a common upper airway and digestive tract is a rare congenital anomaly that is usually fatal and exact incidence of which is not known .
the diagnosis is assumed to be made if there is inability to perform endotracheal intubation of a newborn with respiratory distress in an expert hand in a neonate not cried at birth .
we present a newborn clinically suspected as a case of esophageal atresia with tracheo - esophageal fistula that was diagnosed retrospectively to have laryngeal atresia with absent vocal cords and a common aerodigestive tract continuing distally with trachea .
we received a spontaneous vaginally delivered male outborn baby at 35 weeks period of gestation , weighing 1900 grams to a 24-years - old primigravida with antenatal risk factors of gestational diabetes mellitus and polyhydramnios .
the baby was born limp without any cry and required immediate resuscitation with bag and mask ventilation .
the initial intubation was reportedly difficult , and baby required frequent et suctioning for copious secretions .
clinically , a strong suspicion of esophageal atresia ( ea ) and tracheo - esophageal fistula ( tef ) was made as feeding tube did not pass into the stomach .
the chest x - ray revealed lower end of feeding tube going very low almost to t 6/7 level , and serial x rays revealed the feeding tube going sometimes to left side and sometimes to the right side , in retrospect , we came to know that it was in the trachea and was negotiating to left or right main bronchus .
baby also had other associated anomalies at birth i.e. imperforate anus and absent right kidney .
the evaluation with ultrasound revealed dilated left renal pelvis with non - visualized right kidney .
the newborn was then placed in the left lateral decubitus position and a right posterolateral thoracotomy was performed .
tracheo - esophageal fistula was isolated just one cm above the carina and was transfixed and ligated .
the feeding tube could not be seen or felt in the operative field on maneuvering by anesthesiologist .
a trial of passing a large bore tube i.e. mucus sucker was attempted , which went through but again could not be traced in the operating field as it was going into the trachea along with the ett .
a trial of suctioning attempt on the mucus sucker made the right lung deflate with desaturation noticed by the anesthesiologist , which gave us a clue as to the connection of the upper end of esophagus with the trachea .
an attempt was made by the otolaryngologist intraoperatively to negotiate the fiber - optic scope through the blind upper pouch , which was unsuccessful .
neck exploration for creating a cervical esophagostomy was carried out ; however , the procedure was abandoned due to non - visualization of the upper end of esophagus .
peroperatively , we found after neck exploration that there was only one continuous hollow tube containing the et tube .
a feeding gastrostomy and sigmoid colostomy was carried out , and baby was shifted back to neonatal intensive care after the completion of surgery .
baby was continued on ventilation and other supportive management with antibiotics , iv fluids , and inotropes .
however , the baby succumbed on day 4 of life despite aggressive therapeutic and ventilatory support .
direct laryngoscopy revealed only aryepiglottic folds behind the epiglottis , no vocal cords , and there was no visible opening for the trachea suggesting a common upper airway and digestive tract .
fiber - optic scope was passed through the common opening , which revealed normal hypopharynx with normal development of the epiglottis but no evidence of true vocal cords .
there was a collapsing lumen opening into a non - collapsible structure i.e. esophagus ( collapsible ) with absence of proximal trachea continuing with distal trachea ( non - collapsible ) [ figure 1 ] .
a complete autopsy revealed laryngeal atresia with absent vocal cords and a common aerodigestive tract continuing distally with trachea [ figure 2 ] .
flexible fiber - optic scopy view of the upper airway showing the epiglottis superiorly , an atretic larynx anteriorly , and esophagus ( hollow tube ) posteriorly postmortem specimen of upper airway showing atretic larynx with no vocal cords and dilator in esophagus
very early in the development of a fetus during the third and fourth weeks of gestation , foregut divides to form the esophagus and the trachea . for an unknown reason , sometimes
, the wall does not form properly and a tracheal esophageal fistula and/or esophageal atresia may be the result .
upper airway agenesis seems to result from the ventral displacement of the tracheo - esophageal septum that forms during this period and a variety of different anomalies can result , including laryngeal and tracheal atresia .
the various types of atresia are the result of arrest at different stages in embryonic development .
the infant with pure laryngeal atresia presents with a normal color at birth , but cyanosis rapidly develops after clamping of the umbilical cord .
about one - half the cases reported in the literature had other potentially fatal malformations .
the vast majority of fetuses with complete larynx atresia die because the condition is not recognized and not treated immediately or because of other life - threatening anomalies .
laryngotracheoesophageal cleft ( ltec ) is a rare congenital anomaly that results from failed posterior fusion of the cricoid cartilage associated with incomplete development of the tracheo - esophageal septum .
ltec presents with increased secretions , respiratory distress , aspiration , and recurrent pulmonary infections .
peroperatively , we anticipated that we might be dealing with a case of ltec , and we had planned for a second stage repair after complete evaluation and optimal stabilization .
suspicion for a possible esophageal atresia and trachea - esophageal fistula in our case was based on clinical presentation with copious oral secretions and failure to pass down the feeding tube . at operation
we found to have an absent upper blind pouch of esophagus with a common upper airway and digestive tract continuing with trachea distally and lower end of esophagus opening into the trachea .
difficulty in locating the upper end of esophagus and deflation of right lung with desaturations while suctioning with a mucus sucker passed for locating the upper end raised a strong possibility of this rare congenital anomaly , which was established in the post - mortem .
the diagnosis of congenital defect of a common upper airway and esophagus must be suspected if a newborn infant does not cry and develops severe cyanosis with respiratory distress soon after birth and an attempt for endotracheal intubation is unsuccessful even in expert hand , although such cases are diagnosed peroperatively or in autopsies .
antenatal ultrasound findings of fetal ascites , fluid in the upper airway or enlarged and hyperechogenic lungs can raise suspicion of upper airway anatomical defects .
these signs may be absent as in our case in the presence of a tracheo - esophageal or a broncho - esophageal fistula because the fluid from the lungs can pass into the stomach via the fistula .
hence , in our case , an antenatal ultrasound failed to raise suspicion of a possible laryngeal atresia and tracheal agenesis .
first , multiple views of feeding tube through orogastric route on chest x - ray did not show any coiling of the tube but showed passage into left or right side ( which we now know was passing into left or right main bronchus ) .
second , inability to locate the upper blind pouch of esophagus in a case of ea with tef should raise the suspicion of a common wall of aerodigestive tract .
we aim to familiarize our colleagues with this rare and challenging congenital anomaly for which a high index of suspicion and good team management is required .
 a common upper airway and digestive tract is a rare congenital anomaly that is usually fatal and its exact incidence is not known . 
 it is a diagnostic challenge as it requires high index of suspicion . 
 it should be considered in a neonate with respiratory distress in a non - vigorous baby requiring endotracheal intubation , which is difficult even in expert hand . 
 we present a newborn with suspected tracheo - esophageal fistula that was diagnosed intraoperatively to have absent upper blind pouch of the esophagus and on autopsy found to have laryngeal atresia with absent vocal cords and a common aerodigestive tract continuing distally with trachea . 
 the neonate was ventilated with endotracheal tube ( ett ) placement which in retrospect we came to know that it was in the esophagus . 
 the neonate also had associated multiple congenital anomalies of vacterl association . 
 the importance of teamwork between neonatologist , pediatric surgeon , anesthesiologist , and radiologist is highlighted for diagnosis and management of such rare cases . 
INTRODUCTION
CASE REPORT
DISCUSSION