The esophagoscope is to be passed only with ocular guidance, never blindly with a mandrin or obturator, as was done before the bevel-ended esophagoscope was developed. Blind introduction of the esophagoscope is equally as dangerous as blind bouginage. It is almost certain to cause over-riding of foreign bodies and disease. In either condition perforation of the esophagus is possible by pushing a sharp foreign body through the normal wall or by penetrating a wall weakened by disease. Landmarks must be identified as reached, in order to know the locality reached. The secretions present form sufficient lubrication for the instrument. A clear conception of the endoscopic anatomy, the narrowings, direction, and changes of direction of the axis of the esophagus, are necessary. The services of a trained assistant to place the head in the proper sequential "high-low" positions are indispensible (Figs. 52 and 70). Introduction may be divided into four stages. 1. Entering the right pyriform sinus. 2. Passing the cricopharyngeus. 3. Passing through the thoracic esophagus. 4. Passing through the hiatus.
The patient is placed in the Boyce position as described in Chapter VI. As previously stated, the esophagus in its upper portion follows the curves of the cervical and dorsal spine. It is necessary, therefore, to bring the cervical spine into a straight line with the upper portion of the dorsal spine and this is accomplished by elevation of the head—the "high" position (Figs. 66-71).
[PLATE III—ESOPHAGOSCOPIC VIEWS FROM OIL-COLOR DRAWINGS FROM LIFE, BY THE AUTHOR: 1, Direct view of the larynx and laryngopharynx in the dorsally recumbent patient, the epiglottis and hyoid bone being lifted with the direct laryngoscope or the esophageal speculum. The spasmodically adducted vocal cords are partially hidden by the over-hang of the spasmodically prominent ventricular hands. Posterior to this the aryepiglottic folds ending posteriorly in the arytenoid eminences are seen in apposition. The esophagoscope should be passed to the right of the median line into the right pyriform sinus, represented here by the right arm of the dark crescent. 2, The right pyriform sinus in the dorsally recumbent patient, the eminence at the upper left border, corresponds to the edge of the cricoid cartilage. 3, The cricopharyngeal constriction of the esophagus in the dorsally recumbent patient, the cricoid cartilage being lifted forward with the esophageal speculum. The lower (posterior) half of the lumen is closed by the fold corresponding to the orbicular fibers of the cricopharyngeus which advances spasmodically from the posterior wall. (Compare Fig. 10.) This view is not obtained with an esophagoscope. 4, Passing through the right pyriform sinus with the esophagoscope; dorsally recumbent patient. The walls seem in tight apposition, and, at the edges of the slit-like lumen, bulge toward the observer. The direction of the axis of the slit varies, and in some instances it is like a rosette, depending on the degree of spasm. 5, Cervical esophagus. The lumen is not so patulent during inspiration as lower down; and it closes completely during expiration. 6, Thoracic esophagus; dorsally recumbent patient. The ridge crossing above the lumen corresponds to the left bronchus. It is seldom so prominent as in this patient, but can always be found if searched for. 7, The normal esophagus at the hiatus. This is often mistaken for the cardia by esophagoscopists. It is more truly a sphincter than the cardia itself. In the author's opinion there is no truly sphincteric action at the cardia. It is the failure of this hiatal sphincter to open as in the normal deglutitory cycle that produces the syndrome called "cardiospasm." 8, View in the stomach with the open-tube gastroscope. The form of the folds varies continually. 9, Sarcoma of the posterior wall of the upper third of the esophagus in a woman of thirty-one years. Seen through the esophageal speculum, patient sitting. The lumen of the mouth of the esophagus, much encroached upon by the sarcomatous infiltration, is seen at the lower part of the circle. 10, Coin (half-dollar) wedged in the upper third of the esophagus of a boy aged fourteen years. Seen through the esophageal speculum, recumbent patient. Forceps are retracting the posterior lip of the esophageal "mouth" preparatory to removal. 11, Fungating squamous-celled epithelioma in a man of seventy-four years. Fungations are not always present, and are often pale and edematous. 12, Cicatricial stenosis of the esophagus due to the swallowing of lye in a boy of four years. Below tile upper stricture is seen a second stricture. An ulcer surrounded by an inflammatory areola and the granulation tissue together illustrates the etiology of cicatricial tissue. The fan-shaped scar is really almost linear, but it is viewed in perspective. Patient was cured by esophagoscopic dilatation. 13, Angioma of the esophagus in a man of forty years. The patient had hemorrhoids and varicose veins of the legs. 14, Luetic ulcer of the esophagus 26 cm. from the upper teeth in a woman of thirty-eight years. Two scars from healed ulcerations are seen in perspective on the anterior wall. Branching vessels are seen in the livid areola of the ulcers. 15, Tuberculosis of the esophagus in a man of thirty-four years. 16, Leukoplakia of the esophagus near the hiatus in a man aged fifty-six years.]
The hypopharynx tapers down to the gullet like a funnel, and the larynx is suspended in its lumen from the anterior wall. The larynx is attached only to the anterior wall, but is held closely against the posterior pharyngeal wall by the action of the inferior constrictor of the pharynx, and particularly by its specialized portion—the cricopharyngeus muscle. A bolus of food is split by the epiglottis and the two portions drifted laterally into the pyriform sinuses, the recesses seen on either side of the larynx. But little of the food bolus passes posterior to the larynx during the act of swallowing. It is through the pyriform sinus that the esophagoscope is to be inserted, thereby following the natural food passage. To insert the esophagoscope in the midline, posterior to the arytenoids, requires a degree of force dangerous to exert and almost certain to produce damage to the cricoarytenoid joint or to the pharyngeal wall, or to both.
The esophagoscope is steadied by the left hand like a billiard cue, the terminal phalanges of the left middle and ring fingers hooked over the upper teeth, while the left index finger and thumb encircle the tube and retract the upper lip to prevent its being pinched between the tube and upper teeth. The right hand holds the tube in pen fashion at the collar of the handle, not by the handle. During introduction the handle is to be pointed upward toward the zenith.
Stage I. Entering the Right Pyriform Sinus.—The operator standing (as in Fig. 66), inserts the esophagoscope along the right side of the tongue as far as and down the posterior pharyngeal wall. A lifting motion imparted to the tip of the esophagoscope by the left thumb will bring the rounded right arytenoid eminence into view (A, Fig. 69). This is the landmark of the pyriform sinus, and care must be taken to avoid injury by hooking the tube mouth over it or its fellow. The tip of the tube should now be directed somewhat toward the midline, remembering the funnel shape of the hypopharynx. It will then be found to glide readily through the right pyriform sinus for 2 or 3 cm., when it comes to a full stop, and the lumen disappears. This is the spasmodically closed cricopharyngeal constriction.
[FIG. 66.—Esophagoscopy by the author's "high-low" method. First stage. "High" position. Finding the right pyriform sinus. In this and the second stage the patient's vertex is about 15 cm. above the level of the table.]
Stage 2. Passing the cricopharyngeusis the most difficult part of esophagoscopy, especially if the patient is unanesthetized. Local anesthesia helps little, if at all. The handle of the esophagoscope is still pointing upward and consequently we are sure that the lip of the esophagoscope is directed anteriorly. Force must not be used, but steady firm pressure against the tonically contracted cricopharyngeus is made, while at the same time the distal end of the esophagoscope is lifted by the left thumb. At the first inspiration a lumen will usually appear in the upper portion of the endoscopic field. The tip of the esophagoscope enters this lumen and the slanted end slides over the fold of the cricopharyngeus into the cervical esophagus. There is usually from 1 to 3 cm. of this constricted lumen at the level of the cricopharyngeus and the subjacent orbicular esophageal fibers.
[109] [FIG. 67.—Schematic illustration of the author's "high-low" method of esophagoscopy. In the first and second stages the patient's head fully extended is held high so as to bring it in line with the thoracic esophagus, as shown above. The Rose position is shown by way of accentuation.]
[FIG. 68.—Schematic illustration of the anatomic basis for difficulty in introduction of the esophagoscope. The cricoid cartilage is pulled backward against the cervical spine, by the cricopharyngeus, so strongly that it is difficult to realize that the cricopharyngeus is not inserted into the vertebral periosteum instead of into the median raphe.]
[FIG. 69.—The upper illustration shows movements necessary for passing the cricopharyngeus.
The lower illustration shows schematically the method of finding the pyriform sinus in the author's method of esophagoscopy. The large circle represents the cricoid cartilage. G, Glottic chink, spasmodically closed; VB, ventricular band; A, right arytenoid eminence; P, right pyriform sinus, through which the tube is passed in the recumbent posture. The pyriform sinuses are the normal food passages.]
Stage 3. Passing Through the Thoracic Esophagus.—The thoracic esophagus will be seen to expand during inspiration and contract during expiration, due to the change in thoracic pressure. The esophagoscope usually glides easily through the thoracic esophagus if the patient's position is correct. After the levels of the aorta and left bronchus are passed the lumen of the esophagus seems to have a tendency to disappear anteriorly. The lumen must be kept in axial view and the head lowered as required for this purpose.
Stage 4. Passing Through the Hiatus Esophageus.—When the head is dropped, it must at the same time be moved horizontally to the right in order that the axis of the tube shall correspond to the axis of the lower third of the esophagus, which deviates to the left and turns anteriorly. The head and shoulders at this time will be found to be considerably below the plane of the table top (Fig. 71). The hiatal constriction may assume the form of a slit or rosette. If the rosette or slit cannot be promptly found, as may be the case in various degrees of diffuse dilatation, the tube mouth must be shifted farther to the left and anteriorly. When the tube mouth is centered over the hiatal constriction moderately firm pressure continued for a short time will cause it to yield. Then the tube, maintaining this same direction will, without further trouble glide into and through the abdominal esophagus. The cardia will not be noticed as a constriction, but its appearance will be announced by the rolling in of reddish gastric mucosal folds, and by a gush of fluid from the stomach.
[FIG. 70.—Schematic illustration of the author's "high-low" method of esophagoscopy, fourth stage. Passing the hiatus. The head is dropped from the position of the 1st and 2nd stages, CL, to the position T, and at the same time the head and shoulders are moved to the right (without rotation) which gives the necessary direction for passing the hiatus.]
[FIG. 71.—Esophagoscopy by the author's "high-low" method. Stage 4. Passing the hiatus The patient's vertex is about 5 cm. below the top of the table.]
Normal esophageal mucosaunder proper illumination is glistening and of a yellowish or bluish pink. The folds are soft and velvety, rendering infiltration quickly noticeable. The cricoid cartilage shows white through the mucosa. The gastric mucosa is a darker pink than that of the esophagus and when actively secreting, its color in some cases tends toward crimson.
Secretionsin the esophagus are readily aspirated through the drainage canal by a negative pressure pump. Food particles are best removed by "sponge pumping," or with forceps. Should the drainage canal become obstructed positive pressure from the pump will clear the canal.
Difficulties of Esophagoscopy.—The beginner may find the esophagoscope seemingly rigidly fixed, so that it can be neither introduced nor withdrawn. This usually results from a wedging of the tube in the dental angle, and is overcome by a wider opening of the jaws, or perhaps by easing up of the bite block, but most often by correcting the position of the patient's head. If the beginner cannot start the tube into the pyriform sinus in an adult, it is a good plan to expose the arytenoid eminence with the laryngoscope and then to insert the 7 mm. esophagoscope into the right pyriform sinus by direct vision. Passing the cricopharyngeal and hiatal spasmodically contracted narrowings will prove the most trying part of esophagoscopy; but with the head properly held, and the tube properly placed and directed, patient waiting for relaxation of the spasm with gentle continuous pressure will usually expose the lumen ahead. In his first few esophagoscopies the novice had best use general anesthesia to avoid these difficulties and to accustom himself to the esophageal image. In the first favorable subject—an emaciated individual with no teeth—esophagoscopy without anesthesia should be tried.
In cases of kyphosis it is a mistake to try to straighten the spine. The head should be held correspondingly higher at the beginning, and should be very slowly and cautiously lowered.
Once inserted, the esophagoscope should not be removed until the completion of the procedure, unless respiratory arrest demands it. Occasionally in stenotic conditions the light may become covered by the upwelling of a flood of fluid, and it will be thought the light has gone out. As soon as the fluid has been aspirated the light will be found burning as brightly as before. If a lamp should fail it is unnecessary to remove the tube, as the light carrier and light can be withdrawn and quickly adjusted. A complete instrument equipment with proper selection of instruments for the particular case are necessary for smooth working.
Ballooning Esophagoscopy.—By inserting the window plug shown in Fig. 6 the esophagus may be inflated and studied in the distended state. The folds are thus smoothed out and constrictions rendered more marked. Ether anesthesia is advocated by Mosher. The danger of respiratory arrest from pressure, should the patient be dyspneic, is always present unless the anesthetic be given by the intratracheal method. If necessary to use forceps the window cap is removed. If the perforated rubber diaphragm cap be substituted the esophagus can be reballooned, but work is no longer ocularly guided. The fluoroscope may be used but is so misleading as to render perforation and false passage likely.
Specular Esophagoscopy.—Inspection of the hypopharynx and upper esophagus is readily made with the esophageal speculum shown in Fig. 4. High lesions and foreign bodies lodged behind the larynx are thus discovered with ease, and such a condition as a retropharyngeal abscess which has burrowed downward is much less apt to be overlooked than with the esophagoscope. High strictures of the esophagus may be exposed and treated by direct visual bouginage until the lumen is sufficiently dilated to allow the passage of the esophagoscope for bouginage of the deeper strictures.
Technic of Specular Esophagoscopy.—Recumbent patient. Boyce position. The larynx is to be exposed as in direct laryngoscopy, the right pyriform sinus identified, the tip of the speculum inserted therein, and gently insinuated to the cricopharyngeal constriction. Too great extension of the head is to be avoided—even slight flexion at the occipito-atloid joint may be found useful at times. Moderate anterior or upward traction pulls the cricoid away from the posterior pharyngeal wall and the lumen of the esophagus opens above a crescentic fold (the cricopharyngeus). The speculum readily slides over this fold and enters the cervical esophagus. In searching for foreign bodies in the esophagus the speculum has the disadvantage of limited length, so that should the foreign body move downward it could not be followed.
Complications Following Esophagoscopy.—These are to be avoided in large measure by the exercise of gentleness, care, and skill that are acquired by practice. If the instructions herein given are followed, esophagoscopy is absolutely without mortality apart from the conditions for which it is done.
Injury to the crico-arytenoid joint may simulate recurrent paralysis. Posticus paralysis may occur from recurrent or vagal pressure by a misdirected esophagoscope. These conditions usually recover but may persist. Perforation of the esophageal wall may cause death from septic mediastinitis. The pleura may be entered,—pyopneumothorax will result and demand immediate thoracotomy and gastrostomy. Aneurysm of the aorta may be ruptured. Patients with tuberculosis, decompensating cardiovascular lesions, or other advanced organic disease, may have serious complications precipitated by esophagoscopy.
Retrograde Esophagoscopy.—The first step is to get rid of the gastric secretions. There is always fluid in the stomach, and this keeps pouring out of the tube in a steady stream. Fold after fold is emptied of fluid. Once the stomach is empty, the search begins for the cardial opening. The best landmark is a mark with a dermal pencil on the skin at a point corresponding to the level of the hiatus esophageus. When it is desired to do a retrograde esophagoscopy and the gastrostomy is done for this special purpose, it is wise to have it very high. Once the cardia is located and the esophagus entered, the remainder of the work is very easy. Bouginage can be carried out from below the same as from above and may be of advantage in some cases. Strictural lumina are much more apt to be concentric as approached from below because there has been no distortion by pressure dilatation due to stagnation of the food operating through a long period of time. At retrograde esophagoscopy there seems to be no abdominal esophagus and no cardia. The esophagoscope encounters only the diaphragmatic pinchcock which seems to be at the top of the stomach like the puckering string at the top of a bag.
Retrograde esophagoscopy is sometimes useful for "stringing" the esophagus in cases in which the patient is unable to swallow a string because he is too young or because of an epithelial scaling over of the upper entrance of the stricture. In such cases the smallest size of the author's filiform bougies (Fig. 40) is inserted through the retrograde esophagoscope (Fig. 43) and insinuated upward through the stricture. When the tip reaches the pharynx coughing, choking and gagging are noticed. The filiform end is brought out the mouth sufficiently far to attach a silk braided cord which is then pulled down and out of the gastrostomic opening. The braided silk "string" must be long enough so that the oral and the abdominal ends can be tied together to make it "endless;" but before doing so the oral end should be drawn through nose where it will be less annoying than in the mouth. The purpose of the "string" is to pull up the retrograde bougies (Fig. 35)
Endoscopic ability cannot be bought with the instruments. As with all mechanical procedures, facility can be obtained only by educating the eye and the fingers in repeated exercise of a particular series of maneuvers. As with learning to play a musical instrument, a fundamental knowledge of technic, positions, and landmarks is necessary, after which only continued manual practice makes for proficiency. For instance, efficient use of forceps requires that they be so familiar to the grasp that their use is automatic. Endoscopy is a purely manual procedure, hence to know how is not enough: manual practice is necessary. Even in the handling of the electrical equipment, practice in quickly locating trouble is as essential as theoretic knowledge. There is no mystery about electric lighting. No source of illumination other than electricity is possible for endoscopy. Therefore a small amount of electrical knowledge, rendered practical by practice, is essential to maintain the simple lighting system in working order. It is an insult to the intelligence of the physician to say that he cannot master a simple problem of electric testing involving the locating of one or more of five possibilities. It is simply a matter of memorizing five tests. It is repeated for emphasis that a commercial current reduced by means of a rheostat should never be used as a source of current for endoscopy with any kind of instrument, because of the danger to the patient of a possible "grounding" of the circuit during the extensive moist contact of a metallic endoscopic tube in the mediastinum. The battery shown in Fig. 8 should be used. The most frequent cause of trouble is the mistake of over-illuminating the lamps.The lamp should not be over-illuminated to the dazzling whiteness usually used in flash lights. Excessive illumination alters the proper perception of the coloring of the mucosa, besides shortening the life of the lamps. The proper degree of brightness is obtained when, as the current is increased, the first change from yellow to white light is obtained. Never turn up the rheostat without watching the lamp.
Testing for Electric Defects.—These tests should be made beforehand; not when about to commence introduction.
If the first lamp lights up properly, use it with its light-carrier to test out the other cords.
If the lamp lights up, but flickers, locate the trouble before attempting to do an endoscopy. If shaking the carrier cord-terminal produces flickering there may be a film of corrosion on the central contact of the light carrier that goes into the carrier cord-terminal.
If the lamp fails to show a light, the trouble may be in one of five places which should be tested for in the following order and manner. 1. The lamp may not be firmly screwed into the light-carrier. Withdraw the light-carrier and try screwing it in, though not too strongly, lest the central wire terminal in the lamp be bent over. 2. The light-carrier may be defective. 3. The cord may be defective or its terminals not tight in the binding posts. If screwing down the thumb nuts does not produce a light, test the light-carrier with lamp on the other cords. Reserve cords in each pair of binding posts are for use instead of the defective cords. The two sets of cords from one pair of binding posts should not be used simultaneously. 4. The lamp may be defective. Try another lamp. 5. The battery may be defective. Take a cord and light-carrier with lamp that lights up, detaching the cord-terminals at the binding posts, and attach the terminals to the binding posts of the battery to be tested.
Efficient use of forcepsrequires previous practice in handling of the forceps until it has become as natural and free from thought as the use of knife and fork. Indeed the coordinate use of the bronchoscopic tube-mouth and the forceps very much resembles the use of knife and fork. Yet only too often a practitioner will telegraph for a bronchoscope and forceps, and without any practice start in to remove an entangled or impacted foreign body from the tiny bronchi of a child. Failure and mortality are almost inevitable. A few hundred hours spent in working out, on a bit of rubber tubing, the various mechanical problems given in the section on that subject will save lives and render easily successful many removals that would otherwise be impossible.
It is often difficult for the beginner to judge the distance the forceps have been inserted into the tube. This difficulty is readily solved if upon inserting the forceps slowly into the tube, he observes that as the blades pass the light they become brightly illuminated. By thislight reflexit is known, therefore, that the forceps blades are at the tube-mouth, and distance from this point can be readily gauged. Excellent practice may be had by picking up through the bronchoscope or esophagoscope black threads from a white background, then white threads from a black background, and finally white threads on a white background and black threads on a black background. This should be done first with the 9 mm. bronchoscope. It is to be remembered that the majority of foreign body accidents occur in children, with whom small tubes must be used; therefore, practice work, after say the first 100 hours, should be done with the 5 mm. bronchoscope and corresponding forceps rather than adult size tubes, so that the operator will be accustomed to work through a small calibre tube when the actual case presents itself.
[120]Cadaver Practice.—The fundamental principles of peroral endoscopy are best taught on the cadaver. It is necessary that a specially prepared subject be had, in order to obtain the required degree of flexibility. Injecting fluid of the following formula worked out by Prof. J. Parsons Schaeffer for the Bronchoscopic Clinic courses, has proved very satisfactory: Sodium carbonate—1 1/2 lbs. White arsenic—2 1/2 lbs. Potassium nitrate—3 lbs. Water—5 gal.
Boil until arsenic is dissolved. When cold add:Carbolic acid 1500 c.c.Glycerin 1250 c.c.Alcohol (95%) 1250 c.c.
For each body use about 3 gal. of fluid.
The method of introduction of the endoscopic tube, and its various positions can be demonstrated and repeatedly practiced on the cadaver until a perfected technic is developed in both the operator and assistant who holds the head, and the one who passes the instruments to the operator. In no other manner can the landmarks and endoscopic anatomy be studied so thoroughly and practically, and in no other way can the pupil be taught to avoid killing his patient. The danger-points in esophagoscopy are not demonstrable on the living without actually incurring mortality. Laryngeal growths may be simulated, foreign body problems created and their mechanical difficulties solved and practice work with the forceps and tube perfected.
Practice on the Rubber-tube Manikin.—This must be carried out in two ways. 1. General practice with all sorts of objects for the education of the eye and the fingers. 2. Before undertaking a foreign body case, practice should be had with a duplicate of the foreign body.
It is not possible to have a cadaver for daily practice, but fortunately the eye and fingers may be trained quite as effectually by simulating foreign body conditions in a small red rubber tube and solving these mechanical problems with the bronchoscope and forceps. The tubing may be placed on the desk and held by a small vise (Fig. 72) so that at odd moments during the day or evening the fascinating work may be picked up and put aside without loss of time. Complicated rubber manikins are of no value in the practice of introduction, and foreign body problems can be equally well studied in a piece of rubber tubing about 10 inches long. No endoscopist has enough practice on the living subject, because the cases are too infrequent and furthermore the tube is inserted for too short a space of time. Practice on the rubber tube trains the eye to recognize objects and to gauge distance; it develops the tactile sense so that a knowledge of the character of the object grasped or the nature of the tissues palpated may be acquired. Before attempting the removal of a particular foreign body from a living patient, the anticipated problem should be simulated with a duplicate of the foreign body in a rubber tube. In this way the endoscopist may precede each case with a practical experience equivalent to any number of cases of precisely the same kind of foreign body. If the object cannot be removed from the rubber tube without violence, it is obvious that no attempt should be made on the patient until further practice has shown a definite method of harmless removal. During practice work the value of the beveled lip of the bronchoscope and esophagoscope in solving mechanical problems will be evidenced. With it alone, a foreign body may be turned into favorable positions for extraction, and folds can always be held out of the way. Sufficient combined practice with the bronchoscope and the forceps enable the endoscopist easily to do things that at first seem impossible. It is to be remembered that lateral motion of the long slender tube-forceps cannot be controlled accurately by the handle, this is obtained by a change in position of the endoscopic tube, the object being so centered that it is grasped without side motion of the forceps. When necessary, the distal end of the forceps may be pushed laterally by the manipulation of the bronchoscope.
[FIG. 72.—A simple manikin. The weight of the small vise serves to steady the rubber tubing. By the use of tubing of the size of the invaded bronchus and a duplicate of the foreign body, any mechanical problem can he simulated for solution or for practice, study of all possible presentations, etc.]
Practice on the Dog.—Having mastered the technic of introduction on the cadaver and trained the eye and fingers by practice work on the rubber tube, experience should be had in the living lower air and food passages with their pulsatory, respiratory, bechic and deglutitory movements, and ever-present secretions. It is not only inhuman but impossible to obtain this experience on children. Fortunately the dog offers a most ready subject and need in no way be harmed nor pained by this invaluable and life-saving practice. A small dog the size of a terrier (say 6 to 10 pounds in weight) should be chosen and anesthetized by the hypodermic injection of morphin sulphate in dosage of approximately one-sixth of a grain per pound of body weight, given about 45 minutes before the time of practice. Dogs stand large doses of morphin without apparent ill effect, so that repeated injection may be given in smaller dosage until the desired degree of relaxation results. The first effect is vomiting which gives an empty stomach for esophagoscopy and gastroscopy. Vomiting is soon followed by relaxation and stupor. The dog is normal and hungry in a few hours. Dosage must be governed in the clog as in the human being by the susceptibility to the drug and by the temperament of the animal. Other forms of anesthesia have been tried in my teaching, and none has proven so safe and satisfactory. Phonation may be prevented during esophagoscopy by preventing approximation of the cords, through inserting a silk-woven cathether in the trachea. The larynx and trachea may be painted with cocain solution if it is found necessary for bronchoscopy. A very comfortable and safe mouth gag is shown in Fig. 73. Great gentleness should be exercised, and no force should be used, for none is required in endoscopic work; and the endoscopist will lose much of the value of his dog practice if he fails to regard the dog as a child. He should remember he is not learning how to do endoscopy on the dog; but learning on the dog how safely to do bronchoscopy on a human being. The degree of resistance during introduction can be gauged and the color of the mucosa studied, while that interesting phenomenon, the dilatation and lengthening of the bronchi during inspiration and their contraction and shortening during expiration, is readily observed and always forms subject for thought in its possible connection with pathological conditions. Foreign body problems are now to be solved under these living conditions, and it is my feeling that no one should attempt the removal of a foreign body from the bronchus of a child until he has removed at least 100 foreign bodies from the dog without harming the animal. Dogs have the faculty of easily ridding their air-passages of foreign objects, so that one need not be alarmed if a foreign body is lost during practice removal. It is to be remembered that dogs swallow very large objects with apparent ease. The dog's esophagus is relatively much larger than that of human beings. Therefore a small dog (of six to eight pounds' weight) must be used for esophagoscopic practice, if practice is to be had with objects of the size usually encountered in human beings. The bronchi of a dog of this weight will be about the size of those of a child.
[FIG. 73.—Author's mouth gag for use on the dog. The thumb-nut serves to prevent an uncomfortable degree of expansion of the gag. A bandage may be wound around the dog's jaws to prevent undue spread of the jaws.]
Endoscopy on the Human Being.—Dog work offers but little practice in laryngoscopy. Because of the slight angle at which the dog's head joins his spine, the larynx is in a direct line with the open mouth; hence little displacement of the anterior cervical tissues is necessary. Moreover the interior of the larynx of the dog is quite different from that of the human larynx. The technic of laryngoscopy in the human subject is best perfected by a routine direct examination of the larynx of anesthetized patients after such an operation as, for instance, tonsillectomy, to see that the larynx and laryngopharynx are free of clots. To perform a bronchoscopy or esophagoscopy under these conditions would be reprehensible; but direct laryngoscopy for the seeking and removal of clots serves a useful purpose as a preventative of pulmonary abscess and similar complications.* Diagnosis of laryngeal conditions in young children is possible only by direct laryngoscopy and is neglected in almost all of the cases. No anesthesia, general or local, is required. Much clinical material is neglected. All cases of dyspnea or dysphagia should be studied endoscopically if the cause of the condition cannot be definitely found and treated by other means. Invaluable practice in esophagoscopy is found in the treatment of strictures of the esophagus by weekly or biweekly esophagoscopic bouginage.
* Dr. William Frederick Moore, of the Bronchoscopic Clinic, has recently collected statistics of 202 cases of post-tonsillectomic pulmonary abscess that point strongly to aspiration of infected clots and other infective materials as the most frequent etiologic mechanism (Moore, W. F., Pulmonary Abscess. Journ. Am. Med. Assn., April 29, 1922, Vol. 78, pp. 1279-1281).
In acquiring skill as an endoscopist the following paraphrased aphorisms afford food for thought.
Educate your eye and your fingers.Be sure you are right, but not too sure.Follow your judgment, never your impulse.Cry over spilled milk enough to memorize how you spilled it.Let your mistakes worry you enough to prevent repetition.Let your left hand know what your right hand does and howto do it.Nature helps, but she is no more interested in the survival of yourpatient than in the survival of the attacking pathogenic bacteria.
The air and food passages may be invaded by any foreign substance of solid, liquid or gaseous nature, from the animal, vegetable, or mineral kingdoms. Its origin may be from within the body (blood, pus, secretion, broncholiths, sequestra, worms); introduced from without by way of the natural passages (aspirated or swallowed objects); or it may enter by penetration (bullet, dart, drainage tube from the neck).
Prophylaxis.—If one put into his mouth nothing but food, foreign body accidents would be rare. The habit of holding tacks, pins and whatnot in the mouth is quite universal and deplorable. Children are prone to follow the bad example of their elders. No small objects such as safety pins, buttons, and coins should be left within a baby's reach; children should be watched and taught not to place things in their mouths. Mothers should be specially cautioned not to give nuts or nut candy of any kind to a child whose powers of mastication are imperfect, because the molar teeth are not erupted. It might be made a dictum that: "No child under 3 years of age should be allowed to eat nuts, unless ground finely as in peanut butter." Digital efforts at removal of foreign bodies frequently force the object downward, or may hook it forward into the larynx, whereas if not meddled with digitally the intruder might be spat out. Before general anesthesia the mouth should be searched for loose teeth, removable dentures, etc., and all unconscious individuals should be likewise examined. When working in the mouth precautions should be taken against the possible inhalation or swallowing of loose objects or instruments.
[126] Objects that have lodged in the esophagus, larynx, trachea, or bronchi should be endoscopically removed.
Foreign Bodies in the Insane.—Foreign bodies may be introduced voluntarily and in great numbers by the insane. Hysterical individuals may assert the presence of a foreign body, or may even volitionally swallow or aspirate objects. It is a mistake to do a bronchoscopy in order to cure by suggestion the delusion of foreign body presence. Such "cures" are ephemeral.
Foreign Bodies in the Stomach.—Gastroscopy is indicated in cases of a foreign body that refuses to pass after a month or two. Foreign bodies in very large numbers in the stomach, as in the insane, may be removed by gastrostomy.
The symptomatology of foreign bodiesmay be epitomized as given below; but it must be kept in mind, that certain symptoms may not be manifest immediately after intrusion, and others may persist for a time after the passage, removal, or expulsion of a foreign body.
1. There are no absolutely diagnostic symptoms. 2. Dysphagia, however, is the most constant complaint, varying with the size of the foreign body, and the degree of inflammatory or spasmodic reaction produced. 3. Pain may be caused by penetration of a sharp foreign body, by inflammation secondary thereto, by impaction of a large object, or by spasmodic closure of the hiatus esophageus. 4. The subjective sensation of foreign body is usually present, but cannot be relied upon as assuring the presence of a foreign body for this sensation often remains for a time after the passage onward of the intruder. 5. All of these symptoms may exist, often in the most intense degree, as the result of previous violent attempts at removal; and the foreign body may or may not be present.
1. Initial laryngeal spasm followed by wheezing respiration, croupy cough, and varying degrees of impairment of phonation. 2. Pain may be a symptom. If so, it is usually located in the laryngeal region, though in some cases it is referred to the ears. 3. The larynx may tolerate a thin, flat, foreign body for a relatively long period of time, a month or more; but the development of increasing dyspnea renders early removal imperative in the majority of cases.
1. Tracheal foreign bodies are usually movable and their movements can usually be felt by the patient. 2. Cough is usually present at once, may disappear for a time and recur, or may be continuous, and may be so violent as to induce vomiting. In recent cases fixed foreign bodies cause little cough; shifting foreign bodies cause violent coughing. 3. Sudden shutting off of the expiratory blast and the phonation during paroxysmal cough is almost pathognomonic of a movable tracheal foreign body. 4. Dyspnea is usually present in tracheal foreign bodies, and is due to the bulk of the foreign body plus the subglottic swelling caused by the traumatism of the shiftings of the intruder. 5. Dyspnea is usually absent in bronchial foreign bodies. 6. The respiratory rate is increased only if a considerable portion of lung is out of function, by the obstruction of a main bronchus, or if inflammatory sequelae are extensive. 7. The asthmatoid wheeze is usually present in tracheal foreign bodies, and is often louder and of lower pitch than the asthmatoid wheeze of bronchial foreign bodies. It is heard at the open mouth, not at the chest wall; and prolonged expiration as though to rid the lungs of all residual air, may be necessary to elicit it. 8. Pain is not a common symptom, but may occur and be accurately localized by the patient, in case of either tracheal or bronchial foreign body.
1. Initial laryngeal spasm is almost invariably present with foreign bodies of organic nature, such as nut kernels, peas, beans, maize, etc. 2. A diffuse purulent laryngo-tracheo-bronchitis develops within 24 hours in children under 2 years. 3. Fever, toxemia, cyanosis, dyspnea and paroxysmal cough are promptly shown. 4. The child is unable to cough up the thick mucilaginous pus through the swollen larynx and may "drown in its own secretions" unless the offender be removed. 5. "Drowned lung," that is to say natural passages idled with pus and secretions, rapidly forms. 6. Pulmonary abscess develops sooner than in case of mineral foreign bodies. 7. The older the child the less severe the reaction.
1. The time of inhalation of a foreign body may be unknown or forgotten. 2. Cough and purulent expectoration ultimately result, although there may be a delusive protracted symptomless interval. [130] 3. Periodic attacks of fever, with chills and sweats, and followed by increased coughing and the expulsion of a large amount of purulent, usually more or less foul material, are so nearly diagnostic of foreign body as to call for exclusion of this probability with the utmost care. 4. Emaciation, clubbing of the fingers and toes, night sweats, hemoptysis, in fact all of the symptoms of tuberculosis are in most cases simulated with exactitude, even to the gain in weight by an out-door regime. 5. Tubercle bacilli have never been found, in the cases at the Bronchoscopic Clinic, associated with foreign body in the bronchus.* In cases of prolonged sojourn this has been the only element lacking in a complete clinical picture of advanced tuberculosis. One point of difference was the almost invariably rapid recovery after removal of the foreign body. The statement in all of the text-books, that foreign body is followed by phthisis pulmonalis is a relic of the days when the bacillary origin of true tuberculosis was unknown, hence the foreign-body phthisis pulmonalis, or pseudo tuberculosis, was confused with the true pulmonary tuberculosis of bacillary origin. 6. The subjective sensation of pain may allow the patient accurately to localize a foreign body. 7. Foreign bodies of metallic or organic nature may cause their peculiar taste in the sputum. 8. Offensive odored sputum should always suggest bronchial foreign body; but absence of sputum, odorous or not, should not exclude foreign body. 9. Sudden complete obstruction of one main bronchus does not cause noticeable dyspnea provided its fellow is functionating. [131] 10. Complete obstruction of a bronchus is followed by rapid onset of symptoms. 11. The physical signs usually show limitation of expansion on the affected side, impairment of percussion, and lessened trans-mission or absence of breath-sounds distal to the foreign body.
* The exceptional case has at last been encountered. A boy with a tack in the bronchus was found to have pulmonary tuberculosis.
Foreign body in the stomach ordinarily produces no symptoms. The roentgenogram and the fluoroscopic study with an opaque mixture are the chief means of diagnosis.
The questions arising are: I. Is a foreign body present? 2. Where is it located? 3. Is a peroral endoscopic procedure indicated? 4. Are there any contraindications to endoscopy?
In order to answer these questions the definite routine given below isfollowed unvaryingly in the Bronchoscopic Clinic.1. History.2. Complete physical examination, including mirror laryngoscopy.3. Roentgenologic study.4. Endoscopy.
The history should note the date of, and should delve into the details of the accident; special note being made of the occurrence of laryngeal spasm, wheezing respiration heard by the patient or others (asthmatoid wheeze), fever, cough, pain, dyspnea, dysphagia, odynphagia, regurgitation, etc. The amount, character and odor of sputum are important. Increasing amounts of purulent, foul-odored, sometimes blood-tinged sputum strongly suggest prolonged bronchial foreign body sojourn. The mode of onset of the persisting symptoms, whether immediately following the supposed accident or delayed in their occurrence, is to be noted. Do attacks of sudden dyspnea and cyanosis occur? What has been the previous treatment and what attempts at removal have been made? The nature of the foreign body is to be determined, and if possible a duplicate thereof obtained.
General physical examinationshould be complete including inspection of the eyes, ears, nose, pharynx, and mirror inspection of the naso-pharynx and larynx. Special attention is paid to the chest for the localization of the object. In order to discover conditions rendering endoscopy unusually hazardous, all parts of the body are to be examined. Aneurysm of the aorta, excessive blood pressure, serious cardiac and renal conditions, the presence of a hernia and the existence of central nervous disease, as tabes dorsalis, should be at least known before attempting any endoscopic procedure. Dysphagia might result from the pressure of an unknown aneurysm, the symptoms being attributed to a foreign body, and aortic aneurysm is a definite contraindication to esophagoscopy unless there be foreign body present also. There is no absolute contraindication to the endoscopic removal of a foreign body, though many conditions may render it wise to post-pone endoscopy. Laryngeal crises of tabes might, because of their sudden onset, be thought due to foreign body.
There are no constant physical signs associated with uncomplicated impaction of a foreign body in the esophagus. Should perforation of the cervical esophagus occur, subcutaneous emphysema, and perhaps cellulitis, may be found; while a perforation of the thoracic region causing mediastinitis is manifested by toxemia, fever, and rapid sinking. Perforation of the pleura, with the development of pyopneumothorax, is manifested by the usual signs. It is to be emphasized that blind bouginage has no place in the diagnosis of any esophageal condition. The roentgenologist will give the information we desire without danger to the patient, and with far greater accuracy.
Laryngeally lodged foreign bodies produce a wheezing respiration, the quality of which is peculiar to the larynx and is readily localized to this organ. If swelling or the size of the foreign body be sufficient to produce dyspnea, inspiratory indrawing of the suprasternal notch, supraclavicular fossae, costal interspaces and lower sternum will be present. Cyanosis is only an accompaniment of suddenly produced dyspnea; the facies will therefore usually be anxious and pale, unless the patient is seen immediately after the aspiration of the foreign body. If labored breathing has been prolonged, and exhaustion threatened, the heart's action will be irregular and weak. The foreign body can be seen with the mirror, but a roentgenograph must nevertheless be made, for the object may be of another nature than was first thought. The roentgenograph will show its position, and from this knowledge the plan of removal can be formulated. For example, a straight pin may be so placed in the larynx that only a portion of its shaft will be visible, the roentgenogram will tell where the head and point are located, and which of these will be the more readily disengaged. (See Chapter on Mechanical Problems.)
If fixed in the trachea the only objective sign of foreign body may be a wheezing respiration, the site of which may be localized with the stethoscope, by the intensity of the sound. Movable foreign bodies may produce a palpatory thrill, and the rumble and sudden stop can be heard with the stethoscope and often with the naked ear. The lungs will show equal aeration, but there may be marked dyspnea without the indrawing of the fossae, if the object be of large size and located below the manubrium.
To the peculiar sound of the sudden subglottic, expiratory or bechic arrest of the foreign body the author has given the name "audible slap;" when felt by the thumb on the trachea he calls it the "palpatory thud." These signs can be produced by no condition other than the arrest of some substance by the subglottic taper. Once heard and felt they are unmistakable.
In most cases there will be limitation of expansion on the invaded side, even though the foreign body is of such a shape as to cause no bronchial obstruction. It has been noted frequently in conjunction with the presence of such objects as a common straight pin in a small branch bronchus. This peculiar phenomenon was first noted by Thomas McCrae in one of the author's cases and has since been abundantly corroborated by McCrae and others as one of the most constant physical signs.
To understand the peculiar physical findings in these cases it is necessary to remember that the bronchi are not tubes of constant caliber; there occurs a dilatation during inspiration, and a contraction of the lumen during expiration; furthermore, the lumen may be narrowed by swollen mucosa if the foreign body be of an irritant nature. The signs vary with the degree of obstruction of the bronchus, and with the consequent degree of interference with aeration and drainage of the subjacent portion of the lung. We have three definite types which show practically constant signs in the earlier stages of foreign body invasion.
1. Complete bronchial occlusion.2. Obstruction complete during expiration, but allowing the passageof air during the bronchial dilatation incident to inspiration,constituting an expiratory valve-like obstruction.3. Partial bronchial obstruction, allowing to-and-fro passage ofair.
1.Complete bronchial obstructionis manifested by limitation of expansion, markedly impaired percussion note, particularly at the base, absence of breath-sounds, and rales on the invaded side. An atelectasis here exists; the air imprisoned in the lung is soon absorbed, and secretions rapidly accumulate. On the free side a compensatory emphysema is present.
2.Expiratory Valve-like Obstruction.—The obstructed side shows marked limitation of expansion. Percussion is of a tympanitic character. The duration of the vibrations may be shortened giving a muffled tympany. Various grades and degrees of tympany may be noted. Breath sounds are markedly diminished or absent. No rales are heard on the invaded side, although rales of all types may be present on the free side. In some cases it is possible to hear a short inspiratory sound. Vocal resonance and fremitus are but little altered. The heart will be found displaced somewhat to the opposite side. These signs are explained by the passage of some air past the foreign body during inspiration with its trapping during expiration, so that there is air under pressure constantly maintained in the obstructed area. This type of obstruction is most frequently observed when the foreign body is of an organic nature such as nut kernels, beans, corn, seed, etc. The localized swelling about the irritating foreign body completes the expiratory obstruction. It may also be present with any foreign body whose size and shape are such as to occlude the lumen of the bronchus during its contracted expiratory phase. It was present in cases of pebbles, cylindrical metallic objects, thick tough balls of secretion etcetera. The valvular action is here produced most often by a change in the size of the valve seat and not by a movement of the foreign body plug. In other cases I have found at bronchoscopy, a regular ball-valve mechanism. Pneumothorax is the only pathologic condition associated with signs similar to those of expiratory, valve-like bronchial obstruction by a foreign body.
3.Partial bronchial obstructionby an object such as a nail allows air to pass to and fro with some degree of retardation, and impairs the drainage of the subjacent lung. Limitation of expansion will be found on the invaded side. The area below the foreign body will give an impaired percussion note. Breath-sounds are diminished in the area of dullness, and vocal resonance and fremitus are impaired. Rales are of great diagnostic import; the passage of air past the foreign body is accompanied by blowing, harsh breathing, and snoring; snapping rales are heard usually with greatest intensity posteriorly over the site of the foreign body (usually about the scapular angle).
A knowledge of the topographical lung anatomy, the bronchial tree, and of endoscopic pathology* should enable the examiner of the chest to locate very accurately a bronchial foreign body by physical signs alone, for all the significant signs occur distal to the foreign body lodgment.
* Jackson, Chevalier. Pathology of Foreign Bodies in the Air and FoodPassages. Mutter Lecture, 1918. Surgery, Gynecology and Obstetrics,March, 1919. Also, by the same author, Mechanism of the Physical Signsof Foreign Bodies in the Lungs. Proceedings of the College ofPhysicians, Philadelphia, 1922.
The asthmatoid wheezehas been found by the author a valuable confirmatory sign of bronchial foreign body. It is a wheezing heard by placing the observer's ear at the open mouth of the patient (not at the chest wall) during a prolonged forced expiration. Thomas McCrae elicits this sign by placing the stethoscope bell at the patient's open mouth. The quality of the sound is dryer than that heard in asthma and the wheeze is clearest after all secretion has been removed by coughing. The mechanism of production is, probably, the passage of air by a foreign body which narrows the lumen of a large bronchus. As the foreign body works downward the wheeze lessens. The wheeze is often so loud as to be heard at some distance from the patient. It is of greatest value in the diagnosis of non-roentgenopaque foreign body but its absence in no way negates foreign body. Its presence or absence should be recorded in every case.
Prolonged bronchial obstructionby foreign body is followed by bronchiectasis and lung abscess usually in a lower lobe. The symptoms may with exactitude simulate tuberculosis, but this disease should be readily excluded by the basal, unilateral site of the lesion, absence of tubercle bacilli in the sputum, and roentgenographic study. Chest examination in the foreign body cases reveals limitation of expansion, often some retraction, flat percussion note, and greatly diminished or absent breath-sounds over the site of the pulmonary lesion. Rales vary with the amount of secretion present. These physical signs suggest empyema; and rib resection had been done before admission in a number of cases only to find the pleura normal.
Roentgenography.—All cases of chest disease should have the benefit of a roentgenologic study to exclude bronchial foreign body as an etiological factor. Negative opinions should never be based upon any plates except the best that the wonderful modern development of the art and science of roentgenology can produce. In doubtful cases, the negative opinion should not be conclusive until a roentgenologist of long experience in chest work, and especially in foreign body cases, has been called in consultation. Even then there will be an occasional case calling for diagnostic bronchoscopy. Antero-posterior and lateral roentgenograms should always be made. In an antero-posterior film a flat foreign body lying in the lateral body plane might be invisible in the shadow of the spine, heart, and great vessels; but would be revealed in the lateral view because of the greater edgewise density of the intruder and the absence of other confusing shadows. Fluoroscopic examination will often discover the best angle from which to make a plate; but foreign bodies casting a very faint shadow on a plate may be totally invisible on the fluoroscopic screen. The value of a roentgenogram after the removal of a foreign body cannot be too strongly emphasized. It is evidence of removal and will exclude the presence of a second intruder which might have been overlooked in the first study.
Fluoroscopic study of the swallowing function with barium mixture, or a barium-filled capsule, will give the location of a nonroentgenopaque object (such as bone, meat, etc.) in the esophagus. If a flat or disc-shaped object located in the cervical region is seen to be lying in the lateral body plane, it will be found to be in the esophagus, for it assumed that position by passing down flatwise behind the larynx. If, however, the object is seen to be in the sagittal plane it must lie in the trachea. This position was necessary for it to pass through the glottic chink, and can be maintained because of the yielding of the posterior membranous wall of the trachea.
The roentgenray signs in expiratory valve-like obstruction of a bronchus are those ofan acute obstructive emphysema(Fig. 74), namely, 1. Greater transparency on the obstructed side (Iglauer). 2. Displacement of the heart to the free side (Iglauer). 3. Depression and flattening of the dome of the diaphragm on the invaded side (Iglauer). 4. Limitation of the diaphragmatic excursion on the obstructed side (Manges).
It is very important to note that, as discovered by Manges, the 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 obstructionshows 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 mappingis 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.)]
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.
Initial symptomsare 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 signsvary 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 roentgenrayis 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.