Report
Case
Acquired tracheo-esophageal fistula caused by a denture P. Rekha, M. Sajitha, J. M. Pappachan*, Akash Babu**, T. K. Jayakumar**, P. Sukumaran Departments of Chest Diseases, *Internal Medicine, **Thoracic and Cardiovascular Surgery, Kottayam Medical College, Kerala, India
m rf o d s a ABSTRACT o ion l A majority of the cases of acquired tracheo-esophageal fistula n (TEF) are at result of complication of a these causes, the most w malignancy. Acquired non-malignant TEFs result from a variety of causes.cAmong i o l common is iatrogenic that results from prolonged tracheal intubation. impaction of the esophagus d beuDenture b resulting in the development of an acquired TEF is rare. Whatever the cause, the diagnosis of a TEF is e in devastating a surgical emergency because delay in treatment can result pulmonary from . e r wTEFsP usually)gives goodcomplications f aspiration through the TEF. Surgical treatment of non-malignant results. An unusual m r aspiration case of non-resolving pneumonia resulting fromorecurrent through an acquired TEF caused by o o f Patient’s n pneumonia c resolved completely following the an accidentally swallowed denture is reported here. . k e l ed ow surgical correction of the fistula. b la M kn i a y d v a d b me is te w. F os w D h (w P INTRODUCTION CASE REPORT s site i h The majorityT of cases of acquired tracheo A 20-year-old male was admitted for evaluation of cough a esophageal fistulas (TEF) result from and loss of weight for two months. He reported that the For correspondence: M. J. Pappachan, Department of Internal Medicine, Kottayam Medical College, Kerala - 686 008, India. E-mail:
[email protected]
Key words: Denture, non-resolving pneumonia, tracheo-esophageal fistula
How to cite this article: Parameswari R, Musthafa S, Pappachan JM, Babu A, Thanath JK, Parackal S. Acquired tracheo-esophageal fistula caused by a denture. Indian J Surg 2007;69:??-??.
malignancy.[1] Iatrogenic injury from prolonged tracheal intubation is the commonest cause of non-malignant acquired TEF.[1,2] Diagnosis of a TEF warrants urgent surgical intervention because the delay in treatment can cause catastrophic pulmonary complications resulting from aspiration through the TEF. Denture impaction of the esophagus resulting in an acquired TEF has been very rarely reported in the literature and such a case poses much diagnostic and therapeutic difficulties. [3] Esophageal impaction of an accidentally swallowed denture causing an acquired TEF and non-resolving pneumonia and its surgical correction is reported here. Paper Received: Oct., 2006. Paper Accepted: Dec., 2006. Source of Support: Nil. Conflict of Interest: None declared.
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cough would become more severe while taking food, especially liquids. He tried to avoid drinking fluids for fear of getting bouts of cough and the reduced food intake was accompanied by a weight loss of 6 kg. He had epilepsy in the previous 6 years, which had been inadequately controlled owing to poor compliance to antiepileptic medication. Multiple courses of antibiotics before admission, with a clinical and radiological diagnosis of left lower lobe pneumonia, had given little relief to the cough. Clinical examination revealed anemia and coarse crackles in the left infra-scapular and infra-axillary areas. Chest radiography confirmed the clinical diagnosis of left lower lobe pneumonia [Figure 1a]. No other abnormalities were revealed in the preliminary clinical and laboratory evaluation. A bronchoscopy was performed to exclude the possibility of a tumor or inhaled foreign body causing 19
P. Rekha, et al.: Acquired tracheo-esophageal fistula
m rf o d s a o ion l n at w non-resolving left lower lobe pneumonia. It showed a frequent cause of acquired TEF is c fromnon-malignant i o l fistulous opening at the lower end of trachea [Figure 2a, iatrogenic and results prolonged tracheal d ub denture as a cause of acquired white arrow]. A biopsy from that site revealed nonintubation. Impacted e specific inflammation only. Esophagoscopy and barium non-malignant is rare . and poses much diagnostic PTEF ) retherapeutic esophagography [Figure 1b] confirmed the presence of and challenges. f w om rIn clinical a TEF.
o o practice, the most commonly encountered f esophageal n c . k Further probes into the patient’s history revealed that foreign bodies in adults are impacted meat e ordbones. Usewof dentures increases l he had started getting the coughs a few days following the risk of impaction b ebecausenthey o an episode of generalized seizures. He had been missing decrease the palatal sensations leading to a il taken M misjudging k usually a denture following the seizures. The patient was of the size of the swallowed bolus of food. a d y up for surgery and through a cervical approach the fistula Impaction occurs at the cricopharynx and the v b removal e of the object was dissected. The impacted dentureawas removed if delayed, may result in local d m [Figure 2b, black arrow] after separating the trachea from necrosis and formation of a TEF. Swallowing dentures s . i te of thew and dental plates has been the esophagus. Tracheal and esophageal ends a cause of distress among s F fistulous track were freshened. The tracheal end was elderly patients and may result w o w gets impacted in the esophagus.in a TEF if the denture D sutured horizontally with interrupted vicryl sutures h Pesophageal ( also (coated with polyglactin). The end was e t s i the samesimaterial. A pedicled Regardless of the etiology, the sequelae of the TEF are sutured in two layers with strap muscle flap washinter-positioned the the same: tracheobroncheal contamination with Tand wasaheld in placebetween trachea and esophagus with coated significant pulmonary compromise and inadequate Figure 1: (a) Chest radiograph showing left lower lobe pneumonia, (b) Barium esophagogram showing the tracheoesophageal fistula
Figure 2: (a) Bronchoscopic view of the tracheo-esophageal fistula (white arrow). (b) Denture being removed at surgery (black arrow)
[1,2]
[3]
[3]
polyglactin suture in order to reinforce the closure for prevention of recurrence of the fistula. The wound was closed with suction drain. After surgery, the pneumonia resolved completely and he regained his original weight within a period of two months.
DISCUSSION A majority of the cases of acquired TEFs are a result of complication of malignancy. The tumors of the esophagus, lung, trachea, larynx, thyroid, and lymph nodes can cause TEF.[1] Acquired non-malignant TEFs result from a variety of causes such as iatrogenic injuries, granulomatous infections (tuberculosis, histoplasmosis, candidiasis, syphilis, and actinomycosis), inflammations (Crohn’s disease and Behcet’s disease), blunt and penetrating chest trauma, ingestion of foreign bodies and corrosives, AIDS, prior esophageal and tracheal surgery, and indwelling stents. The most
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nutrition.[1] Symptoms and signs are due to the increase in tracheal secretions and aspiration during swallowing resulting in paroxysms of cough and recurrent pneumonia. Patients may try to avoid food and drinks for fear of choking spells and may report presence of food particles in the expectorated material. Bronchoscopy, esophagoscopy, fistulography, and computed tomography might aid the diagnosis of TEF but clinical suspicion in a patient at high risk is more crucial considering increased morbidity and mortality in cases of delayed diagnosis and treatment. Once diagnosed, surgical correction of acquired TEF is usually required because spontaneous closure is rare and the delay in repair is hazardous. Surgical repair usually gives good results in acquired TEF resulting from non-malignant diseases and recurrences are rare.[4,5] Tracheo-esophageal fistula from malignancy, which accounts for more than 50% of acquired TEFs, is a
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P. Rekha, et al.: Acquired tracheo-esophageal fistula
devastating complication. It can’t be cured because of the underlying incurable disease process and the most effective treatments are esophageal bypass and esophageal stenting.[1]
4.
REFERENCES 1. 2.
3.
Reed MF, Mathisen DJ. Tracheoesophageal fistula. Chest Surg Clin N Am 2003;13:271-89. Oliaro A, Rena O, Papalia E, Filosso PL, Ruffini E, Piscedda F,
5.
et al. Surgical management of acquired non-malignant tracheo esophageal fistulas. J Cardiovasc Surg (Torino) 2001;42:257 60. Samarasam I, Chandran S, Shukla V, Mathew G. A missing denture’s misadventure! Dis Esophagus 2006;19:53-5. Cherveniakov A, Tzekov C, Grigorov GE, Cherveniakov P. Acquired benign esophago-airway fistulas. Eur J Cardiothorac Surg 1996;10:713-6. Baisi A, Bonavina L, Narne S, Peracchia A. Benign tracheoesophageal fistula: Results of surgical therapy. Dis Esophagus 1999;12:209-11.
m rf o d s a o ion l n at w c do ubli e P . e fr w m) r fo kno .co le ed ow b la M kn i a y d v a d b me is te w. F os w D P e h (w JPGM WriteCon 2007
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