Congenital isolated H-type tracheo-oesophageal fistula identified by milk scan

A 2-month-old male child presented with recurrent respiratory tract infections and choking during feedings. On respiratory system examination, the patient had bilateral rhonchi and crepitations. Chest X-ray revealed pneumonic consolidation. Gastro-oesophageal reflux (GER) or milk scan was performed (18.5 MBq of Tc sulphur colloid mixed with milk, instilled through a nasogastric tube). Significant GER is appreciated in the first frame of the dynamic image mimicking contamination in the oral cavity. Within seconds after tracer instillation, the patient had a severe cough explaining the significant entry of refluxate into the right bronchus through a tracheo-oesophageal fistula (TOF). Minimal refluxate was also noted in the left bronchus. Our case also highlights the advantage of oblique static views that delineate the tracer accumulation in the right bronchus, visualized separately from the oesophagus. Barium swallow showed an isolated H-type TOF which was later confirmed by bronchoscopy. This is a rare type of TOF which occurs in only 4% of reported TOF cases. Milk scan and salivagram are performed to identify retrograde and antegrade aspiration respectively. This case is unique as milk scan itself demonstrates the presence of GER and the actual entry of the refluxate into the lungs (antegrade aspiration).