ENT

1. Surgery Lecture
MUHAMAMD ATIF KHAN
ASSISTANT PROFESSOR SUII
HFH RAWALPINDI

2. Clinical Presentation
ADULTS
Cough (56%), Aspiration (37%),
Fever (25%), Dysphagia (19%),
Pneumonia (5%),
Haemoptysis (5%) chest pain
(5%)
worsening cough with swallowing
solid/liquid
NEWBORNS
Excessive salivation and
Violent response during feeding : (3 C
s) • Coughing • Chocking • Cyanosis
Fluid returns through the mouth and
nostrils
Frothy salivation
constant drooling of saliva from the
mouth
Aspiration Pneumonia
FAETUS
maternal polyhydramnios
Absence of stomach gas on prenatal
ultrasonography

3. Clinical Examination
• Abdominal distention
• Inability to pass
nasogastric tube due to
resistance.

4. Differential Diagnoses
Tracheo-Esophageal Fistula
Tracheomalacia
Esophageal Stricture
Esophageal Diverticula
Esophageal Cancer

5. Investigations

6. CXR
• Curling of the nasogastric
tube in a dilated proximal
esophagus
• Gas distally in the gastric
cavity
• Hyperinflated lungs.

7. Flouroscopy
• Opacification of the esophagus.
• Immediate opacification of the
trachea and bronchi with
contrast extending into the right
upper lobe.

8. Bronchoscopy:
Shows fistula between trachea
and esophagus.

9. PRENATAL WORKUP:
a) Ultrasound :
polyhydramnios, absence of fluid filled
stomach, a small abdomen, and a
distended esophageal pouch.
a) Fetal MRI: Confirmatory.

10. Tracheo-Esophgeal Fistula
• An abnormal connection between
the trachea and the esophagus.
• 1 in 2,500 births

12. Clinical Types

13. RISK FACTORS:
IN ADULTS NEWBORN
Prolonged mechanical ventilation via endotracheal
tube or tracheostomy tube
decongestants that contain imidazoline derivatives
(Alpha-2 agonist)by women during the first trimester
of pregnancy
Excessive cuff pressure of endotracheal tube or
tracheostomy tube
Age of mother < 20 years Elderly mothers
Blunt trauma to the chest or the neck Trisomy 18 ( Edward’s Syndrome)
Traumatic airway injury
Granulomatous mediastinal infections
Stent-related injuries
Ingestion of foreign bodies or corrosive products
Cancers arising from the oesophagus, trachea, lungs,
larynx and thyroid

16. TREATMENT

17. TREATMENT IN NEWBORNS
1.PREOPERATIVE MEASURES :
Attention to the respiratory status of the infant.
Positioning of infant.
Passing of a nasogastric tube.
Decompression of the upper pouch
Upper pouch suction.
IV antibiotics.
IV fluids.
Appropriate timing of surgery
Presence of other associated anomalies like congenital cardiac disease.
TPN.

18. STAGING SURGERY:
1st Stage:
TEF ligated and gastrostomy is done to reduce the risk of reflux to provide
feeding.
2nd Stage:
Both proximal and distal segments are anastomosed at 18-24 months

19. TREATMENT IN ADULTS:

20. A case of malignant tracheo-oesophageal fistula (TOF) after a surgical resection of oesophageal cancer followed by radiation treatment. a) Oesophagogram showing
the contrast leak in right upper lobe airways (arrowhead); b) computed tomography scan of the chest showing the defect at the level of right mainstem bronchus
(arrowhead); c) bronchoscopic view of the TOF at the posterior wall of proximal right bronchus intermedius; d) oesophageal endoscopic view of the same TOF
showing the fistula and mucosal abnormalities; e) TOF closure utilising Alloderm (*) and self-expanding metallic stent in the trachea.

21. A case of malignant tracheo-oesophageal fistula (TOF) from metastatic oesophageal cancer after radiation treatment followed by oesophageal self-expandable metallic
stent placement: a) computed tomography scan of the chest showing TOF (arrowhead) at the level of proximal end of the oesophageal stent; b) bronchoscopic view
showing muscosal abnormality obscuring the view of the fistula at the posterior wall of the trachea. c) A close-up bronchoscopic view of TOF; the oesophageal stent
can be seen at the bottom of TOF (arrowhead). d) A case of iatrogenic TOF: closure with Alloderm (*) and covered, self-expandable metallic stent in trachea.

22. Surgical Comlications

23. Thank you