S2034 Wrong Tube: A Mysterious Case of Dysphagia in a Patient with Tracheostomy

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Introduction: Dysphagia simply means difficulty swallowing. It occurs in 11% to 93% of patients following tracheostomy and is therefore one of the most common side effects seen after the procedure [1]. We present a case of dysphagia following tracheostomy with unusual endoscopic findings. Case Description/Methods: An 83-year-old male with a past medical history of laryngeal cancer treated with partial laryngectomy followed by complete laryngectomy and permanent tracheostomy. Complete laryngectomy and tracheostomy were performed 15 years prior to his presentation. He presented with a chief complaint of dysphagia. Patient had dysphagia to both solids and liquids associated with weight loss for 6 months’ duration. Patient was in no acute distress. A diagnostic upper endoscopy was done which showed a trachea-esophageal fistula through which the tracheostomy tube was seen penetrating the esophageal wall. Patient was subsequently referred to ENT for possible removal of tracheostomy and consideration of esophageal stenting in an attempt to heal the trachea-esophageal fistula. Discussion: Some of the proposed hypotheses for dysphagia after tracheostomy include loss of hypomandibular muscle group function and a delayed trigger in the swallowing response [1-2]. More commonly it is seen with esophageal compression which can sometimes cause excessive pressure on the posterior wall of the esophagus leading to tracheoesophageal fistula as well [3]. In our case, the tracheostomy tube was seen penetrating the wall of the esophagus. We propose this likely occurred due to excessive pressure by the tracheostomy tube eventually causing necrosis, tissue breakdown and fistula formation through which the tube slowly migrated into the esophagus, presenting with symptoms of dysphagia. Fortunately the patient was stable from a respiratory perspective with adequate gas exchange thought to be secondary to the fenestrated tracheostomy which allowed for air ventilation despite misplaced position. To our knowledge this is one of the first reported cases of such a complication which makes this a unique case. It gives us ground for early endoscopy to rule out any structural defects similar to this in a patient with a tracheostomy presenting with dysphagia.Figure 1.: Tracheostomy penetrating esophageal wall visualized during endoscopy.