[size=20px]A 25-day old infant girl had intermittent coughing with feeding. An esophageal contrast study was inconclusive and a bronchoscopy showed no evidence of laryngoesophageal cleft but revealed an H type tracheoesophageal fistula. She undergoes repair via a right cervical incision. Five days postoperatively, she is offered oral feeding, but exhibits coughing and aspiration with every feed.

 

The next best step in management of this patient with an H type fistula is

 

A bedside flexible laryngoscopy.

 

B esophagogram.

 

C video fluoroscopic swallowing study.

 

D rigid bronchoscopy.

 

E neck ultrasound.[/size]

D

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D

think again my dear

think again my dear

Can be Recurrence nerve injury (most likely) or recurrent TEF

Can be Recurrence nerve injury (most likely) or recurrent TEF. If Laryngoscopy will show vocal cord paralysis - no need for tracheoscopy. If there is no vocal cord palsy - tracheoscopy.

B

think again my dear

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a

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c

a

correct

 

Isolated H type tracheoesophageal fistula accounts for about four percent of tracheoesophageal anomalies with a reported incidence of 1:50,000 to 100,000 live births. Classic symptoms are coughing and choking with feeding, recurrent pneumonia and increased air in the stomach. Standard initial investigation is a contrast study of the esophagus. It is best accomplished with the baby or child prone with a tube placed into the distal esophagus. Contrast is then injected as the tube is pulled back to best identify the fistula as it typically courses from caudad to cephalad from the esophagus to the trachea. An H type fistula can also be identified by computerized tomography or magentic resonance scanning.

 

In some instances, the fistula will only be seen on a bronchoscopic exam. However, it is often obscured by a fold in the membranous trachea and can be overlooked. Passage of a small catheter can confirm the presence of the fistula if the catheter disappears into the posterior fold without resistance. The vast majority of these fistulae are located from the C5 to T3 level and can be repaired through a lower right anterior neck incision.

 

Postoperative complications include stricture, recurrence, tracheomalacia and manifestations of recurrent laryngeal nerve injury. Both the right and left nerves are at risk. The left nerve courses lower than the right and can be difficult to see from the right side. On the other hand, the right recurrent laryngeal nerve is in the field during most of the dissection. While there are no large series of H type fistulae, and objective documentation of postoperative vocal cord paralysis is scant, descriptions of voice hoarseness or difficulty with oral feeding have been reported. The symptoms often resolve over time and differentiation between a transient recurrent laryngeal neuropraxia and a permanent injury will require expectant management over a period of several months.

 

The patient in the scenario described above would not likely have a recurrent fistula so quickly, so suspicion of vocal cord dysfunction should be high based on the symptoms presented. Laryngoscopy would best define this.