For a patient with a history of carcinoma of the pyriform sinus, presenting with dysphagia and stridor, suspected of having a tracheoesophageal fistula, would a Computed Tomography (CT) scan of the neck and thorax with intravenous contrast be more helpful than esophagography in diagnosing the condition?

CECT Neck and Thorax is Superior to Esophagography for Suspected Tracheoesophageal Fistula

For a patient with pyriform sinus carcinoma presenting with dysphagia and stridor concerning for tracheoesophageal fistula, CT neck and thorax with IV contrast should be the initial imaging study, as it has superior sensitivity (86%) compared to esophagography (79%) for detecting leaks and fistulas, and can lead to earlier diagnosis and treatment of lesions missed on esophagography. 1

Diagnostic Performance Comparison

CT Advantages for Fistula Detection

• CT demonstrates 86% sensitivity for detecting leaks and fistulas, compared to esophagography's 79% sensitivity, though CT has lower specificity (33% vs 73%) 1
• The combination of both modalities achieves 100% sensitivity, with esophagography and CT together having a negative predictive value of 100% for excluding leaks 1
• CT is critical when clinical suspicion remains high after negative esophagography, as esophagrams have poor sensitivity (36% in some studies) despite 97% specificity 1

Anatomic Assessment Superiority

• CT with IV contrast better defines neck and chest anatomic structures by delineating normal soft tissue and blood vessel enhancement from postoperative fluid collections, hematomas, and abscesses 1
• CT is superior for evaluating airway involvement, including assessment of tracheal anatomy and complications related to tumor invasion—essential in this patient with stridor 1
• CT provides comprehensive evaluation of both the primary tumor site and potential fistula tract, whereas esophagography only evaluates the esophageal lumen 1

Clinical Algorithm for This Patient

Initial Imaging Strategy

• Order CT neck and thorax with IV contrast as the first-line study given the high clinical suspicion for tracheoesophageal fistula and the presence of stridor indicating airway compromise 1
• Administer oral contrast immediately before CT examination as an adjunct to facilitate interpretation of esophageal integrity, though one study showed this doesn't change sensitivity for leak detection 1
• Do not obtain CT without and with IV contrast, as this offers little additional benefit compared to CT with IV contrast alone 1

If CT is Negative but Suspicion Remains High

• Proceed to single-contrast esophagram with water-soluble contrast first, followed by high-density barium if the water-soluble study is negative 1
• The sensitivity of esophagography increases when high-density barium is administered after water-soluble contrast, whereas CT sensitivity remains the same with or without oral contrast 1

Critical Clinical Pitfalls

Esophagography Limitations in This Context

• Esophagography has unacceptably low sensitivity (36-79%) for detecting fistulas, making it inadequate as the sole initial study when clinical suspicion is high 1
• Esophagography cannot assess airway involvement or tracheal anatomy, which is critical in this patient presenting with stridor 1
• Esophagography provides no information about tumor extent or regional complications such as abscess formation or vascular involvement 1

Why CT Must Be First-Line Here

• Earlier diagnosis with CT leads to earlier treatment of leaks and fistulas that would be missed on esophagography alone 1
• This patient's stridor indicates potential airway compromise requiring immediate anatomic assessment that only CT can provide 1
• The history of pyriform sinus carcinoma necessitates evaluation for tumor recurrence, second primary tumors, and extent of disease—all better assessed by CT than esophagography 1, 2

Complementary Role of Esophagography

• If CT is negative but clinical suspicion persists, esophagography should follow to achieve the 100% combined sensitivity 1
• Esophagography's high specificity (97%) makes it valuable for confirmation when CT findings are equivocal 1