Early Tracheoesophageal Fistula Following Tracheostomy in Severe Facial Burn with Inhalation Injury

Tracheoesophageal fistula (TEF) is a rare but devastating complication of mechanical ventilation and tracheostomy, classically described as a late sequela of prolonged airway instrumentation. Patients with severe burn injury and inhalation injury represent a uniquely vulnerable population due to airway mucosal ischemia, thermal injury, and impaired tissue healing. We report a case of fulminant posterior tracheal wall failure with early TEF formation occurring within days of tracheostomy in a 75-year-old patient with extensive full-thickness facial burns following thermal inhalation injury from hot liquid exposure. The clinical course was marked by early ventilatory warning signs including intermittent ventilator dyssynchrony, transient reductions in tidal volumes, and progressive cuff leak prior to catastrophic airway failure. Bronchoscopy demonstrated a large posterior tracheal defect with migration of the tracheostomy tube into the esophagus. Given the extent of injury and limited reconstructive options, care was transitioned to a comfort-focused approach. This case highlights an early airway failure phenotype that differs from the traditional delayed presentation of TEF and underscores the importance of heightened clinical vigilance. Persistent cuff leaks or unexplained ventilatory instability in patients with inhalation injury should prompt urgent airway reassessment to allow early intervention before irreversible airway disruption occurs.