tef develops after 12 - 200 days of mechanical ventilation , with a mean of 42 days . a 27-year - old man , with history of polytrauma , presented to the emergency department with the loss of consciousness followed by emergency tracheal intubation done for poor glasgow coma score ( gcs ) coma . he had been operated for head injury ( dural repair for csf leak ) and facial injury ( fracture maxilla ) . magnetic resonance imaging ( mri ) neck showed tef at the level of t1 - 2 . fiberoptic bronchoscopy was done under la which identified the orifice of tef on smooth posterior membranous wall 34 cm from carina and measuring 1.5  2 cm in size , and circumferential injury of trachea was present . the patient was planned for anterolateral thoracotomy and retrosternal gastric pull - up , after 15 days after the patient had recovered nutritionally . on the morning of surgery , intravenous in addition to routine monitoring central venous and radial artery cannulation was done for central venous pressure and invasive blood pressure monitoring . thoracic epidural catheter was placed through the t5 - 6 interspace and 1.5 mg morphine was given epidural as preemptive analgesia . the table was tilted to the right to keep fistula down and avoid aspiration during positive pressure ventilation . endobronchial intubation was done with 32 fg left - sided double lumen tube . during the passage of the tube through the cords , was inserted through the tube and tube end was visualized just at the junction of trachea and esophageal fistula . the tube was gently withdrawn and the fob advanced beyond fistulous opening up to the left main bronchus and tube was railroaded over the fob . at this position the fistula was localized by the surgeon and the cuff of the tube was just blocking the fistula and its tip was beyond the fistula making it an ideal position . distal end of esophagus closed and retrosternal gastric pull up done through a neck incision . patient was not administered oral fluids or solids until barium swallow demonstrated absence of extravasation . tef occurs after prolonged ventilatory support as a result of pressure on the opposed walls of esophagus and trachea by the inflated tracheal cuff and the in - lying esophageal feeding tube . it can develop anytime from 12200 days after intubation with a mean of 40 days . time taken for an acquired tef to develop and become symptomatic is dependent on precipitating cause and is illustrated as [ table 1 ] . time taken for acquired tef to develop and become symptomatic , based on the causative factor traumatic tracheobronchial injury is usually the result of blunt chest trauma and appears as horizontal or irregularly shaped disruptions involving the carina and often extending into main bronchi . iatrogenic tracheobronchial injury , which could be a cause in our case as patient was having history of emergency intubation , in contrast usually presents as longitudinal laceration of posterior tracheal wall either centrally or laterally . the exact mechanism remains uncertain , but the most probable explanation is direct laceration from endotracheal tube tip caught in the fold of flaccid posterior tracheal membrane , while advancing the tube . since the inflammatory process is progressive , in case of cuff - induced tracheal injury , there is never leakage into mediastinum as is seen in a traumatic fistula . factors implicated in the development of postintubation tof are high cuff pressure , high airway pressure , excessive motion of tracheal tube , prolonged duration of intubation , respiratory infections , esophageal infection , hypotension , steroids , nasogastric tube , and advanced age . high intracuff pressure is probably the single most important factor in the development of tef . total obstruction of tracheal blood flow occurs at pressure > 50 cm h2o . in patients with hypotension , even a cuff pressure of 34 cm of h2o may cause signs of tracheal damage . there is a linear relationship between peak inflation pressure and minimum occlusive pressure of high volume low pressure cuff that may promote tracheal ischemic complications under certain circumstances . head position may change the amount and location of lateral wall pressure exerted by cuff . flexion of head causes more pressure to be applied anteriorly on trachea , while extension of head results in more pressure on the posterior wall . excessive movement of tube can occur while positioning , suctioning or by weighing down by the ventilator equipment . presence of nasogastric tube reflects more pressure on posterior wall and it acts as an abrasive surface against anterior esophageal wall . demonstrated a significantly high incidence of laryngotracheal pathology in head injury patients . in the present case , fistula was located 3 cm above carina and it had a circumferential appearance on bronchoscopy with no sign of air leakage , gastric distension , or mediastinitis , even on positive pressure ventilation , indicating an early postintubation etiology . however , history of polytrauma , emergency intubation in unconscious patient , repeated episodes of hypotension , and infection due to repeated surgeries favors trauma as the causative factor . a patient with acquired tef should be preoperatively given good supportive therapy , measures taken to prevent aspiration and pulmonary infections aggressively managed . if a patient on ventilator , the tef may fail to close . a spontaneously breathing and nutritionally fit patient is prerequisite for success of the therapy the site and size of the lesion must be carefully noted as this may dictate the anesthetic approach . failure to ventilate , due to intubation of the lumen of large tef , is a major concern . proper selection of an appropriate size endotracheal tube , frequent cuff pressure monitoring ( keeping cuff pressure between 20 and 30 mm of h2o ) , minimal endotracheal tube movement on positioning / suctioning and using flexible nasogastric tube prevent the occurrence of tef .
tracheoesophageal fistula ( tef ) in adults occurs as a result of trauma , malignancy , cuff - induced tracheal necrosis from prolonged mechanical ventilation , traumatic endotracheal intubation , foreign body ingestion , prolonged presence of rigid nasogastric tube , and surgical complication . 
 anesthetic management for repair of tef is a challenge . 
 challenges include difficulties in oxygenation or ventilation resulting from placement of endotracheal tube in or above the fistula ; large fistula defect causing loss of tidal volume with subsequent gastric dilatation , atelactasis , and maintenance of one lung ventilation . 
 the most common cause of acquired nonmalignant tef is postintubation fistula , which develops after prolonged intubation for ventilatory support . acquired tef , which occurs after prolonged intubation , usually develops after 12200 days of mechanical ventilation , with a mean of 42 days . 
 we present a rare case of tef that developed after 7 days of intubation . 
 it was a difficult case to be diagnosed as patient had a history of polytrauma , followed by emergency intubation and both these conditions can contribute to tracheobronchial injury .