Bronchoscopy and Esophagoscopy Part 9

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 obstruction_ shows a density over the whole area the aeration and drainage of which has been cut off (Fig. 75).

Pulmonary abscess formation and "drowned lung" (acc.u.mulated secretion in the bronchi and bronchioli) are shown by the definite shadows produced (Fig. 76).

[140] Dense and metallic objects will usually be readily seen in the roentgenograms and fluoroscope, but many foreign bodies are of a nature which will produce no shadow; the roentgenologist should, therefore, be prepared to interpret the pulmonary pathology, and should not dismiss the case as negative for foreign body because one is not seen. Even metallic objects are in rare cases exceedingly difficult to demonstrate.

[FIG. 75.--Radiograph showing pathology resulting from complete obstruction of a bronchus with atelectasis and drowned lung resulting.

Foot of an alarm clock in left bronchus of 4 year old child. Present 25 days. Plate made by Johnston and Grier.]

_Positive Films of the Tracheo-bronchial Tree as an Aid to Localization_.--In order to localize the bronchus invaded by a small foreign body the positive film is laid over the negative of the patient showing the foreign body. The shadow of the foreign body will then show through the overlying positive film. These positive films are made in twelve sizes, and the size selected should be that corresponding to the size of the patient as shown by the roentgenograph. The dome of the diaphragm and the dome of the pleura are taken as visceral landmarks for placing the positive films which have lines indicating these levels. If the shadow of the foreign body be faint it may be strengthened by an ink mark on the uncoated side of the plate.

[FIG. 76.--Partial bronchial obstruction for long period of time Pathology, bronchiectasis and pulmonary abscess, produced by the presence for 4 years of a nail in the left lung of a boy of 10 years]

_Bronchial mapping_ is readily accomplished by the author's method of endobronchial insufflation of a roentgenopaque inert powder such as bis.m.u.th 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 bis.m.u.th subnitrate) into the lung of the patient. Plate made by David R. Bowen. (Ill.u.s.tration, strengthened for reproduction, is from author's article in American Journal of Roentgenology, Oct., 1918.)]

ERRORS TO AVOID IN SUSPECTED FOREIGN BODY CASES

1. Do not reach for the foreign body with the fingers, lest the foreign body be thereby pushed into the larynx, or the larynx be thus traumatized.

2. Do not hold up the patient by the heels, lest a tracheally lodged foreign body be dislodged and asphyxiate the patient by becoming jammed in the glottis.

[143] 3. Do not fail to have a roentgenogram made, if possible, whether the foreign body in question is of a kind dense to the ray or not.

4. Do not fail to search endoscopically for a foreign body in all cases of doubt.

5. Do not pa.s.s blindly an esophageal bougie, probang, or other instrument.

6. Do not tell the patient he has no foreign body until after roentgenray examination, physical examination, indirect examination, and endoscopy have all proven negative.

SUMMARY

SYMPTOMATOLOGY AND DIAGNOSIS OF FOREIGN BODIES IN THE AIR AND FOOD Pa.s.sAGES

_Initial symptoms_ are choking, gagging, coughing, and wheezing, often followed by a symptomless interval. The foreign body may be in the larynx, trachea, bronchi, nasal chambers, nasopharynx, fauces, tonsil, pharynx, hypopharynx, esophagus, stomach, intestinal ca.n.a.l, or may have been pa.s.sed 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: Hoa.r.s.eness, 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-pa.s.sages.

7. Laryngeal symptoms may persist from the trauma of a foreign body that has pa.s.sed on into the deeper air or food pa.s.sages or that has been coughed or spat out.

8. Laryngeal symptoms (hoa.r.s.eness, 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, hoa.r.s.eness, 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 sh.e.l.ls and inorganic bodies after months or years produce changes which cause chills, fever, sweats, emaciation, clubbed fingers, incurved nails, cough, foul expectoration, hemoptysis, in fact, all the symptoms of chronic pulmonary sepsis, abscess, and bronchiectasis. These symptoms and some of the physical signs may suggest pulmonary tuberculosis, but the apices are normal and bacilli are absent from the sputum. Every acute or chronic chest case calls for the exclusion of foreign body.

_The physical signs_ vary with conditions present in different cases and at different times in the same case. Secretions, normal and pathologic, may shift from one location to another; the foreign body may change its position admitting more, less, or no air, or it may shift to a new location in the same lung or even in the other lung. A recently aspirated pin may produce no signs at all. The signs of diagnostic importance are chiefly those of partial or complete bronchial obstruction, though a non-obstructive foreign body, a pin for instance, may cause limited expansion (McCrae) or, rarely, a peculiar rale or a peculiar auscultatory sound. The most nearly characteristic physical signs are: (1) Limited expansion; (2) decreased vocal fremitus; (3) impaired percussion note; (4) diminished intensity of the breath-sounds distal to the foreign body. Complete obstruction of a bronchus followed by drowned lung adds absence of vocal resonance and vocal fremitus, thus often leading to an erroneous diagnosis of empyema. Varying grades of tympany are obtained over areas of obstructive or compensatory emphysema. With complete obstruction there may be tympany from the collapsed lung for a time.

Rales in case of complete obstruction are usually most intense on the uninvaded side. In partial obstruction they are most often found on the invaded side distal to the foreign body, especially posteriorly, and are most intense at the site corresponding to that of the foreign body. A foreign body at the bifurcation of the trachea may give signs in both lungs. Early in a foreign body case, diminished expansion of one side, with dulness, may suggest pneumonia in the affected side; but absence of, or decreased, vocal resonance, and absence of typical tubular breathing should soon exclude this diagnosis. Bronchial obstruction in pneumonia is exceedingly rare.

Memorize these signs suggestive of foreign body: 1. Expansion--diminished.

2. Percussion note--impaired (except in obstructive emphysema).

3. Vocal fremitus--diminished.

4. Breath sounds--diminished.

The foregoing is only for memorizing, and must be considered in the light of the following fundamental note by Prof. McCrae "There is no one description of physical signs which covers all cases. If the student will remember that complete obstruction of a bronchus leads to a shutting off of this area, there should be little difficulty in understanding the signs present. The diagnosis of empyema may be made, but the outline of the area of dulness, the fact that there is no shifting dulness, and the greater resistance which is present in empyema nearly always clear up any difficulty promptly. The absence of the frequent change in the voice sounds, so significant in an early small empyema, is of value. A large empyema should give no difficulty.

If difficulty remains the use of the needle should be sufficient. In thickened pleura vocal fremitus is not entirely absent, and the breath-sounds can usually be heard, even if diminished. In case of partial obstruction of a bronchus, it is evident that air will still be present, hence the dulness may be only slight. The presence of air and secretion will probably result in the breath-sounds being somewhat harsh, and will cause a great variety of rales, princ.i.p.ally coa.r.s.e, and many of them bubbling. Difficulty may be caused by signs in the other lung or in a lobe other than the one affected by the foreign body. If it is remembered that these signs are likely to be only on auscultation, and to consist largely in the presence of rales, while the signs in the area supplied by the affected bronchus will include those on inspection, palpation, and percussion, there should be little difficulty."

_The roentgenray_ is the most valuable diagnostic means; but careful notation of physical signs by an expert should be made in all cases preferably without knowledge of ray findings. Expert ray work will show all metallic foreign bodies and many of less density, such as teeth, bones, sh.e.l.ls, b.u.t.tons, 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 s.p.a.ces" 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 un.o.bstructed 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-pa.s.sages may be present due to: (1) Overflow of the secretions on attempts to swallow through the obstructed esophagus; (2) erosion of the foreign body through from the esophagus into the trachea; or (3) trauma inflicted on the larynx during attempts at removal, digital or instrumental, the foreign body still being present or not.

Diagnosis is by the roentgenray, first without, then, if necessary, with a capsule filled with an opaque mixture. Flat objects, like coins, always lie with their greatest diameter in the coronal plane of the body, when in the esophagus; in the sagittal plane, when in the trachea or larynx. Lateral, anteroposterior, and sometimes also quartering roentgenograms are necessary. One taken laterally, low down on the neck but clear of the shoulder, will often show a bone or other semiopaque object invisible in the anteroposterior exposure.

[149] CHAPTER XIII--FOREIGN BODIES IN THE LARYNX AND TRACHEOBRONCHIAL TREE

The protective reflexes preventing the entrance of foreign bodies into the lower air pa.s.sages 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 pa.s.sages 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.