A 74-year-old male, non-smoker presented with dysphagia for 2 days. About 3 years previously, he was diagnosed with poorly differentiated squamous cell carcinoma of the oesophagus (upper third), by imaging and biopsy. At that time he was treated with concurrent chemoradiation therapy (5-fluorouracil and cisplatin, plus radiotherapy for a total of 50.4 Gy). A feeding gastrostomy tube was also implanted. Over the following years, dysphagia due to oesophageal strictures occurred seven times and he was treated with endoscopic oesophageal dilatation. During hospitalisation for his endoscopic oesophageal dilatation, an orifice over the upper third of the oesophagus was found incidentally (fig 1A). No symptoms such as suffocation, cough or fever were noted. Bronchoscopy (fig 1B) and computed tomography (fig 1C) confirmed the presence of a tracheo-oesophageal fistula (TEF), measuring about 2.5–4.0 mm in diameter, between the tracheal lumen at the level of about 3 cm above the carina and oesophagus. An oesophageal stent was implanted, but 2 months later he was readmitted because of tracheal stenosis and received medical treatment.

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Figure 1

(A) Upper gastrointestinal endoscopy revealing suspected hole/fistula over the oesophagus (arrow) 20 cm from the patient’s mouth. (B) Bronchoscopy showing an orifice (arrow), 3 cm above the carina (arrowhead), in the trachea. (C) Computed tomography scan (transverse and sagittal view) showing a fistula (arrow) between the tracheal lumen and the oesophagus.

A TEF is a communication between the trachea and oesophagus and often leads to severe and fatal pulmonary complications such as aspiration or suffocation. Acquired TEFs develop secondary to malignant disease, infection, ruptured diverticula, and trauma. The most frequent sign of TEF is coughing after swallowing. A high index of suspicion is required in patients at risk of developing a TEF. The diagnostic evaluation is by bronchoscopy and oesophagoscopy.1 Currently, self expanding metal stents, instead of traditional surgery, have become the treatment of choice in these situations.2 They improve survival and quality of life for these unfortunate patients.