AJR 2003; 180:212
© American Roentgen Ray Society
Trauma Cases from Harborview Medical Center |
Tracheoesophageal Fistula from a Gunshot Wound to the Neck
Jeffrey P. Kanne1,
Eric J. Stern and
Timothy H. Pohlman
1 All authors: Department of Radiology, Harborview Medical Center, University of
Washington School of Medicine, 325 Ninth Ave., Box 359728, Seattle, WA
98104-2499.
Received July 2, 2002;
accepted after revision July 2, 2002.
This is another in the continuing series on radiology in trauma cases from
the Harborview Medical Center. Editors: Fred A. Mann and Lee B. Talner.
Address correspondence to F. A. Mann.
A 40-year-old woman sustained a T2-pedicle fracture, fractures of the right
posterior second and third ribs, and a contusion of the apex of the right lung
with subcutaneous and mediastinal emphysema resulting from a self-inflicted
rifle wound to the left side of her neck. Surgical exploration of the left
neck revealed a through-and-through esophageal perforation, which was
repaired, as well as an injury to the C7-T1 intervertebral disk. No tracheal
injury was identified. On postoperative day 5, the patient underwent
single-contrast esophagography to evaluate the integrity of the esophageal
repair. Iodinated contrast material was seen leaking from the esophagus into
the mediastinum at the surgical anastomosis, as well as into the airway
(Fig. 1A). Contrast-enhanced CT
of the neck and chest was performed, which showed a previously undiscovered
direct communication between the esophagus and the trachea at the level of the
aortic arch, distal to the surgical repair
(Fig. 1B).
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Fig. 1A. —40-year-old woman with tracheoesophageal fistula resulting
from gunshot wound to neck. Single-contrast esophagogram obtained on
postoperative day 5 shows that contrast material is leaking into bronchi and
is outlining distal trachea. Anastomotic leak (black arrow) adjacent
to surgical drain is also visible. Metallic bullet fragments (white
arrows) are adjacent to leak.
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Injury involving both the trachea and the esophagus should be suspected in
all patients who have had a projectile traverse the mediastinum or neck.
Symptoms of tracheoesophageal injury vary depending on the size of the
fistula. Coughing attacks after swallowing suggest the presence of tracheal or
esophageal injury. However, with smaller fistulas, symptoms may be subtle or
may not initially be evident. Thus, urgent performance of thorough clinical,
endoscopic, and imaging evaluations is the standard of care for patients with
penetrating injuries believed to have traversed the expected course of the
aerodigestive tract.
The presence and extent of the tracheoesophageal fistula can be diagnosed
on esophagography and CT; supplemental information may be acquired with
esophagoscopy and bronchoscopy
[1]. In addition to direct
signs of tracheoesophageal fistula, imaging can also show indirect findings of
the communication, such as pneumonia, gaseous distention of the esophagus,
pneumomediastinum, and subcutaneous air.
In simultaneous injuries of the esophagus and the trachea, repair of the
airway can be jeopardized if it becomes infected by the salivary stream from
an unrecognized esophageal perforation or from a leaking repair. Treatment of
acquired tracheoesophageal fistula is surgical, with complete separation of
the two structures and interposition of a muscle flap, if necessary
[2,3,4].
Imaging can play an important role in the early diagnosis and comprehensive
characterization of aerodigestive tract injuries and helps form the foundation
of successful therapies
[5].
References
- Vasquez RE, Landay M, Kilman WJ, Estrera A, Schreiber T. Benign
esophagorespiratory fistulas in adults. Radiology
1988;167:93
-96[Abstract/Free Full Text]
- Coleman FP, Bunch GH Jr. Acquired nonmalignant
esophagotracheobronchial fistula. J Thorac Surg
1950;19:542
-558
- Wychulis AR, Ellis FH Jr, Anderson HA. Acquired nonmalignant
esophagotracheobronchial fistula. JAMA
1966;196:117
-122[Abstract/Free Full Text]
- Kelly JP, Webb WR, Moulder PV, Moustouakas NM, Lirtzman M.
Management of airway trauma II: combined injuries of the trachea and
esophagus. Ann Thorac Surg
1987;43:160
-163[Abstract]
- Kelly JP, Webb WR, Moulder PV, Everson C, Burch BH, Lindsey ES.
Management of airway trauma. I. Tracheobronchial injuries. Ann
Thorac Surg 1985;40:551
-555[Abstract]
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