Unrecognized tracheo‐oesophageal fistula

Abstract

Tumours which arise in the wall of either the oesophagus or the respiratory tract may extend to involve the contiguous wall of the other structure and create a fistula. There may be no suggestive symptoms of a tracheo-oesophageal fistula (TOF) pre-operatively and signs may appear for the first time during anaesthesia when positive pressure is applied to the airway. Case reportAn emaciated, 57-year-old male, who weighed 45 kg was admitted because of progressive dysphagia; liquids were swallowed easily but semisolids only with difficulty. A squamous cell carcinoma of the floor of the mouth had been treated by extensive resection, including right radical neck dissection, 7 years earlier. It was not possible to pass a nasogastric tube.Barium swallow showed a large retropharyngeal mass which pushed the pharynx and trachea forwards. There was a constant puddle of secretions in the pharynx and perilaryngeal areas which made indirect laryngoscopy difficult. Recurrence of the carcinoma with metastasis was suspected and examination of the posterior pharynx, larynx and oesophagus, both to determine the extent of the tumour and also to obtain a biopsy prior to palliative radiotherapy, was required. The patient also had widespread atherosclerosis including cerebral atherosclerosis, chronic obstructive pulmonary disease, severe arthritis and Korsakow's psychosis secondary to chronic alcoholism.An intravenous infusion was started; a blood pressure cuff, electrocardiograph (ECG) and a precordial stethoscope were attached to the patient. Laryngoscopy was attempted under topical anaesthesia. The patient was very uncooperative and started to fight and move around. He became cyanosed and retained secretions. Oxygen was given andaslow infusion with Thalamonal (droperidol and fentanyl, 50: 1 ; 10 ml in 500 ml5% dextrose) was started. A 16-gauge catheter was inserted percutaneously through the cricothyroid membrane into the trachea under local anaesthesia without difficulty after 50 ml of solution had been given. The patient was then ventilated with intermittent jets of oxygen at 345 kPa (50 psi). The chest did not appear to expand although breath sounds were audible on auscultation and there was good diaphragmatic movement. A further attempt at laryngoscopy was made but the patient was moving and three doses of thiopentone, 50 mg each, followed by suxamethonium 20 mg intravenously were given. Laryngoscopy was then carried out. The pre-operative blood pressure of 160/100 mmHg decreased to a systolic pressure of 80 mmHg by palpation and the pulse rate from 120 to 80/minute. The patient became cyanosed despite hyperventilation with oxygen through the catheter.The patient's trachea was now intubated with