Abstract Introduction Tracheomediastinal fistulas (TMF) are rare findings with a high mortality rate. In this case, the patient developed TMF post op of anterior spinal fusion and presented with septic arthritis. Case Presentation A 73-year-old male with a history of emphysema and nonalcoholic fatty liver disease (NAFLD) sustained a cervical spine fracture in June 2025 following a ground-level fall. He underwent anterior cervical spinal fusion, complicated by postoperative stridor and a retropharyngeal fluid pouch, resulting in airway obstruction and necessitating intubation. His clinical course was further complicated by prolonged intubation leading to tracheostomy placement on 7/25/25 and transfer to a long-term acute care facility (LTAC). While clinically stable on room air at the LTAC, the patient developed acute severe right shoulder pain. Workup revealed septic arthritis of the glenohumeral joint, which rapidly developed into severe sepsis. Imaging demonstrated a tracheomediastinal fistula originating from a tracheostomy tract. Microorganisms from both shoulder and tracheal wound grew Streptococcus anginosus and Candida parapsilosis. Treatment with Meropenem and Eraxis was initiated, and the patient underwent surgical debridement and flap reconstruction on 9/29/25 with Plastic Surgery. Despite aggressive management, he developed septic shock. Bronchoscopy revealed posterior glottic stenosis and bilateral vocal cord granulomas resulting in failed swallowing evaluations. The patient ultimately declined percutaneous gastrostomy (PEG) placement, elected hospice care, and expired on 10/15/25. Discussion TMFs are rare but life-threatening complications that are often diagnosed only after severe life-threatening complications. The trauma to the bronchial tube can often cause scarred tissue paths to form and can create a fistula with the mediastinum directly behind the bronchus5. Early recognition remains challenging due to the nonspecific presentation of cough, malaise, or shoulder pain in this case. Currently, there is no consensus on the optimal treatment for TMF, but there has been reported successful interventions of argon plasma coagulation6, multiple pediculed muscle flaps2 or endoscopically. TMFs often lead to serious complications including pneumonia1, ARDS, mediastinal lymphadenitis7, or sepsis4. Long term tracheostomy use, as in this case, does not inherently predispose patients to TMF unless recently local trauma or other precipitating factors are present3,8. Establishing standardized management could improve outcomes. Computed tomography (CT) aids diagnosis, while bronchoscopy provides both diagnostic and therapeutic capabilities. Future research studies should assess routine imaging or endoscopic surveillance after specific chemotherapies or surgeries for earlier TMF detection. They should also compare medical vs. surgical approaches to determine optimal management and the impact of early intervention on prognosis. This abstract is funded by: None
Mangal et al. (Fri,) studied this question.