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A case of cough and dysphagia
Q1: What abnormalities are seen on the computed tomogram (fig 1; see p 104) and on views of the right main bronchus at bronchoscopy (fig 2; see p 105)?
The computed tomogram shows the presence of a large fistula between the right main bronchus and oesophagus, with resultant areas of shadowing seen in both lungs due to aspiration. At bronchoscopy, the oesophagus containing the nasogastric tube can be visualised through the fistula.
Q2: What is the most likely cause of these appearances?
The most likely cause of these appearances is a malignant broncho-oesophageal fistula. Oesophageal biopsies confirmed adenocarcinoma.
Q3: What other conditions may cause similar appearances?
Non-malignant causes of oesophago-respiratory fistula include congenital lesions, infection, and trauma.
Q4: What treatment options are available?
Possible treatment modalities include:
Insertion of oesophageal stent.
Malignant oesophago-respiratory fistula is estimated to develop in 4.5% and 0.3% of all primary oesophageal and bronchial carcinomas respectively.1 It is associated with a dismal prognosis, with a median survival for untreated cases of between one to six weeks. Typical features include cough, which is worse on swallowing (Ono's sign), aspiration, fever, dysphagia, and pneumonia. Appropriate investigations include bronchoscopy, oesophagoscopy and contrast radiography, although all may be misleadingly normal. Initial management is primarily aimed at reducing pulmonary contamination from the fistula, and should be started as soon as possible after diagnosis, as delay is associated with exponential increase in early mortality. Immediate treatment includes keeping the patient nil by mouth, and providing general supportive therapy, including broad spectrum antibiotics where appropriate. Insertion of an oesophageal stent, which occludes the opening of the fistula, is generally effective in preventing pulmonary aspiration, but may be complicated by bleeding, migration, oesophageal obstruction, and perforation.2 Surgical techniques, including oesophageal exclusion or by-pass, are associated with high operative mortality, but result in effective symptom palliation in survivors.
Congenital oesophago-respiratory fistulae generally present in early childhood, although are occasionally not diagnosed until adult life.3 Other reported causes of fistula include tuberculosis,4 and herpes virus infection, chest trauma, and pressure necrosis from tracheal cuff after prolonged ventilation. Surgical repair is generally required for non-malignant oesophago-respiratory fistulae, but lesions may be amenable to less invasive techniques, including closure with fibrin glue applied via the bronchoscope.
Oesophageal carcinoma resulting in broncho-oesophageal fistula and bronchopneumonia.