Oesophageal perforation presenting as oesophageal atresia in a premature neonate following difficult intubation

Abstract

Iatrogenic oesophageal perforation in neonates is well recognized in the medical and surgical literature with intubation injury listed as a possible contributing mechanism besides nasogastric tube placement and suctioning. Diagnosis can be difficult and sometimes confused with other entities. With early diagnosis, nonsurgical management often leads to complete resolution in neonates. We report the case of a 1-day-old premature neonate who was brought to the operating room with the preliminary diagnosis of proximal oesophageal atresia with stump perforation and distal tracheo-esophageal fistula. His intubation for respiratory distress at birth had been difficult due to Pierre-Robin sequence with micrognathia. Oesophagoscopy in the operating room revealed a patent oesophagus but perforations in the pharynx and in the proximal oesophagus with the nasogastric tube entering the pharyngeal perforation. Oesophageal perforation and the limitations of the difficult airway algorithm in small neonates are discussed.

Changes in resuscitation practice at birth

“…3 More serious injuries including vocal cord avulsion and tracheal or oesophageal perforation have been reported. [4][5][6] Systemic adverse effects of airway manipulation during laryngoscopy and intubation include tachycardia or bradycardia, hypoxaemia, hypertension, [7][8][9] and raised intracranial pressure. [10][11][12] Such adverse responses have been implicated as contributory factors in the aetiology of intraventricular haemorrhage.…”

Easily missed, potentially fatal complication in an extremely preterm infant

“…It may be misdiagnosed as oesophageal atresia due to compression of the lumen of the oesophagus by mass effect created by the false passage. Misdiagnosis can lead to unnecessary surgery 4 5. Contrast oesophagography is helpful in confirming the diagnosis; however, it is important to use a low osmolar contrast medium due to the risk of chemical mediastinitis.…”

KTP laser: An important tool in refractory recurrent tracheo-esophageal fistula in children

“…Upper pouch injuries are not uncommon and can be due to oesophageal tube passage [2,3], operative dissection or even attempts at endotracheal intubation [4]. The fibrosis seen around the upper pouch may have been indicative of healing of the oesophageal injury seen at the first operation.…”