67.1 Tracheobronchomalacia

• Cartilage to muscle ratio should be 2:1

• Secondary condition may occur secondary to external compression—vascular/mediastinal mass/ventilation, e.g., double aortic arch

• Usually improves by 18 months

• Larsen syndrome

• TOF

• Symptoms/signs:

Cyanotic episodes

Cough

Aspiration

Timing of stridor—prolonged expiratory phase seen on Ba swallow

MLB required—avoid airway splinting—underdiagnosis

67.2 Tracheoesophageal Fistula (TOF)

67.2.1 Epidemiology and Aetiology

• Majority associated with oesophageal atresia (96–97%)

• 1 in 3000/4000 births

• Failure of complete separation of foregut from respiratory tract

• 40% have other malformations

OA + distal TOF 87%

OA alone 6–7%

OA + prox TOF 2%

OA + prox + distal TOF <1%

TOF alone 3–4%

• Infants often premature and have polyhydramnios

• Associated malformations:

V: vertebral

A: anal

C: cardiac

T: trachea

E: oesophageal

R: renal

L: limb

67.2.2 Symptoms

• Often asymptomatic at birth

• Respiratory:

Cough; choke; cyanosis (when feeding); aspiration (leading to respiratory distress, atelectasis, pneumonia)

• GI:

Excessive drooling, gastric distension—respiratory compromise

67.2.3 Investigation

• Oesophageal catheter, i.e., NG tube, and check position on plain CXR

• AXR: air stomach/small bowel suggests distal fistula. Lack of air in stomach suggests oesophageal atresia

• Bronchoscopy + oesophagoscopy

• ECHO diagnoses any cardiac abnormalities + position of aortic arch

• GG swallow (risk of aspiration)

67.2.4 Waterson Classification

• Pretreatment risk evaluation

Category A

– Birth wt >5.5 lb (2.5 kg)