Dear Editor,

We read with interest Love and Morice’s article [1] on tracheo-oesophageal fistula repair and sequelae related to chronic “TOF cough”. As clinicians from varying paediatric specialities, we also recognise significant long-term symptoms for some of our patients that have undergone oesophageal atresia repair as neonates. The apparent deficiencies in care noted from the patients’ perspective highlight the importance of multi-disciplinary follow-up throughout childhood as many symptoms might otherwise go unrecognised and untreated [2]. Many tertiary paediatric institutions recognise this need and provide specialised clinics for a variety of childhood conditions, including transition clinics into the adult sector.

We agree with Professor Morice’s suggestions for assessment and treatment of gastro-oesophageal reflux, although the long term consequences of untreated, unrecognised gastro-oesophageal reflux (in addition of problematic cough) are worthy of further mention. Assessment of long-term outcomes have demonstrated more significant complications than previously appreciated, including reflux oesophagitis, Barrett’s oesophagus and oesophageal squamous cell carcinoma [3].

We concur that tracheomalacia is also a longstanding problem for many children, but Professor Morice makes no mention of the role of brochoscopy, either rigid or flexible, in the management of ongoing cough for these children and adults. A well-recognised complication of surgery is the persistence of a tracheal pouch with pooling of secretions leading to significant cough, aspiration, pulmonary soiling and acute life-threatening events[4-7]. Tracheal pouches arise after surgery due to the oblique submucosal course of the fistula. Although the surgeon divides and closes the fistula flush with the outer aspect of the trachealis muscle in the neonatal period, a small “blind” submucosal pouch can enlarge over time with growth of the patient. Pouches are reported to occur in 7-8% of patients following TOF repair [8] although the incidence of symptomatic pouches remains unknown. We, along with others, [4-7] have observed and reported improved airway symptoms with the division of these pouches.

We understand that this information may have been omitted due to editorial limitations but would like to remind clinicians of the importance of these potentially treatable conditions.

W. Andrew Clement Paediatric Otolaryngologist,
Haytham Kubba Paediatric Otolaryngologist,
Jonathan Coutts Neonatologist,
Gregor Walker Paediatric Surgeon
Phil Hammond Paediatric Surgeon
Royal Hospital for Sick Children,
Yorkhill, Glasgow

1. After repair of tracheo-oesophageal atresia. Love C, Morice AH. BMJ. 2012 Jun 15;344:e3517.
2. Legrand C, Michaud L, Salleron J, Neut D, Sfeir R, Thumerelle C, Bonnevalle M, Turck D, Gottrand F. Long-term outcome of children with oesophageal atresia type III. Arch Dis Child doi:10.1136/archdischild-2012-301730)
3. Taylor AC, Breen KJ, Auldist A, Catto-Smith A, Clarnette T, Crameri J, Taylor R, Nagarajah S, Brady J, Stokes K. Gastroesophageal reflux and related pathology in adults who were born with esophageal atresia: a long-term follow-up study. Clin Gastroenterol Hepatol. 2007 Jun;5(6):702-6.
4. Residual tracheal pouch after repair of tracheaoesophageal fistula: endoscopic KTP laser treatment. Baring DE, Ansari S, Clement WA, Kubba H. J Pediatr Surg. 2010 May;45(5):1040-3.
5. Management of symptomatic tracheal pouches. Johnson LB, Cotton RT, Rutter MJ. Int J Pediatr Otorhinolaryngol. 2007 Apr;71(4):527-31.
6. Endoscopic treatment of tracheal diverticulum after primary repair of esophageal atresia and tracheoesophageal fistula. Bhatnagar V, Lal R, Agarwala S, Mitra DK. J Pediatr Surg. 1998 Aug;33(8):1323-4.
7. Tracheal diverticulum after surgical correction of esophageal atresia. Lequien P, Ponte C, Ribet M. Arch Fr Pediatr. 1978 Jun-Jul;35(6):641-5.
8. P. Holinger, W.T. Brown, D.G. Maurizi, Endoscopic aspects of post-surgical management of congenital esophageal atresia and tracheoesophageal fistula, J. Thorac. Cardiovasc. Surg. 49 (1) (1965) 22—32.

Competing interests: None declared