What is the pathophysiology of acquired nonmalignant tracheoesophageal fistula (TEF)?

Updated: Nov 07, 2018
  • Author: Sat Sharma, MD, FRCPC; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
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Answer

Traumatic TEFs occur secondary to either blunt trauma or open avulsion injury to the neck and thorax. In blunt traumatic injuries, the TEF is intrathoracic and is usually located at the carina level. The TEF appears several days later as a result of tracheal wall necrosis. TEFs caused by endotracheal tube intubation depend on several factors, including prolonged intubation, an irritating or abrasive tube, and pressure exerted by the cuff. Pressures exceeding 30 mm Hg can significantly reduce mucosal capillary circulation and result in tracheal necrosis. Cuff pressure is particularly risky when exerted posteriorly against a rigid nasogastric tube in the esophagus. Poor nutrition, infection, and steroid use cause tissue alteration, which predisposes patients to development of TEFs.

TEFs occur uncommonly at the time of tracheostomy or secondary to improper positioning of the tracheal tube because of improper tracheal incision. The malpositioned tracheostomy tube exerts posterior pressure against the esophagus, resulting in tissue damage and a TEF.

In areas and populations where tuberculosis (TB) is still common, involvement of the esophagus and mediastinal lymph nodes may result in an acquired tubercular TEF. Diagnosis is established at endoscopy and biopsy; treatment is with antitubercular therapy—rarely, surgical repair may be required. [1]


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