation. This mechanism could account for the 11.5% of patients whose onset of symptoms was immediate.

The majority (80.4%) of TEFs became symptomatic within the first 10 days of injury (Table 2Go). In 11.5% (n = 7) of the cases, the onset was immediate; in 4, the onset was not reported; in 2, the onset was reported as ``early''; and in 1, the patient was asymptomatic. In addition, Gerzic and colleagues [52] reported on 1 patient who became symptomatic 425 days after his injury. Coughing and choking after swallowing, the ``swallow-cough complex'' or Ono's sign, is considered a classic sign of TEF. Other signs and symptoms are crepitation felt over the neck or chest; neck, chest, or abdominal pain; hemoptysis or hematemesis; dyspnea; dysphagia; hoarseness; odynophagia; and abdominal distention. The most commonly associated findings reported include subcutaneous air (n = 33; 54.1%) and pneumothorax or pneumomediastinum (n = 25; 41.0%). Rib fractures (n = 19; 31.1%) and hemoptysis (n = 16; 26.2%) are other commonly reported findings.


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  		Table 2. . Onset of Symptoms
 
Diagnosis of TEF has been achieved using both endoscopy and contrast radiography. Esophagoscopy and bronchoscopy are useful in determining the location and extent of the fistula. Esophagography using a water-soluble contrast medium is both technically easier to perform and better tolerated by patients. However, both studies are limited. Gerzic and colleagues [52] reported a false negative rate of nearly 33% associated with the use of endoscopy, and Kelly and co-workers [51] found a false negative rate of 12.5% associated with esophagography. It is important to note that, in a symptomatic patient, normal study findings do not preclude the diagnosis of TEF. Other diagnostic methods reported include computer-assisted tomography [54], detection of a positive-pressure air leak from a nasogastric tube during the inspiratory phase in a patient on assisted ventilation [47], and detection of the odor of anesthetic gas ejected through the fistula during esophagoscopy [2].

After diagnosis is confirmed, surgical repair should be carried out as soon as possible. In our review, nonoperative management resulted in death in 4 of the 5 patients treated in this way, while the operative mortality was only 9.3%. If the diagnosis is suspected, one should minimize further mediastinal contamination by placing a large nasogastric tube in the patient's stomach and another in the proximal esophagus to remove secretions. Good enteral or parenteral nutrition should be started. Fluid and electrolyte problems should be corrected if necessary, and patients should receive broad-spectrum antibiotic prophylaxis.

Anesthetic management has been accomplished using both single-lumen and double-lumen endotracheal tubes. The repair is best carried out through a right posterolateral thoracotomy with subsequent division of the azygos vein. This approach allows access to all levels of the trachea and esophagus. The fistula is then divided and the esophageal and tracheal defects are both closed with nonabsorbable suture. Repairs have been achieved both with and without the interposition of muscle, pleural, or pericardial flaps. However, Feliciano and associates [55] recently recommended the interposition of sternocleidomastoid or strap muscle flaps, as this will not only promote healing but will also protect the suture line and carotid artery in the event of esophageal leak. Interposition of a flap is also believed to decrease the incidence of recurrence of TEF. Pate [56] suggests that, if mediastinal infections are drained intraoperatively, the drains should be left in place until the patient is asymptomatic in the postoperative period. Postoperative esophagography is recommended. The literature contained one report of a non–blunt trauma–related fistula that was successfully closed with fibrin glue applied by means of bronchoscopy [57]. In our review, breakdown of the original repair occurred in 7 cases (see Table 1Go), and in 1 case (No. 22) surgical repair involved esophageal resection with colonic interposition.

The overall mortality associated with TEF was 14.7% (9 of 61 cases). As already mentioned, four of the deaths occurred in the nonoperative group and death was the result of infection in 2 of these cases (Nos. 51 and 56). Survival without surgical repair of the fistula occurred in only 1 patient (No. 45), with spontaneous healing of the fistula 6 weeks after gastric bypass. Death in the operative group was due to infection in 2 cases (Nos. 52 and 55), to associated injuries in 2 cases (Nos. 23 and 24), and to breakdown of the original repair in 1 case (No. 6). Fifty patients (82.0%) survived and the outcome of 2 patients (3.3%) is unknown.

In summary, TEF is a rare but potentially fatal complication of blunt chest trauma. As noted, the majority of victims sustained considerable decelerative and crush forces, usually being thrown against the automobile steering wheel or air bag, as in the current case. Although air bags can bring about a substantial decrease in the morbidity and mortality resulting from front-end collisions, it is obvious from our current case that serious injuries still occur. We also emphasize the need for a high level of suspicion of TEF when treating blunt chest trauma victims, as prompt recognition and surgical intervention are mandatory.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Case Report
 Comment
 References
 
Address reprint requests to Dr Reed, Aviation Medicine, Unit 50082, VQ-2, Box 72, FPO AE 09645-2900, Spain.


   References
Top
 Footnotes
 Abstract
 Introduction
 Case Report
 Comment
 References
 

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