Life-threatening Choking Caused by Unrecognized H-type tracheo-esophageal Fistula

Abstract

H-type tracheo-esophageal fistula (TEF) is a rare congenital anomaly. Although typical symptoms, such as easy choking and frequent cough, are often noted since birth, the disease is frequently not recognized. We report a 2-month-old infant with H-type tracheo-esophageal fistula. She had symptom/signs of TEF at birth, but the disease was not considered by pediatric facilities at two centers and three local medical departments. Two episodes of life threatening choking were noted at 2 m/o. The choking was so severe that cardiopulmonary resuscitation and ventilator use was necessary. The disease being suspected and then confirmed by esophagography, surgical treatment was arranged. Since surgical treatment, the patient has well with no further episodes of choking. H-type tracheo-esophageal fistula (TEF) is one subtype of congenital esophageal anomaly. Patients with H-type fistula often suffer from choking, and its complications, such as aspiration pneumonia and asphyxiation were the major cause of mortality and morbidity before the 1940s. Surgical repair has become the standard treatment since the 1940s; its complications were rare and survival rates were high. Early diagnosis and treatment are the major factors for better outcome in recent years. Unfortunately, early diagnosis is still a challenge today. Clinicians' failure to recognize the disease is the major cause. Technical examination that cannot totally diagnose the disease is another reason. Here we report one case with frequent choking since birth, but it was not timely diagnosed. Due to a lack of awareness by physicians, two episodes of severe choking almost deprived her of life. We will discuss why H-type fistula is often not diagnosed early by clinical evaluation, and the difficulties of technical examination.