long - term intubation is the cause of the majority of acquired , nonmalignant tracheoesophageal fistulae ( tef ) . post - intubation tef could present as chronic aspiration after intubation , and could therefore be mistaken as unilateral or bilateral vocal fold palsy , especially when there was combined posterior glottic synechia due to the variety of surgical options to repair a tef , including direct closure of the tracheal and esophageal defects with or without pedicled muscle flaps , tracheal closure with an esophageal patch , segmental tracheal resection , and anastomosis with esophageal closure and esophageal diversion , the timing and type of repair are still being debated . we present a case of post - intubation tef which was successfully treated with tracheal resection and anastomosis , using primary esophageal closure and endoscopic lysis for the accompanying posterior glottic web . approval for this case report was granted by the institutional review board of the author 's hospital ( no . 20090428/06 - 2009 - 54/83 ) . a forty four - year - old woman was referred from a local general hospital for dyspnea and aspiration on eating . she had history of drug intoxication from a suicidal attempt 2 months prior . at that time she had been intubated and had a gastric lavage , after which she had a nasogastric feeding tube . a tracheotomy was necessary because of prolonged intubation ( longer than 20 days ) . during the hospital stay her t - cannula was recurrently obstructed by crust and secretion and her symptoms seemed to be relieved after t - cannula change . on endoscopic examination , performed by an ent resident , it was apparent that the right side of her vocal fold seemed to be paralyzed , and injection laryngoplasty was initially planned to solve her aspiration problem . on detailed examination of her airway , however , a glottic scar band was found at the posterior glottis , which seemed to be the cause of the limited mobility of her right vocal fold ( fig . moreover , there was a tef on the left posterior wall of the trachea , 1 cm above the level of tracheostoma ( fig . we confirmed that it was a tef by verifying leakage through the fistula on oral intake of water . the skin , subcutaneous fat , and platysma were elevated as one layer and the flap was raised to the level of the suprahyoid region . the sternohyoid muscles were divided in the midline and the thyroid isthmus was divided and ligated to expose the anterior surface of the trachea . the trachea was freed circumferentially only above and below the site of the fistula , and care was taken to maintain the dissection as close as possible to the outer tracheal surface , thereby avoiding injury to the recurrent laryngeal nerves and to preserve the lateral blood supply to the unresected trachea . the tracheal resection was done from the 2nd to the 4th tracheal rings ( 2.5 cm in length ) , and the esophageal fistula was found to be a slit - like shape , 1 cm in length ( fig . it is of paramount importance to assure that the tracheal cut end has a normal diameter and mucosal appearance . the edges of the esophageal defect were debrided and a two - layer closure was was made over a nasogastric tube . after closure of the esophageal defect , the trachea was reconstructed via interrupted 4 - 0 vicryl sutures with 4 mm interval between stitches . before completion of the anastomosis , the distal ventilation system was removed and a new endotracheal tube advanced beyond the anastomosis line . the cervical incision was closed by covering the anastomotic line with the thyroid isthmus and by approaching the linea alba cervicalis . two soft multi - holed drain catheters were placed . soon after , the larynx was evaluated with suspension laryngoscopy . under microscopic magnification topical 0.04% mitomycin c solution was applied with 3 mm - sized cotton balls around the interarytenoid area , to prevent synechia or scarring . the patient was moved to ward via recovery room with her intubation tube in situ . follow - up visit , she had no dyspnea or aspiration and both vocal folds were freely mobile ( fig . surgical repair for tef can be accomplished by simple division and closure of the fistula ( 1 ) . the lateral approach used for the simple division and repair is limited in that it gives a limited and unilateral exposure of the fistulous tract , and requires identification of the recurrent laryngeal nerve ( 1 , 2 ) . identification of the fistulous tract may not be simple and usually requires a more extensive dissection than expected . moreover , the separation of the tracheal and esophageal lines requires esophageal rotation and thus esophageal devascularization , which can result in late tracheal stenosis at the level of the repair or muscle interposition . in addition , there could be a combined tracheostoma , which should be closed by secondary healing , if it were not resected with tef closure simultaneously ( 1 ) . therefore , tracheal resection and anastomosis with primary esophageal closure has some advantages over simple division and closure of the fistula : 1 ) it is a one - stage procedure , 2 ) easy visualization and division of the esophageal fistula site , 3 ) reliable result despite the risk of anastomosis site problems ( 1 - 3 ) . in this case , we could manage the patient successfully by tracheal resection and end - to - end anastomosis with primary esophageal closure 1 ) in one stage , 2 ) without identification of recurrent laryngeal nerve , and 3 ) with early rehabilitation . except for the possible morbidity related to tracheal resection and anastomosis , including disruption of anastomosis , emphysema or pneumomediastinum caused by air leakage , this procedure could be one of the best options for acquired tef after prolonged intubation ( 1 ) . prolonged intubation caused various problems such as glottic or subglottic stenosis , tef , vocal fold paralysis , hypertrophic scar , and so on ( 4 - 6 ) . because these complications could be brought - on at the same time , clinicians should be alert to find all the problems in the aerodigestive tract comprehensively ( 4 ) . therefore , thorough endoscopic and imaging work - up should precede the initial surgical intervention . in this case , initial the misdiagnosis was idiopathic unilateral vocal fold paralysis , which was based on vocal fold immobility on endoscopic examination and chronic aspiration on medical history . posterior glottic stenosis is , for clinicians , a troublesome and hard to solve complication after prolonged intubation ( 6 - 8 ) . nd - yag laser and mitomycin c shows good result for posterior glottic stenosis after prolonged intubation ( 9 , 10 ) . the posterior glottic scar band in this case was easily resolved by endoscopic resection and topical mitomycin c application . tracheal resection and anastomosis with primary esophageal closure was successfully used to treate tef occurring after prolonged intubation , with , and endoscopic technique of web lysis for the accompanying posterior glottic web . careful evaluation for combined complications from prolonged intubation is mandatory and should be settled simultaneously .
tracheoesophageal fistula ( tef ) after prolonged intubation could present as chronic aspiration and could be mistaken as unilateral or bilateral vocal fold palsy , especially when there was combined posterior glottic synechia . 
 we present a case of post - intubation tef which was successfully treated with tracheal resection and anastomosis with primary esophageal closure . 
 the accompanying posterior glottic web was treated by endoscopic technique of web lysis , with topical application of mitomycin c solution .