[FIG. 72.—A simple manikin. The weight of the small vise serves to steady the rubber tubing. By the use of tubing of the size of the invaded bronchus and a duplicate of the foreign body, any mechanical problem can he simulated for solution or for practice, study of all possible presentations, etc.]

Practice on the Dog.—Having mastered the technic of introduction on the cadaver and trained the eye and fingers by practice work on the rubber tube, experience should be had in the living lower air and food passages with their pulsatory, respiratory, bechic and deglutitory movements, and ever-present secretions. It is not only inhuman but impossible to obtain this experience on children. Fortunately the dog offers a most ready subject and need in no way be harmed nor pained by this invaluable and life-saving practice. A small dog the size of a terrier (say 6 to 10 pounds in weight) should be chosen and anesthetized by the hypodermic injection of morphin sulphate in dosage of approximately one-sixth of a grain per pound of body weight, given about 45 minutes before the time of practice. Dogs stand large doses of morphin without apparent ill effect, so that repeated injection may be given in smaller dosage until the desired degree of relaxation results. The first effect is vomiting which gives an empty stomach for esophagoscopy and gastroscopy. Vomiting is soon followed by relaxation and stupor. The dog is normal and hungry in a few hours. Dosage must be governed in the clog as in the human being by the susceptibility to the drug and by the temperament of the animal. Other forms of anesthesia have been tried in my teaching, and none has proven so safe and satisfactory. Phonation may be prevented during esophagoscopy by preventing approximation of the cords, through inserting a silk-woven cathether in the trachea. The larynx and trachea may be painted with cocain solution if it is found necessary for bronchoscopy. A very comfortable and safe mouth gag is shown in Fig. 73. Great gentleness should be exercised, and no force should be used, for none is required in endoscopic work; and the endoscopist will lose much of the value of his dog practice if he fails to regard the dog as a child. He should remember he is not learning how to do endoscopy on the dog; but learning on the dog how safely to do bronchoscopy on a human being. The degree of resistance during introduction can be gauged and the color of the mucosa studied, while that interesting phenomenon, the dilatation and lengthening of the bronchi during inspiration and their contraction and shortening during expiration, is readily observed and always forms subject for thought in its possible connection with pathological conditions. Foreign body problems are now to be solved under these living conditions, and it is my feeling that no one should attempt the removal of a foreign body from the bronchus of a child until he has removed at least 100 foreign bodies from the dog without harming the animal. Dogs have the faculty of easily ridding their air-passages of foreign objects, so that one need not be alarmed if a foreign body is lost during practice removal. It is to be remembered that dogs swallow very large objects with apparent ease. The dog's esophagus is relatively much larger than that of human beings. Therefore a small dog (of six to eight pounds' weight) must be used for esophagoscopic practice, if practice is to be had with objects of the size usually encountered in human beings. The bronchi of a dog of this weight will be about the size of those of a child.

[FIG. 73.—Author's mouth gag for use on the dog. The thumb-nut serves to prevent an uncomfortable degree of expansion of the gag. A bandage may be wound around the dog's jaws to prevent undue spread of the jaws.]

Endoscopy on the Human Being.—Dog work offers but little practice in laryngoscopy. Because of the slight angle at which the dog's head joins his spine, the larynx is in a direct line with the open mouth; hence little displacement of the anterior cervical tissues is necessary. Moreover the interior of the larynx of the dog is quite different from that of the human larynx. The technic of laryngoscopy in the human subject is best perfected by a routine direct examination of the larynx of anesthetized patients after such an operation as, for instance, tonsillectomy, to see that the larynx and laryngopharynx are free of clots. To perform a bronchoscopy or esophagoscopy under these conditions would be reprehensible; but direct laryngoscopy for the seeking and removal of clots serves a useful purpose as a preventative of pulmonary abscess and similar complications.* Diagnosis of laryngeal conditions in young children is possible only by direct laryngoscopy and is neglected in almost all of the cases. No anesthesia, general or local, is required. Much clinical material is neglected. All cases of dyspnea or dysphagia should be studied endoscopically if the cause of the condition cannot be definitely found and treated by other means. Invaluable practice in esophagoscopy is found in the treatment of strictures of the esophagus by weekly or biweekly esophagoscopic bouginage.

* Dr. William Frederick Moore, of the Bronchoscopic Clinic, has recently collected statistics of 202 cases of post-tonsillectomic pulmonary abscess that point strongly to aspiration of infected clots and other infective materials as the most frequent etiologic mechanism (Moore, W. F., Pulmonary Abscess. Journ. Am. Med. Assn., April 29, 1922, Vol. 78, pp. 1279-1281).

In acquiring skill as an endoscopist the following paraphrased aphorisms afford food for thought.

APHORISMS

Educate your eye and your fingers. Be sure you are right, but not too sure. Follow your judgment, never your impulse. Cry over spilled milk enough to memorize how you spilled it. Let your mistakes worry you enough to prevent repetition. Let your left hand know what your right hand does and how to do it. Nature helps, but she is no more interested in the survival of your patient than in the survival of the attacking pathogenic bacteria.



[126] CHAPTER XII—FOREIGN BODIES IN THE AIR AND FOOD PASSAGES

The air and food passages may be invaded by any foreign substance of solid, liquid or gaseous nature, from the animal, vegetable, or mineral kingdoms. Its origin may be from within the body (blood, pus, secretion, broncholiths, sequestra, worms); introduced from without by way of the natural passages (aspirated or swallowed objects); or it may enter by penetration (bullet, dart, drainage tube from the neck).

Prophylaxis.—If one put into his mouth nothing but food, foreign body accidents would be rare. The habit of holding tacks, pins and whatnot in the mouth is quite universal and deplorable. Children are prone to follow the bad example of their elders. No small objects such as safety pins, buttons, and coins should be left within a baby's reach; children should be watched and taught not to place things in their mouths. Mothers should be specially cautioned not to give nuts or nut candy of any kind to a child whose powers of mastication are imperfect, because the molar teeth are not erupted. It might be made a dictum that: "No child under 3 years of age should be allowed to eat nuts, unless ground finely as in peanut butter." Digital efforts at removal of foreign bodies frequently force the object downward, or may hook it forward into the larynx, whereas if not meddled with digitally the intruder might be spat out. Before general anesthesia the mouth should be searched for loose teeth, removable dentures, etc., and all unconscious individuals should be likewise examined. When working in the mouth precautions should be taken against the possible inhalation or swallowing of loose objects or instruments.

[126] Objects that have lodged in the esophagus, larynx, trachea, or bronchi should be endoscopically removed.

Foreign Bodies in the Insane.—Foreign bodies may be introduced voluntarily and in great numbers by the insane. Hysterical individuals may assert the presence of a foreign body, or may even volitionally swallow or aspirate objects. It is a mistake to do a bronchoscopy in order to cure by suggestion the delusion of foreign body presence. Such "cures" are ephemeral.

Foreign Bodies in the Stomach.—Gastroscopy is indicated in cases of a foreign body that refuses to pass after a month or two. Foreign bodies in very large numbers in the stomach, as in the insane, may be removed by gastrostomy.

The symptomatology of foreign bodies may be epitomized as given below; but it must be kept in mind, that certain symptoms may not be manifest immediately after intrusion, and others may persist for a time after the passage, removal, or expulsion of a foreign body.

ESOPHAGEAL FOREIGN BODY SYMPTOMS

1. There are no absolutely diagnostic symptoms. 2. Dysphagia, however, is the most constant complaint, varying with the size of the foreign body, and the degree of inflammatory or spasmodic reaction produced. 3. Pain may be caused by penetration of a sharp foreign body, by inflammation secondary thereto, by impaction of a large object, or by spasmodic closure of the hiatus esophageus. 4. The subjective sensation of foreign body is usually present, but cannot be relied upon as assuring the presence of a foreign body for this sensation often remains for a time after the passage onward of the intruder. 5. All of these symptoms may exist, often in the most intense degree, as the result of previous violent attempts at removal; and the foreign body may or may not be present.

SYMPTOMS OF LARYNGEAL FOREIGN BODY

1. Initial laryngeal spasm followed by wheezing respiration, croupy cough, and varying degrees of impairment of phonation. 2. Pain may be a symptom. If so, it is usually located in the laryngeal region, though in some cases it is referred to the ears. 3. The larynx may tolerate a thin, flat, foreign body for a relatively long period of time, a month or more; but the development of increasing dyspnea renders early removal imperative in the majority of cases.

SYMPTOMS OF TRACHEAL AND BRONCHIAL FOREIGN BODY

1. Tracheal foreign bodies are usually movable and their movements can usually be felt by the patient. 2. Cough is usually present at once, may disappear for a time and recur, or may be continuous, and may be so violent as to induce vomiting. In recent cases fixed foreign bodies cause little cough; shifting foreign bodies cause violent coughing. 3. Sudden shutting off of the expiratory blast and the phonation during paroxysmal cough is almost pathognomonic of a movable tracheal foreign body. 4. Dyspnea is usually present in tracheal foreign bodies, and is due to the bulk of the foreign body plus the subglottic swelling caused by the traumatism of the shiftings of the intruder. 5. Dyspnea is usually absent in bronchial foreign bodies. 6. The respiratory rate is increased only if a considerable portion of lung is out of function, by the obstruction of a main bronchus, or if inflammatory sequelae are extensive. 7. The asthmatoid wheeze is usually present in tracheal foreign bodies, and is often louder and of lower pitch than the asthmatoid wheeze of bronchial foreign bodies. It is heard at the open mouth, not at the chest wall; and prolonged expiration as though to rid the lungs of all residual air, may be necessary to elicit it. 8. Pain is not a common symptom, but may occur and be accurately localized by the patient, in case of either tracheal or bronchial foreign body.

EARLY SYMPTOMS OF IRRITATING FOREIGN BODY SUCH AS A PEANUT KERNEL IN THE BRONCHUS

1. Initial laryngeal spasm is almost invariably present with foreign bodies of organic nature, such as nut kernels, peas, beans, maize, etc. 2. A diffuse purulent laryngo-tracheo-bronchitis develops within 24 hours in children under 2 years. 3. Fever, toxemia, cyanosis, dyspnea and paroxysmal cough are promptly shown. 4. The child is unable to cough up the thick mucilaginous pus through the swollen larynx and may "drown in its own secretions" unless the offender be removed. 5. "Drowned lung," that is to say natural passages idled with pus and secretions, rapidly forms. 6. Pulmonary abscess develops sooner than in case of mineral foreign bodies. 7. The older the child the less severe the reaction.

SYMPTOMS OF PROLONGED FOREIGN BODY SOJOURN IN THE BRONCHUS

1. The time of inhalation of a foreign body may be unknown or forgotten. 2. Cough and purulent expectoration ultimately result, although there may be a delusive protracted symptomless interval. [130] 3. Periodic attacks of fever, with chills and sweats, and followed by increased coughing and the expulsion of a large amount of purulent, usually more or less foul material, are so nearly diagnostic of foreign body as to call for exclusion of this probability with the utmost care. 4. Emaciation, clubbing of the fingers and toes, night sweats, hemoptysis, in fact all of the symptoms of tuberculosis are in most cases simulated with exactitude, even to the gain in weight by an out-door regime. 5. Tubercle bacilli have never been found, in the cases at the Bronchoscopic Clinic, associated with foreign body in the bronchus.* In cases of prolonged sojourn this has been the only element lacking in a complete clinical picture of advanced tuberculosis. One point of difference was the almost invariably rapid recovery after removal of the foreign body. The statement in all of the text-books, that foreign body is followed by phthisis pulmonalis is a relic of the days when the bacillary origin of true tuberculosis was unknown, hence the foreign-body phthisis pulmonalis, or pseudo tuberculosis, was confused with the true pulmonary tuberculosis of bacillary origin. 6. The subjective sensation of pain may allow the patient accurately to localize a foreign body. 7. Foreign bodies of metallic or organic nature may cause their peculiar taste in the sputum. 8. Offensive odored sputum should always suggest bronchial foreign body; but absence of sputum, odorous or not, should not exclude foreign body. 9. Sudden complete obstruction of one main bronchus does not cause noticeable dyspnea provided its fellow is functionating. [131] 10. Complete obstruction of a bronchus is followed by rapid onset of symptoms. 11. The physical signs usually show limitation of expansion on the affected side, impairment of percussion, and lessened trans-mission or absence of breath-sounds distal to the foreign body.

* The exceptional case has at last been encountered. A boy with a tack in the bronchus was found to have pulmonary tuberculosis.

SYMPTOMS OF GASTRIC FOREIGN BODY

Foreign body in the stomach ordinarily produces no symptoms. The roentgenogram and the fluoroscopic study with an opaque mixture are the chief means of diagnosis.

DIAGNOSIS OF FOREIGN BODY IN THE AIR OR FOOD PASSAGES

The questions arising are: I. Is a foreign body present? 2. Where is it located? 3. Is a peroral endoscopic procedure indicated? 4. Are there any contraindications to endoscopy?

In order to answer these questions the definite routine given below is followed unvaryingly in the Bronchoscopic Clinic. 1. History. 2. Complete physical examination, including mirror laryngoscopy. 3. Roentgenologic study. 4. Endoscopy.

The history should note the date of, and should delve into the details of the accident; special note being made of the occurrence of laryngeal spasm, wheezing respiration heard by the patient or others (asthmatoid wheeze), fever, cough, pain, dyspnea, dysphagia, odynphagia, regurgitation, etc. The amount, character and odor of sputum are important. Increasing amounts of purulent, foul-odored, sometimes blood-tinged sputum strongly suggest prolonged bronchial foreign body sojourn. The mode of onset of the persisting symptoms, whether immediately following the supposed accident or delayed in their occurrence, is to be noted. Do attacks of sudden dyspnea and cyanosis occur? What has been the previous treatment and what attempts at removal have been made? The nature of the foreign body is to be determined, and if possible a duplicate thereof obtained.

General physical examination should be complete including inspection of the eyes, ears, nose, pharynx, and mirror inspection of the naso-pharynx and larynx. Special attention is paid to the chest for the localization of the object. In order to discover conditions rendering endoscopy unusually hazardous, all parts of the body are to be examined. Aneurysm of the aorta, excessive blood pressure, serious cardiac and renal conditions, the presence of a hernia and the existence of central nervous disease, as tabes dorsalis, should be at least known before attempting any endoscopic procedure. Dysphagia might result from the pressure of an unknown aneurysm, the symptoms being attributed to a foreign body, and aortic aneurysm is a definite contraindication to esophagoscopy unless there be foreign body present also. There is no absolute contraindication to the endoscopic removal of a foreign body, though many conditions may render it wise to post-pone endoscopy. Laryngeal crises of tabes might, because of their sudden onset, be thought due to foreign body.

PHYSICAL SIGNS IN ESOPHAGEAL FOREIGN BODY

There are no constant physical signs associated with uncomplicated impaction of a foreign body in the esophagus. Should perforation of the cervical esophagus occur, subcutaneous emphysema, and perhaps cellulitis, may be found; while a perforation of the thoracic region causing mediastinitis is manifested by toxemia, fever, and rapid sinking. Perforation of the pleura, with the development of pyopneumothorax, is manifested by the usual signs. It is to be emphasized that blind bouginage has no place in the diagnosis of any esophageal condition. The roentgenologist will give the information we desire without danger to the patient, and with far greater accuracy.

FOREIGN BODIES IN THE LARYNX

Laryngeally lodged foreign bodies produce a wheezing respiration, the quality of which is peculiar to the larynx and is readily localized to this organ. If swelling or the size of the foreign body be sufficient to produce dyspnea, inspiratory indrawing of the suprasternal notch, supraclavicular fossae, costal interspaces and lower sternum will be present. Cyanosis is only an accompaniment of suddenly produced dyspnea; the facies will therefore usually be anxious and pale, unless the patient is seen immediately after the aspiration of the foreign body. If labored breathing has been prolonged, and exhaustion threatened, the heart's action will be irregular and weak. The foreign body can be seen with the mirror, but a roentgenograph must nevertheless be made, for the object may be of another nature than was first thought. The roentgenograph will show its position, and from this knowledge the plan of removal can be formulated. For example, a straight pin may be so placed in the larynx that only a portion of its shaft will be visible, the roentgenogram will tell where the head and point are located, and which of these will be the more readily disengaged. (See Chapter on Mechanical Problems.)

PHYSICAL SIGNS OF TRACHEAL FOREIGN BODY

If fixed in the trachea the only objective sign of foreign body may be a wheezing respiration, the site of which may be localized with the stethoscope, by the intensity of the sound. Movable foreign bodies may produce a palpatory thrill, and the rumble and sudden stop can be heard with the stethoscope and often with the naked ear. The lungs will show equal aeration, but there may be marked dyspnea without the indrawing of the fossae, if the object be of large size and located below the manubrium.

To the peculiar sound of the sudden subglottic, expiratory or bechic arrest of the foreign body the author has given the name "audible slap;" when felt by the thumb on the trachea he calls it the "palpatory thud." These signs can be produced by no condition other than the arrest of some substance by the subglottic taper. Once heard and felt they are unmistakable.

PHYSICAL SIGNS OF BRONCHIAL FOREIGN BODY

In most cases there will be limitation of expansion on the invaded side, even though the foreign body is of such a shape as to cause no bronchial obstruction. It has been noted frequently in conjunction with the presence of such objects as a common straight pin in a small branch bronchus. This peculiar phenomenon was first noted by Thomas McCrae in one of the author's cases and has since been abundantly corroborated by McCrae and others as one of the most constant physical signs.

To understand the peculiar physical findings in these cases it is necessary to remember that the bronchi are not tubes of constant caliber; there occurs a dilatation during inspiration, and a contraction of the lumen during expiration; furthermore, the lumen may be narrowed by swollen mucosa if the foreign body be of an irritant nature. The signs vary with the degree of obstruction of the bronchus, and with the consequent degree of interference with aeration and drainage of the subjacent portion of the lung. We have three definite types which show practically constant signs in the earlier stages of foreign body invasion.

1. Complete bronchial occlusion. 2. Obstruction complete during expiration, but allowing the passage of air during the bronchial dilatation incident to inspiration, constituting an expiratory valve-like obstruction. 3. Partial bronchial obstruction, allowing to-and-fro passage of air.

1. Complete bronchial obstruction is manifested by limitation of expansion, markedly impaired percussion note, particularly at the base, absence of breath-sounds, and rales on the invaded side. An atelectasis here exists; the air imprisoned in the lung is soon absorbed, and secretions rapidly accumulate. On the free side a compensatory emphysema is present.

2. Expiratory Valve-like Obstruction.—The obstructed side shows marked limitation of expansion. Percussion is of a tympanitic character. The duration of the vibrations may be shortened giving a muffled tympany. Various grades and degrees of tympany may be noted. Breath sounds are markedly diminished or absent. No rales are heard on the invaded side, although rales of all types may be present on the free side. In some cases it is possible to hear a short inspiratory sound. Vocal resonance and fremitus are but little altered. The heart will be found displaced somewhat to the opposite side. These signs are explained by the passage of some air past the foreign body during inspiration with its trapping during expiration, so that there is air under pressure constantly maintained in the obstructed area. This type of obstruction is most frequently observed when the foreign body is of an organic nature such as nut kernels, beans, corn, seed, etc. The localized swelling about the irritating foreign body completes the expiratory obstruction. It may also be present with any foreign body whose size and shape are such as to occlude the lumen of the bronchus during its contracted expiratory phase. It was present in cases of pebbles, cylindrical metallic objects, thick tough balls of secretion etcetera. The valvular action is here produced most often by a change in the size of the valve seat and not by a movement of the foreign body plug. In other cases I have found at bronchoscopy, a regular ball-valve mechanism. Pneumothorax is the only pathologic condition associated with signs similar to those of expiratory, valve-like bronchial obstruction by a foreign body.

3. Partial bronchial obstruction by an object such as a nail allows air to pass to and fro with some degree of retardation, and impairs the drainage of the subjacent lung. Limitation of expansion will be found on the invaded side. The area below the foreign body will give an impaired percussion note. Breath-sounds are diminished in the area of dullness, and vocal resonance and fremitus are impaired. Rales are of great diagnostic import; the passage of air past the foreign body is accompanied by blowing, harsh breathing, and snoring; snapping rales are heard usually with greatest intensity posteriorly over the site of the foreign body (usually about the scapular angle).

A knowledge of the topographical lung anatomy, the bronchial tree, and of endoscopic pathology* should enable the examiner of the chest to locate very accurately a bronchial foreign body by physical signs alone, for all the significant signs occur distal to the foreign body lodgment.

* Jackson, Chevalier. Pathology of Foreign Bodies in the Air and Food Passages. Mutter Lecture, 1918. Surgery, Gynecology and Obstetrics, March, 1919. Also, by the same author, Mechanism of the Physical Signs of Foreign Bodies in the Lungs. Proceedings of the College of Physicians, Philadelphia, 1922.

The asthmatoid wheeze has been found by the author a valuable confirmatory sign of bronchial foreign body. It is a wheezing heard by placing the observer's ear at the open mouth of the patient (not at the chest wall) during a prolonged forced expiration. Thomas McCrae elicits this sign by placing the stethoscope bell at the patient's open mouth. The quality of the sound is dryer than that heard in asthma and the wheeze is clearest after all secretion has been removed by coughing. The mechanism of production is, probably, the passage of air by a foreign body which narrows the lumen of a large bronchus. As the foreign body works downward the wheeze lessens. The wheeze is often so loud as to be heard at some distance from the patient. It is of greatest value in the diagnosis of non-roentgenopaque foreign body but its absence in no way negates foreign body. Its presence or absence should be recorded in every case.

Prolonged bronchial obstruction by foreign body is followed by bronchiectasis and lung abscess usually in a lower lobe. The symptoms may with exactitude simulate tuberculosis, but this disease should be readily excluded by the basal, unilateral site of the lesion, absence of tubercle bacilli in the sputum, and roentgenographic study. Chest examination in the foreign body cases reveals limitation of expansion, often some retraction, flat percussion note, and greatly diminished or absent breath-sounds over the site of the pulmonary lesion. Rales vary with the amount of secretion present. These physical signs suggest empyema; and rib resection had been done before admission in a number of cases only to find the pleura normal.

ROENTGENRAY STUDY IN FOREIGN BODY CASES

Roentgenography.—All cases of chest disease should have the benefit of a roentgenologic study to exclude bronchial foreign body as an etiological factor. Negative opinions should never be based upon any plates except the best that the wonderful modern development of the art and science of roentgenology can produce. In doubtful cases, the negative opinion should not be conclusive until a roentgenologist of long experience in chest work, and especially in foreign body cases, has been called in consultation. Even then there will be an occasional case calling for diagnostic bronchoscopy. Antero-posterior and lateral roentgenograms should always be made. In an antero-posterior film a flat foreign body lying in the lateral body plane might be invisible in the shadow of the spine, heart, and great vessels; but would be revealed in the lateral view because of the greater edgewise density of the intruder and the absence of other confusing shadows. Fluoroscopic examination will often discover the best angle from which to make a plate; but foreign bodies casting a very faint shadow on a plate may be totally invisible on the fluoroscopic screen. The value of a roentgenogram after the removal of a foreign body cannot be too strongly emphasized. It is evidence of removal and will exclude the presence of a second intruder which might have been overlooked in the first study.

Fluoroscopic study of the swallowing function with barium mixture, or a barium-filled capsule, will give the location of a nonroentgenopaque object (such as bone, meat, etc.) in the esophagus. If a flat or disc-shaped object located in the cervical region is seen to be lying in the lateral body plane, it will be found to be in the esophagus, for it assumed that position by passing down flatwise behind the larynx. If, however, the object is seen to be in the sagittal plane it must lie in the trachea. This position was necessary for it to pass through the glottic chink, and can be maintained because of the yielding of the posterior membranous wall of the trachea.

THE ROENTGENOGRAPHIC SIGNS OF EXPIRATORY-VALVE-LIKE BRONCHIAL OBSTRUCTION

The roentgenray signs in expiratory valve-like obstruction of a bronchus are those of an acute obstructive emphysema (Fig. 74), namely, 1. Greater transparency on the obstructed side (Iglauer). 2. Displacement of the heart to the free side (Iglauer). 3. Depression and flattening of the dome of the diaphragm on the invaded side (Iglauer). 4. Limitation of the diaphragmatic excursion on the obstructed side (Manges).

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" (accumulated secretion in the bronchi and bronchioli) are shown by the definite shadows produced (Fig. 76).

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

[FIG. 75.—Radiograph showing pathology resulting from complete obstruction of a bronchus with atelectasis and drowned lung resulting. Foot of an alarm clock in left bronchus of 4 year old child. Present 25 days. Plate made by Johnston and Grier.]

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

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

Bronchial mapping is readily accomplished by the author's method of endobronchial insufflation of a roentgenopaque inert powder such as bismuth subnitrate or subcarbonate (Fig. 77). The roentgenopaque substance may be injected in a fluid mixture if preferred, but the walls are better outlined with the powder (Fig. 77).

[FIG. 77.—Roentgenogram showing the author's method of bronchial mapping or lung-mapping by the bronchoscopic introduction of opaque substances (in this instance powdered bismuth subnitrate) into the lung of the patient. Plate made by David R. Bowen. (Illustration, strengthened for reproduction, is from author's article in American Journal of Roentgenology, Oct., 1918.)]

ERRORS TO AVOID IN SUSPECTED FOREIGN BODY CASES

1. Do not reach for the foreign body with the fingers, lest the foreign body be thereby pushed into the larynx, or the larynx be thus traumatized. 2. Do not hold up the patient by the heels, lest a tracheally lodged foreign body be dislodged and asphyxiate the patient by becoming jammed in the glottis. [143] 3. Do not fail to have a roentgenogram made, if possible, whether the foreign body in question is of a kind dense to the ray or not. 4. Do not fail to search endoscopically for a foreign body in all cases of doubt. 5. Do not pass blindly an esophageal bougie, probang, or other instrument. 6. Do not tell the patient he has no foreign body until after roentgenray examination, physical examination, indirect examination, and endoscopy have all proven negative.

SUMMARY

SYMPTOMATOLOGY AND DIAGNOSIS OF FOREIGN BODIES IN THE AIR AND FOOD PASSAGES

Initial symptoms are choking, gagging, coughing, and wheezing, often followed by a symptomless interval. The foreign body may be in the larynx, trachea, bronchi, nasal chambers, nasopharynx, fauces, tonsil, pharynx, hypopharynx, esophagus, stomach, intestinal canal, or may have been passed by bowel, coughed out or spat out, with or without the knowledge of the patient. Initial choking, etcetera may have escaped notice, or may have been forgotten.

Laryngeal Foreign Body.—One or more of the following laryngeal symptoms may be present: Hoarseness, croupy cough, aphonia, odynphagia, hemoptysis, wheezing, dyspnea, cyanosis, apnea, subjective sensation of foreign body. Croupiness in foreign body cases, as in diphtheria, usually means subglottic swelling. Obstructive foreign body may be quickly fatal by laryngeal impaction on aspiration, or on abortive bechic expulsion. Lodgement of a non-obstructive foreign body may be followed by a symptomless interval. Direct laryngoscopy for diagnosis is indicated in every child having laryngeal diphtheria without faucial membrane. (No anesthetic, general or local is needed.) In the presence of laryngeal symptoms, think of the following: 1. A foreign body in the larynx. 2. A foreign body loose or fixed in the trachea. 3. Digital efforts at removal. 4. Instrumentation. 5. Overflow of food into the larynx from esophageal obstruction due to the foreign body. 6. Esophagotracheal fistula from ulceration set up by a foreign body in the esophagus, followed by the leakage of food into the air-passages. 7. Laryngeal symptoms may persist from the trauma of a foreign body that has passed on into the deeper air or food passages or that has been coughed or spat out. 8. Laryngeal symptoms (hoarseness, croupiness, etcetera) may be due to digital or instrumental efforts at the removal of a foreign body that never was present. 9. Laryngeal symptoms may be due to acute or chronic laryngitis, diphtheria, pertussis, infective laryngotracheitis, and many other diseases. 10. Deductive decisions are dangerous. 11. If the roentgenray is negative, laryngoscopy (direct in children, indirect in adults) without anesthesia, general or local, is the only way to make a laryngeal diagnosis. 12. Before doing a diagnostic laryngoscopy, preparation should be made for taking a swab-specimen and for bronchoscopy and esophagoscopy.

Tracheal Foreign Body.—(1) "Audible slap," (2) "palpatory thud," and (3) "asthmatoid wheeze" are pathognomonic. The "tracheal flutter" has been observed by McCrae in a case of watermelon seed. Cough, hoarseness, dyspnea, and cyanosis are often present. Diagnosis is by roentgenray, auscultation, palpation, and bronchoscopy. Listen long for "audible slap," best heard at open mouth during cough. The "asthmatoid wheeze" is heard with the ear or stethoscope bell (McCrae) at the patient's open mouth. History of initial choking, gagging, and wheezing is important if elicited, but is valueless negatively.

Bronchial Foreign Body.—Initial symptoms are coughing, choking, asthmatoid wheeze, etc. noted above. There may be a history of these or of tooth extraction. At once, or after a symptomless interval, cough, blood-streaked sputum, metallic taste, or special odor of foreign body may be noted. Non-obstructive metallic foreign bodies afford few symptoms and few signs for weeks or months. Obstructive foreign bodies cause atelectasis, drowned lung, and eventually pulmonary abscess. Lobar pneumonia is an exceedingly rare sequel. Vegetable organic foreign bodies as peanut-kernels, beans, watermelon seeds, etcetera, cause at once violent laryngotracheobronchitis, with toxemia, cough and irregular fever, the gravity and severity being inversely to the age of the child. Bones, animal shells and inorganic bodies after months or years produce changes which cause chills, fever, sweats, emaciation, clubbed fingers, incurved nails, cough, foul expectoration, hemoptysis, in fact, all the symptoms of chronic pulmonary sepsis, abscess, and bronchiectasis. These symptoms and some of the physical signs may suggest pulmonary tuberculosis, but the apices are normal and bacilli are absent from the sputum. Every acute or chronic chest case calls for the exclusion of foreign body.

The physical signs vary with conditions present in different cases and at different times in the same case. Secretions, normal and pathologic, may shift from one location to another; the foreign body may change its position admitting more, less, or no air, or it may shift to a new location in the same lung or even in the other lung. A recently aspirated pin may produce no signs at all. The signs of diagnostic importance are chiefly those of partial or complete bronchial obstruction, though a non-obstructive foreign body, a pin for instance, may cause limited expansion (McCrae) or, rarely, a peculiar rale or a peculiar auscultatory sound. The most nearly characteristic physical signs are: (1) Limited expansion; (2) decreased vocal fremitus; (3) impaired percussion note; (4) diminished intensity of the breath-sounds distal to the foreign body. Complete obstruction of a bronchus followed by drowned lung adds absence of vocal resonance and vocal fremitus, thus often leading to an erroneous diagnosis of empyema. Varying grades of tympany are obtained over areas of obstructive or compensatory emphysema. With complete obstruction there may be tympany from the collapsed lung for a time. Rales in case of complete obstruction are usually most intense on the uninvaded side. In partial obstruction they are most often found on the invaded side distal to the foreign body, especially posteriorly, and are most intense at the site corresponding to that of the foreign body. A foreign body at the bifurcation of the trachea may give signs in both lungs. Early in a foreign body case, diminished expansion of one side, with dulness, may suggest pneumonia in the affected side; but absence of, or decreased, vocal resonance, and absence of typical tubular breathing should soon exclude this diagnosis. Bronchial obstruction in pneumonia is exceedingly rare.

Memorize these signs suggestive of foreign body: 1. Expansion—diminished. 2. Percussion note—impaired (except in obstructive emphysema). 3. Vocal fremitus—diminished. 4. Breath sounds—diminished.

The foregoing is only for memorizing, and must be considered in the light of the following fundamental note by Prof. McCrae "There is no one description of physical signs which covers all cases. If the student will remember that complete obstruction of a bronchus leads to a shutting off of this area, there should be little difficulty in understanding the signs present. The diagnosis of empyema may be made, but the outline of the area of dulness, the fact that there is no shifting dulness, and the greater resistance which is present in empyema nearly always clear up any difficulty promptly. The absence of the frequent change in the voice sounds, so significant in an early small empyema, is of value. A large empyema should give no difficulty. If difficulty remains the use of the needle should be sufficient. In thickened pleura vocal fremitus is not entirely absent, and the breath-sounds can usually be heard, even if diminished. In case of partial obstruction of a bronchus, it is evident that air will still be present, hence the dulness may be only slight. The presence of air and secretion will probably result in the breath-sounds being somewhat harsh, and will cause a great variety of rales, principally coarse, and many of them bubbling. Difficulty may be caused by signs in the other lung or in a lobe other than the one affected by the foreign body. If it is remembered that these signs are likely to be only on auscultation, and to consist largely in the presence of rales, while the signs in the area supplied by the affected bronchus will include those on inspection, palpation, and percussion, there should be little difficulty."

The roentgenray is the most valuable diagnostic means; but careful notation of physical signs by an expert should be made in all cases preferably without knowledge of ray findings. Expert ray work will show all metallic foreign bodies and many of less density, such as teeth, bones, shells, buttons, etcetera. If the ray is negative, a diagnostic bronchoscopy should be done in all cases of unexplained bronchial obstruction.

Peanut kernels and watermelon seeds and, rarely, other foreign bodies in the bronchi produce obstructive emphysema of the invaded side. Fluoroscopy shows the diaphragm flattened, depressed and of less excursion on the invaded side; at the end of expiration, the heart and the mediastinal wall move over toward the uninvaded side and the invaded lung becomes less dense than the uninvaded lung, from the trapping of the air by the expiratory, valve-like effect of obliteration of the "forceps spaces" that during inspiration afford air ingress between the foreign body and the swollen bronchial wall. This partial obstruction causes obstructive emphysema, which must be distinguished from compensatory emphysema, in which the ballooning is in the unobstructed lung, because its fellow is wholly out of function through complete "corking" of the main bronchus of the invaded side.

Esophageal Foreign Body.—After initial choking and gagging, or without these, there may be a subjective sense of a foreign body, constant or, more often, on swallowing. Odynphagia and dysphagia or aphagia may or may not be present. Pain, sub-sternal or extending to the back is sometimes present. Hematemesis and fever may occur from the foreign body or from rough instrumentation. Symptoms referable to the air-passages may be present due to: (1) Overflow of the secretions on attempts to swallow through the obstructed esophagus; (2) erosion of the foreign body through from the esophagus into the trachea; or (3) trauma inflicted on the larynx during attempts at removal, digital or instrumental, the foreign body still being present or not.

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



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

The protective reflexes preventing the entrance of foreign bodies into the lower air passages are: (1) The laryngeal closing reflex and (2) the bechic reflex. Laryngeal closing for normal swallowing consists chiefly in the tilting and the closure of the upper laryngeal orifice. The ventricular bands help but slightly; and the epiglottis and the vocal cords little, if at all. The gauntlet to be run by foreign bodies entering the tracheobronchial tree is composed of: 1. Epiglottis. 2. Upper laryngeal orifice. 3. Ventricular bands. 4. Vocal cords. 5. Bechic blast.

The epiglottis acts somewhat as a fender. The superior laryngeal aperture, composed of a pair of movable ridges of tissue, has almost a sphincteric action, in addition to a tilting movement. The ventricular bands can approximate under powerful stimuli. The vocal cords act similarly. The one defect in the efficiency of this barrier, is the tendency to take a deep inspiration preparatory to the cough excited by the contact of a foreign body.

Site of Lodgment.—The majority of foreign bodies in the air passages occur in children. The right bronchus is more frequently invaded than the left because of the following factors: I. Its greater diameter. 2. Its lesser angle of deviation from the tracheal axis. 3. The situation of the carina to the left of the mid-line of the trachea. 4. The action of the trachealis muscle. 5. The greater volume of air going into the right bronchus on inspiration.

The middle lobe bronchus is rarely invaded by foreign body, and, fortunately, in less than one per cent of the cases is the object in an upper lobe bronchus.

Spontaneous Expulsion of Foreign Bodies from the Air Passages. A large, light, foreign body in the larynx or trachea may occasionally be coughed out, but the frequent newspaper accounts of the sudden death of children known to have aspirated objects should teach us never to wait for this occurrence. The cause of death in these cases is usually the impaction of a large foreign body in the glottis producing sudden asphyxiation, and in a certain proportion of these cases the impaction has occurred on the reverse journey, when cough forced the intruder upward from below. The danger of subglottic impaction renders it imperative that attempts to aid spontaneous expulsion by inverting the patient should be discouraged. Sharp objects, such as pins, are rarely coughed out. The tendency of all foreign bodies is to migrate down and out to the periphery as their size and shape will allow. Most of the reported cases of bechic expulsion of bronchially lodged foreign bodies have occurred after a prolonged sojourn of the object, associated which much lung pathology; and in some cases the object has been carried out along with an accumulation of pus suddenly liberated from an abscess cavity, and expelled by cough. This is a rare sequence compared to the usual formation of fibrous stricture above the foreign body that prevents the possibility of bechic expulsion. To delay bronchoscopy with the hope of such a solution of the problem is comparable to the former dependence on nature for the cure of appendiceal abscess.

We do our full duty when we tell the patient or parents that while the foreign body may be coughed up, it is very dangerous to wait; and, further, that the difficulty of removal usually increases with the time the foreign body is allowed to remain in the air passages.

Mortality and morbidity of bronchoscopy vary directly with the degree of skill and experience of the operator, and the conditions for which the endoscopies are performed. The simple insertion of the bronchoscope is devoid of harm if carefully done. The danger lies in misdirected efforts at removal of the intruder and in repeating bronchoscopies in children at too frequent intervals, or in prolonging the procedure unduly. In children under one year endoscopy should be limited to twenty minutes, and should not be repeated sooner than one week after, unless urgently indicated. A child of 5 years will bear 40 to 60 minutes work, while the adult offers no unvarying time limit. More can be ultimately accomplished, and less reaction will follow short endoscopies repeated at proper intervals than in one long procedure.

Indications for bronchoscopy for suspected foreign body may be thus summarized: 1. The appearance of a suspicious shadow in the radiograph, in the line of a bronchus. 2. In any case in which lung symptoms followed a clear history of the patient having choked on a foreign body. 3. In any case showing signs of obstruction in the trachea or of a bronchus. 4. In suspected bronchiectasis. 5. Symptoms of pulmonary tuberculosis with sputum constantly negative for tubercle bacilli. If the physical signs are at the base, particularly the right base, the indication becomes very strong even in the absence of any foreign body circumstance in the history. 6. In all cases of doubt, bronchoscopy should be done anyway.

There is no absolute contraindication to bronchoscopy for foreign bodies. Extreme exhaustion or reaction from previous efforts at removal may call for delay for recuperation, but pulmonary abscess and even the rarer complications, bronchopneumonia and gangrene of the lung, are improved by the early removal of the foreign body.

Choice of Time to do Bronchoscopy for Foreign Body.—The difficulties of removal usually increase from the time of aspiration of the object. It tends to work downward and outward, while the mucosa becomes edematous, partly closing over the foreign body, and even completely obliterating the lumen of smaller bronchi. Later, granulation tissue and the formation of stricture further hide the object. The patient's health deteriorates with the onset of pulmonary pathology, and renders him a less favorable subject for bronchoscopy. Organic foreign bodies, which produce early and intense inflammatory reaction and are liable to swell, call for prompt bronchoscopy. When a bronchus is completely obstructed by the bulk of the foreign body itself immediate removal is urgently demanded to prevent serious lung changes, resulting from atelectasis and want of drainage. In short, removal of the foreign body should be accomplished as soon as possible after its entrance. This, however, does not justify hasty, ill-planned, and poorly equipped bronchoscopy, which in most cases is doomed to failure in removal of the object. The bronchoscopist should not permit himself to be stampeded into a bronchoscopy late at night, when he is fatigued after a hard day's work.

Bronchoscopic finding of a foreign body is not especially difficult if the aspiration has been recent. If secondary processes have developed, or the object be small and in a bronchus too small to admit the tube-mouth, considerable experience may be necessary to discover it. There is usually inflammatory reaction around the orifice of the invaded bronchus, which in a measure serves to localize the intruder. We must not forget, however, that objects may have moved to another location, and also that the irritation may have been the result of previous efforts at removal. Care must be exercised not to mistake the sharp, shining, interbronchial spurs for bright thin objects like new pins just aspirated; after a few days pins become blackened. If these spurs be torn pneumothorax may ensue. If a number of small bronchi are to be searched, the bronchoscope must be brought into the line of the axis of the bronchus to be examined, and any intervening tissue gently pushed aside with the lip of the bronchoscope. Blind probing for exploration is very dangerous unless carefully done. The straight forceps, introduced closed, form the best probe and are ready for grasping if the object is felt. Once the bronchoscope has been introduced, it should not be withdrawn until the procedure is completed. The light carrier alone may be removed from its canal if the illumination be faulty.

COMPLICATIONS AND AFTER-EFFECTS OF BRONCHOSCOPY

All foreign body cases should be watched day and night by special nurses until all danger of complications is passed. Complications are rare after careful work, but if they do occur, they may require immediate attention. This applies especially to the subglottic edema associated with arachidic bronchitis in children under 2 years of age.

General Reaction.—There is usually no elevation in temperature following a short bronchoscopy for the removal of a recently lodged metallic foreign body. If, however, an inflammatory condition of the bronchi existed previous to the bronchoscopy, as for instance the intense diffuse, purulent laryngotracheobronchitis associated with the aspiration of nut kernels, or in the presence of pulmonary abscess from long retained foreign bodies, a moderate temporary rise of temperature may be expected. These cases almost always have had irregular fever before bronchoscopy. Disturbance of the epithelium in the presence of pus without abscess usually permits enough absorption to elevate the temperature slightly for a few days.

Surgical shock in its true form has never followed a carefully performed and time-limited bronchoscopy. Severe fatigue resulting in deep sleep may be seen in children after prolonged work.

Local reaction is ordinarily noted by slight laryngeal congestion causing some hoarseness and disappearing in a few days. If dyspnea occur it is usually due to (1) Drowning of the patient in his own secretions. (2) Subglottic edema. (3) Laryngeal edema.

Drowning of the Patient in His Own Secretions.—The accumulation of secretions in the bronchi due to faulty bechic powers and seen most frequently in children, is quickly relievable by bronchoscopic sponge-pumping or aspiration through the tracheotomic wound, in cases in which the tracheotomy may be deemed necessary. In other cases, the aspirating bronchoscope with side drainage canal (Fig. 1, E) may be used through the larynx. Frequent peroral passage of the bronchoscope for this purpose is contraindicated only in case of children under 3 years of age, because of the likelihood of provoking subglottic edema. In such cases instead of inserting a bronchoscope the aspirating tube (Fig. 9) should be inserted through the direct laryngoscope, or a low tracheotomy should be done.

Supraglottic edema is rarely responsible for dyspnea except when associated with advanced nephritis.

Subglottic edema is a complication rarely seen except in children under 3 years of age. They have a peculiar histologic structure in this region, as is shown by Logan Turner. Even at the predisposing age subglottic edema is a very unusual sequence to bronchoscopy if this region was previously normal. The passage of a bronchoscope through an already inflamed subglottic area is liable to be followed by a temporary increase in the swelling. If the foreign body be associated with but slight amount of secretion, the child can usually obtain sufficient air through the temporarily narrowed lumen. If, however, as in cases of arachidic bronchitis, large amounts of purulent secretion must be expelled, it will be found in certain cases that the decreased glottic lumen and impaired laryngeal motility will render tracheotomy necessary to drain the lungs and prevent drowning in the retained secretions. Subglottic edema occurring in a previously normal larynx may result from: 1. The use of over-sized tubes. 2. Prolonged bronchoscopy. 3. Faulty position of the patient, the axis of the tube not being in that of the trachea. 4. Trauma from undue force or improper direction in the insertion of the bronchoscope. 5. The manipulation of instruments. 6. Trauma inflicted in the extraction of the foreign body.

Diagnosis must be made without waiting for cyanosis which may never appear. Pallor, restlessness, startled awakening after a few minutes sleep, occurring in a child with croupy cough, indrawing around the clavicles, in the intercostal spaces, at the suprasternal notch and at the epigastrium, call for tracheotomy which should always be low. Such a case should not be left unwatched. The child will become exhausted in its fight for air and will give up and die. The respiratory rate naturally increases because of air hunger, accumulating secretions that cannot be expelled because of impaired glottic motility give signs wrongly interpreted as pneumonia. Many children whose lives could have been saved by tracheotomy have died under this erroneous diagnosis.

Treatment.—Intubation is not so safe because the secretions cannot easily be expelled through the tube and postintubational stenosis may be produced. Low tracheotomy, the tracheal incision always below the second ring, is the safest and best method of treatment.



[156] CHAPTER XIV—REMOVAL OF FOREIGN BODIES FROM THE LARYNX

Symptoms and Diagnosis.—The history of a sudden choking attack followed by impairment of voice, wheezing, and more or less dyspnea can be usually elicited. Laryngeal diphtheria is the condition most frequently thought of when these symptoms are present, and antitoxin is rightly given while waiting for a positive diagnosis. Extreme dyspnea may render tracheotomy urgently demanded before any attempts at diagnosis are made. Further consideration of the symptomatology and diagnosis of laryngeal foreign body will be found on pages 128, 133 and 143.

Preliminary Examination.—In the adult, mirror examination of the larynx should be done, the patient being placed in the recumbent position. Whenever time permits roentgenograms, lateral and anteroposterior, should be made, the lateral one as low in the neck as possible. One might think this an unnecessary procedure because of the visibility of the larynx in the mirror; but a child's larynx cannot usually be indirectly examined, and even in the adult a pin may be so situated that neither head nor point is visible, only a portion of the shaft being seen. The roentgenogram will give accurate information as to the position, and will thus allow a planning of the best method for removal of the foreign body. A bone in the larynx usually is visible in a good roentgenogram. Accurate diagnosis in children is made by direct laryngoscopy without anesthesia, but direct laryngoscopy should not be done until one is prepared to remove a foreign body if found, to follow it into the bronchus and remove it if it should be dislodged and aspirated, and to do tracheotomy if sudden respiratory arrest occur.

[157] Technic of Removal of Foreign Bodies from the Larynx.—The patient is to be placed in the author's position, shown in Fig. 53. No general anesthesia should be given, and the application of local anesthesia is usually unnecessary and further, is liable to dislodge and push down the foreign body.* Because of the risk of loss downward it is best to seize the foreign body as soon as seen; then to determine how best to disimpact it. The fundamental principles are that a pointed object must either have its point protected by the forceps grasp or be brought out point trailing, and that a flat object must be so rotated that its plane corresponds to the sagittal plane of the glottic chink. The laryngeal grasping forceps (Fig. 53) will be found the most useful, although the alligator rotation forceps (Fig. 31) may occasionally be required.

* In adolescents or adults a few drops of a 4 per cent solution of cocain applied to the laryngopharynx with an atomizer or a dropper will afford the minimum risk of dislodgement; but the author's personal preference is for no anesthesia, general or local.



[158] CHAPTER XV—MECHANICAL PROBLEMS OF BRONCHOSCOPIC FOREIGN BODY EXTRACTION*

* For more extensive consideration of mechanical problems than is here possible the reader is referred to the Bibliography, page 311, especially reference numbers 1, 11, 37 and 56.

The endoscopic extraction of a foreign body is a mechanical problem pure and simple, and must be studied from this viewpoint. Hasty, ill-equipped, ill-planned, or violent endoscopy on the erroneous principle that if not immediately removed the foreign body will be fatal, is never justifiable. While the lodgement of an organic foreign body (such as a nut kernel) in the bronchus calls for prompt removal and might be included under the list of emergency operations, time is always available for complete preparation, for thorough study of the patient, and localization of the intruder. The patient is better off with the foreign body in the lung than if in its removal a mediastinitis, rupture into the pleura, or tearing of a thoracic blood vessel has resulted. The motto of the endoscopist should be "I will do no harm." If no harm be inflicted, any number of bronchoscopies can be done at suitable intervals, and eventually success will be achieved, whereas if mortality results, all opportunity ceases.

The first step in the solution of the mechanical problem is the study of the roentgenograms made in at least three planes; (1) anteroposterior, (2) lateral, and (3) the plane corresponding to the greatest plane of the foreign body. The next step is to put a duplicate of the foreign body into the rubber-tube manikin previously referred to, and try to simulate the probable position shown by the ray, so as to get an idea of the bronchoscopic appearance of the probable presentation. Then the duplicate foreign body is turned into as many different positions as possible, so as to educate the eye to assist in the comprehension of the largest possible number of presentations that may be encountered at the bronchoscopy on the patient. For each of these presentations a method of disimpaction, disengagement, disentanglement or version and seizure is worked out, according to the kind of foreign body. Prepared by this practice and the radiographic study, the bronchoscope is introduced into the patient. The location of the foreign body is approached slowly and carefully to avoid overriding or displacement. A study of the presentation is as necessary for the bronchoscopist as for the obstetrician. It should be made with a view to determining the following points: 1. The relation of the presenting part to the surrounding tissues. 2. The probable position of the unseen portion, as determined by the appearance of the presenting part taken in connection with the knowledge obtained by the previous ray study, and by inspection of the ray plate upside down on view in front of the bronchoscopist. 3. The version or other manipulation necessary to convert an unfavorable into a favorable presentation for grasping and disengagement. 4. The best instruments to use, and which to use first, as, hook, pincloser, forceps, etc. 5. The presence and position of the "forceps spaces" of which there must be two for all ordinary forceps, one for each jaw, or the "insertion space" for any other instrument.

Until all of these points are determined it is a grave error to insert any kind of instrument. If possible even swabbing of the foreign body should be avoided by swabbing out the bronchus, when necessary, before the region of the intruder is reached. When the operator has determined the instrument to be used, and the method of using it, the instrument is cautiously inserted, under guidance of the eye.

[160] The lip of the bronchoscope is one of the most valuable aids in the solution of foreign-body problems. With it partial or complete version of an object can be accomplished so as to convert an unfavorable presentation into one favorable for grasping with the forceps; edematous mucosa may be displaced, angles straightened and space made at the side of the foreign body for the forceps' jaw. It forms a shield or protector that can be slipped under the point of a sharp foreign body and can make counterpressure on the tissues while the forceps are disembedding the point of the foreign body. With the bronchoscopic lip and the forceps or other instrument inserted through the tube, the bronchoscopist has bimanual, eye-guided control, which if it has been sufficiently practiced to afford the facility in coordinate use common to everyone with knife and fork, will accomplish maneuvers that seem marvelous to anyone who has not developed facility in this coordinate use of the bronchoscopic instruments.

The relation of the tube mouth and foreign body is of vital importance. Generally considered, the tube mouth should be as near the foreign body as possible, and the object must be placed in the center of the bronchoscopic field, so that the ends of the open jaws of the forceps will pass sufficiently far over the object. But little lateral control is had of the long instruments inserted through the tube; sidewise motion is obtained by a shifting of the end of the bronchoscope. When the foreign body has been centered in the bronchoscopic field and placed in a position favorable for grasping, it is important that this position be maintained by anchoring the tube to the upper teeth with the left, third, and fourth fingers hooked over the patient's upper alveolus (Fig. 63)

The Light Reflex on the Forceps.—It is often difficult for the beginner to judge to what depth an instrument has been inserted through the tube. On slowly inserting a forceps through the tube, as the blades come opposite the distal light they will appear brightly illuminated; or should the blades lie close to the light bulb, a shadow will be seen in the previously brilliantly lighted opposite wall. It is then known that the forceps are at the tube mouth, and the endoscopist has but to gauge the distance from this to the foreign body. This assistance in gauging depth is one of the great advances in foreign body bronchoscopy obtained by the development of distal illumination.

Hooks are useful in the solution of various mechanical problems, and may be turned by the operator himself into various shapes by heating small probe-pointed steel rods in a spirit lamp, the proximal end being turned over at a right angle for a controlling handle. Hooks with a greater curve than a right angle are prone to engage in small orifices from which they are with difficulty removed. A right angle curve of the distal end is usually sufficient, and a corkscrew spiral is often advantageous, rendering removal easy by a reversal of the twisting motion (Bib. 11, p. 311).

The Use of Forceps in Endoscopic Foreign Body Extraction.—Two different strengths of forceps are supplied, as will be seen in the list in Chapter 1. The regular forceps have a powerful grasp and are used on dense foreign bodies which require considerable pressure on the object to prevent the forceps from slipping off. For more delicate manipulation, and particularly for friable foreign bodies, the lighter forceps are used. Spring-opposed forceps render any delicacy of touch impossible. Forceps are to be held in the right hand, the thumb in one ring, and the third, or ring finger, in the other ring. These fingers are used to open and close the forceps, while all traction is to be made by the right index finger, which has its position on the forceps handle near the stylet, as shown in Fig. 78. It is absolutely essential for accurate work, that the forceps jaws be seen to close upon the foreign body. The impulse to seize the object as soon as it is discovered must be strongly resisted. A careful study of its size, shape, and position and relation to surrounding structures must be made before any attempt at extraction. The most favorable point and position for grasping having been obtained, the closed forceps are inserted through the bronchoscope, the light reflex obtained, the forceps blades now opened are turned in such a position that, on advancing, the foreign body will enter the open V, a sufficient distance to afford a good grasp. The blades are then closed and the foreign body is drawn against the tube mouth. Few foreign bodies are sufficiently small to allow withdrawal through the tube, so that tube, forceps and foreign body are usually withdrawn together.

[FIG. 78.—Proper hold of forceps. The right thumb and third fingers are inserted into the rings while the right index finger has its place high on the handle. All traction is made with the index finger, the ring fingers being used only to open and close the forceps. If any pushing is deemed safe it may be done by placing the index finger back of the thumb-nut on the stylet.]

Anchoring the Foreign Body Against the Tube Mouth.—If withdrawal be made a bimanual procedure it is almost certain that the foreign body will trail a centimeter or more beyond the tube mouth, and that the closure of the glottic chink as soon as the distal end of the bronchoscope emerges will strip the foreign body from the forceps grasp, when the foreign body reaches the cords. This is avoided by anchoring the foreign body against the tube mouth as soon as the foreign body is grasped, as shown in Fig. 79. The left index finger and thumb grasp the shaft of the forceps close to the ocular end of the tube, while the other fingers encircle the tube; closure of the forceps is maintained by the fingers of the right hand, while all traction for withdrawal is made with the left hand, which firmly clamps forceps and bronchoscope as one piece. Thus the three units are brought out as one; the bronchoscope keeping the cords apart until the foreign body has entered the glottis.

[FIG. 79—Method of anchoring the foreign body against the tube mouth After the object has been drawn firmly against the lip of the endoscopic tube the left finger and thumb grasp the forceps cannula and lock it against the ocular end of the tube, the other fingers of the left hand encircle the tube. Withdrawal is then done with the left hand; the fingers of the right hand maintaining closure of the forceps.]

[164] Bringing the Foreign Body Through the Glottis.—Stripping of the foreign body from the forceps at the glottis may be due to: 1. Not keeping the object against the tube mouth as just mentioned. 2. Not bringing the greatest diameter of the foreign body into the sagittal plane of the glottic chink. 3. Faulty application of the forceps on the foreign body. 4. Mechanically imperfect forceps.

Should the foreign body be lost at the glottis it may, if large become impacted and threaten asphyxia. Prompt insertion of the laryngoscope will usually allow removal of the object by means of the laryngeal grasping forceps. The object may be dropped or expelled into the pharynx and be swallowed. It may even be coughed into the naso-pharynx or it may be re-aspirated. In the latter event the bronchoscope is to be re-inserted and the trachea carefully searched. Care must be used not to override the object. If much inflammatory reaction has occurred in the first invaded bronchus, temporarily suspending the aerating function of the corresponding lung, reaspiration of a dislodged foreign body is liable to carry it into the opposite main bronchus, by reason of the greater inspiratory volume of air entering that side. This may produce sudden death by blocking the only aerating organ.

Extraction of Pins, Needles and Similar Long Pointed Objects.—When searching for such objects especial care must be taken not to override them. Pins are almost always found point upward, and the dictum can therefore be made, "Search not for the pin, but for the point of the pin." If the point be found free, it should be worked into the lumen of the bronchoscope by manipulation with the lip of the tube. It may then be seized with the forceps and withdrawn. Should the pin be grasped by the shaft, it is almost certain to turn crosswise of the tube mouth, where one pull may cause the point to perforate, enormously increasing the difficulties by transfixation, and perhaps resulting fatally (Fig. 80).

[FIG. 80.—Schematic illustration of a serious phase of the error of hastily seizing a transfixed pin near its middle, when first seen as at M. Traction with the forceps in the direction of the dart in Schema B will rip open the esophagus or bronchus inflicting fatal trauma, and probably the pin will be stripped off at the glottic or the cricopharyngeal level, respectively. The point of the pin must be disembedded and gotten into the tube mouth as at A, to make forceps traction safe.]

[FIG. 81.—Schema illustrating the mechanical problem of extracting a pin, a large part of whose shaft is buried in the bronchial wall, B. The pin must be pushed downward and if the orifice of the branches, C, D, are too small to admit the head of the pin some other orifice (as at A) must be found by palpation (not by violent pushing) to admit the head, so that the pin can be pushed downward permitting the point to emerge (E). The point is then manipulated into the bronchoscopic tube-mouth by means of co-ordinated movements of the bronchoscopic lip and the side-curved forceps, as shown at F.]

Inward Rotation Method.—When the point is found to be buried in the mucosa, the best and usually successful method is to grasp the pin as near the point as possible with the side-grasping forceps, then with a spiral motion to push the pin downward while rotating the forceps about ninety degrees. The point is thus disengaged, and the shaft of the pin is brought parallel with that of the forceps, after which the point may be drawn into the tube mouth. The lips added to the side-curved forceps by my assistant Dr. Gabriel Tucker I now use exclusively for this inward rotation method. They are invaluable in preventing the escape of the pin during the manipulation. A hook is sometimes useful in disengaging a buried point. The method of its use is illustrated in Fig. 82.

[FIG. 82.—Mechanical problem of pin, needle, tack or nail with embedded point. If the forceps are pulled upon the pin point will be buried still deeper. The side curved forceps grasp the pin as near the point as possible then with a corkscrew motion the pin is pushed downward and rotated to the right when the pin will be found to be parallel with the shaft of the forceps and can be drawn into the tube. If the pin is prevented by its head from being pushed downward the point may be extracted by the hook as shown above The side curved forceps may be used instead of the hook for freeing the point, the author's "inward rotation" method. The very best instrument for the purpose is the forceps devised by my assistant, Dr. Gabriel Tucker (Fig. 21). The lips prevent all risk of losing the pin from the grasp, and at the same time bring the long axis of the pin parallel to that of the bronchoscope.]

Pins are very prone to drop into the smaller bronchi and disappear completely from the ordinary field of endoscopic exploration. At other times, pins not dropping so deeply may show the point only during expiration or cough, at which times the bronchi are shortened. In such instances the invaded bronchial orifice should be clearly exposed as near the axis of its lumen as possible; the forceps are now inserted, opened, and the next emergence watched for, the point being grasped as soon as seen.

Extraction of Tacks, Nails and Large Headed Foreign Bodies from the Tracheobronchial Tree.—In cases of this sort the point presents the same difficulty and requires solution in the same manner as mentioned in the preceding paragraphs on the extraction of pins. The author's inward-rotation method when executed with the Tucker forceps is ideal. The large head, however, presents a special problem because of its tendency to act as a mushroom anchor when buried in swollen mucosa or in a fibrous stenosis (Fig. 83). The extraction problems of tacks are illustrated in Figs. 84, 85, and 86. Nails, stick pins, and various tacks are dealt with in the same manner by the author's "inward rotation" method.

Hollow metallic bodies presenting an opening toward the observer may be removed with a grooved expansile forceps as shown in Figs 23 and 25, or its edge may be grasped by the regular side-grasping forceps. The latter hold is apt to be very dangerous because of the trauma inflicted by the catching of the free edge opposite the forceps; but with care it is the best method. Should the closed end be uppermost, however, it may be necessary to insert a hook beyond the object, and to coax it upward to a point where it may be turned for grasping and removal with forceps.

[FIG. 83.—"Mushroom anchor" problem of the upholstery tack. If the tack has not been in situ more than a few weeks the stenosis at the level of the darts is simply edematous mucosa and the tack can be pulled through with no more than slight mucosal trauma, provided axis-traction only be used. If the tack has been in situ a year or more the fibrous stricture may need dilatation with the divulsor. Otherwise traction may rupture the bronchial wall. The stenotic tissue in cases of a few months' sojourn maybe composed of granulations, in which case axis-traction will safely withdraw it. The point of a tack rarely projects freely into the lumen as here shown. More often it is buried in the wall.]

[168] [FIG. 84.-Schema illustrating the "mushroom anchor" problem of the brass headed upholstery tack. At A the tack is shown with the head bedded in swollen mucosa. The bronchoscopist, looking through the bronchoscope, E, considering himself lucky to have found the point of the tack, seizes it and starts to withdraw it, making traction as shown by the dart in drawing B. The head of the tack catches below a chondrial ring and rips in, tearing its way through the bronchial wall (D) causing death by mediastinal emphysema. This accident is still more likely to occur if, as often happens, the tack-head is lodged in the orifice of the upper lobe bronchus, F. But if the bronchoscopist swings the patient's head far to the opposite side and makes axis-traction, as shown at C, the head of the tack can be drawn through the swollen mucosa without anchoring itself in a cartilage. If necessary, in addition, the lip of the bronchoscope can be used to repress the angle, h, and the swollen mucosa, H. If the swollen mucosa, H, has been replaced by fibrous tissue from many months' sojourn of the tack, the stenosis may require dilatation with the divulsor.]

[FIG. 85.—Problem of the upholstery tack with buried point. If pulled upon, the imminent perforation of the mediastinum, as shown at A will be completed, the bronchus will be torn and death will follow even if the tack be removed, which is of doubtful possibility. The proper method is gently to close the side curved forceps on the shank of the tack near the head, push downward as shown by the dart, in B, until the point emerges. Then the forceps are rotated to bring the point of the tack away from the bronchial wall.]

[169] Removal of Open Safety Pins from the Trachea and Bronchi.— Removal of a closed safety pin presents no difficulty if it is grasped at one or the other end. A grasp in the middle produces a "toggle and ring" action which would prevent extraction. When the safety pin is open with the point downward care must be exercised not to override it with the bronchoscope or to push the point through the wall. The spring or near end is to be grasped with the side-curved or the rotation forceps (Figs. 19, 20 and 31) and pulled into the bronchoscope, thus closing the pin. An open safety pin lodged point up presents an entirely different and a very difficult problem. If traction is made without closing the pin or protecting the point severe and probably fatal trauma will be produced. The pin may be closed with the pin-closer as illustrated in Fig. 37, and then removed with forceps. Arrowsmith's pin-closer is excellent. Another method (Fig. 87) consists in bringing the point of the safety pin into the bronchoscope, after disengaging the point with the side curved forceps, by the author's "inward rotation" method. The forceps-jaws (Fig. 21) devised recently by my assistant, Dr. Gabriel Tucker, are ideal for this maneuver. As the point is now protected, the spring, seen just off the tube mouth, is best grasped with the rotation forceps, which afford the securest hold. The keeper and its shaft are outside the bronchoscope, but its rounded portion is uppermost and will glide over the tissues without trauma upon careful withdrawal of the tube and safety pin. Care must be taken to rotate the pin so that it lies in the sagittal plane of the glottis with the keeper placed posteriorly, for the reason that the base of the glottic triangle is posterior, and that the posterior wall of the larynx is membranous above the cricoid cartilage, and will yield. A small safety-pin may be removed by version, the point being turned into a branch bronchial orifice. No one should think of attempting the extraction of a safety pin lodged point upward without having practiced for at least a hundred hours on the rubber tube manikin. This practice should be carried out by anyone expecting to do endoscopy, because it affords excellent education of the eye and the fingers in the endoscopic manipulation of any kind of foreign body. Then, when a safety pin case is encountered, the bronchoscopist will be prepared to cope with its difficulties, and he will be able to determine which of the methods will be best suited to his personal equation in the particular case.

[FIG. 86.—Schema illustrating the "upper-lobe-bronchus problem," combined with the "mushroom-anchor" problem and the author's method for their solution. The patient being recumbent, the bronchoscopist looking down the right main bronchus, M, sees the point of the tack projecting from the right upper-lobe-bronchus, A. He seizes the point with the side-curved forceps; then slides down the bronchoscope to the position shown dotted at B. Next he pushes the bronchoscopic tube-mouth downward and medianward, simultaneously moving the patient's head to the right, thus swinging the bronchoscopic level on its fulcrum, and dragging the tack downward and inward out of its bed, to the position, 1). Traction, as shown at C, will then safely and easily withdraw the tack. A very small bronchoscope is essential. The lip of the bronchoscopic tube-mouth must be used to pry the forceps down and over, and the lip must be brought close to the tack just before the prying-pushing movement. S, right stem-bronchus.]

[FIG. 87.—One method of dealing with an open safety pin without closing it.]

Removal of Double Pointed Tacks.—If the tack or staple be small, and lodged in a relatively large trachea a version may be done. That is, the staple may be turned over with the hook or rotation forceps and brought out with the points trailing. With a long staple in a child's trachea the best method is to "coax" the intruder along gently under ocular guidance, never making traction enough to bury the point deeply, and lifting the point with the hook whenever it shows any inclination to enter the wall. Great care and dexterity are required to get the intruder through the glottis. In certain locations, one or both points may be turned into branch bronchi as illustrated in Fig. 88, or over the carina into the opposite main bronchus. Another method is to get both points into the tube-mouth. This may be favored, as demonstrated by my assistant, Dr. Gabriel Tucker, by tilting the staple so as to get both points into the longest diameter of the tube-mouth. In some cases I have squeezed the bronchoscope in a vise to create an oval tube-mouth. In other cases I have used expanding forceps with grooved blades.

[FIG. 88.-Schema illustrating podalic version of bronchially-lodged staples or double-pointed tacks. H, bronchoscope. A, swollen mucosa covering points of staple. At E the staple has been manipulated upward with bronchoscopic lip and hooks until the points are opposite the branch bronchial orifices, B, C. Traction being made in the direction of the dart (F), by means of the rotation forceps, and counterpressure being made with the bronchoscopic lip on the points of the staple, the points enter the branch bronchi and permit the staple to be turned over and removed with points trailing harmlessly behind (K).]

The Extraction of Tightly Fitting Foreign Bodies from the Bronchi. Annular Edema.—Such objects as marbles, pebbles, corks, etc., are drawn deeply and with force by the inspiratory blast into the smallest bronchus they can enter. The air distal to the impacted foreign body is soon absorbed, and the negative pressure thus produced increases the impaction. A ring of edematous mucosa quickly forms and covers the presenting part of the object, leaving visible only a small surface in the center of an acute edematous stenosis. A forceps with narrow, stiff, expansive-spring jaws may press back a portion of the edema and may allow a grasp on the sides of the foreign body; but usually the attempt to apply forceps when there are no spaces between the presenting part of the foreign body and the bronchial wall, will result only in pushing the foreign body deeper.* A better method is to use the lip of the bronchoscope to press back the swollen mucosa at one point, so that a hook may be introduced below the foreign body, which then can be worked up to a wider place where forceps may be applied (Fig. 89). Sometimes the object may even be held firmly against the tube mouth with the hook and thus extracted. For this the unslanted tube-mouth is used.