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Computed tomography evaluation of tracheoesophageal fistula
CT: THE JOURNAL
COMPUTED TOMOGRAPHY OF TRACHEOESOPHAGEAL YOGINDER N. VAID,
MD,
KEY WORDS: Esophagus;
Trachea
The occurrence of tracheoesophageal fistula is not a rare event (1). Though most of these fistulas are the result of malignancies of the esophagus or bronchus, various benign conditions have been known to cause fistulas (2). Accurate diagnosis of the site and nature of tracheoesophageal fistula has traditionally required multiple procedures such as esophagoscopy, bronchoscopy, and biopsy in addition to esophagraphy, most of which are invasive and poorly tolerated by a critically ill patient. Since the advent of computed tomography (CT), this modality has been used for various esophageal problems (3-i’), but its role in the diagnosis of tracheoesophageal fistula has not been utilized effectively (8). We wish to communicate our recent experience
From the Department of Radiology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama. Address reprint requests to: Yoginder N. Vaid, MD, Department of Radiology, University of Alabama Hospital, 619 South 19th Street, Birmingham, Alabama 35233. Received June 1985. 0 1986 by Elsevier Science Publishing Co., Inc.
1986;
10281-285
281
EVALUATION FISTULA MD
with CT in four cases of tracheoesophageal our institution.
fistula at
CASE REPORTS Case 1 A 27-year-old woman presented with a history of fatigue, weakness, and difficulty in ambulation. A chest radiograph revealed a large, superior mediastinal mass. A mediastinoscopy for biopsy of the mass was followed by profound weakness and decreased vital capacity requiring artificial ventilatory support. She responded dramatically to neostigmine and atropine and a diagnosis of myasthenia gravis was made. The mediastinal mass proved to be a malignant thymoma. The patient received radiation and chemotherapy and remained asymptomatic for about 2 years. Subsequently she developed pneumonia and respiratory failure requiring tracheostomy, and 6 months later she developed a cervical abscess. A CT study of the thorax, obtained to evaluate the mediastinal widening, revealed a tracheoesophageal fistula and the esophageal tube directly situated against the tracheostomy tube with extensive mediastinitis (Figure 1). Drainage of the abscess via right thoracotomy and feeding jejunostomy was performed. Her mediastinitis and pneumonia improved dramatically on an antibiotic course, and she was discharged on pyridostigmine bromide (Mestinon). Case
52 Vanderbilt Avenue, New York, NY 10017 0149-936x1861$3.50
TOMOGRAPHY
AND MYUNG S. SHIN,
Four cases of tracheoesophageal fistuia evaluated by computed tomography are presented. In addition to demonstrating the site of fistula, computed tomography was helpful in suggesting etiology and detecting pulmonary and mediastinal complications. Due to its ease of performance in critically ill patients and its unequivocal display of anatomy, we believe c.omputed tomography should be the recommended diagnostic modality for tracheoesophageal fistula.
Computed tomography; Fistula;
OF COMPUTED
2
A 74year-old man presented to the hospital with several weeks history of productive cough and fever. A physical examination revealed rales bilaterally at bases more on the right side. A chest radiograph showed a right perihilar and lower lobe opacity consistent with pneumonia (Figures 2A and B). A bronchoscopy revealed no malignancy, but an
282
VAIL AND SHIN
CT: THE JOURNAL OF COMPUTED
TOMOGRAPHY
VOL. 10 NO. 3
1. A CT study of the thorax at the level of sternoclavicular junction. By revealing a tracheostomy tube in place with a nasogastric tube in close proximity without soft tissue separation, this study confirms the presence of tracheoesophageal fistula (arrow) with extensive mediastinitis.
FIGURE
ulcer was seen on the posterior medial wall of the bronchus intermedius. An esophagogram showed bronchoesophageal fistula (Figure ZC). A CT study was performed for further evaluation in view of a negative bronchoscopy for malignancy. In addition to demonstating the site of the fistula, CT showed no evidence of a mass to account for the maligA right lower lobar consolidation and nancy. changes of mediastinitis were present. Calcified granulomata in the right lung and hilar region adjoining the fistula suggested possibility of bronchoesophageal fistula due to tuberculosis or histoplasmosis (Figure 2D). A thoracotomy revealed fistula, and a biopsy showed chronic inflammation consistent with histoplasmosis without malignancy.
Case 3 A 69-year-old woman was diagnosed as having squamous cell carcinoma of the right upper lung and was treated earlier with radiation therapy at another hospital. Six months later she presented with a persistent cough and attacks of choking. A chest radiograph revealed a right upper lung abscess. An esophagram, obtained because of her choking, revealed a tracheoesophageal fistula. A bronchoscopic biopsy revealed squamous cell carcinoma invading the esophageal wall. She was treated conservatively with antibiotics, tube feeding, and radiation therapy and the fistula healed. The patient developed a recurrence of her symptoms about 8 months later. At that time a CT study was performed for further evaluation. The CT study showed a recurrence of fistula at a higher level, with right upper lobar pneumonia
and a thick-walled upper lobe cavitary mass with a loss of volume. These findings were interpreted as a recurrent tumor, and a cervical esophagectomy and a feeding gastrostomy were subsequently performed. She responded to antibiotic therapy very well and was discharged with no fever, no respiratory symptoms, and feeding through gastrostomy.
Case 4 A 62-year-old man, a chronic alcohol abuser, presented with 22% second degree burns over his face, neck, and anterior chest wall. He was electively intubated in the emergency room. He had a prolonged course of hospital stay. After a Xl-day period of intubation, a tracheostomy was performed. About a month after the tracheostomy, the patient developed a cough, choking, and fever. A barium esophagram was inconclusive but did suggest a fistula. A CT study of the thorax was performed for further evaluation and showed a tracheoesophageal fistula just below the distal end of the tracheostomy (Figure 3). The patient was managed on nasogastric tube feeding and antibiotics, but no surgical inter1 vention was attempted. A barium esophagogram month later showed closure of the fistula. The patient subsequently underwent management for burns and was later discharged. DISCUSSION Occurrence of tracheoesophageal fistula is a catastrophic event resulting in continual aspiration, coughing and rapid supervention of respiratory in-
TRACHEOESOPHAGEAL FISTLJLA
1986
283
D
FIGURE 2. (A, B) Posteroanterior and lateral chest radiographs reveal a right hilar mass and air space pneumonia in the right lower lobe. (C) Esophagogram reveals extravasation of barium into mediastinum and opacification of trachea and right bronchial tree. (D) A CT scan of the thorax at subcarinal level shows a communication between right main stem bronchus and esophagus [a nasogastric tube in situ) (arrow). A small calcified granuloma is present, protruding into the fistulous tract. Massive air space consolidation is present in the right lower lobe with air bronchograms.
284
VAIL AND SHIN
CT: THE JOURNAL
FIGURE 3. A CT scan of thorax at the T-2 level reveals
direct communication of the esophagus (nasogastric tube in situ) and the trachea with distal end of the tracheostomy tube (arrow). Mediastinitis is present around the end of the tracheostomy tube. Pleural effusion is evident on the right. fection (11). Its incidence in esophageal and lung cancer has been placed at 5 to 13% in various studies (12-14). In addition, the incidence of benign, especially traumatic, tracheoesophageal fistula is on the rise. Most untreated patients with tracheoesophageal fistula die within 1 month of developing a fistula. The cause of death is predominately pulmo(11).Proper management requires nary infection prompt localization of the fistula and determination of its nature-benign or malignant. Therapy in young patients with benign fistula focuses on mechanical interruption of the fistula and restoration of esophageal continuity. Older patients with malignant fistula are usually treated with permanent intubation and supportive therapy, including tracheostomy, gastrostomy, and cervical esophagectomy. Colon bypass and resection may be possible in smaller tumors in younger patients (1). In most cases diagnosis of tracheoesophageal fistula can be achieved by esophagogram, bronchoscopy, and esophagoscopy. These procedures are, however, poorly tolerated by most critically ill patients. Barium results in coughing and choking and may spill into the trachea and bronchi without demonstrating the fistula or allowing diagnosis of aspiration (13).
OF COMPUTED
TOMOGRAPHY
VOL. 10 NO. 3
Similarly endoscopy sometimes fails to reveal a fistula (14). Due to its noninvasive nature and requirement of no oral contrast, CT provides an ideal means for diagnosing not only the site of communication but also a comprehensive display of anatomic structures, such as mediastinum, lungs, and pleura and their relation to the fistula (8-10). The CT demonstration of the mediastinitis or calcified nodes within the vicinity of the fistula, suggesting a diagnosis of chronic inflammatory disease like tuberculosis or histoplasmosis, has been well documented (15). The etiology of tracheoesophageal fistula was well demonstrated by our case 2, whereas the pathogenesis of medistinal fibrosis in a patient due to radiation therapy and necrosis was well demonstrated by case 3. Demonstration of a mass in relation to a bronchus or esophagus is more in favor of a malignant fistula. However, some cases still will require bronchoscopy and biopsy for definitive pathologic diagnosis of the etiology. By providing this additional anatomic and morphologic information and a definitive demonstration of fistula, as presented in our cases, CT is shown to be a superior modality in the evaluation of tracheoesophageal fistula.
REFERENCES 1. Lolley DM, Ray JF III, Ransdell HT: Management of malignant esophagorespiratory fistula. Ann Thorac Surg 1978;25:516-20. 2. Storey CF: Acquired benign esophagotracheobronchial fistula in acquired surgical lesions of the esophagus. Charles C Thomas, Springfield, IL, 1962:169-204. 3. Halber MD, Daffner RH, Thompson WM: CT of esophagusI: normal appearance. AJR 1979;133:1047. 4. Daffner RH, Halber MD, Postlethwait II: carcinoma. AJR 1979;133:1651-5.
RW: CT of esophagus-
5. Moss AA, Schnydner P, Thoeni RF: Esophageal pretherapy staging by CT. AJR 1981;136:1051-6.
carcinoma:
6. Tishler JM, Shin MS, Stanley RJ: CT of the thorax in patients with achalasia. Digest Dis Sci 1983; 28, 8:692-7. 7. Gamsu Gordan, Webb WR: Computed tomography chea-“normal & abnormal.” AJR 1982;139:321-6. 8. Berkmen YM, Auh YH: CT diagnosis of acquired esophageal fistula in adults. J Comput Assist 1985;9:302-4.
of the tratracheoTomogr
9. Brown BM: Computed tomography of mediastinal abscess secondary to posttraumatic esophageal laceration. J Comput Assist Tomogr 1984;8:765-7. 10. Baron RL, Levitt RG, Sage1 SS: Computed tomography in the evaluation of mediastinal widening. Radiology 1981;138:107-13. 11. Duranceau A, Jamison GG: Malignant tula. Ann Thorac Surg 1984;37:346-54.
tracheosophageal
fis-
TRACHEOESOPHAGEAL
1986
12. Daffner RH, Postlethwait RW, Putman normalities. AJR 1978;130:719. 13. Coleman FP: Acquired nonmalignant fistula. Am J Surg 1957;93:321-8.
CE: Retrotracheal
ab-
esophagorespiratory
14. Spalding AR, Burney DP, Richie RF2 Acquired choesophageal fistulas in adults. Ann 1979;28:378-83.
benign Thorac
bronSurg
15. Weinstein JB, Aronberg DJ, Sage1 SS: CT of fibrosing mediastinitis: Findings and their utility AJR 141:247-51, 1983.
CONTINUING 1. The
MEDICAL
incidence on rise. a. True. b. False.
EDUCATION
of benign
QUESTIONS
tracheoesophageal
fistula
is
2. The cause of death in an untreated fistula is: a. Pulmonary infection. b. Malnutrition. c. Hemorrhage. 3. The most comprehensive tracheoesophageal fistula a. Esophagogram. b. Mediastinoscopy. c. Computed tomography. d. Bronchoscopy.
modality is:
FISTULA
285
tracheoesophageal
for evaluation
of
COMPUTED TOMOGRAPHY OF TRACHEOESOPHAGEAL YOGINDER N. VAID,
MD,
KEY WORDS: Esophagus;
Trachea
The occurrence of tracheoesophageal fistula is not a rare event (1). Though most of these fistulas are the result of malignancies of the esophagus or bronchus, various benign conditions have been known to cause fistulas (2). Accurate diagnosis of the site and nature of tracheoesophageal fistula has traditionally required multiple procedures such as esophagoscopy, bronchoscopy, and biopsy in addition to esophagraphy, most of which are invasive and poorly tolerated by a critically ill patient. Since the advent of computed tomography (CT), this modality has been used for various esophageal problems (3-i’), but its role in the diagnosis of tracheoesophageal fistula has not been utilized effectively (8). We wish to communicate our recent experience
From the Department of Radiology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama. Address reprint requests to: Yoginder N. Vaid, MD, Department of Radiology, University of Alabama Hospital, 619 South 19th Street, Birmingham, Alabama 35233. Received June 1985. 0 1986 by Elsevier Science Publishing Co., Inc.
1986;
10281-285
281
EVALUATION FISTULA MD
with CT in four cases of tracheoesophageal our institution.
fistula at
CASE REPORTS Case 1 A 27-year-old woman presented with a history of fatigue, weakness, and difficulty in ambulation. A chest radiograph revealed a large, superior mediastinal mass. A mediastinoscopy for biopsy of the mass was followed by profound weakness and decreased vital capacity requiring artificial ventilatory support. She responded dramatically to neostigmine and atropine and a diagnosis of myasthenia gravis was made. The mediastinal mass proved to be a malignant thymoma. The patient received radiation and chemotherapy and remained asymptomatic for about 2 years. Subsequently she developed pneumonia and respiratory failure requiring tracheostomy, and 6 months later she developed a cervical abscess. A CT study of the thorax, obtained to evaluate the mediastinal widening, revealed a tracheoesophageal fistula and the esophageal tube directly situated against the tracheostomy tube with extensive mediastinitis (Figure 1). Drainage of the abscess via right thoracotomy and feeding jejunostomy was performed. Her mediastinitis and pneumonia improved dramatically on an antibiotic course, and she was discharged on pyridostigmine bromide (Mestinon). Case
52 Vanderbilt Avenue, New York, NY 10017 0149-936x1861$3.50
TOMOGRAPHY
AND MYUNG S. SHIN,
Four cases of tracheoesophageal fistuia evaluated by computed tomography are presented. In addition to demonstrating the site of fistula, computed tomography was helpful in suggesting etiology and detecting pulmonary and mediastinal complications. Due to its ease of performance in critically ill patients and its unequivocal display of anatomy, we believe c.omputed tomography should be the recommended diagnostic modality for tracheoesophageal fistula.
Computed tomography; Fistula;
OF COMPUTED
2
A 74year-old man presented to the hospital with several weeks history of productive cough and fever. A physical examination revealed rales bilaterally at bases more on the right side. A chest radiograph showed a right perihilar and lower lobe opacity consistent with pneumonia (Figures 2A and B). A bronchoscopy revealed no malignancy, but an
282
VAIL AND SHIN
CT: THE JOURNAL OF COMPUTED
TOMOGRAPHY
VOL. 10 NO. 3
1. A CT study of the thorax at the level of sternoclavicular junction. By revealing a tracheostomy tube in place with a nasogastric tube in close proximity without soft tissue separation, this study confirms the presence of tracheoesophageal fistula (arrow) with extensive mediastinitis.
FIGURE
ulcer was seen on the posterior medial wall of the bronchus intermedius. An esophagogram showed bronchoesophageal fistula (Figure ZC). A CT study was performed for further evaluation in view of a negative bronchoscopy for malignancy. In addition to demonstating the site of the fistula, CT showed no evidence of a mass to account for the maligA right lower lobar consolidation and nancy. changes of mediastinitis were present. Calcified granulomata in the right lung and hilar region adjoining the fistula suggested possibility of bronchoesophageal fistula due to tuberculosis or histoplasmosis (Figure 2D). A thoracotomy revealed fistula, and a biopsy showed chronic inflammation consistent with histoplasmosis without malignancy.
Case 3 A 69-year-old woman was diagnosed as having squamous cell carcinoma of the right upper lung and was treated earlier with radiation therapy at another hospital. Six months later she presented with a persistent cough and attacks of choking. A chest radiograph revealed a right upper lung abscess. An esophagram, obtained because of her choking, revealed a tracheoesophageal fistula. A bronchoscopic biopsy revealed squamous cell carcinoma invading the esophageal wall. She was treated conservatively with antibiotics, tube feeding, and radiation therapy and the fistula healed. The patient developed a recurrence of her symptoms about 8 months later. At that time a CT study was performed for further evaluation. The CT study showed a recurrence of fistula at a higher level, with right upper lobar pneumonia
and a thick-walled upper lobe cavitary mass with a loss of volume. These findings were interpreted as a recurrent tumor, and a cervical esophagectomy and a feeding gastrostomy were subsequently performed. She responded to antibiotic therapy very well and was discharged with no fever, no respiratory symptoms, and feeding through gastrostomy.
Case 4 A 62-year-old man, a chronic alcohol abuser, presented with 22% second degree burns over his face, neck, and anterior chest wall. He was electively intubated in the emergency room. He had a prolonged course of hospital stay. After a Xl-day period of intubation, a tracheostomy was performed. About a month after the tracheostomy, the patient developed a cough, choking, and fever. A barium esophagram was inconclusive but did suggest a fistula. A CT study of the thorax was performed for further evaluation and showed a tracheoesophageal fistula just below the distal end of the tracheostomy (Figure 3). The patient was managed on nasogastric tube feeding and antibiotics, but no surgical inter1 vention was attempted. A barium esophagogram month later showed closure of the fistula. The patient subsequently underwent management for burns and was later discharged. DISCUSSION Occurrence of tracheoesophageal fistula is a catastrophic event resulting in continual aspiration, coughing and rapid supervention of respiratory in-
TRACHEOESOPHAGEAL FISTLJLA
1986
283
D
FIGURE 2. (A, B) Posteroanterior and lateral chest radiographs reveal a right hilar mass and air space pneumonia in the right lower lobe. (C) Esophagogram reveals extravasation of barium into mediastinum and opacification of trachea and right bronchial tree. (D) A CT scan of the thorax at subcarinal level shows a communication between right main stem bronchus and esophagus [a nasogastric tube in situ) (arrow). A small calcified granuloma is present, protruding into the fistulous tract. Massive air space consolidation is present in the right lower lobe with air bronchograms.
284
VAIL AND SHIN
CT: THE JOURNAL
FIGURE 3. A CT scan of thorax at the T-2 level reveals
direct communication of the esophagus (nasogastric tube in situ) and the trachea with distal end of the tracheostomy tube (arrow). Mediastinitis is present around the end of the tracheostomy tube. Pleural effusion is evident on the right. fection (11). Its incidence in esophageal and lung cancer has been placed at 5 to 13% in various studies (12-14). In addition, the incidence of benign, especially traumatic, tracheoesophageal fistula is on the rise. Most untreated patients with tracheoesophageal fistula die within 1 month of developing a fistula. The cause of death is predominately pulmo(11).Proper management requires nary infection prompt localization of the fistula and determination of its nature-benign or malignant. Therapy in young patients with benign fistula focuses on mechanical interruption of the fistula and restoration of esophageal continuity. Older patients with malignant fistula are usually treated with permanent intubation and supportive therapy, including tracheostomy, gastrostomy, and cervical esophagectomy. Colon bypass and resection may be possible in smaller tumors in younger patients (1). In most cases diagnosis of tracheoesophageal fistula can be achieved by esophagogram, bronchoscopy, and esophagoscopy. These procedures are, however, poorly tolerated by most critically ill patients. Barium results in coughing and choking and may spill into the trachea and bronchi without demonstrating the fistula or allowing diagnosis of aspiration (13).
OF COMPUTED
TOMOGRAPHY
VOL. 10 NO. 3
Similarly endoscopy sometimes fails to reveal a fistula (14). Due to its noninvasive nature and requirement of no oral contrast, CT provides an ideal means for diagnosing not only the site of communication but also a comprehensive display of anatomic structures, such as mediastinum, lungs, and pleura and their relation to the fistula (8-10). The CT demonstration of the mediastinitis or calcified nodes within the vicinity of the fistula, suggesting a diagnosis of chronic inflammatory disease like tuberculosis or histoplasmosis, has been well documented (15). The etiology of tracheoesophageal fistula was well demonstrated by our case 2, whereas the pathogenesis of medistinal fibrosis in a patient due to radiation therapy and necrosis was well demonstrated by case 3. Demonstration of a mass in relation to a bronchus or esophagus is more in favor of a malignant fistula. However, some cases still will require bronchoscopy and biopsy for definitive pathologic diagnosis of the etiology. By providing this additional anatomic and morphologic information and a definitive demonstration of fistula, as presented in our cases, CT is shown to be a superior modality in the evaluation of tracheoesophageal fistula.
REFERENCES 1. Lolley DM, Ray JF III, Ransdell HT: Management of malignant esophagorespiratory fistula. Ann Thorac Surg 1978;25:516-20. 2. Storey CF: Acquired benign esophagotracheobronchial fistula in acquired surgical lesions of the esophagus. Charles C Thomas, Springfield, IL, 1962:169-204. 3. Halber MD, Daffner RH, Thompson WM: CT of esophagusI: normal appearance. AJR 1979;133:1047. 4. Daffner RH, Halber MD, Postlethwait II: carcinoma. AJR 1979;133:1651-5.
RW: CT of esophagus-
5. Moss AA, Schnydner P, Thoeni RF: Esophageal pretherapy staging by CT. AJR 1981;136:1051-6.
carcinoma:
6. Tishler JM, Shin MS, Stanley RJ: CT of the thorax in patients with achalasia. Digest Dis Sci 1983; 28, 8:692-7. 7. Gamsu Gordan, Webb WR: Computed tomography chea-“normal & abnormal.” AJR 1982;139:321-6. 8. Berkmen YM, Auh YH: CT diagnosis of acquired esophageal fistula in adults. J Comput Assist 1985;9:302-4.
of the tratracheoTomogr
9. Brown BM: Computed tomography of mediastinal abscess secondary to posttraumatic esophageal laceration. J Comput Assist Tomogr 1984;8:765-7. 10. Baron RL, Levitt RG, Sage1 SS: Computed tomography in the evaluation of mediastinal widening. Radiology 1981;138:107-13. 11. Duranceau A, Jamison GG: Malignant tula. Ann Thorac Surg 1984;37:346-54.
tracheosophageal
fis-
TRACHEOESOPHAGEAL
1986
12. Daffner RH, Postlethwait RW, Putman normalities. AJR 1978;130:719. 13. Coleman FP: Acquired nonmalignant fistula. Am J Surg 1957;93:321-8.
CE: Retrotracheal
ab-
esophagorespiratory
14. Spalding AR, Burney DP, Richie RF2 Acquired choesophageal fistulas in adults. Ann 1979;28:378-83.
benign Thorac
bronSurg
15. Weinstein JB, Aronberg DJ, Sage1 SS: CT of fibrosing mediastinitis: Findings and their utility AJR 141:247-51, 1983.
CONTINUING 1. The
MEDICAL
incidence on rise. a. True. b. False.
EDUCATION
of benign
QUESTIONS
tracheoesophageal
fistula
is
2. The cause of death in an untreated fistula is: a. Pulmonary infection. b. Malnutrition. c. Hemorrhage. 3. The most comprehensive tracheoesophageal fistula a. Esophagogram. b. Mediastinoscopy. c. Computed tomography. d. Bronchoscopy.
modality is:
FISTULA
285
tracheoesophageal
for evaluation
of