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.
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.
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.
* 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.]
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.
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.
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.
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.
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.
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.
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.