Traumatic tracheo-oesophageal fistula following steering-wheel type of injury

Abstract

CONSULTANT TliORAClC SURGEON, N.W. REGIONAL HOSPITAL BOARD INJURIES of the chest wall and lungs are now common as a result of the driver being flung violently against the steering-wheel following a head-on collision.This may result in fractures of the ribs and sternum, pneumothorax, haemopneumothorax, and, very rarely, damage to the trachea and oesophagus resulting in a fistulous communication.When one considers the vast number of traffic accidents and the high speeds of the modern car, it is strange that amongst the many and varied injuries that can result from such accidents tracheo-oesophageal fistula has been reported on only 9 occasions. In addition, 3 similar cases have been recorded following accidents of a different type. T h e case reported appears to be the tenth instance following a steering-wheel injury. CASE REPORTIn the early hours of 9 Dec., 1959, a young man. aged 28 years, driving a saloon car left the road and ran into a tree. He was admitted into a local hospital and found to be suffering from slight concussion, minor facial injuries, a broken nose, and fractures of the first and second ribs on the right, and the first, second, third, fourth, and fifth ribs on the left. The chest was strapped but the strapping was removed on the next day owing to difficulty in breathing. On the day after the accident he coughed up a little blood and on swalloying fluids felt the throat to be 'restricted and blocked . On the fifth day a radiograph showed a left-sided pneumothorax, which was treated by the insertion of a needle and continuous suction. He was also given some iced water to drink and this made him cough violently and he vomited up a quantity of dark brown blood. From now onwards any food or drink made him cough and, as a test, he was given a drink of Ribena which he coughed back a second or two after swallowing. It appears that he was considered to have some nerve damage causing fluid to enter the trachea and a Ryle's tube was passed and feeding instituted through this for a week.Meanwhile, he was treated for a lung infection which cleared slowly. On removal of the Ryle's tube, he found that the taking of food, particularly drink, again produced paroxysms of coughing, although after a time he learned that by adopting a certain position he could swallow perhaps a quarter of the food without too much reaction.

Ulcerative tracheo-oesophageal fistula during treatment by tracheostomy and intermittent positive pressure ventilation

“…The passage of swallowed material into the trachea produces the characteristic swallow-cough symptom complex or hallmark (Stephens, 1965;Killen and Collins, 1965;Chapman and Braun, 1970). This is not likely to occur if the patient is being fed through a nasogastric tube.…”

“…Each of the above radiological and endoscopic diagnostic procedures may fail to reveal the fistula (Stephens, 1965;Chapman and Braun, 1970) so that several of them may be required to confirm the diagnosis. Their relative merits are debatable, but the findings in 28 cases of traumatic tracheooesophageal fistula collected by Chapman and Braun (1970) suggest that there is little difference between them.…”

“…Fistulae caused by closed crushing injuries nearly always follow automobile accidents, especially steering wheel injuries (Stephens, 1965;Killen and Collins, 1965;Judd and Dubuque, 1968;St0ren and Vasli, 1968;Chapman and Braun, 1970), but usually do not manifest themselves for several days, when the patient is already under treatment by assisted ventilation, should this be required. Patients whose trachea and oesophagus are injured at the time of tracheostomy may also be having assisted ventilation before the condition is recognized.…”

“…With regard to traumatic fistulae, Stephens (1965) states that ideally closure should be performed within seven to 10 days of the onset of symptoms, but that if the diagnosis is made later, or the general condition is too bad, gastrostomy or jejunostomy should be performed and operative closure deferred for about one month, so as to allow inflammation and necrosis of the tissues to resolve. St0ren and Vasli (1968) state that as spontaneous closure of traumatic fistulae never occurs operative closure should be planned as soon as the diagnosis is made, but that no generalization should be made as to the correct time.…”

“…Traumatic fistulae occur as the result of chest injury, either closed (Stephens, 1965; Killen and Collins, 1965;Judd and Dubuque, 1968;St0ren and Vasli, 1968;Chapman and Braun, 1970) or open. Such an aetiology must be considered whenever assisted ventilation is used for treating crush injuries, as the tracheo-oesophageal fistula does not manifest itself clinically until after a latent period, usually of three to five days.…”