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Four cases of H-type tracheoesophageal fistula are reported. The patients all had chronic aspiration from the esophagus. Although serious symptoms were present in all, definitive diagnoses were not made until the patients had reached 1, 6, 12, and 50 years of age, because ordinary radiologic methods failed to establish the diagnosis. The angulation of the fistula usually prevents contrast medium in the esophagus from entering the trachea, especially with the subject upright. On the other hand, air easily passes from the trachea to the esophagus, eventually producing megaesophagus which may be confused with the picture of achalasia. An ill-advised Heller esophagomyotomy was done on 1 patient. All 4 patients eventually had successful closure of the fistulas. Three operations were by the transthoracic route, and 1 high fistula in an infant was closed through a cervical approach.

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