Tracheoesophageal Fistula Workup

Updated: Nov 07, 2018
  • Author: Sat Sharma, MD, FRCPC; Chief Editor: Vinay K Kapoor, MBBS, MS, FRCSEd, FICS, FAMS  more...
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Imaging Studies

Prenatal diagnosis of congenital tracheoesophageal fistulas (TEFs)

Prenatal ultrasonography may reveal polyhydramnios, absence of fluid-filled stomach, small abdomen, lower-than-expected fetal weight, and a distended esophageal pouch.

Postnatal diagnosis of congenital TEFs

Note the following:

  • Plain chest radiographs may reveal tracheal compression and deviation. Absence of a gastric bubble indicates esophageal atresia without a TEF or esophageal atresia with a proximal TEF. Chest radiography leads to the diagnosis of TEF in most cases of congenital TEF, and other investigations are rarely required.

  • Aspiration pneumonia in the posterior segments of the upper lobes may occur secondary to aspiration of the contents from the esophageal pouch or stomach. Recurrent or massive aspiration may lead to acute lung injury in some patients. (Infiltrates occur diffusely in these patients.)

  • Insertion of a nasogastric tube may show coiling in the mediastinum of patients who have concomitant esophageal atresia. This finding is diagnostic of TEFs associated with esophageal atresia.

  • Contrast studies are seldom required to confirm the diagnosis. These studies have the risk of aspiration pneumonitis and pulmonary injury, and they add minimal information to the diagnostic workup. If the contrast study is performed, 1-2 mL of barium is instilled through an 8F catheter placed into the esophagus. Chest radiographs are taken in the lateral decubitus position as well as the anteroposterior position to detect spilling of the contrast into the trachea.

  • Use of multidetector-row CT scans have made 3-dimensional (3D) displays of many organs and structures a popular clinical examination tool, as the quality of images has markedly improved. Presence of TEF was correctly diagnosed with multidetector-row CT esophagography. Furthermore, the images provided crucial information for planning surgery, and, without contrast medium, it is a less invasive examination.

Diagnosis of acquired TEFs

Acquired TEFs can be diagnosed by instillation of contrast media into the esophagus or during direct visualization by flexible esophagoscopy or bronchoscopy. Either method can be useful, depending on the individual center's expertise and experience.

Some clinicians prefer to visualize the fistula and assess its exact location prior to surgery. The diagnosis of a TEF secondary to malignancy is confirmed by contrast radiography, esophagoscopy, bronchoscopy, and clinical testing (methylene blue).



Flexible esophagoscopy or flexible bronchoscopy may be useful in the diagnosis of acquired tracheoesophageal fistulas (TEFs). Either or both of these procedures may be required to evaluate the anatomy of these structures and to exclude an unsuspecting mucosal lesion. The role of endoscopic procedures is especially important in localizing the acquired nonmalignant or malignant TEF.