NOT ALL THE ASPIRATIONS ARE COMING FROM THE OROPHARYNX

Abstract

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Aspiration is the entry of oral or gastric materials into the lungs leading to chemical pneumonitis, bacterial infection, or airway obstruction. Frequent conditions that predispose aspiration result from reduced level of consciousness without airway protection, neurologic disorders, or dysphagia from gastrointestinal tract disorders. While the most common route of aspiration is oropharyngeal, tracheoesophageal fistula (TEF) may initially present in the same manner. We present a middle-aged male with repeated aspiration pneumonia and pneumonitis secondary to TEF. CASE PRESENTATION: A 58-year-old male with history of squamous cell lung carcinoma stage IIIa in remission after chemoradiation and recurrent aspiration pneumonia with gastrostomy tube. Presented to the hospital in hypoxic respiratory failure due to sudden onset of dyspnea after attempting tube feeds. Initial evaluation was significant for leukocytosis and normal procalcitonin level. A CT of the chest showed ground glass opacities with consolidation in bilateral upper and lower lobes and tree-in-bud pattern. A bronchoscopy revealed tracheobronchial erythema with multilobar exudate and large tracheal fistula. An Upper GI series identified aspiration coating the trachea and left main bronchus. The patient was diagnosed with chemical pneumonitis and aspiration pneumonia secondary to tracheoesophageal fistula most likely from recurrent infections and radiation. He was transferred to a tertiary care center for esophageal and tracheal stent placement. DISCUSSION: TEF is an abnormal connection between the trachea and the esophagus that is mostly congenital, and in rare occasions can be acquired most commonly through esophageal malignancy, trauma, and chemoradiation. TEF is often associated with abnormal esophageal motility causing recurrent pneumonia and acute lung injury from chemical pneumonitis. Diagnosis of TEF as a result of these conditions can be challenging, but the preferred diagnosis method is direct visualization with esophagoscopy or bronchoscopy. Treatment consists of interventional procedures including airway and/or esophageal stent placement. It is the most common approach to prevent liquid leakage and help with the healing. Biological glue or thermal ablation can also be performed, as well as surgical intervention or conservative management. CONCLUSIONS: The patient presented with respiratory failure secondary to recurrent aspiration pneumonia and chemical pneumonitis who failed therapy with gastrostomy tube placement, due to tracheoesophageal fistula. TEF is a rare complication of chemoradiation that increases morbidity and mortality. It can be treated with airway/esophageal stent placement or more invasive surgical intervention. It is important to expand work up and differential diagnosis in patients with aspiration who continue failing therapy to include endoscopy for direct visualization of anatomical abnormalities. REFERENCE #1: Ke M, Wu X, Zeng J. The treatment strategy for tracheoesophageal fistula. J Thorac Dis. 2015;7(Suppl 4):S389-S397. doi:10.3978/j.issn.2072-1439.2015.12.11 REFERENCE #2: Abugroun A, Ahmed F, Singh N, Nadiri M. Late Onset Chemo/Radiation Induced Tracheoesophageal Fistula in Squamous Cell Cancer of the Lung. World J Oncol. 2017;8(5):171-173. REFERENCE #3: Lo WL, Leu HB, Yang MC, et al. Dysphagia and risk of aspiration pneumonia: A nonrandomized, pair-matched cohort study. J Dent Sci 2019; 14:241. DISCLOSURES: No relevant relationships by Nehal Bhatt, source=Web Response No relevant relationships by Joshuam Ruiz Vega, source=Web Response