✅ Model Answer:
• Radiograph findings: Nasogastric tube coiled in proximal esophagus (at T2-T3 level), indicating esophageal atresia. Bowel gas present in stomach and intestines → confirms distal tracheoesophageal fistula (air travels from trachea through fistula into stomach).
• Diagnosis: Esophageal atresia with distal tracheoesophageal fistula (EA with distal TEF).
• Commonest type: Gross type C (EA with distal TEF) – accounts for ~85% of cases.

✅ Model Answer:
• Type A (8%): Pure esophageal atresia (no fistula) – "long gap." No bowel gas on X-ray.
• Type B (1%): EA with proximal TEF – rare.
• Type C (85%): EA with distal TEF – most common. Bowel gas present.
• Type D (1%): EA with both proximal and distal TEF (double fistula) – very rare.
• Type E (4%): Isolated TEF (H-type fistula) – no EA; presents later with choking, recurrent pneumonia.
• Type F: Congenital esophageal stenosis (very rare).

✅ Model Answer:
• Antenatal findings: Polyhydramnios, small or absent fetal stomach bubble (in pure EA type A), occasionally dilated proximal esophageal pouch.
• VACTERL association: Vertebral anomalies, Anal atresia, Cardiac defects, TE fistula, Renal anomalies, Limb anomalies.
• Key point: At least 3 of the above = VACTERL association. EA/TEF patients require screening for all these anomalies.

✅ Model Answer:
• Excessive oral secretions – frothy, non-bilious salivation (first sign).
• Choking, coughing, cyanosis with feeds – aspiration into trachea through fistula.
• Respiratory distress – tachypnea, retractions, crackles (aspiration pneumonia).
• Inability to pass nasogastric/orogastric tube – tube coils in upper pouch.
• Abdominal distention – in type C (distal TEF) as air enters stomach via fistula.
• Scaphoid abdomen – in pure EA (type A) – no air in stomach.

✅ Model Answer:
1. Keep NPO (nil per oral).
2. Place Replogle tube (double-lumen suction catheter) in proximal pouch on continuous low suction.
3. Position head-up (30-45°) to reduce reflux of gastric contents through distal fistula.
4. Administer IV antibiotics (ampicillin + gentamicin) for aspiration pneumonia.
5. Secure IV access, maintain hydration.
6. Evaluate for associated anomalies – echocardiogram, renal ultrasound, spine X-ray.
7. Avoid bag-mask ventilation – distends stomach through fistula.
8. Refer to pediatric surgery.

✅ Model Answer:
• Timing: After stabilization, typically within 24-48 hours. Delayed if extreme prematurity, severe pneumonia, or major cardiac anomalies.
• Approach: Right extrapleural thoracotomy (4th-5th intercostal space) or thoracoscopic repair.
• Procedure: Division of fistula, closure of tracheal defect, primary end-to-end esophageal anastomosis.
• Long-gap EA: Delayed repair, esophageal substitution (gastric pull-up, colonic interposition), or Foker technique.
• Gastrostomy tube for decompression or feeding in selected cases.

✅ Model Answer:
• Early: Anastomotic leak (5-10%), recurrent TEF (3-5%), pneumothorax, chylothorax, vocal cord paralysis.
• Late: Anastomotic stricture (20-40%), GERD (>50%), tracheomalacia (barking cough, cyanotic spells), esophageal dysmotility, recurrent aspiration pneumonia.

✅ Model Answer:
• Presentation: Dysphagia, feeding refusal, choking, failure to thrive (4-8 weeks post-repair).
• Diagnosis: Upper GI contrast study (barium swallow) shows narrowing; esophagoscopy confirms.
• Management: Esophageal dilation (balloon or bougie) – most require 1-3 dilations. Refractory strictures: local steroid injection or resection.

✅ Model Answer:
• Why common: Impaired esophageal motility, short intra-abdominal esophagus, abnormal angle of His, vagal nerve injury.
• Medical management: Positioning (head-up, prone after feeds), thickened feeds, PPIs or H2 blockers.
• Surgical management (fundoplication): Indicated for severe GERD with FTT, recurrent aspiration, stricture refractory to dilation, or recurrent TEF.

✅ Model Answer:
• Tracheomalacia: Weakness of tracheal cartilage where TEF located → dynamic airway collapse during expiration/crying.
• Features: "Barking"/"brassy" cough, expiratory stridor, recurrent cyanotic spells ("dying spells").
• Aortopexy: Surgical suspension of innominate artery (and aorta) to sternum to lift anterior trachea. Indicated for severe, life-threatening episodes.
• Other: CPAP may stent trachea; most improve by 2-3 years as cartilage matures.

✅ Model Answer:
• Postoperative: NPO 5-7 days; parenteral nutrition. Esophagram day 5-7 to check for leak.
• Oral feeding difficulties: Common due to dysmotility. Start with continuous NG feeds → bolus → oral.
• Gastrostomy tube for long-gap EA or severe GERD.
• Long-term: Small frequent meals, semi-solid foods. Speech/feeding therapy for oral aversion.
• Failure to thrive: Look for stricture, GERD, recurrent TEF.

✅ Model Answer:
• Tracheomalacia (improves with age).
• Recurrent aspiration pneumonia (GERD, TEF recurrence, vocal cord dysfunction).
• Reactive airway disease / asthma-like symptoms – wheezing, chronic cough.
• Bronchiectasis from repeated aspiration/infection.
• Follow-up: Pulmonology, PFTs, immunization (influenza, RSV prophylaxis).