The changes in bispectral index during a hypovolemic cardiac arrest.

was erosion of the patient’s nasogastric tube through the anterior esophageal wall into the trachea. The finding that the defect was larger on the esophageal side than on the tracheal side makes bronchoscopy an unlikely cause. None of the other common causes of TEF in adults (radiation therapy, trauma, corrosive burn, malignancy, congenital defect, or tuberculosis) apply to this patient. There are several causes of air leak after tracheal intubation, most of which are easily verifiable. The most common are inadequate depth of ETT insertion (with the ETT cuff straddling the vocal cords), inadequate cuff inflation, and inadvertent placement of an esophageal stethoscope or nasogastric tube into the trachea. Exclusion of these causes, in the presence of an increased leak associated with removal of the esophageal stethoscope, led to a presumptive diagnosis of TEF. This diagnosis was confirmed postoperatively. During directed questioning postoperatively, the patient admitted to a history of coughing when drinking fluids (especially carbonated beverages). Despite several weeks of keeping the patient as non per os and providing nutrition via a feeding tube, the fistula failed to close. Subsequently, the patient underwent esophagoscopy and injection of the fistula with a fibrin sealant. Her coughing immediately ceased, and she remains asymptomatic.