Tracheoesophageal fistula.

A 70-year-old woman with lymphoma had undergone concurrent radiation and chemotherapy. During the final weeks of radiation therapy, she began to experience difficulty swallowing.

We performed a clinical swallowing evaluation and fiberoptic endoscopic evaluation of swallowing (FEES). FEES revealed normal oropharyngeal swallowing function and no prandial aspiration. However, we did observe that large amounts of applesauce and milk, which had been administered during FEES, would be expelled from the lower airway on reflexive coughing (figure 1). Given the high sensitivity and specificity of FEES in identifying prandial aspiration, our leading diagnosis was tracheoesophageal fistula. Indeed, a barium-swallow study did reveal the presence of a tracheoesophageal fistula in the mid-esophagus (figure 2, A).

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The patient underwent stenting of both her esophagus and right mainstem bronchus. A follow-up contrast study revealed patent stents and no fistula (figure 2, B). The patient was placed on a mechanical soft diet with thin liquids, and she was able to swallow without difficulty.