Tracheo-oesophageal fistula and bilateral recurrent laryngeal nerve palsies after blunt chest trauma.

A 23-year-old man fell out of his car and was hit by another passing car. He was unconscious from head injuries but was breathing satisfactorily. Surgical emphysema and bruising were present over his upper chest and neck. He vomited once and the vomit was bloodstained. A chest radiograph showed gross surgical emphysema, shallow bilateral pneumothoraces, and multiple right-sided rib fractures. Within an hour of admission his breathing became laboured. He was intubated and put on intermittent positive-pressure ventilation, and drainage tubes were inserted into each pleural cavity. Three hours later gross gastric dilatation was noted (fig 1); it was relieved by nasogastric suction. The arterial gases showed an A-a shunt of 20% with a Pao2 of 106 mmHg (14.1 kPa) and a Paco2 of 48.7 mmHg (6.5 kPa). Rigid bronchoscopy showed a 5 cm longitudinal tear in the posterior wall of the trachea between 23 and 28 cm from the upper incisor teeth and ending 2 cm above the carina. Rigid oesophagoscopy showed, firstly, air bubbling up the oesophagoscope and, secondly, the balloon of the endotracheal tube at 24-25 cm, exactly corresponding with the level of the tracheal tear. The endotracheal tube was replaced by a double-lumen endobronchial tube and the patient underwent an immediate right lateral thoracotomy through the fourth intercostal space, preserving the intercostal muscle bundle for a future pedicle graft. The oesophagus was found to have two tears. One, a full-thickness anterior tear measuring 6 cm vertically, lay immediately alongside the tracheal tear. The second, a partial-thickness posterior tear measuring 7 cm vertically, was a muscular tear positioned immediately anterior to the vertebral column. The mucosa here was swollen but not ruptured. The tracheal tear was of full thickness posteriorly and measured 5 cm vertically. There was extensive mediastinal emphysema and moderate inflammation between the trachea and oesophagus, the injury now being 20 hours