Cervical tracheoesophageal fistula.

Four unusual cases of cervical tracheoesophageal fistula (TEF) are presented. The incidence, diagnosis and treatment of cervical TEF are discussed. Surgically, if the location is above the level of T2 a cervical approach may be utilized. The cases included a cervical "H" type TEF occurring in an adult. Congenital "H" type TEFs frequently occur in the neck. An adult presenting with a cervical "H" type TEF, having as an infant undergone repair of a thoracic TEF, is unique. Two layer closure of both trachea and esophagus with strap muscle interposition is preferred. The other cases include a TEF secondary to metastatic breast carcinoma, one associated with a stomal recurrence, and an acquired TEF following laryngectomy. Metastatic breast carcinoma resulting in a TEF is reported for the first time. Malignant TEF's are usually secondary to carcinoma of the esophagus, lung, or thyroid. Best palliation is achieved either by esophageal intubation, by colon bypass, or by gastric pull-up with esophageal exclusion. Stomal recurrence with TEF following laryngectomy is treated with one-stage resection and reconstruction with a pectoralis major myocutaneous flap and gastric pull-up. A patient 5 years post-laryngectomy illustrates an acquired non-malignant cervical TEF, a category which includes fistulas due to trauma, tracheotomy, or endotracheal tubes, instrumentation, and inflammatory disease. Prompt surgical closure as in congenital cases is the treatment of choice although select cases require medical therapy.