From the Guidelines
Tracheoesophageal fistula (TEF) typically presents with respiratory distress, choking, coughing, or cyanosis during feeding in newborns, and its management should prioritize preventing complications and improving quality of life (QOL) through prompt surgical repair and multidisciplinary follow-up, as highlighted by the International Network on Oesophageal Atresia (INoEA) consensus guidelines 1. The classic presentation of TEF includes the "3 Cs": coughing, choking, and cyanosis during feeding, along with excessive salivation and regurgitation. In the most common form (esophageal atresia with distal TEF), infants may have difficulty swallowing, with saliva pooling in the blind-ending esophageal pouch, leading to drooling and respiratory complications from aspiration. Key diagnostic findings include:
- Inability to pass a nasogastric tube into the stomach
- Radiographic studies, such as plain chest X-ray showing the tube coiled in the upper esophageal pouch
- Contrast studies in some cases
- Prenatal suspicion of TEF when polyhydramnios is detected on ultrasound Abdominal distension may occur as air enters the stomach through the fistula, and pneumonia or respiratory distress can develop from gastric contents refluxing through the fistula into the lungs. In adults with acquired TEF, presentation typically includes chronic cough, recurrent pneumonia, and symptoms worsening with swallowing or lying flat. Management requires:
- Prompt surgical repair to prevent complications
- Initial stabilization focusing on preventing aspiration through proper positioning and suction of secretions
- Multidisciplinary follow-up to address long-term complications, such as gastro-oesophageal reflux disease (GERD), peptic oesophagitis, gastric metaplasia, and Barrett oesophagus, as well as respiratory and psychological issues 1.
From the Research
Presentation of Tracheoesophageal Fistula
The presentation of tracheoesophageal fistula (TEF) can vary, but common symptoms include:
- Severe coughing symptoms 2
- Recurrent aspiration pneumonia 2
- Ventilator air leaks and recurrent pneumonia 3
- Feeding difficulties, such as prolonged meal time, feeding refusal, coughing during feeding, and vomiting during feeding 4
- Growth retardation, including stunting, wasting, and underweight 4
Diagnostic Methods
Diagnostic methods for TEF include:
- Flexible bronchoscopy, which is the main diagnostic modality 5
- Imaging modalities, such as CT scans of the chest 5
- Modified esophagram, which is an effective and reliable method for diagnosing recurrent TEF 4
Management and Treatment
Management and treatment of TEF may involve:
- Noninvasive positive airway pressure support 5
- Surgical techniques, such as tracheopexy and tracheostomy 5
- Endoscopic repair, which has gained popularity as a safer first-line treatment for recurrent TEF 6
- Open surgical repair, which is considered the gold standard but is associated with significant morbidity and rates of recurrence 6
- Optimized preoperative management, including continuous aspiration to prevent reflux and aspiration pneumonia, and enteral nutrition through a jejunal feeding tube 4