Evidence-Based Diagnosis and Management of ENT Emergencies

Michael Winters, MD


February 15, 2007

TI Fistula

TI fistula is a rare but life-threatening complication of tracheostomy, long-term mechanical ventilation, neck tumors, and tracheal surgery. In patients with a tracheostomy, the incidence of TI fistula ranges from 0.6% to 0.7%.[61] Even with aggressive treatment, mortality approaches 80%.[62]

Patients with a TI fistula secondary to tracheostomy typically present between the first and second week following the procedure.[61,63] Risk factors for TI fistula include tracheal infection, steroid use, and an anomalous innominate artery.[61] The most common site for fistula formation is at the level of the endotracheal cuff. Fifty percent of patients present with massive hemorrhage. The remainder will report a brief episode of bright red blood from the tracheostomy site, referred to as a "sentinel bleed". A sentinel bleed can occur anywhere from hours to days before the onset of catastrophic bleeding. It is imperative that clinicians recognize a sentinel bleed because this may be the only opportunity to intervene while the patient remains hemodynamically stable.

Definitive treatment of a TI fistula requires median sternotomy and ligation of the innominate artery. For patients with massive hemorrhage, a variety of temporizing measures can be performed at the bedside in an attempt to get the patient to the operating room. Because the most common site for hemorrhage is at the level of the endotracheal cuff, the first maneuver is to overinflate the tracheostomy. This technique is reportedly successful in almost 85% of cases.[61,64] In patients in whom overinflation is unsuccessful, replace the tracheostomy with a cuffed endotracheal tube. Ensure that the cuff is placed distal to the site of bleeding to protect the airway. If the endotracheal balloon does not tamponade bleeding, a final maneuver is simply to place a finger in the airway and compress the innominate artery against the posterior sternum.

Maintain a high index of suspicion for a sentinel bleed in tracheostomy patients presenting with hemoptysis or peritracheal bleeding. Patients with a sentinel bleed require urgent thoracic surgery consultation for bronchoscopy. Rigid bronchoscopy is recommended over flexible bronchoscopy for its superior visualization and ability to apply direct pressure. Rigid bronchoscopy should always be performed in the operating room.[61]

Epiglottitis, angioedema, malignant otitis externa, Ludwig's angina, and tracheoinnominate fistula are potentially life-threatening ENT disorders that must be recognized and treated promptly. On the basis of the information provided, the EP can more effectively diagnose and deliver current, evidence-based therapies.


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