differential emphysema occurs at the end of expiration and the plate
must be exposed at that time, before inspiration starts. He also noted
that at fluoroscopy the heart moved laterally toward the uninvaded
side during expiration.*
* Dr. Manges has developed such a high degree of skill in the
fluoroscopic diagnosis of non-opaque foreign bodies by the obstructive
emphysema they produce that he has located peanut kernels and other
vegetable substances with absolute accuracy and unfailing certainty in
dozens of cases at the Bronchoscopic Clinic.
[FIG. 74--Expiratory valve-like bronchial obstruction by
non-radiopaque foreign body, producing an acute obstructive emphysema.
Peanut kernel in right main bronchus. Note (a) depression of right
diaphragm; (b) displacement of heart and mediastinum to left; (c)
greater transparency of the invaded side. Ray-plate made by Willis F.
Manges.]
_Complete bronchial obstruction_ shows a density over the whole area
the aeration and drainage of which has been cut off (Fig. 75).
Pulmonary abscess formation and "drowned lung" (accumulated secretion
in the bronchi and bronchioli) are shown by the definite shadows
produced (Fig. 76).
[140] Dense and metallic objects will usually be readily seen in the
roentgenograms and fluoroscope, but many foreign bodies are of a
nature which will produce no shadow; the roentgenologist should,
therefore, be prepared to interpret the pulmonary pathology, and
should not dismiss the case as negative for foreign body because one
is not seen. Even metallic objects are in rare cases exceedingly
difficult to demonstrate.
[FIG. 75.--Radiograph showing pathology resulting from complete
obstruction of a bronchus with atelectasis and drowned lung resulting.
Foot of an alarm clock in left bronchus of 4 year old child. Present
25 days. Plate made by Johnston and Grier.]
_Positive Films of the Tracheo-bronchial Tree as an Aid to
Localization_.--In order to localize the bronchus invaded by a small
foreign body the positive film is laid over the negative of the
patient showing the foreign body. The shadow of the foreign body will
then show through the overlying positive film. These positive films
are made in twelve sizes, and the size selected should be that
corresponding to the size of the patient as shown by the
roentgenograph. The dome of the diaphragm and the dome of the pleura
are taken as visceral landmarks for placing the positive films which
have lines indicating these levels. If the shadow of the foreign body
be faint it may be strengthened by an ink mark on the
uncoated side of the plate.
[FIG. 76.--Partial bronchial obstruction for long period of time
Pathology, bronchiectasis and pulmonary abscess, produced by the
presence for 4 years of a nail in the left lung of a boy of 10 years]
_Bronchial mapping_ is readily accomplished by the author's method of
endobronchial insufflation of a roentgenopaque inert powder such as
bismuth subnitrate or subcarbonate (Fig. 77). The roentgenopaque
substance may be injected in a fluid mixture if preferred, but the
walls are better outlined with the powder (Fig. 77).
[FIG. 77.--Roentgenogram showing the author's method of bronchial
mapping or lung-mapping by the bronchoscopic introduction of opaque
substances (in this instance powdered bismuth subnitrate) into the
lung of the patient. Plate made by David R. Bowen. (Illustration,
strengthened for reproduction, is from author's article in American
Journal of Roentgenology, Oct., 1918.)]
ERRORS TO AVOID IN SUSPECTED FOREIGN BODY CASES
1. Do not reach for the foreign body with the fingers, lest the
foreign body be thereby pushed into the larynx, or the larynx be thus
traumatized.
2. Do not hold up the patient by the heels, lest a tracheally lodged
foreign body be dislodged and asphyxiate the patient by becoming
jammed in the glottis.
[143] 3. Do not fail to have a roentgenogram made, if possible,
whether the foreign body in question is of a kind dense to the ray or
not.
4. Do not fail to search endoscopically for a foreign body in all
cases of doubt.
5. Do not pass blindly an esophageal bougie, probang, or other
instrument.
6. Do not tell the patient he has no foreign body until after
roentgenray examination, physical examination, indirect examination,
and endoscopy have all proven negative.
SUMMARY
SYMPTOMATOLOGY AND DIAGNOSIS OF FOREIGN BODIES IN THE AIR AND FOOD
PASSAGES
_Initial symptoms_ are choking, gagging, coughing, and wheezing, often
followed by a symptomless interval. The foreign body may be in the
larynx, trachea, bronchi, nasal chambers, nasopharynx, fauces, tonsil,
pharynx, hypopharynx, esophagus, stomach, intestinal canal, or may
have been passed by bowel, coughed out or spat out, with or without
the knowledge of the patient. Initial choking, etcetera may have
escaped notice, or may have been forgotten.
_Laryngeal Foreign Body_.--One or more of the following laryngeal
symptoms may be present: Hoarseness, croupy cough, aphonia,
odynphagia, hemoptysis, wheezing, dyspnea, cyanosis, apnea, subjective
sensation of foreign body. Croupiness in foreign body cases, as in
diphtheria, usually means subglottic swelling. Obstructive foreign
body may be quickly fatal by laryngeal impaction on aspiration, or on
abortive bechic expulsion. Lodgement of a non-obstructive foreign body
may be followed by a symptomless interval. Direct laryngoscopy for
diagnosis is indicated in every child having laryngeal diphtheria
without faucial membrane. (No anesthetic, general or local is needed.)
In the presence of laryngeal symptoms, think of the following:
1. A foreign body in the larynx.
2. A foreign body loose or fixed in the trachea.
3. Digital efforts at removal.
4. Instrumentation.
5. Overflow of food into the larynx from esophageal obstruction due
to the foreign body.
6. Esophagotracheal fistula from ulceration set up by a foreign body
in the esophagus, followed by the leakage of food into the
air-passages.
7. Laryngeal symptoms may persist from the trauma of a foreign body
that has passed on into the deeper air or food passages or that has
been coughed or spat out.
8. Laryngeal symptoms (hoarseness, croupiness, etcetera) may be due
to digital or instrumental efforts at the removal of a foreign body
that never was present.
9. Laryngeal symptoms may be due to acute or chronic laryngitis,
diphtheria, pertussis, infective laryngotracheitis, and many other
diseases.
10. Deductive decisions are dangerous.
11. If the roentgenray is negative, laryngoscopy (direct in
children, indirect in adults) without anesthesia, general or local, is
the only way to make a laryngeal diagnosis.
12. Before doing a diagnostic laryngoscopy, preparation should be
made for taking a swab-specimen and for bronchoscopy and
esophagoscopy.
_Tracheal Foreign Body_.--(1) "Audible slap," (2) "palpatory thud,"
and (3) "asthmatoid wheeze" are pathognomonic. The "tracheal flutter"
has been observed by McCrae in a case of watermelon seed. Cough,
hoarseness, dyspnea, and cyanosis are often present. Diagnosis is by
roentgenray, auscultation, palpation, and bronchoscopy. Listen long
for "audible slap," best heard at open mouth during cough. The
"asthmatoid wheeze" is heard with the ear or stethoscope bell (McCrae)
at the patient's open mouth. History of initial choking, gagging, and
wheezing is important if elicited, but is valueless negatively.
_Bronchial Foreign Body_.--Initial symptoms are coughing, choking,
asthmatoid wheeze, etc. noted above. There may be a history of these
or of tooth extraction. At once, or after a symptomless interval,
cough, blood-streaked sputum, metallic taste, or special odor of
foreign body may be noted. Non-obstructive metallic foreign bodies
afford few symptoms and few signs for weeks or months. Obstructive
foreign bodies cause atelectasis, drowned lung, and eventually
pulmonary abscess. Lobar pneumonia is an exceedingly rare sequel.
Vegetable organic foreign bodies as peanut-kernels, beans, watermelon
seeds, etcetera, cause at once violent laryngotracheobronchitis, with
toxemia, cough and irregular fever, the gravity and severity being
inversely to the age of the child. Bones, animal shells and inorganic
bodies after months or years produce changes which cause chills,
fever, sweats, emaciation, clubbed fingers, incurved nails, cough,
foul expectoration, hemoptysis, in fact, all the symptoms of chronic
pulmonary sepsis, abscess, and bronchiectasis. These symptoms and some
of the physical signs may suggest pulmonary tuberculosis, but the
apices are normal and bacilli are absent from the sputum. Every acute
or chronic chest case calls for the exclusion of foreign body.
_The physical signs_ vary with conditions present in different cases
and at different times in the same case. Secretions, normal and
pathologic, may shift from one location to another; the foreign body
may change its position admitting more, less, or no air, or it may
shift to a new location in the same lung or even in the other lung. A
recently aspirated pin may produce no signs at all. The signs of
diagnostic importance are chiefly those of partial or complete
bronchial obstruction, though a non-obstructive foreign body, a pin
for instance, may cause limited expansion (McCrae) or, rarely, a
peculiar rale or a peculiar auscultatory sound. The most nearly
characteristic physical signs are: (1) Limited expansion; (2)
decreased vocal fremitus; (3) impaired percussion note; (4) diminished
intensity of the breath-sounds distal to the foreign body. Complete
obstruction of a bronchus followed by drowned lung adds absence of
vocal resonance and vocal fremitus, thus often leading to an erroneous
diagnosis of empyema. Varying grades of tympany are obtained over
areas of obstructive or compensatory emphysema. With complete
obstruction there may be tympany from the collapsed lung for a time.
Rales in case of complete obstruction are usually most intense on the
uninvaded side. In partial obstruction they are most often found on
the invaded side distal to the foreign body, especially posteriorly,
and are most intense at the site corresponding to that of the foreign
body. A foreign body at the bifurcation of the trachea may give signs
in both lungs. Early in a foreign body case, diminished expansion of
one side, with dulness, may suggest pneumonia in the affected side;
but absence of, or decreased, vocal resonance, and absence of typical
tubular breathing should soon exclude this diagnosis. Bronchial
obstruction in pneumonia is exceedingly rare.
Memorize these signs suggestive of foreign body:
1. Expansion--diminished.
2. Percussion note--impaired (except in obstructive emphysema).
3. Vocal fremitus--diminished.
4. Breath sounds--diminished.
The foregoing is only for memorizing, and must be considered in the
light of the following fundamental note by Prof. McCrae "There is no
one description of physical signs which covers all cases. If the
student will remember that complete obstruction of a bronchus leads to
a shutting off of this area, there should be little difficulty in
understanding the signs present. The diagnosis of empyema may be made,
but the outline of the area of dulness, the fact that there is no
shifting dulness, and the greater resistance which is present in
empyema nearly always clear up any difficulty promptly. The absence of
the frequent change in the voice sounds, so significant in an early
small empyema, is of value. A large empyema should give no difficulty.
If difficulty remains the use of the needle should be sufficient. In
thickened pleura vocal fremitus is not entirely absent, and the
breath-sounds can usually be heard, even if diminished. In case of
partial obstruction of a bronchus, it is evident that air will still
be present, hence the dulness may be only slight. The presence of air
and secretion will probably result in the breath-sounds being somewhat
harsh, and will cause a great variety of rales, principally coarse,
and many of them bubbling. Difficulty may be caused by signs in the
other lung or in a lobe other than the one affected by the foreign
body. If it is remembered that these signs are likely to be only on
auscultation, and to consist largely in the presence of rales, while
the signs in the area supplied by the affected bronchus will include
those on inspection, palpation, and percussion, there should be little
difficulty."
_The roentgenray_ is the most valuable diagnostic means; but careful
notation of physical signs by an expert should be made in all cases
preferably without knowledge of ray findings. Expert ray work will
show all metallic foreign bodies and many of less density, such as
teeth, bones, shells, buttons, etcetera. If the ray is negative, a
diagnostic bronchoscopy should be done in all cases of unexplained
bronchial obstruction.
Peanut kernels and watermelon seeds and, rarely, other foreign bodies
in the bronchi produce obstructive emphysema of the invaded side.
Fluoroscopy shows the diaphragm flattened, depressed and of less
excursion on the invaded side; at the end of expiration, the heart and
the mediastinal wall move over toward the uninvaded side and the
invaded lung becomes less dense than the uninvaded lung, from the
trapping of the air by the expiratory, valve-like effect of
obliteration of the "forceps spaces" that during inspiration afford
air ingress between the foreign body and the swollen bronchial wall.
This partial obstruction causes obstructive emphysema, which must be
distinguished from compensatory emphysema, in which the ballooning is
in the unobstructed lung, because its fellow is wholly out of function
through complete "corking" of the main bronchus of the invaded side.
_Esophageal Foreign Body_.--After initial choking and gagging, or
without these, there may be a subjective sense of a foreign body,
constant or, more often, on swallowing. Odynphagia and dysphagia or
aphagia may or may not be present. Pain, sub-sternal or extending to
the back is sometimes present. Hematemesis and fever may occur from
the foreign body or from rough instrumentation. Symptoms referable to
the air-passages may be present due to: (1) Overflow of the secretions
on attempts to swallow through the obstructed esophagus; (2) erosion
of the foreign body through from the esophagus into the trachea; or
(3) trauma inflicted on the larynx during attempts at removal, digital
or instrumental, the foreign body still being present or not.
Diagnosis is by the roentgenray, first without, then, if necessary,
with a capsule filled with an opaque mixture. Flat objects, like
coins, always lie with their greatest diameter in the coronal plane of
the body, when in the esophagus; in the sagittal plane, when in the
trachea or larynx. Lateral, anteroposterior, and sometimes also
quartering roentgenograms are necessary. One taken laterally, low down
on the neck but clear of the shoulder, will often show a bone or other
semiopaque object invisible in the anteroposterior exposure.
[149] CHAPTER XIII--FOREIGN BODIES IN THE LARYNX AND TRACHEOBRONCHIAL
TREE
The protective reflexes preventing the entrance of foreign bodies into
the lower air passages are: (1) The laryngeal closing reflex and (2)
the bechic reflex. Laryngeal closing for normal swallowing consists
chiefly in the tilting and the closure of the upper laryngeal orifice.
The ventricular bands help but slightly; and the epiglottis and the
vocal cords little, if at all. The gauntlet to be run by foreign
bodies entering the tracheobronchial tree is composed of:
1. Epiglottis.
2. Upper laryngeal orifice.
3. Ventricular bands.
4. Vocal cords.
5. Bechic blast.
The epiglottis acts somewhat as a fender. The superior laryngeal
aperture, composed of a pair of movable ridges of tissue, has almost a
sphincteric action, in addition to a tilting movement. The ventricular
bands can approximate under powerful stimuli. The vocal cords act
similarly. The one defect in the efficiency of this barrier, is the
tendency to take a deep inspiration preparatory to the cough excited
by the contact of a foreign body.
_Site of Lodgment_.--The majority of foreign bodies in the air
passages occur in children. The right bronchus is more frequently
invaded than the left because of the following factors: I. Its greater
diameter. 2. Its lesser angle of deviation from the tracheal axis. 3.
The situation of the carina to the left of the mid-line of the
trachea. 4. The action of the trachealis muscle. 5. The greater volume
of air going into the right bronchus on inspiration.
The middle lobe bronchus is rarely invaded by foreign body, and,
fortunately, in less than one per cent of the cases is the object in
an upper lobe bronchus.
_Spontaneous Expulsion of Foreign Bodies from the Air Passages_. A
large, light, foreign body in the larynx or trachea may occasionally
be coughed out, but the frequent newspaper accounts of the sudden
death of children known to have aspirated objects should teach us
never to wait for this occurrence. The cause of death in these cases
is usually the impaction of a large foreign body in the glottis
producing sudden asphyxiation, and in a certain proportion of these
cases the impaction has occurred on the reverse journey, when cough
forced the intruder upward from below. The danger of subglottic
impaction renders it imperative that attempts to aid spontaneous
expulsion by inverting the patient should be discouraged. Sharp
objects, such as pins, are rarely coughed out. The tendency of all
foreign bodies is to migrate down and out to the periphery as their
size and shape will allow. Most of the reported cases of bechic
expulsion of bronchially lodged foreign bodies have occurred after a
prolonged sojourn of the object, associated which much lung pathology;
and in some cases the object has been carried out along with an
accumulation of pus suddenly liberated from an abscess cavity, and
expelled by cough. This is a rare sequence compared to the usual
formation of fibrous stricture above the foreign body that prevents
the possibility of bechic expulsion. To delay bronchoscopy with the
hope of such a solution of the problem is comparable to the former
dependence on nature for the cure of appendiceal abscess.
We do our full duty when we tell the patient or parents that while the
foreign body may be coughed up, it is very dangerous to wait; and,
further, that the difficulty of removal usually increases with the
time the foreign body is allowed to remain in the air passages.
_Mortality and morbidity of bronchoscopy_ vary directly with the
degree of skill and experience of the operator, and the conditions for
which the endoscopies are performed. The simple insertion of the
bronchoscope is devoid of harm if carefully done. The danger lies in
misdirected efforts at removal of the intruder and in repeating
bronchoscopies in children at too frequent intervals, or in prolonging
the procedure unduly. In children under one year endoscopy should be
limited to twenty minutes, and should not be repeated sooner than one
week after, unless urgently indicated. A child of 5 years will bear 40
to 60 minutes work, while the adult offers no unvarying time limit.
More can be ultimately accomplished, and less reaction will follow
short endoscopies repeated at proper intervals than in one long
procedure.
_Indications for bronchoscopy for suspected foreign body_ may be thus
summarized:
1. The appearance of a suspicious shadow in the radiograph, in the
line of a bronchus.
2. In any case in which lung symptoms followed a clear history of
the patient having choked on a foreign body.
3. In any case showing signs of obstruction in the trachea or of a
bronchus.
4. In suspected bronchiectasis.
5. Symptoms of pulmonary tuberculosis with sputum constantly
negative for tubercle bacilli. If the physical signs are at the base,
particularly the right base, the indication becomes very strong even
in the absence of any foreign body circumstance in the history.
6. In all cases of doubt, bronchoscopy should be done anyway.
There is no absolute _contraindication to bronchoscopy for foreign
bodies_. Extreme exhaustion or reaction from previous efforts at
removal may call for delay for recuperation, but pulmonary abscess and
even the rarer complications, bronchopneumonia and gangrene of the
lung, are improved by the early removal of the foreign body.
_Choice of Time to do Bronchoscopy for Foreign Body_.--The
difficulties of removal usually increase from the time of aspiration
of the object. It tends to work downward and outward, while the mucosa
becomes edematous, partly closing over the foreign body, and even
completely obliterating the lumen of smaller bronchi. Later,
granulation tissue and the formation of stricture further hide the
object. The patient's health deteriorates with the onset of pulmonary
pathology, and renders him a less favorable subject for bronchoscopy.
Organic foreign bodies, which produce early and intense inflammatory
reaction and are liable to swell, call for prompt bronchoscopy. When a
bronchus is completely obstructed by the bulk of the foreign body
itself immediate removal is urgently demanded to prevent serious lung
changes, resulting from atelectasis and want of drainage. In short,
removal of the foreign body should be accomplished as soon as possible
after its entrance. This, however, does not justify hasty,
ill-planned, and poorly equipped bronchoscopy, which in most cases is
doomed to failure in removal of the object. The bronchoscopist should
not permit himself to be stampeded into a bronchoscopy late at night,
when he is fatigued after a hard day's work.
_Bronchoscopic finding of a foreign body_ is not especially difficult
if the aspiration has been recent. If secondary processes have
developed, or the object be small and in a bronchus too small to admit
the tube-mouth, considerable experience may be necessary to discover
it. There is usually inflammatory reaction around the orifice of the
invaded bronchus, which in a measure serves to localize the intruder.
We must not forget, however, that objects may have moved to another
location, and also that the irritation may have been the result of
previous efforts at removal. Care must be exercised not to mistake the
sharp, shining, interbronchial spurs for bright thin objects like new
pins just aspirated; after a few days pins become blackened. If these
spurs be torn pneumothorax may ensue. If a number of small bronchi are
to be searched, the bronchoscope must be brought into the line of the
axis of the bronchus to be examined, and any intervening tissue gently
pushed aside with the lip of the bronchoscope. Blind probing for
exploration is very dangerous unless carefully done. The straight
forceps, introduced closed, form the best probe and are ready for
grasping if the object is felt. Once the bronchoscope has been
introduced, it should not be withdrawn until the procedure is
completed. The light carrier alone may be removed from its canal if
the illumination be faulty.
COMPLICATIONS AND AFTER-EFFECTS OF BRONCHOSCOPY
All foreign body cases should be watched day and night by special
nurses until all danger of complications is passed. Complications are
rare after careful work, but if they do occur, they may require
immediate attention. This applies especially to the subglottic edema
associated with arachidic bronchitis in children under 2 years of age.
_General Reaction_.--There is usually no elevation in temperature
following a short bronchoscopy for the removal of a recently lodged
metallic foreign body. If, however, an inflammatory condition of the
bronchi existed previous to the bronchoscopy, as for instance the
intense diffuse, purulent laryngotracheobronchitis associated with
the aspiration of nut kernels, or in the presence of pulmonary abscess
from long retained foreign bodies, a moderate temporary rise of
temperature may be expected. These cases almost always have had
irregular fever before bronchoscopy. Disturbance of the epithelium in
the presence of pus without abscess usually permits enough absorption
to elevate the temperature slightly for a few days.
_Surgical shock_ in its true form has never followed a carefully
performed and time-limited bronchoscopy. Severe fatigue resulting in
deep sleep may be seen in children after prolonged work.
_Local reaction_ is ordinarily noted by slight laryngeal congestion
causing some hoarseness and disappearing in a few days. If dyspnea
occur it is usually due to (1) Drowning of the patient in his own
secretions. (2) Subglottic edema. (3) Laryngeal edema.
_Drowning of the Patient in His Own Secretions_.--The accumulation of
secretions in the bronchi due to faulty bechic powers and seen most
frequently in children, is quickly relievable by bronchoscopic
sponge-pumping or aspiration through the tracheotomic wound, in cases
in which the tracheotomy may be deemed necessary. In other cases, the
aspirating bronchoscope with side drainage canal (Fig. 1, E) may be
used through the larynx. Frequent peroral passage of the bronchoscope
for this purpose is contraindicated only in case of children under 3
years of age, because of the likelihood of provoking subglottic edema.
In such cases instead of inserting a bronchoscope the aspirating tube
(Fig. 9) should be inserted through the direct laryngoscope, or a low
tracheotomy should be done.
_Supraglottic edema_ is rarely responsible for dyspnea except when
associated with advanced nephritis.
_Subglottic edema_ is a complication rarely seen except in children
under 3 years of age. They have a peculiar histologic structure in
this region, as is shown by Logan Turner. Even at the predisposing age
subglottic edema is a very unusual sequence to bronchoscopy if this
region was previously normal. The passage of a bronchoscope through an
already inflamed subglottic area is liable to be followed by a
temporary increase in the swelling. If the foreign body be associated
with but slight amount of secretion, the child can usually obtain
sufficient air through the temporarily narrowed lumen. If, however, as
in cases of arachidic bronchitis, large amounts of purulent secretion
must be expelled, it will be found in certain cases that the decreased
glottic lumen and impaired laryngeal motility will render tracheotomy
necessary to drain the lungs and prevent drowning in the retained
secretions. Subglottic edema occurring in a previously normal larynx
may result from: 1. The use of over-sized tubes. 2. Prolonged
bronchoscopy. 3. Faulty position of the patient, the axis of the tube
not being in that of the trachea. 4. Trauma from undue force or
improper direction in the insertion of the bronchoscope. 5. The
manipulation of instruments. 6. Trauma inflicted in the extraction of
the foreign body.
_Diagnosis_ must be made without waiting for cyanosis which may never
appear. Pallor, restlessness, startled awakening after a few minutes
sleep, occurring in a child with croupy cough, indrawing around the
clavicles, in the intercostal spaces, at the suprasternal notch and at
the epigastrium, call for tracheotomy which should always be low. Such
a case should not be left unwatched. The child will become exhausted
in its fight for air and will give up and die. The respiratory rate
naturally increases because of air hunger, accumulating secretions
that cannot be expelled because of impaired glottic motility give
signs wrongly interpreted as pneumonia. Many children whose lives
could have been saved by tracheotomy have died under this erroneous
diagnosis.
_Treatment_.--Intubation is not so safe because the secretions cannot
easily be expelled through the tube and postintubational stenosis may
be produced. Low tracheotomy, the tracheal incision always below the
second ring, is the safest and best method of treatment.
[156] CHAPTER XIV--REMOVAL OF FOREIGN BODIES FROM THE LARYNX
_Symptoms and Diagnosis_.--The history of a sudden choking attack
followed by impairment of voice, wheezing, and more or less dyspnea
can be usually elicited. Laryngeal diphtheria is the condition most
frequently thought of when these symptoms are present, and antitoxin
is rightly given while waiting for a positive diagnosis. Extreme
dyspnea may render tracheotomy urgently demanded before any attempts
at diagnosis are made. Further consideration of the symptomatology and
diagnosis of laryngeal foreign body will be found on pages 128, 133
and 143.
_Preliminary Examination_.--In the adult, mirror examination of the
larynx should be done, the patient being placed in the recumbent
position. Whenever time permits roentgenograms, lateral and
anteroposterior, should be made, the lateral one as low in the neck as
possible. One might think this an unnecessary procedure because of the
visibility of the larynx in the mirror; but a child's larynx cannot
usually be indirectly examined, and even in the adult a pin may be so
situated that neither head nor point is visible, only a portion of the
shaft being seen. The roentgenogram will give accurate information as
to the position, and will thus allow a planning of the best method for
removal of the foreign body. A bone in the larynx usually is visible
in a good roentgenogram. Accurate diagnosis in children is made by
direct laryngoscopy without anesthesia, but direct laryngoscopy should
not be done until one is prepared to remove a foreign body if found,
to follow it into the bronchus and remove it if it should be dislodged
and aspirated, and to do tracheotomy if sudden respiratory arrest
occur.
[157] _Technic of Removal of Foreign Bodies from the Larynx_.--The
patient is to be placed in the author's position, shown in Fig. 53. No
general anesthesia should be given, and the application of local
anesthesia is usually unnecessary and further, is liable to dislodge
and push down the foreign body.* Because of the risk of loss downward
it is best to seize the foreign body as soon as seen; then to
determine how best to disimpact it. The fundamental principles are
that a pointed object must either have its point protected by the
forceps grasp or be brought out point trailing, and that a flat object
must be so rotated that its plane corresponds to the sagittal plane of
the glottic chink. The laryngeal grasping forceps (Fig. 53) will be
found the most useful, although the alligator rotation forceps (Fig.
31) may occasionally be required.
* In adolescents or adults a few drops of a 4 per cent solution of
cocain applied to the laryngopharynx with an atomizer or a dropper
will afford the minimum risk of dislodgement; but the author's
personal preference is for no anesthesia, general or local.
[158] CHAPTER XV--MECHANICAL PROBLEMS OF BRONCHOSCOPIC FOREIGN BODY
EXTRACTION*
* For more extensive consideration of mechanical problems than is here
possible the reader is referred to the Bibliography, page 311,
especially reference numbers 1, 11, 37 and 56.
The endoscopic extraction of a foreign body is a mechanical problem
pure and simple, and must be studied from this viewpoint. Hasty,
ill-equipped, ill-planned, or violent endoscopy on the erroneous
principle that if not immediately removed the foreign body will be
fatal, is never justifiable. While the lodgement of an organic foreign
body (such as a nut kernel) in the bronchus calls for prompt removal
and might be included under the list of emergency operations, time is
always available for complete preparation, for thorough study of the
patient, and localization of the intruder. The patient is better off
with the foreign body in the lung than if in its removal a
mediastinitis, rupture into the pleura, or tearing of a thoracic blood
vessel has resulted. The motto of the endoscopist should be "I will do
no harm." If no harm be inflicted, any number of bronchoscopies can be
done at suitable intervals, and eventually success will be achieved,
whereas if mortality results, all opportunity ceases.
The first step in the solution of the mechanical problem is the study
of the roentgenograms made in at least three planes; (1)
anteroposterior, (2) lateral, and (3) the plane corresponding to the
greatest plane of the foreign body. The next step is to put a
duplicate of the foreign body into the rubber-tube manikin previously
referred to, and try to simulate the probable position shown by the
ray, so as to get an idea of the bronchoscopic appearance of the
probable presentation. Then the duplicate foreign body is turned into
as many different positions as possible, so as to educate the eye to
assist in the comprehension of the largest possible number of
presentations that may be encountered at the bronchoscopy on the
patient. For each of these presentations a method of disimpaction,
disengagement, disentanglement or version and seizure is worked out,
according to the kind of foreign body. Prepared by this practice and
the radiographic study, the bronchoscope is introduced into the
patient. The location of the foreign body is approached slowly and
carefully to avoid overriding or displacement. A _study of the
presentation_ is as necessary for the bronchoscopist as for the
obstetrician. It should be made with a view to determining the
following points:
1. The relation of the presenting part to the surrounding tissues.
2. The probable position of the unseen portion, as determined by the
appearance of the presenting part taken in connection with the
knowledge obtained by the previous ray study, and by inspection of the
ray plate upside down on view in front of the bronchoscopist.
3. The version or other manipulation necessary to convert an
unfavorable into a favorable presentation for grasping and
disengagement.
4. The best instruments to use, and which to use first, as, hook,
pincloser, forceps, etc.
5. The presence and position of the "forceps spaces" of which there
must be two for all ordinary forceps, one for each jaw, or the
"insertion space" for any other instrument.
Until all of these points are determined it is a grave error to insert
any kind of instrument. If possible even swabbing of the foreign body
should be avoided by swabbing out the bronchus, when necessary, before
the region of the intruder is reached. When the operator has
determined the instrument to be used, and the method of using it, the
instrument is cautiously inserted, under guidance of the eye.
[160] _The lip of the bronchoscope_ is one of the most valuable aids
in the solution of foreign-body problems. With it partial or complete
version of an object can be accomplished so as to convert an
unfavorable presentation into one favorable for grasping with the
forceps; edematous mucosa may be displaced, angles straightened and
space made at the side of the foreign body for the forceps' jaw. It
forms a shield or protector that can be slipped under the point of a
sharp foreign body and can make counterpressure on the tissues while
the forceps are disembedding the point of the foreign body. With the
bronchoscopic lip and the forceps or other instrument inserted through
the tube, the bronchoscopist has bimanual, eye-guided control, which
if it has been sufficiently practiced to afford the facility in
coordinate use common to everyone with knife and fork, will accomplish
maneuvers that seem marvelous to anyone who has not developed facility
in this coordinate use of the bronchoscopic instruments.
_The relation of the tube mouth and foreign body_ is of vital
importance. Generally considered, the tube mouth should be as near the
foreign body as possible, and the object must be placed in the center
of the bronchoscopic field, so that the ends of the open jaws of the
forceps will pass sufficiently far over the object. But little lateral
control is had of the long instruments inserted through the tube;
sidewise motion is obtained by a shifting of the end of the
bronchoscope. When the foreign body has been centered in the
bronchoscopic field and placed in a position favorable for grasping,
it is important that this position be maintained by anchoring the tube
to the upper teeth with the left, third, and fourth fingers hooked
over the patient's upper alveolus (Fig. 63)
_The Light Reflex on the Forceps_.--It is often difficult for the
beginner to judge to what depth an instrument has been inserted
through the tube. On slowly inserting a forceps through the tube, as
the blades come opposite the distal light they will appear brightly
illuminated; or should the blades lie close to the light bulb, a
shadow will be seen in the previously brilliantly lighted opposite
wall. It is then known that the forceps are at the tube mouth, and the
endoscopist has but to gauge the distance from this to the foreign
body. This assistance in gauging depth is one of the great advances in
foreign body bronchoscopy obtained by the development of distal
illumination.
_Hooks_ are useful in the solution of various mechanical problems, and
may be turned by the operator himself into various shapes by heating
small probe-pointed steel rods in a spirit lamp, the proximal end
being turned over at a right angle for a controlling handle. Hooks
with a greater curve than a right angle are prone to engage in small
orifices from which they are with difficulty removed. A right angle
curve of the distal end is usually sufficient, and a corkscrew spiral
is often advantageous, rendering removal easy by a reversal of the
twisting motion (Bib. 11, p. 311).
_The Use of Forceps in Endoscopic Foreign Body Extraction_.--Two
different strengths of forceps are supplied, as will be seen in the
list in Chapter 1. The regular forceps have a powerful grasp and are
used on dense foreign bodies which require considerable pressure on
the object to prevent the forceps from slipping off. For more delicate
manipulation, and particularly for friable foreign bodies, the lighter
forceps are used. Spring-opposed forceps render any delicacy of touch
impossible. Forceps are to be held in the right hand, the thumb in one
ring, and the third, or ring finger, in the other ring. These fingers
are used to open and close the forceps, while all traction is to be
made by the right index finger, which has its position on the forceps
handle near the stylet, as shown in Fig. 78. It is absolutely
essential for accurate work, that the forceps jaws be seen to close
upon the foreign body. The impulse to seize the object as soon as it
is discovered must be strongly resisted. A careful study of its size,
shape, and position and relation to surrounding structures must be
made before any attempt at extraction. The most favorable point and
position for grasping having been obtained, the closed forceps are
inserted through the bronchoscope, the light reflex obtained, the
forceps blades now opened are turned in such a position that, on
advancing, the foreign body will enter the open V, a sufficient
distance to afford a good grasp. The blades are then closed and the
foreign body is drawn against the tube mouth. Few foreign bodies are
sufficiently small to allow withdrawal through the tube, so that tube,
forceps and foreign body are usually withdrawn together.
[FIG. 78.--Proper hold of forceps. The right thumb and third fingers
are inserted into the rings while the right index finger has its place
high on the handle. All traction is made with the index finger, the
ring fingers being used only to open and close the forceps. If any
pushing is deemed safe it may be done by placing the index finger back
of the thumb-nut on the stylet.]
_Anchoring the Foreign Body Against the Tube Mouth_.--If withdrawal be
made a bimanual procedure it is almost certain that the foreign body
will trail a centimeter or more beyond the tube mouth, and that the
closure of the glottic chink as soon as the distal end of the
bronchoscope emerges will strip the foreign body from the forceps
grasp, when the foreign body reaches the cords. This is avoided by
anchoring the foreign body against the tube mouth as soon as the
foreign body is grasped, as shown in Fig. 79. The left index finger
and thumb grasp the shaft of the forceps close to the ocular end of
the tube, while the other fingers encircle the tube; closure of the
forceps is maintained by the fingers of the right hand, while all
traction for withdrawal is made with the left hand, which firmly
clamps forceps and bronchoscope as one piece. Thus the three units are
brought out as one; the bronchoscope keeping the cords apart until the
foreign body has entered the glottis.
[FIG. 79--Method of anchoring the foreign body against the tube mouth
After the object has been drawn firmly against the lip of the
endoscopic tube the left finger and thumb grasp the forceps cannula
and lock it against the ocular end of the tube, the other fingers of
the left hand encircle the tube. Withdrawal is then done with the left
hand; the fingers of the right hand maintaining closure of the
forceps.]
[164] _Bringing the Foreign Body Through the Glottis_.--Stripping of
the foreign body from the forceps at the glottis may be due to:
1. Not keeping the object against the tube mouth as just mentioned.
2. Not bringing the greatest diameter of the foreign body into the
sagittal plane of the glottic chink.
3. Faulty application of the forceps on the foreign body.
4. Mechanically imperfect forceps.
Should the foreign body be lost at the glottis it may, if large become
impacted and threaten asphyxia. Prompt insertion of the laryngoscope
will usually allow removal of the object by means of the laryngeal
grasping forceps. The object may be dropped or expelled into the
pharynx and be swallowed. It may even be coughed into the naso-pharynx
or it may be re-aspirated. In the latter event the bronchoscope is to
be re-inserted and the trachea carefully searched. Care must be used
not to override the object. If much inflammatory reaction has occurred
in the first invaded bronchus, temporarily suspending the aerating
function of the corresponding lung, reaspiration of a dislodged
foreign body is liable to carry it into the opposite main bronchus, by
reason of the greater inspiratory volume of air entering that side.
This may produce sudden death by blocking the only aerating organ.
_Extraction of Pins, Needles and Similar Long Pointed Objects_.--When
searching for such objects especial care must be taken not to override
them. Pins are almost always found point upward, and the dictum can
therefore be made, "Search not for the pin, but for the point of the
pin." If the point be found free, it should be worked into the lumen
of the bronchoscope by manipulation with the lip of the tube. It may
then be seized with the forceps and withdrawn. Should the pin be
grasped by the shaft, it is almost certain to turn crosswise of the
tube mouth, where one pull may cause the point to perforate,
enormously increasing the difficulties by transfixation, and perhaps
resulting fatally (Fig. 80).
[FIG. 80.--Schematic illustration of a serious phase of the error of
hastily seizing a transfixed pin near its middle, when first seen as
at M. Traction with the forceps in the direction of the dart in Schema
B will rip open the esophagus or bronchus inflicting fatal trauma, and
probably the pin will be stripped off at the glottic or the
cricopharyngeal level, respectively. The point of the pin must be
disembedded and gotten into the tube mouth as at A, to make forceps
traction safe.]
[FIG. 81.--Schema illustrating the mechanical problem of extracting a
pin, a large part of whose shaft is buried in the bronchial wall, B.
The pin must be pushed downward and if the orifice of the branches, C,
D, are too small to admit the head of the pin some other orifice (as
at A) must be found by palpation (not by violent pushing) to admit the
head, so that the pin can be pushed downward permitting the point to
emerge (E). The point is then manipulated into the bronchoscopic
tube-mouth by means of co-ordinated movements of the bronchoscopic lip
and the side-curved forceps, as shown at F.]
_Inward Rotation Method_.--When the point is found to be buried in the
mucosa, the best and usually successful method is to grasp the pin as
near the point as possible with the side-grasping forceps, then with a
spiral motion to push the pin downward while rotating the forceps
about ninety degrees. The point is thus disengaged, and the shaft of
the pin is brought parallel with that of the forceps, after which the
point may be drawn into the tube mouth. The lips added to the
side-curved forceps by my assistant Dr. Gabriel Tucker I now use
exclusively for this inward rotation method. They are invaluable in
preventing the escape of the pin during the manipulation. A hook is
sometimes useful in disengaging a buried point. The method of its use
is illustrated in Fig. 82.
[FIG. 82.--Mechanical problem of pin, needle, tack or nail with
embedded point. If the forceps are pulled upon the pin point will be
buried still deeper. The side curved forceps grasp the pin as near the
point as possible then with a corkscrew motion the pin is pushed
downward and rotated to the right when the pin will be found to be
parallel with the shaft of the forceps and can be drawn into the tube.
If the pin is prevented by its head from being pushed downward the
point may be extracted by the hook as shown above The side curved
forceps may be used instead of the hook for freeing the point, the
author's "inward rotation" method. The very best instrument for the
purpose is the forceps devised by my assistant, Dr. Gabriel Tucker
(Fig. 21). The lips prevent all risk of losing the pin from the grasp,
and at the same time bring the long axis of the pin parallel to that
of the bronchoscope.]
Pins are very prone to drop into the smaller bronchi and disappear
completely from the ordinary field of endoscopic exploration. At other
times, pins not dropping so deeply may show the point only during
expiration or cough, at which times the bronchi are shortened. In such
instances the invaded bronchial orifice should be clearly exposed as
near the axis of its lumen as possible; the forceps are now inserted,
opened, and the next emergence watched for, the point being grasped as
soon as seen.
_Extraction of Tacks, Nails and Large Headed Foreign Bodies from the
Tracheobronchial Tree_.--In cases of this sort the point presents the
same difficulty and requires solution in the same manner as mentioned
in the preceding paragraphs on the extraction of pins. The author's
inward-rotation method when executed with the Tucker forceps is ideal.
The large head, however, presents a special problem because of its
tendency to act as a mushroom anchor when buried in swollen mucosa or
in a fibrous stenosis (Fig. 83). The extraction problems of tacks are
illustrated in Figs. 84, 85, and 86. Nails, stick pins, and various
tacks are dealt with in the same manner by the author's "inward
rotation" method.
_Hollow metallic bodies_ presenting an opening toward the observer may
be removed with a grooved expansile forceps as shown in Figs 23 and
25, or its edge may be grasped by the regular side-grasping forceps.
The latter hold is apt to be very dangerous because of the trauma
inflicted by the catching of the free edge opposite the forceps; but
with care it is the best method. Should the closed end be uppermost,
however, it may be necessary to insert a hook beyond the object, and
to coax it upward to a point where it may be turned for grasping and
removal with forceps.
[FIG. 83.--"Mushroom anchor" problem of the upholstery tack. If the
tack has not been _in situ_ more than a few weeks the stenosis at the
level of the darts is simply edematous mucosa and the tack can be
pulled through with no more than slight mucosal trauma, _provided_
axis-traction only be used. If the tack has been in situ a year or
more the fibrous stricture may need dilatation with the divulsor.
Otherwise traction may rupture the bronchial wall. The stenotic tissue
in cases of a few months' sojourn maybe composed of granulations, in
which case axis-traction will safely withdraw it. The point of a tack
rarely projects freely into the lumen as here shown. More often it is
buried in the wall.]
[168] [FIG. 84.-Schema illustrating the "mushroom anchor" problem of
the brass headed upholstery tack. At A the tack is shown with the head
bedded in swollen mucosa. The bronchoscopist, looking through the
bronchoscope, E, considering himself lucky to have found the point of
the tack, seizes it and starts to withdraw it, making traction as
shown by the dart in drawing B. The head of the tack catches below a
chondrial ring and rips in, tearing its way through the bronchial wall
(D) causing death by mediastinal emphysema. This accident is still
more likely to occur if, as often happens, the tack-head is lodged in
the orifice of the upper lobe bronchus, F. But if the bronchoscopist
swings the patient's head far to the opposite side and makes
axis-traction, as shown at C, the head of the tack can be drawn
through the swollen mucosa without anchoring itself in a cartilage. If
necessary, in addition, the lip of the bronchoscope can be used to
repress the angle, h, and the swollen mucosa, H. If the swollen
mucosa, H, has been replaced by fibrous tissue from many months'
sojourn of the tack, the stenosis may require dilatation with the
divulsor.]
[FIG. 85.--Problem of the upholstery tack with buried point. If pulled
upon, the imminent perforation of the mediastinum, as shown at A will
be completed, the bronchus will be torn and death will follow even if
the tack be removed, which is of doubtful possibility. The proper
method is gently to close the side curved forceps on the shank of the
tack near the head, push downward as shown by the dart, in B, until
the point emerges. Then the forceps are rotated to bring the point of
the tack away from the bronchial wall.]
[169] _Removal of Open Safety Pins from the Trachea and Bronchi_.--
Removal of a closed safety pin presents no difficulty if it is grasped
at one or the other end. A grasp in the middle produces a "toggle
and ring" action which would prevent extraction. When the
safety pin is _open with the point downward_ care must be exercised
not to override it with the bronchoscope or to push the point through
the wall. The spring or near end is to be grasped with the side-curved
or the rotation forceps (Figs. 19, 20 and 31) and pulled into the
bronchoscope, thus closing the pin. An open safety pin lodged point up
presents an entirely different and a very difficult problem. If
traction is made without closing the pin or protecting the point
severe and probably fatal trauma will be produced. The pin may be
closed with the pin-closer as illustrated in Fig. 37, and then removed
with forceps. Arrowsmith's pin-closer is excellent. Another method
(Fig. 87) consists in bringing the point of the safety pin into the
bronchoscope, after disengaging the point with the side curved
forceps, by the author's "inward rotation" method. The forceps-jaws
(Fig. 21) devised recently by my assistant, Dr. Gabriel Tucker, are
ideal for this maneuver. As the point is now protected, the spring,
seen just off the tube mouth, is best grasped with the rotation
forceps, which afford the securest hold. The keeper and its shaft are
outside the bronchoscope, but its rounded portion is uppermost and
will glide over the tissues without trauma upon careful withdrawal of
the tube and safety pin. Care must be taken to rotate the pin so that
it lies in the sagittal plane of the glottis with the keeper placed
posteriorly, for the reason that the base of the glottic triangle is
posterior, and that the posterior wall of the larynx is membranous
above the cricoid cartilage, and will yield. A small safety-pin may be
removed by version, the point being turned into a branch bronchial
orifice. No one should think of attempting the extraction of a safety
pin lodged point upward without having practiced for at least a
hundred hours on the rubber tube manikin. This practice should be
carried out by anyone expecting to do endoscopy, because it affords
excellent education of the eye and the fingers in the endoscopic
manipulation of any kind of foreign body. Then, when a safety pin case
is encountered, the bronchoscopist will be prepared to cope with its
difficulties, and he will be able to determine which of the methods
will be best suited to his personal equation in the particular case.
[FIG. 86.--Schema illustrating the "upper-lobe-bronchus problem,"
combined with the "mushroom-anchor" problem and the author's method
for their solution. The patient being recumbent, the bronchoscopist
looking down the right main bronchus, M, sees the point of the tack
projecting from the right upper-lobe-bronchus, A. He seizes the point
with the side-curved forceps; then slides down the bronchoscope to the
position shown dotted at B. Next he pushes the bronchoscopic
tube-mouth downward and medianward, simultaneously moving the
patient's head to the right, thus swinging the bronchoscopic level on
its fulcrum, and dragging the tack downward and inward out of its bed,
to the position, 1). Traction, as shown at C, will then safely and
easily withdraw the tack. A very small bronchoscope is essential. The
lip of the bronchoscopic tube-mouth must be used to pry the forceps
down and over, and the lip must be brought close to the tack just
before the prying-pushing movement. S, right stem-bronchus.]
[FIG. 87.--One method of dealing with an open safety pin without
closing it.]
_Removal of Double Pointed Tacks_.--If the tack or staple be small,
and lodged in a relatively large trachea a version may be done. That
is, the staple may be turned over with the hook or rotation forceps
and brought out with the points trailing. With a long staple in a
child's trachea the best method is to "coax" the intruder along gently
under ocular guidance, never making traction enough to bury the point
deeply, and lifting the point with the hook whenever it shows any
inclination to enter the wall. Great care and dexterity are required
to get the intruder through the glottis. In certain locations, one or
both points may be turned into branch bronchi as illustrated in Fig.
88, or over the carina into the opposite main bronchus. Another method
is to get both points into the tube-mouth. This may be favored, as
demonstrated by my assistant, Dr. Gabriel Tucker, by tilting the
staple so as to get both points into the longest diameter of the
tube-mouth. In some cases I have squeezed the bronchoscope in a vise
to create an oval tube-mouth. In other cases I have used expanding
forceps with grooved blades.
[FIG. 88.-Schema illustrating podalic version of bronchially-lodged
staples or double-pointed tacks. H, bronchoscope. A, swollen mucosa
covering points of staple. At E the staple has been manipulated upward
with bronchoscopic lip and hooks until the points are opposite the
branch bronchial orifices, B, C. Traction being made in the direction
of the dart (F), by means of the rotation forceps, and counterpressure
being made with the bronchoscopic lip on the points of the staple, the
points enter the branch bronchi and permit the staple to be turned
over and removed with points trailing harmlessly behind (K).]
_The Extraction of Tightly Fitting Foreign Bodies from the Bronchi.
Annular Edema_.--Such objects as marbles, pebbles, corks, etc., are
drawn deeply and with force by the inspiratory blast into the smallest
bronchus they can enter. The air distal to the impacted foreign body
is soon absorbed, and the negative pressure thus produced increases
the impaction. A ring of edematous mucosa quickly forms and covers the
presenting part of the object, leaving visible only a small surface in
the center of an acute edematous stenosis. A forceps with narrow,
stiff, expansive-spring jaws may press back a portion of the edema and
may allow a grasp on the sides of the foreign body; but usually the
attempt to apply forceps when there are no spaces between the
presenting part of the foreign body and the bronchial wall, will
result only in pushing the foreign body deeper.* A better method is to
use the lip of the bronchoscope to press back the swollen mucosa at
one point, so that a hook may be introduced below the foreign body,
which then can be worked up to a wider place where forceps may be
applied (Fig. 89). Sometimes the object may even be held firmly
against the tube mouth with the hook and thus extracted. For this the
unslanted tube-mouth is used.
* The author's new ball forceps are very successful with ball-bearing
balls and marbles.
[FIG. 89.--Schema illustrating the use of the lip of the bronchoscope
in disimpaction of foreign bodies. A and B show an annular edema above
the foreign body, F. At C the edematous mucosa is being repressed by
the lip of the tube mouth, permitting insinuation of the hook, H, past
one side of the foreign body, which is then withdrawn to a convenient
place for application of the forceps. This repression by the lip is
often used for purposes other than the insertion of hooks. The lip of
the esophagoscope can be used in the same way.]
_Extraction of Soft Friable Foreign Bodies from the Tracheobronchial
Tree_.--The difficulties here consist in the liability of crushing or
fragmenting the object, and scattering portions into minute bronchi,
as well as the problem of disimpaction from a ring of annular edema,
with little or no forceps space. There is usually in these cases an
abundance of purulent secretion which further hinders the work. The
great danger of pushing the foreign body downward so that the swollen
mucosa hides it completely from view, must always be kept in mind.
Extremely delicate forceps with rather broad blades are required for
this work. The fenestrated "peanut" forceps are best for large pieces
in the large bronchi. The operator should develop his tactile sense
with forceps by repeated practice in order to acquire the skill to
grasp peanut kernels sufficiently firmly to hold them during
withdrawal, yet not so firmly as to crush them. Nipping off an edge by
not inserting the forceps far enough is also to be avoided. Small
fragments under 2 mm. in diameter may be expelled with the secretions
and fragments may be found on the sponges and in the secretions
aspirated or removed by sponge pumping. It is, however, never
justifiable deliberately to break a friable foreign body with the hope
that the fragments will be expelled, for these may be aspirated into
small bronchi, and cause multiple abscesses. A hook may be found
useful in dealing with round, friable, foreign bodies; and in some
cases the mechanical spoon or safety-pin closer may be used to
advantage. The foreign body is then brought close to, but not crushed
against the tube mouth.
[174] _Removal of animal objects from the tracheobronchial tree_ is
readily accomplished with the side-curved forceps. Leeches are not
uncommon intruders in European countries. Small insects are usually
coughed out. Worms and larvae may be found. Cocaine or salt solution
will cause a leech to loosen its hold.
_Foreign bodies in the upper-lobe bronchi_ are fortunately not common.
If the object is not too far out to the periphery it may be grasped by
the upper-lobe-bronchus forceps (Fig. 90), guided by the collaboration
of the fluoroscopist. These forceps are made so as to reach high into
the ascending branches of the upper-lobe bronchus. Full-curved
coil-spring hooks will reach high, but must be used with the utmost
caution, and the method of their disengagement must be practiced
beforehand.
_Penetrating Projectiles_.--Foreign bodies that have penetrated the
chest wall and lodged in the lung may be removed by oral bronchoscopy
if the intruder is not larger than the lumen of the corresponding main
bronchus (see Bibliography, 43)
[FIG. 90.--Schematic illustration of the author's upper-lobe-bronchus
forceps in position grasping a pin in an anteriorly ascending branch
of the upper-lobe bronchus. T, Trachea; UL, upper-lobe bronchus; LB,
left bronchus; SB, stem bronchus. These forceps are made to extend
around 180 degrees.]
RULES FOR ENDOSCOPIC FOREIGN BODY EXTRACTION
1. Never endoscope a foreign body case unprepared, with the idea of
taking a preliminary look.
2. Approach carefully the suspected location of a foreign body, so
as not to override any portion of it.
[175] 3. Avoid grasping a foreign body hastily as soon as seen.
4. The shape, size and position of a foreign body, and its relations
to surrounding structures, should be studied before attempting to
apply the forceps. (Exception cited in Rule 10.)
5. Preliminary study of a foreign body should be from a distance.
6. As the first grasp of the forceps is the best, it should be well
planned beforehand so as to seize the proper part of the intruder.
7. With all long foreign bodies the motto should be "Search, not for
the foreign body, but for its nearer end." With pins, needles, and the
like, with point upward, _search always for the point_. Try to see it
first.
8. Remember that a long foreign body grasped near the middle
becomes, mechanically speaking, a "toggle and ring."
9. Remember that the mortality to follow failure to remove a foreign
body does not justify probably fatal violence during its removal.
10. _Laryngeally lodged_ foreign bodies, because of the likelihood
of dislodgment and loss, may be seized by any part first presented,
and plan of withdrawal can be determined afterward.
11. For similar reasons, laryngeal cases should be dealt with only
in the author's position (Fig. 53).
12. An esophagoscopy may be needed in a bronchoscopic case, or a
bronchoscopy in an esophageal case. In every case both kinds of tubes
should be sterile and ready before starting. It is the unexpected that
happens in foreign body endoscopy.
13. Do not pull on a foreign body unless it is properly grasped to
come away readily without trauma. Then do not pull hard.
14. Do no harm, if you cannot remove the foreign body.
15. Full-curved hooks are to be used in the bronchi with greatest
caution, if used at all, lest they catch inextricably in branch
bronchi.
[176] 16. Don't force a foreign body downward. Coax it back. The
deeper it gets the greater your difficulties.
17. The watchword of the bronchoscopist should be, "If I can do no
good, I will at least do no harm."
_Fluoroscopic bronchoscopy_ is so deceptively easy from a superficial,
theoretical, point of view that it has been used unsuccessfully in
cases easily handled in the regular endoscopic way with the eye at the
proximal tube-mouth. In a collected series of cases by various
operators the object was removed in 66.7 per cent with a mortality of
41.6 per cent. In the problem of a pin located out of the field of
bronchoscopic vision, the fluoroscopist will yield invaluable aid. An
extremely delicate forceps is to be inserted closed into the invaded
bronchus, the grasp on the object being confirmed by the
fluoroscopist. It is to be kept in mind that while the object itself
may be in the grasp of the forceps, the fluoroscope will not show
whether there may not be included in the forceps' grasp a bronchial
spur or other tissue, the tearing of which may be fatal. Therefore
traction must not be sufficient to lacerate tissue. If the foreign
body does not come readily it must be released, and a new grasp may
then be taken. All of the cautions in faulty seizure already
mentioned, apply with particular force to fluoroscopic bronchoscopy.
The fluoroscope is of aid in finding foreign bodies held in abscess
cavities. The fluoroscope should show both the lateral and
anteroposterior planes. To accomplish this quickly, two Coolidge tubes
and two screens are necessary. Fluoroscopic bronchoscopy, because of
its high mortality and low percentage of successes, should be tried
only after regular, ocularly guided, peroral bronchoscopy has failed,
and only by those who have had experience in ocularly guided
bronchoscopy.
[177] CHAPTER XVI--FOREIGN BODIES IN THE BRONCHI FOR PROLONGED PERIODS
The sojourn of an inorganic foreign body in the bronchus for a year or
more is followed by the development of bronchiectasis, pulmonary
abscess, and fibrous changes. The symptoms of tuberculosis may all be
presented, but tubercle bacilli have never been found associated with
any of the many cases that have come to the Bronchoscopic Clinic.* The
history of repeated attacks of malaise, fever, chills, and sweats
lasting for a few days and terminated by the expulsion of an amount of
foul pus, suggests the intermittent drainage of an abscess cavity, and
special study should be made to eliminate foreign body as the cause of
the condition, in all such cases, whether there is any history of a
foreign body accident or not. Bronchoscopy for diagnosis is to be done
unless the etiology can be definitely proven by other means. In all
cases of chronic chest disease foreign body should be eliminated as a
matter of routine.
* One exception has recently come to the Clinic. 12
_The time of aspiration of a foreign body_ may be unknown, having
possibly occurred in infancy, during narcosis, or the object may even
enter the lower air passages without the patient being aware of the
accident, as happened with a particularly intelligent business man who
unknowingly aspirated the tip of an atomizer while spraying his
throat. In many other cases the accident had been forgotten. In still
others, in spite of the patient's statement of a conviction that the
trouble was due to a foreign body he had aspirated, the physician did
not consider it worthy of sufficient consideration to warrant a
roentgenray examination. It is curious to note the various opinions
held in regard to the gravity of the presence of a bronchial foreign
body. One patient was told by his physician that the presence of a
staple in his bronchus was an impossibility, for he would not have
lived five minutes after the accident. Others consider the presence of
a foreign body in the bronchus as comparatively harmless, in spite of
the repeated reports of invalidism and fatality in the medical
literature of centuries. The older authorities state that all cases of
prolonged bronchial foreign body sojourn died from phthisis
pulmonalis, and it is still the opinion of some practitioners that the
presence of a foreign body in the lung predisposes to the development
of true tuberculosis. With the dissemination of knowledge regarding
the possibility of bronchial foreign body, and the marvellous success
in their removal by bronchoscopy, the cases of prolonged foreign body
sojourn should decrease in number. It should be the recognized rule,
and not the exception, that all chest conditions, acute or chronic,
should have the benefit of roentgenographic study, even apart from the
possibility of foreign body.
Often even with the clear history of foreign-body aspiration, both
patient and physician are deluded by a relatively long period of
quiescence in which no symptoms are apparent. This symptomless
interval is followed sooner or later by ever increasing cough and
expectoration of sputum, finally by bronchiectasis and pulmonary
abscess, chronic sepsis, and invalidism.
_Pathology_.--If the foreign body completely obstructs a main
bronchus, preventing both aeration and drainage, such rapid
destruction of lung tissue follows that extensive pathologic changes
may result in a few months, or even in a few weeks, in the case of
irritating foreign bodies such as peanut kernels and soft rubber. Very
minute, inorganic foreign bodies may become encysted as in
anthracosis. Large objects, however, do not become encysted. The
object is drawn down by gravity and aspirated into the smallest
bronchus it can enter. Later the negative pressure below from
absorption of air impacts it still further. Swelling of the bronchial
mucosa from irritation plus infection completes the occlusion of the
bronchus. Retention of secretions and bacterial decomposition thereof
produces first a "drowned lung" (natural passages full of pus); then
sloughing or ulceration in the tissues plus the pressure of the pus,
causes bronchiectasis; further destruction of the cartilaginous rings
results in true abscess formation below the foreign body. The
productive inflammation at the site of lodgement of the foreign body
results in cicatricial contraction and the formation of a stricture at
the top of the cavity, in which the foreign body is usually held. The
abscess may extend to the periphery and rupture into the pleural
cavity. It may drain intermittently into a bronchus. Certain
irritating foreign bodies, such as soft rubber, may produce gangrenous
bronchitis and multiple abscesses. For observations on pathology (see
Bibliography, 38).
_Prognosis_.--If the foreign body be not removed, the resulting
chronic sepsis or pulmonary hemorrhage will prove fatal. Removal of
the foreign body usually results in complete recovery without further
local treatment. Occasionally, secondary dilatation of a bronchial
stricture may be required. All cases will need, besides removal of the
foreign body, an antituberculous regimen, and offer a good prognosis
if this be followed.
_Treatment_.--Bronchoscopy should be done in all cases of chronic
pulmonary abscess and bronchiectasis even though radiographic study
reveals no shadow of foreign body. The patient by assuming a posture
with the head lowered is urged to expel spontaneously all the pus
possible, before the bronchoscopy. The aspirating bronchoscope (Fig.
2, E) is often useful in cases where large amounts of secretion may be
anticipated. Granulations may require removal with forceps and
sponging. Disturbed granulations result in bleeding which further
hampers the operation; therefore, they should not be touched until
ready to apply the forceps, unless it is impossible to study the
presentation without disturbing them. For this reason secretions
hiding a foreign body should be removed with the aspirating tube (Fig.
9) rather than by swabbing or sponge-pumping, when the bronchoscopic
tube-mouth is close to the foreign body. It is inadvisable, however,
to insert a forceps into a mass of granulations to grope blindly for a
foreign body, with no knowledge of the presentation, the forceps
spaces, or the location of branch-bronchial orifices into which one
blade of the forceps may go. Dilatation of a stricture may be
necessary, and may be accomplished by the forms of bronchial dilators
shown in Fig. 25. The hollow type of dilator is to be used in cases in
which the foreign body is held in the stricture (Fig. 83). This
dilator may be pushed down over the stem of such an object as a tack,
and the stricture dilated without the risk of pushing the object
downward. It is only rarely, however, that the point of a tack is
free. Dense cicatricial tissue may require incision or excision.
_Internal bronchotomy_ is doubtless, a very dangerous procedure,
though no fatalities have occurred in any of the three cases in the
Bronchoscopic Clinic. It is advisable only as a last resort.
[181] CHAPTER XVII--UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES
The limitations of bronchoscopic removal of foreign bodies are usually
manifested in the failure to find a small foreign body which has
entered a minute bronchus far down and out toward the periphery. When
localization by means of transparent films, fluoroscopy, and
endobronchial bismuth insufflation has failed, the question arises as
to the advisability of endoscopic excision of the tissue intervening
between the foreign body and bronchoscope with the aid of two
fluoroscopes, one for the lateral and the other the vertical plane.
With foreign bodies in the larger bronchi near the root of the lung
such a procedure is unnecessary, and injury to a large vessel would be
almost certain. At the extreme periphery of the lung the danger is
less, for the vessels are smaller and serious hemorrhage less
probable, through the retention and decomposition of blood in small
bronchi with later abscess formation is a contingency. The nature of
the bridge of tissue is to be considered; should it be cicatricial,
the result of prolonged inflammatory processes, it may be carefully
excised without very great risk of serious complications. The blood
vessels are diminished in size and number by the chronic productive
inflammation, which more than offsets their lessened contractility.
The possibility of the foreign body being coughed out after
suppurative processes have loosened its impaction is too remote; and
the lesions established may result fatally even after the expulsion of
the object. Pulmonary abscess formation and rupture into the pleura
should not be awaited, for the foreign body does not often follow the
pus into the pleural cavity. It remains in the lung, held in a bed of
granulation tissue. Furthermore, to await the development is to
subject the patient to a prolonged and perhaps fatal sepsis, or a
fatal pulmonary hemorrhage from the erosion of a vessel by the
suppurative process. The recent developments in thoracic surgery have
greatly decreased the operative mortality of thoracotomy, so that this
operation is to be considered when bronchoscopy has failed.
Bronchoscopy can be considered as having failed, for the time being,
when two or more expert bronchoscopists on repeated search have been
unable to find the foreign body or to disentangle it; but the art of
bronchoscopy is developing so rapidly that the failures of a few years
ago would be easy successes today. Before considering thoracotomy
months of study of the mechanical problem are advisable. It is
probable that any foreign body of appreciable size that has gone down
the natural passages can be brought back the same way.
In the event of a foreign body reaching the pleura, either with or
without pus, it should be removed immediately by pleuroscopy or by
thoracotomy, without waiting for adhesive pleuritis.
The problem may be summarized thus:
1. Large foreign bodies in the trachea or large bronchi can always
be removed by bronchoscopy.
2. The development of bronchoscopy having subsequently solved the
problems presented by previous failures, it seems probable that by
patient developmental endeavor, any foreign body of appreciable size
that has gone down through the natural passages, can be
bronchoscopically removed the same way, provided fatal trauma is
avoided.
At the author's Bronchoscopic Clinics 98.7 per cent of foreign bodies
have been removed.
CHAPTER XVIII--FOREIGN BODIES IN THE ESOPHAGUS
_Etiology_.--The lodgement of foreign bodies in the esophagus is
influenced by:
1. The shape of the foreign body (disc-shaped, pointed, irregular).
2. Resiliency of the object (safety pins).
3. The size of the foreign body.
4. Narrowing of the esophagus, spasmodic or organic, normal, or
pathologic.
5. Paralysis of the normal esophageal propulsory mechanism.
The lodgement of a bolus of ordinary food in the esophagus is strongly
suggestive of a preexisting narrowing of the lumen of either a
spasmodic or organic nature; a large bolus of food, poorly masticated
and hurriedly swallowed, may, however, become impacted in a perfectly
normal esophagus.
Carelessness is the cause of over 80 per cent of the foreign bodies in
the esophagus (see Bibliography, 29).
_Site of Lodgement_.--Almost all foreign bodies are arrested in the
cervical esophagus at the level of the superior aperture of the
thorax. A physiologic narrowing is present at this level, produced in
part by muscular contraction, and mainly by the crowding of the
adjacent viscera into the fixed and narrow upper thoracic aperture. If
dislodged from this position the foreign body usually passes downward
to be arrested at the next narrowing or to pass into the stomach. The
esophagoscopist who encounters the difficulty of introduction at the
cricopharyngeal fold expects to find the foreign body above the fold.
Such, however, is almost never the case. The cricopharyngeus muscle
functionates in starting the foreign body downward as if it were food;
but the narrowing at the upper thoracic aperture arrests it because
the esophageal peristaltic musculature is feeble as compared to the
powerful inferior constrictor.
_Symptoms_.--_Dysphagia_ is the most frequent complaint in cases of
esophageally lodged foreign bodies. A very small object may excite
sufficient spasm to cause aphagia, while a relatively large foreign
body may be tolerated, after a time, so that the swallowing function
may seem normal. Intermittent dysphagia suggests the tilting or
shifting of a foreign body in a valve-like fashion; but may be due to
occlusion of the by-passages by food arrested by the foreign body.
_Dyspnea_ may be present if the foreign body is large enough to
compress the trachea. _Cough_ may be excited by reflex irritation,
overflow of secretions into the larynx, or by perforation of the
posterior tracheal wall, traumatic or ulcerative, allowing leakage of
food or secretion into the trachea. (See Chapter XII for discussion of
symptomatology and diagnosis.)
_Prognosis_.--A foreign body lodged in the esophagus may prove quickly
fatal from _hemorrhage_ due to perforation of a large vessel; from
_asphyxia_ by pressure on the trachea; or from _perforation_ and
_septic mediastinitis_. Slower fatalities may result from suppuration
extending to the trachea or bronchi with consequent edema and
asphyxia. Sooner or later, if not removed, the foreign body causes
death. It may be tolerated for a long period of time, causing abscess,
cervical cellulitis, fistulous tracts, and ultimately extreme stenosis
from cicatricial contraction. Perichondritis of the laryngeal or
tracheal cartilages may follow, and result in laryngeal stenosis
requiring tracheotomy. The damage produced by the foreign body is
often much less than that caused by blind and ill-advised attempts at
removal. If the foreign body becomes dislodged and moves downward, the
danger of intestinal perforation is encountered. The _prognosis_,
therefore, must be guarded so long as the intruder remains in the
body.
_Treatment_.--It is a mistake to try to force a foreign body into the
stomach with the stomach tube or bougie. Sounding the esophagus with
bougies to determine the level of the obstruction, or to palpate the
nature of the foreign body, is unnecessary and dangerous.
Esophagoscopy should not be done without a previous roentgenographic
and fluoroscopic examination of the chest and esophagus, except for
urgent reasons. The level of the stenosis, and usually the nature of
the foreign body, can thus be decided. Blind instrumentation is
dangerous, and in view of the safety and success of esophagoscopy,
reprehensible.
If for any reason removal should be delayed, bismuth sub-nitrate,
gramme 0.6, should be given dry on the tongue every four hours. It
will adhere to the denuded surfaces. The addition of calomel, gramme
0.003, for a few doses will increase the antiseptic action. Should
swallowing be painful, gramme 0.2 of orthoform or anesthesin will be
helpful. Emetics are inefficient and dangerous. Holding the patient up
by the heels is rarely, if ever, successful if the foreign body is in
the esophagus. In the reported cases the intruder was probably in the
pharynx.
_External esophagotomy_ for the removal of foreign bodies is
unjustifiable until esophagoscopy has failed in the hands of at least
two skillful esophagoscopists. It has been the observation in the
Bronchoscopic Clinic that every foreign body that has gone down
through the mouth into the esophagus can be brought back the same way,
unless it has already perforated the esophageal wall, in which event
it is no longer a case of foreign body in the esophagus. The mortality
of external esophagotomy for foreign bodies is from twenty to
forty-two per cent, while that of esophagoscopy is less than two per
cent, if the foreign body has not already set up a serious
complication before the esophagoscopy. Furthermore, external
esophagotomy can be successful only with objects lodged
in the cervical esophagus and, moreover, it has happened that after
the esophagus has been opened, the foreign body could not be found
because of dislodgement and passage downward during the relaxation of
the general anesthesia. Should this occur during esophagoscopy, the
foreign body can be followed with the esophagoscope, and even if it is
not overtaken and removed, no risk has been incurred.
Esophagoscopy is the one method of removal worthy of serious
consideration. Should it repeatedly fail in the hands of two skillful
endoscopists, which will be very rarely, if ever, then external
operation is to be considered in cervically lodged foreign bodies.
[187] CHAPTER XIX--ESOPHAGOSCOPY FOR FOREIGN BODY
_Indications_.--Esophagoscopy is demanded in every case in which a
foreign body is known to be, or suspected of being, in the esophagus.
_Contraindications_.--There is no absolute contraindication to careful
esophagoscopy for the removal of foreign bodies, even in the presence
of aneurism, serious cardiovascular disease, hypertension or the like,
although these conditions would render the procedure inadvisable.
Should the patient be in bad condition from previous ill-advised or
blind attempts at extraction, endoscopy should be delayed until the
traumatic esophagitis has subsided and the general state improved. It
is rarely the foreign body itself which is producing these symptoms,
and the removal of the object will not cause their immediate
subsidence; while the passage of the tube through the lacerated,
infected, and inflamed esophagus might further harm the patient.
Moreover, the foreign body will be difficult to find and to remove
from the edematous and bleeding folds, and the risk of following a
false passage into the mediastinum or overriding the foreign body is
great. Water starvation should be relieved by means of proctoclysis
and hypodermoclysis before endoscopy is done. The esophagitis is best
treated by placing dry on the tongue at four-hour intervals the
following powder:
Rx. Anesthesin...gramme 0.12
Bismuth subnitrate...gramme 0.6
Calomel, gramme 0.006 to 0.003 may be added to each powder for a few
doses to increase the antiseptic effect. If the patient can swallow
liquids it is best to wait one week from the time of the last attempt
at removal before any endoscopy for extraction be done. This will give
time for nature to repair the damage and render the removal of the
object more certain and less hazardous. Perforation of the esophagus
by the foreign body, or by blind instrumentation, is a
contraindication to esophagoscopy. It is manifested by such signs as
subcutaneous emphysema, swelling of the neck, fever, irritability,
increase in pulsatory and respiratory rates, and pain in the neck or
chest. Gaseous emphysema is present in some cases, and denotes a
dangerous infection. Esophagoscopy should be postponed and the
treatment mentioned at the end of this chapter instituted. After the
subsidence of all symptoms other than esophageal, esophagoscopy may be
done safely. Pleural perforation is manifested by the usual signs of
pneumothorax, and will be demonstrated in the roentgenogram.
ESOPHAGOSCOPIC EXTRACTION OF FOREIGN BODIES
It is unwise to do an endoscopy in a foreign-body case for the sole
purpose of taking a preliminary look. Everything likely to be needed
for extraction of the intruder should be sterile and ready at hand.
Furthermore, all required instruments for laryngoscopy, bronchoscopy
or tracheotomy should be prepared as a matter of routine, however
rarely they may be needed.
Sponging should be done cautiously lest the foreign body be hidden in
secretions or food accumulation, and dislodged. Small food masses
often lodge above the foreign body and are best removed with forceps.
The folds of the esophagus are to be carefully searched with the aid
of the lip of the esophagoscope. If the mucosa of the esophagus is
lacerated with the forceps all further work is greatly hampered by the
oozing; if the laceration involve the esophageal wall the accident may
be fatal: and at best the tendency of the tube-mouth to enter the
laceration and create a false passage is very great.
_"Overriding" or failure to find a foreign body known to be present_
is explained by the collapsed walls and folds covering the object,
since the esophagoscope cannot be of sufficient size to smooth out
these folds, and still be of small enough diameter to pass the
constricted points of the esophagus noted in the chapter on anatomy.
Objects are often hidden just distal to the cricopharyngeal fold,
which furthermore makes a veritable chute in throwing the end of the
tube forward to override the foreign body and to interpose a layer of
tissue between the tube and the object, so that the contact at the
side of the tube is not felt as the tube passes over the foreign body
(Fig. 91). The chief factors in overriding an esophageal foreign body
are:
1. The chute-like effect of the plica cricopharyngeus.
2. The chute-like effect of other folds.
3. The lurking of the foreign body in the unexplored pyriform sinus.
4. The use of an esophagoscope of small diameter.
5. The obscuration of the intruder by secretion or food debris.
6. The obscuration of the intruder by its penetration of the
esophageal wall.
7. The obscuration of the intruder by inflammatory sequelae.
[FIG. 91.--Illustrating the hiding of a coin by the folding downward
of the plica cricopharyngeus. The muscular contraction throws the beak
of the esophagoscope upward while the interposed tissue prevents the
tactile appreciation of contact of the foreign body with the side of
the tube after the tip has passed over the foreign body. Other folds
may in rare instances act similarly in hiding a foreign body from
view. This overriding of a foreign body is apt to cause dangerous
dyspnea by compression of the party wall.]
_The esophageal speculum for the removal of foreign bodies_ is useful
when the object is not more than 2 cm. below the cricoid in a child,
and 3 cm. in the adult. The fold of the cricopharyngeus can be
repressed posteriorward by the forceps which are then in position to
grasp the object when it is found. The author's down-jaw forceps (Fig.
22) are very useful to reach down back of the cricopharyngeal fold,
because of the often small posterior forceps space. The speculum has
the disadvantage of not allowing deeper search should the foreign body
move downward. In infants, the child's size laryngoscope may be used
as an esophageal speculum. General anesthesia is not only unnecessary
but dangerous, because of the dyspnea created by the endoscopic tube.
Local anesthesia is unnecessary as well as dangerous in children; and
its application is likely to dislodge the foreign body unless used as
a troche. Forbes esophageal speculum is excellent.
MECHANICAL PROBLEMS OF ESOPHAGOSCOPIC REMOVAL OF FOREIGN BODIES
The bronchoscopic problems considered in the previous chapter should
be studied.
_The extraction of transfixed foreign bodies_ presents much the same
problem as those in the bronchi, though there is no limit here to the
distance an object may be pushed down to free the point. Thin, sharp
foreign bodies such as bones, dentures, pins, safety-pins, etcetera,
are often found to lie crosswise in the esophagus, and it is
imperative that one end be disengaged and the long axis of the object
be made to correspond to that of the esophagus before traction for
removal is made (Fig. 92). Should the intruder be grasped in the
center and traction exerted, serious and perhaps fatal trauma might
ensue.
[191] [FIG. 92.--The problem of the horizontally transfixed foreign
body in the esophagus. The point, D, had caught as the bone, A, was
being swallowed. The end, E, was forced down to C, by food or by blind
attempts at pushing the bone downward. The wall, F, should be
laterally displaced to J, with the esophagoscope, permitting the
forceps to grasp the end, M, of the bone. Traction in the direction of
the dart will disimpact the bone and permit it to rotate. The rotation
forceps are used as at K.]
[FIG. 93.--Solution of the mechanical problem of the broad foreign
body having a sharp point by version. If withdrawn with plain forceps
as applied at A, the point B, will rip open the esophageal wall. If
grasped at C, the point, D, will rotate in the direction of F and will
trail harmlessly. To permit this version the rotation forceps are used
as at H. On this principle flat foreign bodies with jagged or rough
parts are so turned that the potentially traumatizing parts trail
during withdrawal.]
The extraction of broad, flat foreign bodies having a sharp point or a
rough place on part of their periphery is best accomplished by the
method of rotation as shown in Fig. 93.
_Extraction of Open Safety-pins from the Esophagus_.--An open safety
pin with the point down offers no particular mechanical difficulty in
removal. Great care must be exercised, however, that it be not
overridden or pushed upon, as either accident might result in
perforation of the esophagus by the pin point. The coiled spring is to
be sought, and when found, seized with the rotation forceps and the
pin thus drawn into the esophagoscope to effect closure. An open
safety-pin lodged point upward in the esophagus is one of the most
difficult and dangerous problems. A roentgenogram should always be
made in the plane showing the widest spread of the pin. It is to be
remembered that the endoscopist can see but one portion of the pin at
a time (except in cases of very small safety-pins) and that if he
grasps the part first showing, which is almost invariably the keeper,
fatal trauma will surely be inflicted when traction is made. It may be
best to close the safety pin with the safety-pin closer, as
illustrated in Fig. 37. For this purpose Arrowsmith's closer is
excellent. In other cases it may prove best to disengage the point of
the pin and to bring the pointed shaft into the esophagoscope with the
Tucker forceps and withdraw the pin, forceps, and esophagoscope, with
the keeper and its shaft sliding alongside the tube. The rounded end
of the keeper lying outside the tube allows it to slip along the
esophageal walls during withdrawal without inflicting trauma; however,
should resistance be felt, withdrawal must immediately cease and the
pin must be rotated into a different plane to release the keeper from
the fold in which it has probably caught. The sense of touch will aid
the sense of sight in the execution of this maneuver (Fig. 87). When
the pin reaches the cricopharyngeal level the esophagoscope, forceps,
and pin should be turned so that the keeper will be to the right, not
so much because of the cricopharyngeal muscle as to escape the
posteriorly protuberant cricoid cartilage. In certain cases in which
it is found that the pointed shaft of a small safety pin has
penetrated the esophageal wall, the pin has been successfully removed
by working the keeper into the tube mouth, grasping the keeper with
the rotation forceps or side-curved forceps, and pulling the whole pin
into the tube by straightening it. This, however, is a dangerous
method and applicable in but few cases. It is better to disengage the
point by downward and inward rotation with the Tucker forceps.
_Version of a Safety Pin_.--A safety pin of very small size may be
turned over in a direction that will cause the point to trail. An
advancing point will puncture. This is a dangerous procedure with a
large safety pin.
_Endogastric Version_.--A very useful and comparatively safe method is
illustrated in Figs. 94 and 95. In the execution of this maneuver the
pin is seized by the spring with a rotation forceps, and thus passed
along with the esophagoscope into the stomach where it is rotated so
that the spring is uppermost. It can then be drawn into the tube mouth
so as to protect the tissues during withdrawal of the pin, forceps,
and esophagoscope as one piece. Only very small safety-pins can be
withdrawn through the esophagoscope.
_Spatula-protected Method_.--Safety-pins in children, point upward,
when lodged high in the cervical esophagus may be readily removed with
the aid of the laryngoscope, or esophageal speculum. The keeper end is
grasped with the alligator forceps, while the spatular tip of the
laryngoscope is worked under the point. Instruments and foreign body
are then removed together. Often the pin point will catch in the
light-chamber where it is very safely lodged. If the pin be then
pulled upon it will straighten out and may be withdrawn through the
tube.
[FIG. 94.--Endogastric version. One of the author's methods of removal
of upward pointed esophageally lodged open safety-pins by passing them
into stomach, where they are turned and removed. The first
illustration (A) shows the rotation forceps before seizing pin by the
ring of the spring end. (Forceps jaws are shown opening in the wrong
diameter.) At B is shown the pin seized in the ring by the points of
the forceps. At C is shown the pin carried into the stomach and about
to be rotated by withdrawal. D, the withdrawal of the pin into the
esophagoscope which will thereby close it. If withdrawn by flat-jawed
forceps as at F, the esophageal wall would be fatally lacerated.]
_Double pointed tacks and staples_, when lodged point upward, must be
turned so that the points trail on removal. This may be done by
carrying them into the stomach and turning them, as described under
safety-pins.
_The extraction of foreign bodies of very large size_ from the
esophagus is greatly facilitated by the use of general anesthesia,
which relaxes the spasmodic contractions of the esophagus often
occurring when attempt is made to withdraw the foreign body. General
anesthesia, though entirely unnecessary for introduction of the
esophagoscope, in any case may be used if the body is large, sharp,
and rough, in order to prevent laceration through the muscular
contractions otherwise incident to withdrawal.* In exceptional cases
it may be necessary to comminute a large foreign body such as a tooth
plate. A large smooth foreign body may be difficult to seize with
forceps. In this case the mechanical spoon or the author's safety-pin
closer may be used.
* It must always be remembered that large foreign bodies are very
prone to cause dyspnea that renders general anesthesia exceedingly
dangerous especially in children.
[FIG. 95.--Lateral roentgenogram of a safety-pin in a child aged 11
months, demonstrating the esophageal location of the pin in this case
and the great value of the lateral roentgenogram in the localization
of foreign bodies. The pin was removed by the author's method of
endogastric version. (Plate made by George C. Johnston )]
_The extraction of meat and other foods from the esophagus_ at the
level of the upper thoracic aperture is usually readily accomplished
with the esophageal speculum and forceps. In certain cases the
mechanical spoon will be found useful. Should the bolus of food be
lodged at the lower level the esophagoscope will be required.
_Extraction of Foreign Bodies from the Strictured Esophagus_.--Foreign
bodies of relatively small size will lodge in a strictured esophagus.
Removal may be rendered difficult when the patient has an upper
stricture relatively larger than the lower one, and the foreign body
passing the first one lodges at the second. Still more difficult is
the case when the second stricture is considerably below the first,
and not concentric. Under these circumstances it is best to divulse
the upper stricture mechanically, when a small tube can be inserted
past the first stricture to the site of lodgement of the foreign body.
_Prolonged sojourn of foreign bodies in the esophagus_, while not so
common as in the bronchi is by no means of rare occurrence. Following
their removal, stricture of greater or less extent is almost certain
to follow from contraction of the fibrous-tissue produced by the
foreign body.
_Fluoroscopic esophagoscopy_ is a questionable procedure, for the
esophagus can be explored throughout by sight. In cases in which it is
suspected that a foreign body, such as pin, has partially escaped from
the esophagus, the fluoroscope may aid in a detailed search to
determine its location, but under no circumstances should it be the
guide for the application of forceps, because the transparent but
vital tissues are almost certain to be included in the grasp.
[197] Complications and Dangers of Esophagoscopy for Foreign Bodies.
Asphyxia from the pressure of the foreign body, or the foreign body
plus the esophagoscope, is a possibility (Fig. 91). Faulty position of
the patient, especially a low position of the head, with faulty
direction of the esophagoscope may cause the tube mouth to press the
membranous tracheo-esophageal wall into the trachea, so as temporarily
to occlude the tracheal lumen, creating a very dangerous situation in
a patient under general anesthesia. Prompt introduction of a
bronchoscope, with oxygen and amyl nitrite insufflation and artificial
respiration, may be necessary to save life. The danger is greater, of
course, with chloroform than with ether anesthesia. Cocain poisoning
may occur in those having an idiosyncrasy to the drug. Cocain should
never be used with children, and is of little use in esophagoscopy in
adults. Its application is more annoying and requires more time than
the esophagoscopic removal of the foreign bodies without local
anesthesia. Traumatic esophagitis, septic mediastinitis, cervical
cellulitis, and, most dangerous, gangrenous esophagitis may be
present, caused by the foreign body itself or ill-advised efforts at
removal. Perforation of the esophagus with the esophagoscope is rare,
in skillful hands, if the esophageal wall is sound. The esophageal
wall, however, may be weakened by ulceration, malignant disease, or
trauma, so that the possibility of making a false passage should
always deter the endoscopist from advancing the tube beyond a visible
point of weakening. To avoid entering a false passage previously
created, is often exceedingly difficult, and usually it is better to
wait for obliterative adhesive inflammation to seal the tissue layers
together.
_Treatment_.--Acute esophagitis calls for rest in bed, sterile liquid
food, and the administration of bismuth powder mentioned in the
paragraph on contraindications. An ice bag applied to the neck may
afford some relief. The mouth should be hourly cleansed with the
following solution:
Dakin's solution 1 part
Cinnamon water 5 parts.
Emphysema unaccompanied by pyogenic processes usually requires no
treatment, though an occasional case may require punctures of the skin
to liberate the air. Gaseous emphysema and pus formation urgently
demand early external drainage, preferably behind the sternomastoid.
Should the pleura be perforated by sudden puncture pyo-pneumothorax is
inevitable. Prompt thoracotomy for drainage may save the patient's
life if the mediastinum has not also been infected. Foreign bodies
ulcerating through may reach the lung without pleural leakage because
of the sealing together of the visceral and parietal pleurae. In the
serious degrees of esophageal trauma, particularly if the pleura be
perforated, gastrostomy is indicated to afford rest of the esophagus,
and for alimentation. A duodenal feeding tube may be placed through an
esophagoscope passed into the stomach in the usual way through the
mouth, avoiding by ocular guidance the perforation into which a
blindly passed stomach tube would be very likely to enter, with
probably dangerous results.