the direct laryngoscope incites spasmodic laryngeal reflexes, and the
traction exerted somewhat distorts the tissues, so that accurate
observations of variations in laryngeal mobility are difficult to
obtain. The function of the laryngeal muscles and structures,
therefore, can best be studied with the laryngeal mirror, except in
infants and small children who will not tolerate the procedure of
indirect laryngoscopy. A true idea of the depth of the larynx is not
obtained with the mirror, and a view of the ventricles is rarely had.
With the introduction of the direct laryngoscope it is found that the
larynx is funnel shaped, and that the adult cords are situated about 3
cm. below the aryepiglottic folds; the cords also assume their true
shelf-like character and take on a pinkish or yellowish tinge, rather
than the pearly white seen in the mirror. They are not to any extent
differentiated by color from the neighboring structures. Their
recognition depends almost wholly on form, position and movement.
Accurate observation is stimulated in all pathologic cases by making
colored crayon sketches, however crude, of the mirror image of the
larynx. The location of a growth may be thus graphically recorded, so
that at the time of operation a glance will serve to refresh the
memory as to its site. It is to be constantly kept in mind, however,
that in the mirror image the sides are reversed because of the facing
positions of the examiner and patient. Direct laryngoscopy is the only
method by which the larynx of children can be seen. The procedure need
require less than a minute of time, and an accurate diagnosis of the
condition present, whether papilloma, foreign body, diphtheria,
paralysis, etc., may be thus obtained. The posterior pharyngeal wall
should be examined in all dyspneic children for the possible existence
of retropharyngeal abscess.
[PLATE II--DIRECT AND INDIRECT LARYNGEAL VIEWS FROM AUTHOR'S OIL-COLOR
DRAWINGS FROM LIFE:
1, Epiglottis of child as seen by direct laryngoscopy in the
recumbent position.
2, Normal larynx spasmodically closed, as is usual on first exposure
without anesthesia.
3, Same on inspiration.
4, Supraglottic papillomata as seen on direct laryngoscopy in a
child of two years.
5, Cyst of the larynx in a child of four years, seen on direct
laryngoscopy without anesthesia.
6, Indirect view of larynx eight weeks after thyrotomy for cancer of
the right cord in a man of fifty years.
7, Same after two years. An adventitious band indistinguishable from
the original one has replaced the lost cord.
8, Condition of the larynx three years after hemilaryngectomy for
epithelioma in a patient fifty-one years of age. Thyrotomy revealed
such extensive involvement, with an open ulceration which had reached
the perichondrium, that the entire left wing of the thyroid cartilage
was removed with the left arytenoid. A sufficiently wide removal was
accomplished without removing any part of the esophageal wall below
the level of the crico-arytenoid joint. There is no attempt on the
part of nature to form an adventitious cord on the left side. The
normal arytenoid drew the normal cord over, approximately to the edge
of the cicatricial tissue of the operated side. The voice, at first a
very hoarse whisper, eventually was fairly loud, though slightly husky
and inflexible.
9, The pharynx seen one year after laryngectomy for endothelioma in
a man aged sixty-eight years. The purple papilla; anteriorly are at
the base of the tongue, and from this the mucosa slopes downward and
backward smoothly into the esophagus. There are some slight folds
toward the left and some of these are quite cicatricial. The
epiglottis was removed at operation. The trachea was sutured to the
skin and did not communicate with the pharynx. (Direct view.)]
_Contraindications to Direct Laryngoscopy_.--There are no absolute
contraindications to direct laryngoscopy in any case where direct
laryngoscopy is really needed for diagnosis or treatment. In extremely
dyspneic patients, if the operator is not confident in his ability for
a prompt and sure introduction of a bronchoscope, it may be wise to do
a tracheotomy first.
_Instructions to the Patient_.--Before beginning endoscopy the
patient should be told that he will feel a very disagreeable pressure
on his neck and that he may feel as though he were about to choke. He
must be gently but positively made to understand (1) that while the
procedure is alarming, it is absolutely free from danger; (2) that you
know just how it feels; (3) that you will not allow his breath to be
shut off completely; (4) that he can help you and himself very much by
paying close attention to breathing deeply and regularly; (5) and that
he must not draw himself up rigidly as though "walking on ice," but
must be easy and relaxed.
_Direct Laryngoscopy. Adult Patient_.--Before starting, every detail
in regard to instrumental equipment and operating room assistants,
(including an assistant to hold the arms and legs of the patient) must
be complete. Preparation of the patient and the technic of local
anesthesia have been discussed in their respective chapters. The
dorsally recumbent patient is draped with (not pinned in) a sterile
sheet. The head, covered by sterile towels, is elevated, and slight
extension is made at the occipitoatloid joint by the left hand of the
first assistant. The bite block placed on the assistant's right thumb
is inserted into the left angle of the patient's open mouth (see Fig.
50).
The laryngoscope must always and invariably be held in the left hand,
and in such a manner that the greatest amount of traction is made at
the swell of the horizontal bar of the handle, rather than on the
vertical bar.
The right hand is then free for the manipulation of forceps, and the
insertion of the bronchoscope or other instrument. During
introduction, the fingers of the right hand retract the upper lip so
as to prevent its being pinched between the laryngoscope and the
teeth. The introduction of the direct laryngoscope and exposure of the
larynx is best described in two stages.
1. Exposure and identification of the epiglottis.
2. Elevation of the epiglottis and all the tissues attached to the
hyoid bone, so as to expose the larynx to direct view.
_First Stage_.--The spatular end of the laryngoscope is introduced in
the right side of the patient's mouth, along the right side of the
anterior two-thirds of the tongue. It was the German method to
introduce the laryngoscope over the dorsum of the tongue but in order
to elevate this sometimes powerful muscular organ considerable force
may be required, which exercise of force may be entirely avoided by
crowding the tongue over to the left. When the posterior third stage
of the tongue is reached, the tip of the laryngoscope is directed
toward the midline and the dorsum of the tongue is elevated by a
lifting motion imparted to the laryngoscope. The epiglottis will then
be seen to project into the endoscopic field, as seen in Fig. 54.
[FIG. 54.--End of the first of direct laryngoscopy, recumbent adult
patient. The epiglottis is exposed by a lifting motion of the spatular
tip on the tongue anterior to the epiglottis.]
_Second Stage_.--The spatular end of the laryngoscope should now be
tipped back toward the posterior wall of the pharynx, passed posterior
to the epiglottis, and advanced about 1 cm. The larynx is now exposed
by a motion that is best described as a suspension of the head and all
the structures attached to the hyoid bone on the tip of the spatular
end of the laryngoscope (Fig. 55). Particular care must be taken at
this stage not to pry on the upper teeth; but rather to impart a
lifting motion with the tip of the speculum without depressing the
proximal tubular orifice. It is to be emphasized that while some
pressure is necessary in the lifting motion, great force should never
be used; the art is a gentle one. The first view is apt to find the
larynx in state of spasm, and affords an excellent demonstration of
the fact that the larynx can he completely closed without the aid of
the epiglottis. Usually little more is seen than the two rounded
arytenoid masses, and, anterior to them, the ventricular bands in more
or less close apposition hiding the cords (Fig. 56). With deep
general anesthesia or thorough local anesthesia the spasm may not be
present. By asking the patient to take a deep breath and maintain
steady breathing, or perhaps by requesting a phonatory effort, the
larynx will open widely and the cords be revealed. If the anterior
commissure of the larynx is not readily seen, the lifting motion and
elevation of the head should be increased, and if there is still
difficulty in exposing the anterior commissure the assistant holding
the head should with the index finger externally on the neck depress
the thyroid cartilage. If by this technic the larynx fails to be
revealed the endoscopist should ask himself which of the following
rules he has violated.
[FIG. 55.--Schema illustrating the technic of direct laryngoscopy on
the recumbent patient. The motion is imparted to the tip of the
laryngoscope as if to lift the patient by his hyoid hone. The portion
of the table indicated by the dotted line may be dropped or not, but
the back of the head must never go lower than here shown, for direct
laryngoscopy; and it is better to have it at least 10 cm. above the
level of the table. The table may be used as a rest for the operator's
left elbow to take the weight of the head. (Note that in bronchoscopy
and esophagoscopy the head section of the table must be dropped, so as
to leave the head and neck of the patient out in the air, supported by
the second assistant.)]
[FIG. 56.--Endoscopic view at the end of the second stage of direct
laryngoscopy. Recumbent patient. Larynx exposed waiting for larynx to
relax its spasmodic contraction.]
RULES FOR DIRECT LARYNGOSCOPY
1. The laryngoscope must always be held in the left hand, never in
the right.
2. The operator's right index finger (never the left) should be used
to retract the patient's upper lip so that there is no danger of
pinching the lip between the instrument and the teeth.
3. The patient's head must always be exactly in the middle line, not
rotated to the right or left, nor bent over sidewise; and the entire
head must be forward with extension at the occipitoatloid joint only.
4. The laryngoscope is inserted to the right side of the anterior
two-thirds of the tongue, the tip of the spatula being directed toward
the midline when the posterior third of the tongue is reached.
5. The epiglottis must always be identified before any attempt is
made to expose the larynx.
6. When first inserting the laryngoscope to find the epiglottis,
great care should be taken not to insert too deeply lest the
epiglottis be overridden and thus hidden.
7. After identification of the epiglottis, too deep insertion of the
laryngoscope must be carefully avoided lest the spatula be inserted
back of the arytenoids into the hypo-pharynx.
8. Exposure of the larynx is accomplished by pulling forward the
epiglottis and the tissues attached to the hyoid bone, and not by
prying these tissues forward with the upper teeth as a fulcrum.
9. Care must be taken to avoid mistaking the ary-epiglottic fold for
the epiglottis itself. (Most likely to occur as the result of rotation
of the patient's head.)
10. The tube should not be retained too long in place, but should be
removed and the patient permitted to swallow the accumulated saliva,
which, if the laryngoscope is too long in place, will trickle down the
trachea and cause cough. (Swallowing is almost impossible while the
laryngoscope is in position.) The secretions may be removed with the
aspirator.
11. The patient must be instructed to breathe deeply and quietly
without making a sound.
[88] _Difficulties of Direct Laryngoscopy_.--The larynx can be
directly exposed in any patient whose mouth can be opened, although
the ease varies greatly with the type of patient. Failure to expose
the epiglottis is usually due to too great haste to enter the speculum
all the way down. The spatula should glide slowly along the posterior
third of the tongue until it reaches the glossoepiglottic fossa, while
at the same time the tongue is lifted; when this is done the
epiglottis will stand out in strong relief. The beginner is apt to
insert the speculum too far and expose the hypopharynx rather than the
larynx. The elusiveness of the epiglottis and its tendency to retreat
downward are very much accentuated in patients who have worn a
tracheotomic cannula; and if still wearing it, the patient can wait
indefinitely before opening his glottis. Over extension of the
patient's head is a frequent cause of difficulty. If the head is held
high enough extension is not necessary, and the less the extension the
less muscular tension there is in the anterior cervical muscles. Only
one arytenoid eminence may be seen. The right and the left look
different. Practice will facilitate identification, so that the
endoscopist will at once know which way to look for the glottis.
Of the difficulties that pertain to the operator himself the greatest
is lack of practice. He must learn to recognize the landmarks even
though a high degree of spasm be present. The epiglottis and the two
rounded eminences corresponding to the arytenoids must be in the
mind's eye, for it is only on deep, relaxed inspiration that anything
like a typical picture of the larynx will be seen. He must know also
the right from the left arytenoid when only one is seen in order to
know whether to move the lip of the laryngoscope to the right or the
left for exposure of the interior of the larynx.
_Instruments for Direct Laryngoscopy_.--In undertaking direct
laryngoscopy one must always be prepared for bronchoscopy,
esophagoscopy, and tracheotomy, as well. Preparations for bronchoscopy
are necessary because the pathological condition may not be found in
the larynx, and further search of the trachea or bronchi may be
required. A foreign body in the larynx may be aspirated to a deeper
location and could only be followed with the bronchoscope. Sudden
respiratory arrest might occur, from pathology or foreign body,
necessitating the inserting of the bronchoscope for breathing
purposes, and the insufflation of oxygen and amyl nitrite. Trachectomy
might be required for dyspnea or other reasons. It might be necessary
to explore the esophagus for conditions associated with laryngeal
lesions, as for instance a foreign body in the esophagus causing
dyspnea by pressure. In short, when planning for direct laryngoscopy,
bronchoscopy, or esophagoscopy, prepare for all three, and for
tracheotomy. A properly done direct laryngoscopy would never
precipitate a tracheotomy in an unanesthetized patient; but direct
laryngoscopy has to deal so frequently with laryngeal stenosis, that
routine preparation for tracheotomy a hundred unnecessary times is
fully compensated for by the certainty of preparedness when the rare
but urgent occasion arises.
_Direct Laryngoscopy in Children_.--The epiglottis in children is
usually strongly curled, often omega shaped, and is very elusive and
slippery. The larynx of a child is very freely movable in the neck
during respiration and deglutition, and has a strong tendency to
retreat downward during examination, and thus withdraw the epiglottis
after the arytenoids have been exposed. In following down with the
laryngoscope the speculum is prone to enter the hypopharynx. Lifting
in this location will expose the mouth of the esophagus and shut off
the larynx, and may cause respiratory arrest. Practice, however, will
soon develop a technic and ability to recognize the landmarks in state
of spasm, so that on exposing the approximated arytenoid eminences the
endoscopist will maintain his position and wait for the larynx to
open. The procedure should be done without any form of anesthesia for
the following reasons:
1. Anesthesia is unnecessary.
2. It is extremely dangerous in a dyspneic patient.
3. It is inadmissable in a patient with diphtheria.
4. If anesthesia is to be used, direct laryngoscopy will never reach
its full degree of usefulness, because anesthesia makes a major
procedure out of a minor one.
5. Cocain in children is dangerous, and its application more
annoying than the examination.
_Inducing a Child to Open its Mouth (Author's Method)_.--The wounding
of the child's mouth, gums, and lips, in the often inefficacious
methods with gags, hemostats, raspatories, etcetera, are entirely
unnecessary. The mouth of any child not unconscious can be opened
quickly and without the slightest harm by passing a curved probe
between the clenched jaws back of the molars and down back of the
tongue toward the laryngopharynx. This will cause the child to gag,
when its mouth invariably opens.
[91] CHAPTER VIII--DIRECT LARYNGOSCOPY (_Continued_)
_Technic of Laryngeal Operations_.--Preparation of the patient and
anesthesia have been mentioned under their respective chapters. The
prime essential of successful laryngeal operations is perfect mastery
of continuous left-handed laryngeal exposure. The right hand must be
equally trained in the manipulation of forceps, and the right eye to
gauge depth. Blood and secretions are best removed by a suction tube
(Fig. 9) inserted through the laryngoscope, or directly into the
pharynx outside the laryngoscope.
_For the removal of benign growths_ the author's papilloma forceps,
Fig. 29, or the laryngeal grasping forceps shown in Fig. 17 will prove
more satisfactory than any form of cutting forceps. These growths
should be removed superficially flush with the normal structure. The
crushing of the base incident to the plucking off of the growth causes
its recession. By this conservative method damage to the cords and
impairment of the voice are avoided. For growths in the anterior
portion of the larynx, and in fact for the removal of most small
benign growths, the anterior commissure laryngoscope is especially
adapted. Its shape allows its introduction into the vestibule of the
larynx, and if desired it may be introduced through the glottic chink
for the treatment of subglottic conditions. It will not infrequently
be observed that a pedunculated subglottic growth which is found with
difficulty will be pulled upward into view by the gauze swab
introduced to remove secretions. The growth is then often held tightly
between the approximated cords for a few seconds--perhaps long enough
to grasp it with forceps.
[92] _Removal of Growth from the Laryngeal Ventricle_.--After exposing
the larynx in the usual manner, if the head is turned strongly to the
right, the tip of the laryngoscope, directed from the right side of
the mouth, may be used to lift the left ventricular hand and thus
expose the ventricle, from which a growth may be removed in the usual
manner (Fig. 57). The right ventricle is exposed by working from the
left side of the mouth.
[FIG. 57.-Schema illustrating the lateral method of exposing a growth
in the ventricle of Morgagni, by bending the patient's head to the
opposite side, while the second assistant externally fixes the larynx
with his hand. M, Patient's mouth; T, thyroid cartilage; R, right
side; L, left. V, B, ventricular band. C, C, vocal cord. The circular
drawing indicates the endoscopic view obtainable by this method. The
tube, E, is dropped to the corner of the mouth, B, and the tube is
inserted down to R. The lip of the spatula can then be used to lift
the ventricular band so as to expose more of the ventricle. The
drawing shows an unusually shallow ventricle.]
_Taking a Laryngeal Specimen for Diagnosis_.--The diagnosis of
carcinoma, sarcoma, and some other conditions can be made certain only
by microscopic study of tissue removed from the growth. The specimen
should be ample but will necessarily be small. If the suspected growth
be small it should be removed entire, together with some of the basal
tissues. If it is a large growth, and there are objections to its
entire removal, the edge of the growth, including apparently normal as
well as neoplastic tissue, is necessary. If it is a diffuse
infiltrative process, a specimen should be taken from at least two
locations. Tissue for biopsy is to be taken with the punch forceps
shown in Fig. 28 or that in Fig. 33. The forceps may be inserted
through the tube or from the angle of the mouth; the "extubal" method
(see Fig. 58).
[FIG. 58.--Schema illustrating removal of a tumor from the upper part
of the larynx by the author's "extubal" method for large tumors. The
large alligator basket punch forceps, F, is inserted from the right
corner of the mouth and the jaws are placed over the tumor, T, under
guidance of the eye looking through the laryngoscope, L. This method
is not used for small tumors. It is excellent for amputation of the
epiglottis with these same punch forceps or with the heavy snare.]
_Removal of large benign tumors above the cords_ may be done with the
snare or with the large laryngeal punch forceps. Both are used in the
extubal method.
_Amputation of the epiglottis_ for palliation of odynophagia or
dysphagia in tuberculous or malignant disease, is of benefit when the
ulceration is confined to this region; though as to tuberculosis the
author feels rather conservatingly inclined. Early malignancy of the
extreme tip can be cured by such means. The function of the epiglottis
seems to be to split the food bolus and direct its portions laterally
into the pyriform sinuses, rather than to take any important part in
the closure of the larynx. Following the removal of the epiglottis
there is rarely complaint of food entering the larynx. The projecting
portion of the epiglottis may be amputated with a heavy snare, or by
means of the large laryngeal punch forceps (Fig. 33).
_Endoscopic Operations for Laryngeal Stenosis_.--Web formations may be
excised with sliding punch forceps, or if the web is due to
contraction only, incision of the true band may allow its retraction.
In some instances liberation of adhesions will favor the formation of
adventitious vocal cords. A sharp anterior commissure is a large
factor in good phonation.
_Endoscopic evisceration of the larynx_ will cure a few cases of
laryngeal cicatricial stenosis, and should be tried before resorting
to laryngostomy. A sliding punch forceps is used to remove all the
tissue in the larynx out to the perichondrium, but care should be
taken in cicatricial cases to avoid removing any part of either
arytenoid cartilage. In cases of posticus paralysis the excision may
include portions of the vocal processes of the arytenoids.
Ventriculocordectomy is preferable to evisceration. The ventricular
floor is removed with punch forceps (Fig. 33) first on one side, then
after two months, on the other.
_Vocal Results_.--A whispering voice can always be had as long as air
can pass through the larynx, and this may be developed to a very loud
penetrating stage whisper. If the arytenoid motility has been
uninjured the repeated pulls on the scar tissue may draw out
adventitious bands and develop a loud, useful, though perhaps rough
and inflexible voice.
_Galvano-cauterization_ is the best method of treatment for chronic
subglottic edema or hyperplasia such as is seen in children following
diphtheria, when the stenosis produced prevents extubation or
decannulation. The utmost caution should be used to avoid deep
cauterizations; they are almost certain to set up perichondritis which
will increase the stenosis. Some of the most difficult cases that have
come to the author have been previously cauterized too deeply.
_Galvano-cautery puncture_ of tuberculous infiltrations of the larynx
at times yields excellent results in cases with mild pulmonary
lesions, and has quite replaced the use of the curette, lactic acid,
and other caustics. The direct method of exposing the larynx renders
the application of the cautery point easy and accurate. In severely
stenosed tuberculous larynges a tracheotomy should first be done, for
though the reaction is slight it might be sufficient to close a
narrowed glottis. The technic is the usual one for laryngeal
operations. Local anesthesia suffices. The larynx is exposed. The
rheostat having been previously adjusted to heat the electrode to
nearly white heat, the circuit is broken and the electrode introduced
cold. When the point is in contact with the desired location the
current is turned on and the point thrust in as deeply as desired.
Usually it should penetrate until a firm resistance is felt; but care
must be used not to damage the cricoarytenoid joint. The circuit is
broken at the instant of withdrawal. Punctures should be made as
nearly as possible perpendicular to the surface, so as to minimize the
destruction of epithelium and thus lessen the reaction. A minute gray
fibrous slough detaches itself in a few days. Cautery puncture should
be repeated every two or three weeks, selecting a new location each
time, until the desired result is obtained. Great caution, as
mentioned above, must be used to avoid setting up perichondritis. Many
cases of laryngeal tuberculosis will recover as quickly by silence and
a general antituberculous regime.
_Radium_, in form of capsules or of needles inserted in the tissues
may be applied with great accuracy; but the author is strongly
impressed with pyriform sinus applications by the Freer method.
_After-care of endolaryngeal operations_ includes careful cleansing of
the teeth and mouth; and if the extrinsic area of the larynx is
involved in the wound, sterile liquid food and water should be given
for four days. The patient should be watched for complications by a
special nurse who is familiar with the signs of laryngeal dyspnea
(q.v.). _Complications during endolaryngeal operations_ are rare.
Dyspnea may require tracheotomy. Idiosyncrasy to cocain, or the sight
or taste of blood may nauseate the patient and cause syncope. Serious
hemorrhage could occur only in a hemophile. The careless handling of a
bite block might damage a frail tool or dental fixture.
_Complications after endolaryngeal operations_ are unusual.
Carelessness in asepsis has been known to cause cervical cellulitis.
Emphysema of the neck has occurred. Edema of the larynx occasionally
occurs, and might necessitate tracheotomy. Serious bleeding after
operation is very rare except in bleeders. Hemorrhage within the
larynx can be stopped by the introduction of a roll of gauze from
above, tracheotomy having been previously performed. Morphin
subcutaneously administered, has a constricting action on the vessels
which renders it of value in controlling hemorrhage.
[97] CHAPTER IX--INTRODUCTION OF THE BRONCHOSCOPE
No one should do bronchoscopy until he is able to expose the glottis
by left-handed direct laryngoscopy in less than one minute. When he
has mastered this, one minute more should be sufficient to introduce
the bronchoscope into the trachea.
TECHNIC OF BRONCHOSCOPY
Local anesthesia is usually employed in the adult. The patient is
placed in the Boyce position shown in Fig. 51, with head and shoulders
projecting over the edge of the table and supported by an assistant.
The glottis is exposed by left-handed laryngoscopy. The
instrument-assistant now inserts the distal end of the bronchoscope
into the lumen of the laryngoscope, the handle being directed to the
right in a horizontal position. The operator now grasps the
bronchoscope, his eye is transferred from the laryngoscope to the
bronchoscope, and the bronchoscope is advanced and so directed that a
good view of the glottis is obtained. The slanted end of the
bronchoscope should then be directed to the left, so as clearly to
expose the left cord. In this position it will be found that the tip
of the slanted end is in the center of the glottic chink and will slip
readily into the trachea. No great force should be used, because if
the bronchoscope does not go through readily, either the tube is too
large a size or it is not correctly placed (Fig. 60). Normally,
however, there is some slight resistance, which in cases of subglottic
laryngitis may be considerable. The trained laryngologist will readily
determine by sense of touch the degree of pressure necessary to
overcome it. When the bronchoscope has been inserted to about the
second or third tracheal ring, the heavy laryngoscope is removed by
rotating the handle to the left, removing the slide, and withdrawing
the instrument. Care must be taken that the bronchoscope is not
withdrawn or coughed out during the removal of the laryngoscope; this
can be avoided by allowing the ocular end to rest against the
gown-covered chest of the operator. If preferred the operator may
train his instrumental assistant to take off the laryngoscope, while
the operator devotes his attention to preventing the withdrawal of the
bronchoscope by holding the handle with his right hand. At the moment
of insertion of the bronchoscope through the glottis, an especially
strong upward lift on the beak of the spatula will facilitate the
passage. It is necessary to be certain that the axis of the
bronchoscope corresponds to the axis of the trachea, in order to avoid
injury to the subglottic tissue which might be followed by subglottic
edema (Fig. 47). If the subglottic region is already edematous and
causes resistance, slight rotation to the laryngoscope, and
bronchoscope will cause the bronchoscope to enter more easily.
[FIG. 59.--Insufflation anesthesia with Elsberg apparatus. Anesthetist
has exposed the larynx and is about to introduce the silk-woven
catheter. Note the full extension of the head on the table.]
[FIG. 60.--Schema illustrating the introduction of the bronchoscope
through the glottis, recumbent patient. The handle, H, is always
horizontally to the right. When the glottis is first seen through the
tube it should be centrally located as at K. At the next inspiration
the end B, is moved horizontally to the left as shown by the dart, M,
until the glottis shows at the right edge of the field, C. This means
that the point of the lip, B, is at the median line, and it is then
quickly (not violently) pushed through into the trachea. At this same
moment or the instant before, the hyoid bone is given a quick
additional lift with the tip of the laryngoscope.]
[FIG. 61.--Schema illustrating oral bronchoscopy. The portion of the
table here shown under the head is, in actual work, dropped all the
way down perpendicularly. It appears in these drawings as a dotted
line to emphasize the fact that the head must be above the level of
the table during introduction of the bronchoscope into the trachea. A,
Exposure of larynx; B, bronchoscope introduced; C, slide removed; D,
laryngoscope removed leaving bronchoscope alone in position.]
_Difficulties in the Introduction of the Bronchoscope_.--The beginner
may enter the esophagus instead of the trachea: this might be
a dangerous accident in a dyspneic case, for the tube could, by
pressure on the trachea, cause respiratory arrest. A bronchoscope thus
misplaced should be resterilized before introducing it into the air
passages, for while the lower air passages are usually free from
bacteria, the esophagus is a septic canal. If the given technic is
carefully carried out the bronchoscope will not be contaminated with
mouth secretions. The trachea is recognized as an open tube, with
whitish rings, and the expiratory blast can be felt and tubular
breathing heard; while if by mistake the bronchoscope has entered the
gullet it will be observed that the cervical esophagus has collapsed
walls. A puff of air may be felt and a fluttering sound heard when the
tube is in the esophagus, but these lack the intensity of the tracheal
blast. Usually a free flow of secretion is met with in the esophagus.
In diseased states the tracheal rings may not be visible because of
swollen mucosa, or the trachea itself may be in partial collapse from
external pressure. The true expiratory blast will, however, always be
recognized when the tube is in the trachea. Wide gagging of the mouth
renders exposure of the larynx difficult.
[FIG. 62.--Insertion of the bronchoscope. Note direction of the
trachea as indicated by the bronchoscope. Note that the patient's head
is held above the level of the table. The assistant's left hand should
be at the patient's mouth holding the bite-block. This is removed and
the assistant is on the wrong side of the table in the illustration in
order not to hide the position of the operator's hands. Note the
handle of the bronchoscope is to the right.]
[FIG. 63.--The heavy laryngoscope has been removed leaving the light
bronchoscope in position. The operator is inserting forceps. Note how
the left hand of the operator holds the tube lightly between the thumb
and first two fingers of the left hand, while the last two fingers are
hooked over the upper teeth of the patient "anchoring" the tube to
prevent it moving in or out or otherwise changing the relation of the
distal tube-mouth to a foreign body or a growth while forceps are
being used. Thus, also, any desired location of the tube can be
maintained in systematic exploration. The assistant's left hand is
dropped out of the way to show the operator's method. The assistant
during bronchoscopy holds the bite-block like a thimble on the index
finger of the left hand, and the assistant should be on the right side
of the patient. He is here put wrongly on the left side so as not to
hide the instruments and the manner of holding them.]
_Examination of the Trachea and Bronchi_.--All bronchial orifices must
be identified _seriatim_; because this is the only way by which the
bronchoscopist can know what part of the tree he is examining.
Appearances alone are not enough. It is the order in which they are
exposed that enables the inexperienced operator to know the orifices.
After the removal of the laryngoscope, the bronchoscope is to be held
by the left hand like a billiard cue, the terminal phalanges of the
left middle and ring fingers hooking over the upper teeth, while the
thumb and index finger hold the bronchoscope, clamping it to the teeth
tightly or loosely as required (Fig. 63). Thus the tube may be
anchored in any position, or at any depth, and the right hand which
was directing the tube may be used for the manipulation of
instruments. The grasp of the bronchoscope in the right hand should be
similar to that of holding a pen, that is, the thumb, first, and
second fingers, encircle the shaft of the tube. The bronchoscope
should never be held by the handle (Fig. 64) for this grasp does not
allow of tactile sense transmission, is rigid, awkward, and renders
rotation of the tube a wrist motion instead of but a gentle finger
action. Any secretion in the trachea is to be removed by sponge
pumping before the bronchoscope is advanced. The inspection of the
walls of the trachea is accomplished by weaving from side to side and,
if necessary, up and down; the head being deflected as required during
the search of the passages, so that the larynx be not made the fulcrum
in the lever-like action.
[FIG. 64.--At A is shown an incorrect manner of holding the
bronchoscope. The grasp is too rigid and the position of the hand is
awkward. B, Correct manner, the collar being held lightly between the
finger and the thumb The thumb must not occlude the tube mouth.]
_The Fulcrum of the Bronchoscopic Lever is at the Upper Thoracic
Aperture; Never at the Larynx_.--Disregard of this rule will cause
subglottic edema and will limit the lateral motion of the tip of the
bronchoscope. It is the function of the assistant to make the head and
neck follow the direction of the proximal end of the bronchoscope and
thus avoid any pressure on the larynx (see Peroral Endoscopy, Fig.
135, p. 164).
In passing down the trachea the following two rules must be kept in
mind:
1. Before attempting to enter either main bronchus the carina must
be identified.
2. Before entering either main bronchus the orifices of both should
be identified and inspected.
_The carina_ is identified as a sharp vertical spur (recumbent
patient) at the distal end of the trachea, on either side of which are
the openings of the main bronchi. As the carina is situated to the
left of the midline of the trachea, the lip of the bronchoscope should
be turned toward the left, and slight lateral pressure should be made
on the left tracheal wall while the head of the patient is held
slightly to the right. This will expose the left bronchial orifice and
carina.
_Entering the Bronchi_.--The lip of the bronchoscope should be turned
in the direction of the bronchus to be explored, and the axis of the
bronchoscope should be made to correspond as nearly as possible to the
axis of this bronchus. The position of the lip is designated by the
direction taken by the handle. Upon entering the right bronchus, the
handle of the bronchoscope is turned horizontally to the right, and at
the same time the assistant deflects the head to the left.
_The right upper-lobe bronchus_ is recognized by its vertical spur;
the orifice is exposed by displacing the right lateral wall of the
right main bronchus at the level of the carina. Usually this orifice
will be thus brought into view. If not the bronchoscope may be
advanced downward 1 or 2 cm., carefully to avoid overriding. This
branch is sometimes found coming off the trachea itself, and even if
it does not, the overriding of the orifice is certain if the right
bronchus is entered before search is made for the upper-lobe-bronchial
orifice. The head must be moved strongly to the left in order to view
the orifice. A lumen image of the right upper-lobe bronchus is not
obtainable because of the sharp angles at which it is given off. _The
left upper-lobe bronchus_ is entered by keeping the handle of the
bronchoscope (and consequently the lip) to the left, and, by keeping
the head of the patient strongly to the right as the bronchoscopist
goes down the left main bronchus. This causes the lip of the
bronchoscope to bear strongly on the left wall of the left main
bronchus, consequently the left upper-lobe-bronchial orifice will not
be overridden. The spur separating the upper-lobe-bronchial orifice
from the stem bronchus is at an angle approximately from two to eight
o'clock, as usually seen in the recumbent patient. A lumen image of a
descending branch of the upper-lobe bronchus is often obtained, if the
patient's head be borne strongly enough to the right.
[FIG. 65.--Schema illustrating the entering of the anteriorly
branching middle lobe bronchus. T, Trachea; B, orifice of left main
bronchus at bifurcation of trachea. The bronchoscope, S, is in the
right main bronchus, pointing in the direction of the right inferior
lobe bronchus, I. In order to cause the lip to enter the middle lobe
bronchus, M, it is necessary to drop the head so that the bronchoscope
in the trachea TT, will point properly to enable the lip of the tube
mouth to enter the middle lobe bronchus, as it is seen to have done at
ML.]
Branches of the stem bronchus in either lung are exposed, or their
respective lumina presented, by manipulation of the lip of the
bronchoscope, with movement of the head in the required direction.
Posterior branches require the head quite high. A large one in the
left stem just below the left upper-lobe bronchus is often invaded by
foreign bodies. Anterior branches require lowering the head. The
_middle-lobe bronchus_ is the largest of all anterior branches. Its
almost horizontal spur is brought into view by directing the lip of
the bronchoscope upward, and dropping the head of the patient until
the lip bears strongly on the anterior wall of the right bronchus (see
Fig. 65).
[106] CHAPTER X--INTRODUCTION OF THE ESOPHAGOSCOPE
The esophagoscope is to be passed only with ocular guidance, never
blindly with a mandrin or obturator, as was done before the
bevel-ended esophagoscope was developed. Blind introduction of the
esophagoscope is equally as dangerous as blind bouginage. It is almost
certain to cause over-riding of foreign bodies and disease. In either
condition perforation of the esophagus is possible by pushing a sharp
foreign body through the normal wall or by penetrating a wall weakened
by disease. Landmarks must be identified as reached, in order to know
the locality reached. The secretions present form sufficient
lubrication for the instrument. A clear conception of the endoscopic
anatomy, the narrowings, direction, and changes of direction of the
axis of the esophagus, are necessary. The services of a trained
assistant to place the head in the proper sequential "high-low"
positions are indispensible (Figs. 52 and 70). Introduction may be
divided into four stages.
1. Entering the right pyriform sinus.
2. Passing the cricopharyngeus.
3. Passing through the thoracic esophagus.
4. Passing through the hiatus.
The patient is placed in the Boyce position as described in Chapter
VI. As previously stated, the esophagus in its upper portion follows
the curves of the cervical and dorsal spine. It is necessary,
therefore, to bring the cervical spine into a straight line with the
upper portion of the dorsal spine and this is accomplished by
elevation of the head--the "high" position (Figs. 66-71).
[PLATE III--ESOPHAGOSCOPIC VIEWS FROM OIL-COLOR DRAWINGS FROM LIFE, BY
THE AUTHOR:
1, Direct view of the larynx and laryngopharynx in the dorsally
recumbent patient, the epiglottis and hyoid bone being lifted with the
direct laryngoscope or the esophageal speculum. The spasmodically
adducted vocal cords are partially hidden by the over-hang of the
spasmodically prominent ventricular hands. Posterior to this the
aryepiglottic folds ending posteriorly in the arytenoid eminences are
seen in apposition. The esophagoscope should be passed to the right of
the median line into the right pyriform sinus, represented here by the
right arm of the dark crescent. 2, The right pyriform sinus in the
dorsally recumbent patient, the eminence at the upper left border,
corresponds to the edge of the cricoid cartilage. 3, The
cricopharyngeal constriction of the esophagus in the dorsally
recumbent patient, the cricoid cartilage being lifted forward with the
esophageal speculum. The lower (posterior) half of the lumen is closed
by the fold corresponding to the orbicular fibers of the
cricopharyngeus which advances spasmodically from the posterior wall.
(Compare Fig. 10.) This view is not obtained with an esophagoscope. 4,
Passing through the right pyriform sinus with the esophagoscope;
dorsally recumbent patient. The walls seem in tight apposition, and,
at the edges of the slit-like lumen, bulge toward the observer. The
direction of the axis of the slit varies, and in some instances it is
like a rosette, depending on the degree of spasm. 5, Cervical
esophagus. The lumen is not so patulent during inspiration as lower
down; and it closes completely during expiration. 6, Thoracic
esophagus; dorsally recumbent patient. The ridge crossing above the
lumen corresponds to the left bronchus. It is seldom so prominent as
in this patient, but can always be found if searched for. 7, The
normal esophagus at the hiatus. This is often mistaken for the cardia
by esophagoscopists. It is more truly a sphincter than the cardia
itself. In the author's opinion there is no truly sphincteric action
at the cardia. It is the failure of this hiatal sphincter to open as
in the normal deglutitory cycle that produces the syndrome called
"cardiospasm." 8, View in the stomach with the open-tube gastroscope.
The form of the folds varies continually. 9, Sarcoma of the posterior
wall of the upper third of the esophagus in a woman of thirty-one
years. Seen through the esophageal speculum, patient sitting. The
lumen of the mouth of the esophagus, much encroached upon by the
sarcomatous infiltration, is seen at the lower part of the circle. 10,
Coin (half-dollar) wedged in the upper third of the esophagus of a boy
aged fourteen years. Seen through the esophageal speculum, recumbent
patient. Forceps are retracting the posterior lip of the esophageal
"mouth" preparatory to removal. 11, Fungating squamous-celled
epithelioma in a man of seventy-four years. Fungations are not always
present, and are often pale and edematous. 12, Cicatricial stenosis of
the esophagus due to the swallowing of lye in a boy of four years.
Below tile upper stricture is seen a second stricture. An ulcer
surrounded by an inflammatory areola and the granulation tissue
together illustrates the etiology of cicatricial tissue. The
fan-shaped scar is really almost linear, but it is viewed in
perspective. Patient was cured by esophagoscopic dilatation. 13,
Angioma of the esophagus in a man of forty years. The patient had
hemorrhoids and varicose veins of the legs. 14, Luetic ulcer of the
esophagus 26 cm. from the upper teeth in a woman of thirty-eight
years. Two scars from healed ulcerations are seen in perspective on
the anterior wall. Branching vessels are seen in the livid areola of
the ulcers. 15, Tuberculosis of the esophagus in a man of thirty-four
years. 16, Leukoplakia of the esophagus near the hiatus in a man aged
fifty-six years.]
The hypopharynx tapers down to the gullet like a funnel, and the
larynx is suspended in its lumen from the anterior wall. The larynx is
attached only to the anterior wall, but is held closely against the
posterior pharyngeal wall by the action of the inferior constrictor of
the pharynx, and particularly by its specialized portion--the
cricopharyngeus muscle. A bolus of food is split by the epiglottis and
the two portions drifted laterally into the pyriform sinuses, the
recesses seen on either side of the larynx. But little of the food
bolus passes posterior to the larynx during the act of swallowing. It
is through the pyriform sinus that the esophagoscope is to be
inserted, thereby following the natural food passage. To insert the
esophagoscope in the midline, posterior to the arytenoids, requires a
degree of force dangerous to exert and almost certain to produce
damage to the cricoarytenoid joint or to the pharyngeal wall, or to
both.
The esophagoscope is steadied by the left hand like a billiard cue, the
terminal phalanges of the left middle and ring fingers hooked over the
upper teeth, while the left index finger and thumb encircle the tube
and retract the upper lip to prevent its being pinched between the
tube and upper teeth. The right hand holds the tube in pen fashion at
the collar of the handle, not by the handle. During introduction the
handle is to be pointed upward toward the zenith.
_Stage I. Entering the Right Pyriform Sinus_.--The operator standing
(as in Fig. 66), inserts the esophagoscope along the right side of the
tongue as far as and down the posterior pharyngeal wall. A lifting
motion imparted to the tip of the esophagoscope by the left thumb will
bring the rounded right arytenoid eminence into view (A, Fig. 69).
This is the landmark of the pyriform sinus, and care must be taken to
avoid injury by hooking the tube mouth over it or its fellow. The tip
of the tube should now be directed somewhat toward the midline,
remembering the funnel shape of the hypopharynx. It will then be found
to glide readily through the right pyriform sinus for 2 or 3 cm., when
it comes to a full stop, and the lumen disappears. This is the
spasmodically closed cricopharyngeal constriction.
[FIG. 66.--Esophagoscopy by the author's "high-low" method. First
stage. "High" position. Finding the right pyriform sinus. In this and
the second stage the patient's vertex is about 15 cm. above the level
of the table.]
_Stage 2. Passing the cricopharyngeus_ is the most difficult part of
esophagoscopy, especially if the patient is unanesthetized. Local
anesthesia helps little, if at all. The handle of the esophagoscope is
still pointing upward and consequently we are sure that the lip of the
esophagoscope is directed anteriorly. Force must not be used, but
steady firm pressure against the tonically contracted cricopharyngeus
is made, while at the same time the distal end of the esophagoscope is
lifted by the left thumb. At the first inspiration a lumen will
usually appear in the upper portion of the endoscopic field. The tip
of the esophagoscope enters this lumen and the slanted end slides over
the fold of the cricopharyngeus into the cervical esophagus. There is
usually from 1 to 3 cm. of this constricted lumen at the level of the
cricopharyngeus and the subjacent orbicular esophageal fibers.
[109] [FIG. 67.--Schematic illustration of the author's "high-low"
method of esophagoscopy. In the first and second stages the patient's
head fully extended is held high so as to bring it in line with the
thoracic esophagus, as shown above. The Rose position is shown by way
of accentuation.]
[FIG. 68.--Schematic illustration of the anatomic basis for difficulty
in introduction of the esophagoscope. The cricoid cartilage is pulled
backward against the cervical spine, by the cricopharyngeus, so
strongly that it is difficult to realize that the cricopharyngeus is
not inserted into the vertebral periosteum instead of into the median
raphe.]
[FIG. 69.--The upper illustration shows movements necessary for
passing the cricopharyngeus.
The lower illustration shows schematically the method of finding the
pyriform sinus in the author's method of esophagoscopy. The large
circle represents the cricoid cartilage. G, Glottic chink,
spasmodically closed; VB, ventricular band; A, right arytenoid
eminence; P, right pyriform sinus, through which the tube is passed in
the recumbent posture. The pyriform sinuses are the normal food
passages.]
_Stage 3. Passing Through the Thoracic Esophagus_.--The thoracic
esophagus will be seen to expand during inspiration and contract
during expiration, due to the change in thoracic pressure. The
esophagoscope usually glides easily through the thoracic esophagus if
the patient's position is correct. After the levels of the aorta and
left bronchus are passed the lumen of the esophagus seems to have a
tendency to disappear anteriorly. The lumen must be kept in axial view
and the head lowered as required for this purpose.
_Stage 4. Passing Through the Hiatus Esophageus_.--When the head is
dropped, it must at the same time be moved horizontally to the right
in order that the axis of the tube shall correspond to the axis of the
lower third of the esophagus, which deviates to the left and turns
anteriorly. The head and shoulders at this time will be found to be
considerably below the plane of the table top (Fig. 71). The hiatal
constriction may assume the form of a slit or rosette. If the rosette
or slit cannot be promptly found, as may be the case in various
degrees of diffuse dilatation, the tube mouth must be shifted farther
to the left and anteriorly. When the tube mouth is centered over the
hiatal constriction moderately firm pressure continued for a short
time will cause it to yield. Then the tube, maintaining this same
direction will, without further trouble glide into and through the
abdominal esophagus. The cardia will not be noticed as a constriction,
but its appearance will be announced by the rolling in of reddish
gastric mucosal folds, and by a gush of fluid from the stomach.
[FIG. 70.--Schematic illustration of the author's "high-low" method of
esophagoscopy, fourth stage. Passing the hiatus. The head is dropped
from the position of the 1st and 2nd stages, CL, to the position T,
and at the same time the head and shoulders are moved to the right
(without rotation) which gives the necessary direction for passing the
hiatus.]
[FIG. 71.--Esophagoscopy by the author's "high-low" method. Stage 4.
Passing the hiatus The patient's vertex is about 5 cm. below the top
of the table.]
_Normal esophageal mucosa_ under proper illumination is glistening and
of a yellowish or bluish pink. The folds are soft and velvety,
rendering infiltration quickly noticeable. The cricoid cartilage shows
white through the mucosa. The gastric mucosa is a darker pink than
that of the esophagus and when actively secreting, its color in some
cases tends toward crimson.
_Secretions_ in the esophagus are readily aspirated through the
drainage canal by a negative pressure pump. Food particles are best
removed by "sponge pumping," or with forceps. Should the drainage
canal become obstructed positive pressure from the pump will clear the
canal.
_Difficulties of Esophagoscopy_.--The beginner may find the
esophagoscope seemingly rigidly fixed, so that it can be neither
introduced nor withdrawn. This usually results from a wedging of the
tube in the dental angle, and is overcome by a wider opening of the
jaws, or perhaps by easing up of the bite block, but most often by
correcting the position of the patient's head. If the beginner cannot
start the tube into the pyriform sinus in an adult, it is a good plan
to expose the arytenoid eminence with the laryngoscope and then to
insert the 7 mm. esophagoscope into the right pyriform sinus by direct
vision. Passing the cricopharyngeal and hiatal spasmodically
contracted narrowings will prove the most trying part of
esophagoscopy; but with the head properly held, and the tube properly
placed and directed, patient waiting for relaxation of the spasm with
gentle continuous pressure will usually expose the lumen ahead. In his
first few esophagoscopies the novice had best use general anesthesia
to avoid these difficulties and to accustom himself to the esophageal
image. In the first favorable subject--an emaciated individual with no
teeth--esophagoscopy without anesthesia should be tried.
In cases of kyphosis it is a mistake to try to straighten the spine.
The head should be held correspondingly higher at the beginning, and
should be very slowly and cautiously lowered.
Once inserted, the esophagoscope should not be removed until the
completion of the procedure, unless respiratory arrest demands it.
Occasionally in stenotic conditions the light may become covered by
the upwelling of a flood of fluid, and it will be thought the light
has gone out. As soon as the fluid has been aspirated the light will
be found burning as brightly as before. If a lamp should fail it is
unnecessary to remove the tube, as the light carrier and light can be
withdrawn and quickly adjusted. A complete instrument equipment with
proper selection of instruments for the particular case are necessary
for smooth working.
_Ballooning Esophagoscopy_.--By inserting the window plug shown in
Fig. 6 the esophagus may be inflated and studied in the distended
state. The folds are thus smoothed out and constrictions rendered more
marked. Ether anesthesia is advocated by Mosher. The danger of
respiratory arrest from pressure, should the patient be dyspneic, is
always present unless the anesthetic be given by the intratracheal
method. If necessary to use forceps the window cap is removed. If the
perforated rubber diaphragm cap be substituted the esophagus can be
reballooned, but work is no longer ocularly guided. The fluoroscope
may be used but is so misleading as to render perforation and false
passage likely.
_Specular Esophagoscopy_.--Inspection of the hypopharynx and upper
esophagus is readily made with the esophageal speculum shown in Fig.
4. High lesions and foreign bodies lodged behind the larynx are thus
discovered with ease, and such a condition as a retropharyngeal
abscess which has burrowed downward is much less apt to be overlooked
than with the esophagoscope. High strictures of the esophagus may be
exposed and treated by direct visual bouginage until the lumen is
sufficiently dilated to allow the passage of the esophagoscope for
bouginage of the deeper strictures.
_Technic of Specular Esophagoscopy_.--Recumbent patient. Boyce
position. The larynx is to be exposed as in direct laryngoscopy, the
right pyriform sinus identified, the tip of the speculum inserted
therein, and gently insinuated to the cricopharyngeal constriction.
Too great extension of the head is to be avoided--even slight flexion
at the occipito-atloid joint may be found useful at times. Moderate
anterior or upward traction pulls the cricoid away from the posterior
pharyngeal wall and the lumen of the esophagus opens above a
crescentic fold (the cricopharyngeus). The speculum readily slides
over this fold and enters the cervical esophagus. In searching for
foreign bodies in the esophagus the speculum has the disadvantage of
limited length, so that should the foreign body move downward it could
not be followed.
_Complications Following Esophagoscopy_.--These are to be avoided in
large measure by the exercise of gentleness, care, and skill that are
acquired by practice. If the instructions herein given are followed,
esophagoscopy is absolutely without mortality apart from the
conditions for which it is done.
Injury to the crico-arytenoid joint may simulate recurrent paralysis.
Posticus paralysis may occur from recurrent or vagal pressure by a
misdirected esophagoscope. These conditions usually recover but may
persist. Perforation of the esophageal wall may cause death from
septic mediastinitis. The pleura may be entered,--pyopneumothorax will
result and demand immediate thoracotomy and gastrostomy. Aneurysm of
the aorta may be ruptured. Patients with tuberculosis, decompensating
cardiovascular lesions, or other advanced organic disease, may have
serious complications precipitated by esophagoscopy.
_Retrograde Esophagoscopy_.--The first step is to get rid of the
gastric secretions. There is always fluid in the stomach, and this
keeps pouring out of the tube in a steady stream. Fold after fold is
emptied of fluid. Once the stomach is empty, the search begins for the
cardial opening. The best landmark is a mark with a dermal pencil on
the skin at a point corresponding to the level of the hiatus
esophageus. When it is desired to do a retrograde esophagoscopy and
the gastrostomy is done for this special purpose, it is wise to have
it very high. Once the cardia is located and the esophagus entered,
the remainder of the work is very easy. Bouginage can be carried out
from below the same as from above and may be of advantage in some
cases. Strictural lumina are much more apt to be concentric as
approached from below because there has been no distortion by pressure
dilatation due to stagnation of the food operating through a long
period of time. At retrograde esophagoscopy there seems to be no
abdominal esophagus and no cardia. The esophagoscope encounters only
the diaphragmatic pinchcock which seems to be at the top of the
stomach like the puckering string at the top of a bag.
Retrograde esophagoscopy is sometimes useful for "stringing" the
esophagus in cases in which the patient is unable to swallow a string
because he is too young or because of an epithelial scaling over of
the upper entrance of the stricture. In such cases the smallest size
of the author's filiform bougies (Fig. 40) is inserted through the
retrograde esophagoscope (Fig. 43) and insinuated upward through the
stricture. When the tip reaches the pharynx coughing, choking and
gagging are noticed. The filiform end is brought out the mouth
sufficiently far to attach a silk braided cord which is then pulled
down and out of the gastrostomic opening. The braided silk "string"
must be long enough so that the oral and the abdominal ends can be
tied together to make it "endless;" but before doing so the oral end
should be drawn through nose where it will be less annoying than in
the mouth. The purpose of the "string" is to pull up the retrograde
bougies (Fig. 35)
[117] CHAPTER XI--ACQUIRING SKILL
Endoscopic ability cannot be bought with the instruments. As with all
mechanical procedures, facility can be obtained only by educating the
eye and the fingers in repeated exercise of a particular series of
maneuvers. As with learning to play a musical instrument, a
fundamental knowledge of technic, positions, and landmarks is
necessary, after which only continued manual practice makes for
proficiency. For instance, efficient use of forceps requires that they
be so familiar to the grasp that their use is automatic. Endoscopy is
a purely manual procedure, hence to know how is not enough: manual
practice is necessary. Even in the handling of the electrical
equipment, practice in quickly locating trouble is as essential as
theoretic knowledge. There is no mystery about electric lighting. No
source of illumination other than electricity is possible for
endoscopy. Therefore a small amount of electrical knowledge, rendered
practical by practice, is essential to maintain the simple lighting
system in working order. It is an insult to the intelligence of the
physician to say that he cannot master a simple problem of electric
testing involving the locating of one or more of five possibilities.
It is simply a matter of memorizing five tests. It is repeated for
emphasis that a commercial current reduced by means of a rheostat
should never be used as a source of current for endoscopy with any
kind of instrument, because of the danger to the patient of a possible
"grounding" of the circuit during the extensive moist contact of a
metallic endoscopic tube in the mediastinum. The battery shown in Fig.
8 should be used. The most frequent cause of trouble is the mistake of
over-illuminating the lamps. _The lamp should not be over-illuminated
to the dazzling whiteness usually used in flash lights_. Excessive
illumination alters the proper perception of the coloring of the
mucosa, besides shortening the life of the lamps. The proper degree of
brightness is obtained when, as the current is increased, the first
change from yellow to white light is obtained. Never turn up the
rheostat without watching the lamp.
_Testing for Electric Defects_.--These tests should be made
beforehand; not when about to commence introduction.
If the first lamp lights up properly, use it with its light-carrier to
test out the other cords.
If the lamp lights up, but flickers, locate the trouble before
attempting to do an endoscopy. If shaking the carrier cord-terminal
produces flickering there may be a film of corrosion on the central
contact of the light carrier that goes into the carrier cord-terminal.
If the lamp fails to show a light, the trouble may be in one of five
places which should be tested for in the following order and manner.
1. The lamp may not be firmly screwed into the light-carrier.
Withdraw the light-carrier and try screwing it in, though not too
strongly, lest the central wire terminal in the lamp be bent over.
2. The light-carrier may be defective.
3. The cord may be defective or its terminals not tight in the
binding posts. If screwing down the thumb nuts does not produce a
light, test the light-carrier with lamp on the other cords. Reserve
cords in each pair of binding posts are for use instead of the
defective cords. The two sets of cords from one pair of binding posts
should not be used simultaneously.
4. The lamp may be defective. Try another lamp.
5. The battery may be defective. Take a cord and light-carrier with
lamp that lights up, detaching the cord-terminals at the binding
posts, and attach the terminals to the binding posts of the battery to
be tested.
_Efficient use of forceps_ requires previous practice in handling of
the forceps until it has become as natural and free from thought as
the use of knife and fork. Indeed the coordinate use of the
bronchoscopic tube-mouth and the forceps very much resembles the use
of knife and fork. Yet only too often a practitioner will telegraph
for a bronchoscope and forceps, and without any practice start in to
remove an entangled or impacted foreign body from the tiny bronchi of
a child. Failure and mortality are almost inevitable. A few hundred
hours spent in working out, on a bit of rubber tubing, the various
mechanical problems given in the section on that subject will save
lives and render easily successful many removals that would otherwise
be impossible.
It is often difficult for the beginner to judge the distance the
forceps have been inserted into the tube. This difficulty is readily
solved if upon inserting the forceps slowly into the tube, he observes
that as the blades pass the light they become brightly illuminated. By
this _light reflex_ it is known, therefore, that the forceps blades
are at the tube-mouth, and distance from this point can be readily
gauged. Excellent practice may be had by picking up through the
bronchoscope or esophagoscope black threads from a white background,
then white threads from a black background, and finally white threads
on a white background and black threads on a black background. This
should be done first with the 9 mm. bronchoscope. It is to be
remembered that the majority of foreign body accidents occur in
children, with whom small tubes must be used; therefore, practice
work, after say the first 100 hours, should be done with the 5 mm.
bronchoscope and corresponding forceps rather than adult size tubes,
so that the operator will be accustomed to work through a small
calibre tube when the actual case presents itself.
[120] _Cadaver Practice_.--The fundamental principles of peroral
endoscopy are best taught on the cadaver. It is necessary that a
specially prepared subject be had, in order to obtain the required
degree of flexibility. Injecting fluid of the following formula worked
out by Prof. J. Parsons Schaeffer for the Bronchoscopic Clinic
courses, has proved very satisfactory:
Sodium carbonate--1 1/2 lbs.
White arsenic--2 1/2 lbs.
Potassium nitrate--3 lbs.
Water--5 gal.
Boil until arsenic is dissolved. When cold add:
Carbolic acid 1500 c.c.
Glycerin 1250 c.c.
Alcohol (95%) 1250 c.c.
For each body use about 3 gal. of fluid.
The method of introduction of the endoscopic tube, and its various
positions can be demonstrated and repeatedly practiced on the cadaver
until a perfected technic is developed in both the operator and
assistant who holds the head, and the one who passes the instruments
to the operator. In no other manner can the landmarks and endoscopic
anatomy be studied so thoroughly and practically, and in no other way
can the pupil be taught to avoid killing his patient. The
danger-points in esophagoscopy are not demonstrable on the living
without actually incurring mortality. Laryngeal growths may be
simulated, foreign body problems created and their mechanical
difficulties solved and practice work with the forceps and tube
perfected.
_Practice on the Rubber-tube Manikin_.--This must be carried out in
two ways.
1. General practice with all sorts of objects for the education of
the eye and the fingers.
2. Before undertaking a foreign body case, practice should be had
with a duplicate of the foreign body.
It is not possible to have a cadaver for daily practice, but
fortunately the eye and fingers may be trained quite as effectually by
simulating foreign body conditions in a small red rubber tube and
solving these mechanical problems with the bronchoscope and forceps.
The tubing may be placed on the desk and held by a small vise (Fig.
72) so that at odd moments during the day or evening the fascinating
work may be picked up and put aside without loss of time. Complicated
rubber manikins are of no value in the practice of introduction, and
foreign body problems can be equally well studied in a piece of rubber
tubing about 10 inches long. No endoscopist has enough practice on the
living subject, because the cases are too infrequent and furthermore
the tube is inserted for too short a space of time. Practice on the
rubber tube trains the eye to recognize objects and to gauge distance;
it develops the tactile sense so that a knowledge of the character of
the object grasped or the nature of the tissues palpated may be
acquired. Before attempting the removal of a particular foreign body
from a living patient, the anticipated problem should be simulated
with a duplicate of the foreign body in a rubber tube. In this way the
endoscopist may precede each case with a practical experience
equivalent to any number of cases of precisely the same kind of
foreign body. If the object cannot be removed from the rubber tube
without violence, it is obvious that no attempt should be made on the
patient until further practice has shown a definite method of harmless
removal. During practice work the value of the beveled lip of the
bronchoscope and esophagoscope in solving mechanical problems will be
evidenced. With it alone, a foreign body may be turned into favorable
positions for extraction, and folds can always be held out of the way.
Sufficient combined practice with the bronchoscope and the forceps
enable the endoscopist easily to do things that at first seem
impossible. It is to be remembered that lateral motion of the long
slender tube-forceps cannot be controlled accurately by the handle,
this is obtained by a change in position of the endoscopic tube, the
object being so centered that it is grasped without side motion of the
forceps. When necessary, the distal end of the forceps may be pushed
laterally by the manipulation of the bronchoscope.
[FIG. 72.--A simple manikin. The weight of the small vise serves to
steady the rubber tubing. By the use of tubing of the size of the
invaded bronchus and a duplicate of the foreign body, any mechanical
problem can he simulated for solution or for practice, study of all
possible presentations, etc.]
_Practice on the Dog_.--Having mastered the technic of introduction on
the cadaver and trained the eye and fingers by practice work on the
rubber tube, experience should be had in the living lower air and food
passages with their pulsatory, respiratory, bechic and deglutitory
movements, and ever-present secretions. It is not only inhuman but
impossible to obtain this experience on children. Fortunately the dog
offers a most ready subject and need in no way be harmed nor pained by
this invaluable and life-saving practice. A small dog the size of a
terrier (say 6 to 10 pounds in weight) should be chosen and
anesthetized by the hypodermic injection of morphin sulphate in dosage
of approximately one-sixth of a grain per pound of body weight, given
about 45 minutes before the time of practice. Dogs stand large doses
of morphin without apparent ill effect, so that repeated injection may
be given in smaller dosage until the desired degree of relaxation
results. The first effect is vomiting which gives an empty stomach for
esophagoscopy and gastroscopy. Vomiting is soon followed by relaxation
and stupor. The dog is normal and hungry in a few hours. Dosage must
be governed in the clog as in the human being by the susceptibility to
the drug and by the temperament of the animal. Other forms of
anesthesia have been tried in my teaching, and none has proven so safe
and satisfactory. Phonation may be prevented during esophagoscopy by
preventing approximation of the cords, through inserting a silk-woven
cathether in the trachea. The larynx and trachea may be painted with
cocain solution if it is found necessary for bronchoscopy. A very
comfortable and safe mouth gag is shown in Fig. 73. Great gentleness
should be exercised, and no force should be used, for none is required
in endoscopic work; and the endoscopist will lose much of the value of
his dog practice if he fails to regard the dog as a child. He should
remember he is not learning how to do endoscopy on the dog; but
learning on the dog how safely to do bronchoscopy on a human being.
The degree of resistance during introduction can be gauged and the
color of the mucosa studied, while that interesting phenomenon, the
dilatation and lengthening of the bronchi during inspiration and their
contraction and shortening during expiration, is readily observed and
always forms subject for thought in its possible connection with
pathological conditions. Foreign body problems are now to be solved
under these living conditions, and it is my feeling that no one should
attempt the removal of a foreign body from the bronchus of a child
until he has removed at least 100 foreign bodies from the dog without
harming the animal. Dogs have the faculty of easily ridding their
air-passages of foreign objects, so that one need not be alarmed if a
foreign body is lost during practice removal. It is to be remembered
that dogs swallow very large objects with apparent ease. The dog's
esophagus is relatively much larger than that of human beings.
Therefore a small dog (of six to eight pounds' weight) must be used
for esophagoscopic practice, if practice is to be had with objects of
the size usually encountered in human beings. The bronchi of a dog of
this weight will be about the size of those of a child.
[FIG. 73.--Author's mouth gag for use on the dog. The thumb-nut serves
to prevent an uncomfortable degree of expansion of the gag. A bandage
may be wound around the dog's jaws to prevent undue spread of the
jaws.]
_Endoscopy on the Human Being_.--Dog work offers but little practice
in laryngoscopy. Because of the slight angle at which the dog's head
joins his spine, the larynx is in a direct line with the open mouth;
hence little displacement of the anterior cervical tissues is
necessary. Moreover the interior of the larynx of the dog is quite
different from that of the human larynx. The technic of laryngoscopy
in the human subject is best perfected by a routine direct examination
of the larynx of anesthetized patients after such an operation as, for
instance, tonsillectomy, to see that the larynx and laryngopharynx are
free of clots. To perform a bronchoscopy or esophagoscopy under these
conditions would be reprehensible; but direct laryngoscopy for the
seeking and removal of clots serves a useful purpose as a preventative
of pulmonary abscess and similar complications.* Diagnosis of
laryngeal conditions in young children is possible only by direct
laryngoscopy and is neglected in almost all of the cases. No
anesthesia, general or local, is required. Much clinical material is
neglected. All cases of dyspnea or dysphagia should be studied
endoscopically if the cause of the condition cannot be definitely
found and treated by other means. Invaluable practice in esophagoscopy
is found in the treatment of strictures of the esophagus by weekly or
biweekly esophagoscopic bouginage.
* Dr. William Frederick Moore, of the Bronchoscopic Clinic, has
recently collected statistics of 202 cases of post-tonsillectomic
pulmonary abscess that point strongly to aspiration of infected clots
and other infective materials as the most frequent etiologic mechanism
(Moore, W. F., Pulmonary Abscess. Journ. Am. Med. Assn., April 29,
1922, Vol. 78, pp. 1279-1281).
In acquiring skill as an endoscopist the following paraphrased
aphorisms afford food for thought.
APHORISMS
Educate your eye and your fingers.
Be sure you are right, but not too sure.
Follow your judgment, never your impulse.
Cry over spilled milk enough to memorize how you spilled it.
Let your mistakes worry you enough to prevent repetition.
Let your left hand know what your right hand does and how
to do it.
Nature helps, but she is no more interested in the survival of your
patient than in the survival of the attacking pathogenic bacteria.
[126] CHAPTER XII--FOREIGN BODIES IN THE AIR AND FOOD PASSAGES
The air and food passages may be invaded by any foreign substance of
solid, liquid or gaseous nature, from the animal, vegetable, or
mineral kingdoms. Its origin may be from within the body (blood, pus,
secretion, broncholiths, sequestra, worms); introduced from without by
way of the natural passages (aspirated or swallowed objects); or it
may enter by penetration (bullet, dart, drainage tube from the neck).
_Prophylaxis_.--If one put into his mouth nothing but food, foreign
body accidents would be rare. The habit of holding tacks, pins and
whatnot in the mouth is quite universal and deplorable. Children are
prone to follow the bad example of their elders. No small objects such
as safety pins, buttons, and coins should be left within a baby's
reach; children should be watched and taught not to place things in
their mouths. Mothers should be specially cautioned not to give nuts
or nut candy of any kind to a child whose powers of mastication are
imperfect, because the molar teeth are not erupted. It might be made a
dictum that: "No child under 3 years of age should be allowed to eat
nuts, unless ground finely as in peanut butter." Digital efforts at
removal of foreign bodies frequently force the object downward, or may
hook it forward into the larynx, whereas if not meddled with digitally
the intruder might be spat out. Before general anesthesia the mouth
should be searched for loose teeth, removable dentures, etc., and all
unconscious individuals should be likewise examined. When working in
the mouth precautions should be taken against the possible inhalation
or swallowing of loose objects or instruments.
[126] Objects that have lodged in the esophagus, larynx, trachea, or
bronchi should be endoscopically removed.
_Foreign Bodies in the Insane_.--Foreign bodies may be introduced
voluntarily and in great numbers by the insane. Hysterical individuals
may assert the presence of a foreign body, or may even volitionally
swallow or aspirate objects. It is a mistake to do a bronchoscopy in
order to cure by suggestion the delusion of foreign body presence.
Such "cures" are ephemeral.
_Foreign Bodies in the Stomach_.--Gastroscopy is indicated in cases of
a foreign body that refuses to pass after a month or two. Foreign
bodies in very large numbers in the stomach, as in the insane, may be
removed by gastrostomy.
_The symptomatology of foreign bodies_ may be epitomized as given
below; but it must be kept in mind, that certain symptoms may not be
manifest immediately after intrusion, and others may persist for a
time after the passage, removal, or expulsion of a foreign body.
ESOPHAGEAL FOREIGN BODY SYMPTOMS
1. There are no absolutely diagnostic symptoms.
2. Dysphagia, however, is the most constant complaint, varying with
the size of the foreign body, and the degree of inflammatory or
spasmodic reaction produced.
3. Pain may be caused by penetration of a sharp foreign body, by
inflammation secondary thereto, by impaction of a large object, or by
spasmodic closure of the hiatus esophageus.
4. The subjective sensation of foreign body is usually present, but
cannot be relied upon as assuring the presence of a foreign body for
this sensation often remains for a time after the passage onward of
the intruder.
5. All of these symptoms may exist, often in the most intense
degree, as the result of previous violent attempts at removal; and the
foreign body may or may not be present.
SYMPTOMS OF LARYNGEAL FOREIGN BODY
1. Initial laryngeal spasm followed by wheezing respiration, croupy
cough, and varying degrees of impairment of phonation.
2. Pain may be a symptom. If so, it is usually located in the
laryngeal region, though in some cases it is referred to the ears.
3. The larynx may tolerate a thin, flat, foreign body for a
relatively long period of time, a month or more; but the development
of increasing dyspnea renders early removal imperative in the majority
of cases.
SYMPTOMS OF TRACHEAL AND BRONCHIAL FOREIGN BODY
1. Tracheal foreign bodies are usually movable and their movements
can usually be felt by the patient.
2. Cough is usually present at once, may disappear for a time and
recur, or may be continuous, and may be so violent as to induce
vomiting. In recent cases fixed foreign bodies cause little cough;
shifting foreign bodies cause violent coughing.
3. Sudden shutting off of the expiratory blast and the phonation
during paroxysmal cough is almost pathognomonic of a movable tracheal
foreign body.
4. Dyspnea is usually present in tracheal foreign bodies, and is due
to the bulk of the foreign body plus the subglottic swelling caused by
the traumatism of the shiftings of the intruder.
5. Dyspnea is usually absent in bronchial foreign bodies.
6. The respiratory rate is increased only if a considerable portion
of lung is out of function, by the obstruction of a main bronchus, or
if inflammatory sequelae are extensive.
7. The asthmatoid wheeze is usually present in tracheal foreign
bodies, and is often louder and of lower pitch than the asthmatoid
wheeze of bronchial foreign bodies. It is heard at the open mouth, not
at the chest wall; and prolonged expiration as though to rid the lungs
of all residual air, may be necessary to elicit it.
8. Pain is not a common symptom, but may occur and be accurately
localized by the patient, in case of either tracheal or bronchial
foreign body.
EARLY SYMPTOMS OF IRRITATING FOREIGN BODY SUCH AS A PEANUT KERNEL IN
THE BRONCHUS
1. Initial laryngeal spasm is almost invariably present with foreign
bodies of organic nature, such as nut kernels, peas, beans, maize,
etc.
2. A diffuse purulent laryngo-tracheo-bronchitis develops within 24
hours in children under 2 years.
3. Fever, toxemia, cyanosis, dyspnea and paroxysmal cough are
promptly shown.
4. The child is unable to cough up the thick mucilaginous pus
through the swollen larynx and may "drown in its own secretions"
unless the offender be removed.
5. "Drowned lung," that is to say natural passages idled with pus
and secretions, rapidly forms.
6. Pulmonary abscess develops sooner than in case of mineral foreign
bodies.
7. The older the child the less severe the reaction.
SYMPTOMS OF PROLONGED FOREIGN BODY SOJOURN IN THE BRONCHUS
1. The time of inhalation of a foreign body may be unknown or
forgotten.
2. Cough and purulent expectoration ultimately result, although
there may be a delusive protracted symptomless interval.
[130] 3. Periodic attacks of fever, with chills and sweats, and
followed by increased coughing and the expulsion of a large amount of
purulent, usually more or less foul material, are so nearly diagnostic
of foreign body as to call for exclusion of this probability with the
utmost care.
4. Emaciation, clubbing of the fingers and toes, night sweats,
hemoptysis, in fact all of the symptoms of tuberculosis are in most
cases simulated with exactitude, even to the gain in weight by an
out-door regime.
5. Tubercle bacilli have never been found, in the cases at the
Bronchoscopic Clinic, associated with foreign body in the bronchus.*
In cases of prolonged sojourn this has been the only element lacking
in a complete clinical picture of advanced tuberculosis. One point of
difference was the almost invariably rapid recovery after removal of
the foreign body. The statement in all of the text-books, that foreign
body is followed by phthisis pulmonalis is a relic of the days when
the bacillary origin of true tuberculosis was unknown, hence the
foreign-body phthisis pulmonalis, or pseudo tuberculosis, was confused
with the true pulmonary tuberculosis of bacillary origin.
6. The subjective sensation of pain may allow the patient accurately
to localize a foreign body.
7. Foreign bodies of metallic or organic nature may cause their
peculiar taste in the sputum.
8. Offensive odored sputum should always suggest bronchial foreign
body; but absence of sputum, odorous or not, should not exclude
foreign body.
9. Sudden complete obstruction of one main bronchus does not cause
noticeable dyspnea provided its fellow is functionating.
[131] 10. Complete obstruction of a bronchus is followed by rapid
onset of
symptoms.
11. The physical signs usually show limitation of expansion on the
affected side, impairment of percussion, and lessened trans-mission or
absence of breath-sounds distal to the foreign body.
* The exceptional case has at last been encountered. A boy with a tack
in the bronchus was found to have pulmonary tuberculosis.
SYMPTOMS OF GASTRIC FOREIGN BODY
Foreign body in the stomach ordinarily produces no symptoms. The
roentgenogram and the fluoroscopic study with an opaque mixture are
the chief means of diagnosis.
DIAGNOSIS OF FOREIGN BODY IN THE AIR OR FOOD PASSAGES
The questions arising are:
I. Is a foreign body present?
2. Where is it located?
3. Is a peroral endoscopic procedure indicated?
4. Are there any contraindications to endoscopy?
In order to answer these questions the definite routine given below is
followed unvaryingly in the Bronchoscopic Clinic.
1. History.
2. Complete physical examination, including mirror laryngoscopy.
3. Roentgenologic study.
4. Endoscopy.
The history should note the date of, and should delve into the details
of the accident; special note being made of the occurrence of
laryngeal spasm, wheezing respiration heard by the patient or others
(asthmatoid wheeze), fever, cough, pain, dyspnea, dysphagia,
odynphagia, regurgitation, etc. The amount, character and odor of
sputum are important. Increasing amounts of purulent, foul-odored,
sometimes blood-tinged sputum strongly suggest prolonged bronchial
foreign body sojourn. The mode of onset of the persisting symptoms,
whether immediately following the supposed accident or delayed in
their occurrence, is to be noted. Do attacks of sudden dyspnea and
cyanosis occur? What has been the previous treatment and what attempts
at removal have been made? The nature of the foreign body is to be
determined, and if possible a duplicate thereof obtained.
_General physical examination_ should be complete including inspection
of the eyes, ears, nose, pharynx, and mirror inspection of the
naso-pharynx and larynx. Special attention is paid to the chest for
the localization of the object. In order to discover conditions
rendering endoscopy unusually hazardous, all parts of the body are to
be examined. Aneurysm of the aorta, excessive blood pressure, serious
cardiac and renal conditions, the presence of a hernia and the
existence of central nervous disease, as tabes dorsalis, should be at
least known before attempting any endoscopic procedure. Dysphagia
might result from the pressure of an unknown aneurysm, the symptoms
being attributed to a foreign body, and aortic aneurysm is a definite
contraindication to esophagoscopy unless there be foreign body present
also. There is no absolute contraindication to the endoscopic removal
of a foreign body, though many conditions may render it wise to
post-pone endoscopy. Laryngeal crises of tabes might, because of their
sudden onset, be thought due to foreign body.
PHYSICAL SIGNS IN ESOPHAGEAL FOREIGN BODY
There are no constant physical signs associated with uncomplicated
impaction of a foreign body in the esophagus. Should perforation of
the cervical esophagus occur, subcutaneous emphysema, and perhaps
cellulitis, may be found; while a perforation of the thoracic region
causing mediastinitis is manifested by toxemia, fever, and rapid
sinking. Perforation of the pleura, with the development of
pyopneumothorax, is manifested by the usual signs. It is to be
emphasized that blind bouginage has no place in the diagnosis of any
esophageal condition. The roentgenologist will give the information we
desire without danger to the patient, and with far greater accuracy.
FOREIGN BODIES IN THE LARYNX
Laryngeally lodged foreign bodies produce a wheezing respiration, the
quality of which is peculiar to the larynx and is readily localized to
this organ. If swelling or the size of the foreign body be sufficient
to produce dyspnea, inspiratory indrawing of the suprasternal notch,
supraclavicular fossae, costal interspaces and lower sternum will be
present. Cyanosis is only an accompaniment of suddenly produced
dyspnea; the facies will therefore usually be anxious and pale, unless
the patient is seen immediately after the aspiration of the foreign
body. If labored breathing has been prolonged, and exhaustion
threatened, the heart's action will be irregular and weak. The foreign
body can be seen with the mirror, but a roentgenograph must
nevertheless be made, for the object may be of another nature than was
first thought. The roentgenograph will show its position, and from
this knowledge the plan of removal can be formulated. For example, a
straight pin may be so placed in the larynx that only a portion of its
shaft will be visible, the roentgenogram will tell where the head and
point are located, and which of these will be the more readily
disengaged. (See Chapter on Mechanical Problems.)
PHYSICAL SIGNS OF TRACHEAL FOREIGN BODY
If fixed in the trachea the only objective sign of foreign body may be
a wheezing respiration, the site of which may be localized with the
stethoscope, by the intensity of the sound. Movable foreign bodies may
produce a palpatory thrill, and the rumble and sudden stop can be
heard with the stethoscope and often with the naked ear. The lungs
will show equal aeration, but there may be marked dyspnea without the
indrawing of the fossae, if the object be of large size and located
below the manubrium.
To the peculiar sound of the sudden subglottic, expiratory or bechic
arrest of the foreign body the author has given the name "audible
slap;" when felt by the thumb on the trachea he calls it the
"palpatory thud." These signs can be produced by no condition other
than the arrest of some substance by the subglottic taper. Once heard
and felt they are unmistakable.
PHYSICAL SIGNS OF BRONCHIAL FOREIGN BODY
In most cases there will be limitation of expansion on the invaded
side, even though the foreign body is of such a shape as to cause no
bronchial obstruction. It has been noted frequently in conjunction
with the presence of such objects as a common straight pin in a small
branch bronchus. This peculiar phenomenon was first noted by Thomas
McCrae in one of the author's cases and has since been abundantly
corroborated by McCrae and others as one of the most constant physical
signs.
To understand the peculiar physical findings in these cases it is
necessary to remember that the bronchi are not tubes of constant
caliber; there occurs a dilatation during inspiration, and a
contraction of the lumen during expiration; furthermore, the lumen may
be narrowed by swollen mucosa if the foreign body be of an irritant
nature. The signs vary with the degree of obstruction of the bronchus,
and with the consequent degree of interference with aeration and
drainage of the subjacent portion of the lung. We have three definite
types which show practically constant signs in the earlier stages of
foreign body invasion.
1. Complete bronchial occlusion.
2. Obstruction complete during expiration, but allowing the passage
of air during the bronchial dilatation incident to inspiration,
constituting an expiratory valve-like obstruction.
3. Partial bronchial obstruction, allowing to-and-fro passage of
air.
1. _Complete bronchial obstruction_ is manifested by limitation of
expansion, markedly impaired percussion note, particularly at the
base, absence of breath-sounds, and rales on the invaded side. An
atelectasis here exists; the air imprisoned in the lung is soon
absorbed, and secretions rapidly accumulate. On the free side a
compensatory emphysema is present.
2. _Expiratory Valve-like Obstruction_.--The obstructed side shows
marked limitation of expansion. Percussion is of a tympanitic
character. The duration of the vibrations may be shortened giving a
muffled tympany. Various grades and degrees of tympany may be noted.
Breath sounds are markedly diminished or absent. No rales are heard on
the invaded side, although rales of all types may be present on the
free side. In some cases it is possible to hear a short inspiratory
sound. Vocal resonance and fremitus are but little altered. The heart
will be found displaced somewhat to the opposite side. These signs are
explained by the passage of some air past the foreign body during
inspiration with its trapping during expiration, so that there is air
under pressure constantly maintained in the obstructed area. This type
of obstruction is most frequently observed when the foreign body is of
an organic nature such as nut kernels, beans, corn, seed, etc. The
localized swelling about the irritating foreign body completes the
expiratory obstruction. It may also be present with any foreign body
whose size and shape are such as to occlude the lumen of the bronchus
during its contracted expiratory phase. It was present in cases of
pebbles, cylindrical metallic objects, thick tough balls of secretion
etcetera. The valvular action is here produced most often by a change
in the size of the valve seat and not by a movement of the foreign
body plug. In other cases I have found at bronchoscopy, a regular
ball-valve mechanism. Pneumothorax is the only pathologic condition
associated with signs similar to those of expiratory, valve-like
bronchial obstruction by a foreign body.
3. _Partial bronchial obstruction_ by an object such as a nail allows
air to pass to and fro with some degree of retardation, and impairs
the drainage of the subjacent lung. Limitation of expansion will be
found on the invaded side. The area below the foreign body will give
an impaired percussion note. Breath-sounds are diminished in the area
of dullness, and vocal resonance and fremitus are impaired. Rales are
of great diagnostic import; the passage of air past the foreign body
is accompanied by blowing, harsh breathing, and snoring; snapping
rales are heard usually with greatest intensity posteriorly over the
site of the foreign body (usually about the scapular angle).
A knowledge of the topographical lung anatomy, the bronchial tree, and
of endoscopic pathology* should enable the examiner of the chest to
locate very accurately a bronchial foreign body by physical signs
alone, for all the significant signs occur distal to the foreign body
lodgment.
* Jackson, Chevalier. Pathology of Foreign Bodies in the Air and Food
Passages. Mutter Lecture, 1918. Surgery, Gynecology and Obstetrics,
March, 1919. Also, by the same author, Mechanism of the Physical Signs
of Foreign Bodies in the Lungs. Proceedings of the College of
Physicians, Philadelphia, 1922.
_The asthmatoid wheeze_ has been found by the author a valuable
confirmatory sign of bronchial foreign body. It is a wheezing heard by
placing the observer's ear at the open mouth of the patient (not at
the chest wall) during a prolonged forced expiration. Thomas McCrae
elicits this sign by placing the stethoscope bell at the patient's
open mouth. The quality of the sound is dryer than that heard in
asthma and the wheeze is clearest after all secretion has been removed
by coughing. The mechanism of production is, probably, the passage of
air by a foreign body which narrows the lumen of a large bronchus. As
the foreign body works downward the wheeze lessens. The wheeze is
often so loud as to be heard at some distance from the patient. It is
of greatest value in the diagnosis of non-roentgenopaque foreign body
but its absence in no way negates foreign body. Its presence or
absence should be recorded in every case.
_Prolonged bronchial obstruction_ by foreign body is followed by
bronchiectasis and lung abscess usually in a lower lobe. The symptoms
may with exactitude simulate tuberculosis, but this disease should be
readily excluded by the basal, unilateral site of the lesion, absence
of tubercle bacilli in the sputum, and roentgenographic study. Chest
examination in the foreign body cases reveals limitation of expansion,
often some retraction, flat percussion note, and greatly diminished or
absent breath-sounds over the site of the pulmonary lesion. Rales vary
with the amount of secretion present. These physical signs suggest
empyema; and rib resection had been done before admission in a number
of cases only to find the pleura normal.
ROENTGENRAY STUDY IN FOREIGN BODY CASES
_Roentgenography_.--All cases of chest disease should have the benefit
of a roentgenologic study to exclude bronchial foreign body as an
etiological factor. Negative opinions should never be based upon any
plates except the best that the wonderful modern development of the
art and science of roentgenology can produce. In doubtful cases, the
negative opinion should not be conclusive until a roentgenologist of
long experience in chest work, and especially in foreign body cases,
has been called in consultation. Even then there will be an occasional
case calling for diagnostic bronchoscopy. Antero-posterior and lateral
roentgenograms should always be made. In an antero-posterior film a
flat foreign body lying in the lateral body plane might be invisible
in the shadow of the spine, heart, and great vessels; but would be
revealed in the lateral view because of the greater edgewise density
of the intruder and the absence of other confusing shadows.
Fluoroscopic examination will often discover the best angle from which
to make a plate; but foreign bodies casting a very faint shadow on a
plate may be totally invisible on the fluoroscopic screen. The value
of a roentgenogram after the removal of a foreign body cannot be too
strongly emphasized. It is evidence of removal and will exclude the
presence of a second intruder which might have been overlooked in the
first study.
Fluoroscopic study of the swallowing function with barium mixture, or
a barium-filled capsule, will give the location of a nonroentgenopaque
object (such as bone, meat, etc.) in the esophagus. If a flat or
disc-shaped object located in the cervical region is seen to be lying
in the lateral body plane, it will be found to be in the esophagus,
for it assumed that position by passing down flatwise behind the
larynx. If, however, the object is seen to be in the sagittal plane it
must lie in the trachea. This position was necessary for it to pass
through the glottic chink, and can be maintained because of the
yielding of the posterior membranous wall of the trachea.
THE ROENTGENOGRAPHIC SIGNS OF EXPIRATORY-VALVE-LIKE BRONCHIAL
OBSTRUCTION
The roentgenray signs in expiratory valve-like obstruction of a
bronchus are those of _an acute obstructive emphysema_ (Fig. 74),
namely,
1. Greater transparency on the obstructed side (Iglauer).
2. Displacement of the heart to the free side (Iglauer).
3. Depression and flattening of the dome of the diaphragm on the
invaded side (Iglauer).
4. Limitation of the diaphragmatic excursion on the obstructed side
(Manges).