[181] CHAPTER XVII--UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES

The limitations of bronchoscopic removal of foreign bodies are usually manifested in the failure to find a small foreign body which has entered a minute bronchus far down and out toward the periphery. When localization by means of transparent films, fluoroscopy, and endobronchial bis.m.u.th insufflation has failed, the question arises as to the advisability of endoscopic excision of the tissue intervening between the foreign body and bronchoscope with the aid of two fluoroscopes, one for the lateral and the other the vertical plane.

With foreign bodies in the larger bronchi near the root of the lung such a procedure is unnecessary, and injury to a large vessel would be almost certain. At the extreme periphery of the lung the danger is less, for the vessels are smaller and serious hemorrhage less probable, through the retention and decomposition of blood in small bronchi with later abscess formation is a contingency. The nature of the bridge of tissue is to be considered; should it be cicatricial, the result of prolonged inflammatory processes, it may be carefully excised without very great risk of serious complications. The blood vessels are diminished in size and number by the chronic productive inflammation, which more than offsets their lessened contractility.

The possibility of the foreign body being coughed out after suppurative processes have loosened its impaction is too remote; and the lesions established may result fatally even after the expulsion of the object. Pulmonary abscess formation and rupture into the pleura should not be awaited, for the foreign body does not often follow the pus into the pleural cavity. It remains in the lung, held in a bed of granulation tissue. Furthermore, to await the development is to subject the patient to a prolonged and perhaps fatal sepsis, or a fatal pulmonary hemorrhage from the erosion of a vessel by the suppurative process. The recent developments in thoracic surgery have greatly decreased the operative mortality of thoracotomy, so that this operation is to be considered when bronchoscopy has failed.

Bronchoscopy can be considered as having failed, for the time being, when two or more expert bronchoscopists on repeated search have been unable to find the foreign body or to disentangle it; but the art of bronchoscopy is developing so rapidly that the failures of a few years ago would be easy successes today. Before considering thoracotomy months of study of the mechanical problem are advisable. It is probable that any foreign body of appreciable size that has gone down the natural pa.s.sages can be brought back the same way.

In the event of a foreign body reaching the pleura, either with or without pus, it should be removed immediately by pleuroscopy or by thoracotomy, without waiting for adhesive pleuritis.

The problem may be summarized thus: 1. Large foreign bodies in the trachea or large bronchi can always be removed by bronchoscopy.

2. The development of bronchoscopy having subsequently solved the problems presented by previous failures, it seems probable that by patient developmental endeavor, any foreign body of appreciable size that has gone down through the natural pa.s.sages, can be bronchoscopically removed the same way, provided fatal trauma is avoided.

At the author's Bronchoscopic Clinics 98.7 per cent of foreign bodies have been removed.

CHAPTER XVIII--FOREIGN BODIES IN THE ESOPHAGUS

_Etiology_.--The lodgement of foreign bodies in the esophagus is influenced by: 1. The shape of the foreign body (disc-shaped, pointed, irregular).

2. Resiliency of the object (safety pins).

3. The size of the foreign body.

4. Narrowing of the esophagus, spasmodic or organic, normal, or pathologic.

5. Paralysis of the normal esophageal propulsory mechanism.

The lodgement of a bolus of ordinary food in the esophagus is strongly suggestive of a preexisting narrowing of the lumen of either a spasmodic or organic nature; a large bolus of food, poorly masticated and hurriedly swallowed, may, however, become impacted in a perfectly normal esophagus.

Carelessness is the cause of over 80 per cent of the foreign bodies in the esophagus (see Bibliography, 29).

_Site of Lodgement_.--Almost all foreign bodies are arrested in the cervical esophagus at the level of the superior aperture of the thorax. A physiologic narrowing is present at this level, produced in part by muscular contraction, and mainly by the crowding of the adjacent viscera into the fixed and narrow upper thoracic aperture. If dislodged from this position the foreign body usually pa.s.ses downward to be arrested at the next narrowing or to pa.s.s into the stomach. The esophagoscopist who encounters the difficulty of introduction at the cricopharyngeal fold expects to find the foreign body above the fold.

Such, however, is almost never the case. The cricopharyngeus muscle functionates in starting the foreign body downward as if it were food; but the narrowing at the upper thoracic aperture arrests it because the esophageal peristaltic musculature is feeble as compared to the powerful inferior constrictor.

_Symptoms_.--_Dysphagia_ is the most frequent complaint in cases of esophageally lodged foreign bodies. A very small object may excite sufficient spasm to cause aphagia, while a relatively large foreign body may be tolerated, after a time, so that the swallowing function may seem normal. Intermittent dysphagia suggests the tilting or shifting of a foreign body in a valve-like fashion; but may be due to occlusion of the by-pa.s.sages by food arrested by the foreign body.

_Dyspnea_ may be present if the foreign body is large enough to compress the trachea. _Cough_ may be excited by reflex irritation, overflow of secretions into the larynx, or by perforation of the posterior tracheal wall, traumatic or ulcerative, allowing leakage of food or secretion into the trachea. (See Chapter XII for discussion of symptomatology and diagnosis.)

_Prognosis_.--A foreign body lodged in the esophagus may prove quickly fatal from _hemorrhage_ due to perforation of a large vessel; from _asphyxia_ by pressure on the trachea; or from _perforation_ and _septic mediastinitis_. Slower fatalities may result from suppuration extending to the trachea or bronchi with consequent edema and asphyxia. Sooner or later, if not removed, the foreign body causes death. It may be tolerated for a long period of time, causing abscess, cervical cellulitis, fistulous tracts, and ultimately extreme stenosis from cicatricial contraction. Perichondritis of the laryngeal or tracheal cartilages may follow, and result in laryngeal stenosis requiring tracheotomy. The damage produced by the foreign body is often much less than that caused by blind and ill-advised attempts at removal. If the foreign body becomes dislodged and moves downward, the danger of intestinal perforation is encountered. The _prognosis_, therefore, must be guarded so long as the intruder remains in the body.

_Treatment_.--It is a mistake to try to force a foreign body into the stomach with the stomach tube or bougie. Sounding the esophagus with bougies to determine the level of the obstruction, or to palpate the nature of the foreign body, is unnecessary and dangerous.

Esophagoscopy should not be done without a previous roentgenographic and fluoroscopic examination of the chest and esophagus, except for urgent reasons. The level of the stenosis, and usually the nature of the foreign body, can thus be decided. Blind instrumentation is dangerous, and in view of the safety and success of esophagoscopy, reprehensible.

If for any reason removal should be delayed, bis.m.u.th sub-nitrate, gramme 0.6, should be given dry on the tongue every four hours. It will adhere to the denuded surfaces. The addition of calomel, gramme 0.003, for a few doses will increase the antiseptic action. Should swallowing be painful, gramme 0.2 of orthoform or anesthesin will be helpful. Emetics are inefficient and dangerous. Holding the patient up by the heels is rarely, if ever, successful if the foreign body is in the esophagus. In the reported cases the intruder was probably in the pharynx.

_External esophagotomy_ for the removal of foreign bodies is unjustifiable until esophagoscopy has failed in the hands of at least two skillful esophagoscopists. It has been the observation in the Bronchoscopic Clinic that every foreign body that has gone down through the mouth into the esophagus can be brought back the same way, unless it has already perforated the esophageal wall, in which event it is no longer a case of foreign body in the esophagus. The mortality of external esophagotomy for foreign bodies is from twenty to forty-two per cent, while that of esophagoscopy is less than two per cent, if the foreign body has not already set up a serious complication before the esophagoscopy. Furthermore, external esophagotomy can be successful only with objects lodged in the cervical esophagus and, moreover, it has happened that after the esophagus has been opened, the foreign body could not be found because of dislodgement and pa.s.sage downward during the relaxation of the general anesthesia. Should this occur during esophagoscopy, the foreign body can be followed with the esophagoscope, and even if it is not overtaken and removed, no risk has been incurred.

Esophagoscopy is the one method of removal worthy of serious consideration. Should it repeatedly fail in the hands of two skillful endoscopists, which will be very rarely, if ever, then external operation is to be considered in cervically lodged foreign bodies.

[187] CHAPTER XIX--ESOPHAGOSCOPY FOR FOREIGN BODY

_Indications_.--Esophagoscopy is demanded in every case in which a foreign body is known to be, or suspected of being, in the esophagus.

_Contraindications_.--There is no absolute contraindication to careful esophagoscopy for the removal of foreign bodies, even in the presence of aneurism, serious cardiovascular disease, hypertension or the like, although these conditions would render the procedure inadvisable.

Should the patient be in bad condition from previous ill-advised or blind attempts at extraction, endoscopy should be delayed until the traumatic esophagitis has subsided and the general state improved. It is rarely the foreign body itself which is producing these symptoms, and the removal of the object will not cause their immediate subsidence; while the pa.s.sage of the tube through the lacerated, infected, and inflamed esophagus might further harm the patient.

Moreover, the foreign body will be difficult to find and to remove from the edematous and bleeding folds, and the risk of following a false pa.s.sage into the mediastinum or overriding the foreign body is great. Water starvation should be relieved by means of proctoclysis and hypodermoclysis before endoscopy is done. The esophagitis is best treated by placing dry on the tongue at four-hour intervals the following powder: Rx. Anesthesin...gramme 0.12 Bis.m.u.th subnitrate...gramme 0.6 Calomel, gramme 0.006 to 0.003 may be added to each powder for a few doses to increase the antiseptic effect. If the patient can swallow liquids it is best to wait one week from the time of the last attempt at removal before any endoscopy for extraction be done. This will give time for nature to repair the damage and render the removal of the object more certain and less hazardous. Perforation of the esophagus by the foreign body, or by blind instrumentation, is a contraindication to esophagoscopy. It is manifested by such signs as subcutaneous emphysema, swelling of the neck, fever, irritability, increase in pulsatory and respiratory rates, and pain in the neck or chest. Gaseous emphysema is present in some cases, and denotes a dangerous infection. Esophagoscopy should be postponed and the treatment mentioned at the end of this chapter inst.i.tuted. After the subsidence of all symptoms other than esophageal, esophagoscopy may be done safely. Pleural perforation is manifested by the usual signs of pneumothorax, and will be demonstrated in the roentgenogram.

ESOPHAGOSCOPIC EXTRACTION OF FOREIGN BODIES

It is unwise to do an endoscopy in a foreign-body case for the sole purpose of taking a preliminary look. Everything likely to be needed for extraction of the intruder should be sterile and ready at hand.

Furthermore, all required instruments for laryngoscopy, bronchoscopy or tracheotomy should be prepared as a matter of routine, however rarely they may be needed.

Sponging should be done cautiously lest the foreign body be hidden in secretions or food acc.u.mulation, and dislodged. Small food ma.s.ses often lodge above the foreign body and are best removed with forceps.

The folds of the esophagus are to be carefully searched with the aid of the lip of the esophagoscope. If the mucosa of the esophagus is lacerated with the forceps all further work is greatly hampered by the oozing; if the laceration involve the esophageal wall the accident may be fatal: and at best the tendency of the tube-mouth to enter the laceration and create a false pa.s.sage is very great.

_"Overriding" or failure to find a foreign body known to be present_ is explained by the collapsed walls and folds covering the object, since the esophagoscope cannot be of sufficient size to smooth out these folds, and still be of small enough diameter to pa.s.s the constricted points of the esophagus noted in the chapter on anatomy.

Objects are often hidden just distal to the cricopharyngeal fold, which furthermore makes a veritable chute in throwing the end of the tube forward to override the foreign body and to interpose a layer of tissue between the tube and the object, so that the contact at the side of the tube is not felt as the tube pa.s.ses over the foreign body (Fig. 91). The chief factors in overriding an esophageal foreign body are: 1. The chute-like effect of the plica cricopharyngeus.

2. The chute-like effect of other folds.

3. The lurking of the foreign body in the unexplored pyriform sinus.

4. The use of an esophagoscope of small diameter.

5. The obscuration of the intruder by secretion or food debris.

6. The obscuration of the intruder by its penetration of the esophageal wall.

7. The obscuration of the intruder by inflammatory sequelae.

[FIG. 91.--Ill.u.s.trating the hiding of a coin by the folding downward of the plica cricopharyngeus. The muscular contraction throws the beak of the esophagoscope upward while the interposed tissue prevents the tactile appreciation of contact of the foreign body with the side of the tube after the tip has pa.s.sed over the foreign body. Other folds may in rare instances act similarly in hiding a foreign body from view. This overriding of a foreign body is apt to cause dangerous dyspnea by compression of the party wall.]

_The esophageal speculum for the removal of foreign bodies_ is useful when the object is not more than 2 cm. below the cricoid in a child, and 3 cm. in the adult. The fold of the cricopharyngeus can be repressed posteriorward by the forceps which are then in position to grasp the object when it is found. The author's down-jaw forceps (Fig.

22) are very useful to reach down back of the cricopharyngeal fold, because of the often small posterior forceps s.p.a.ce. The speculum has the disadvantage of not allowing deeper search should the foreign body move downward. In infants, the child's size laryngoscope may be used as an esophageal speculum. General anesthesia is not only unnecessary but dangerous, because of the dyspnea created by the endoscopic tube.

Local anesthesia is unnecessary as well as dangerous in children; and its application is likely to dislodge the foreign body unless used as a troche. Forbes esophageal speculum is excellent.

MECHANICAL PROBLEMS OF ESOPHAGOSCOPIC REMOVAL OF FOREIGN BODIES

The bronchoscopic problems considered in the previous chapter should be studied.

_The extraction of transfixed foreign bodies_ presents much the same problem as those in the bronchi, though there is no limit here to the distance an object may be pushed down to free the point. Thin, sharp foreign bodies such as bones, dentures, pins, safety-pins, etcetera, are often found to lie crosswise in the esophagus, and it is imperative that one end be disengaged and the long axis of the object be made to correspond to that of the esophagus before traction for removal is made (Fig. 92). Should the intruder be grasped in the center and traction exerted, serious and perhaps fatal trauma might ensue.

[191] [FIG. 92.--The problem of the horizontally transfixed foreign body in the esophagus. The point, D, had caught as the bone, A, was being swallowed. The end, E, was forced down to C, by food or by blind attempts at pushing the bone downward. The wall, F, should be laterally displaced to J, with the esophagoscope, permitting the forceps to grasp the end, M, of the bone. Traction in the direction of the dart will disimpact the bone and permit it to rotate. The rotation forceps are used as at K.]

[FIG. 93.--Solution of the mechanical problem of the broad foreign body having a sharp point by version. If withdrawn with plain forceps as applied at A, the point B, will rip open the esophageal wall. If grasped at C, the point, D, will rotate in the direction of F and will trail harmlessly. To permit this version the rotation forceps are used as at H. On this principle flat foreign bodies with jagged or rough parts are so turned that the potentially traumatizing parts trail during withdrawal.]

The extraction of broad, flat foreign bodies having a sharp point or a rough place on part of their periphery is best accomplished by the method of rotation as shown in Fig. 93.

_Extraction of Open Safety-pins from the Esophagus_.--An open safety pin with the point down offers no particular mechanical difficulty in removal. Great care must be exercised, however, that it be not overridden or pushed upon, as either accident might result in perforation of the esophagus by the pin point. The coiled spring is to be sought, and when found, seized with the rotation forceps and the pin thus drawn into the esophagoscope to effect closure. An open safety-pin lodged point upward in the esophagus is one of the most difficult and dangerous problems. A roentgenogram should always be made in the plane showing the widest spread of the pin. It is to be remembered that the endoscopist can see but one portion of the pin at a time (except in cases of very small safety-pins) and that if he grasps the part first showing, which is almost invariably the keeper, fatal trauma will surely be inflicted when traction is made. It may be best to close the safety pin with the safety-pin closer, as ill.u.s.trated in Fig. 37. For this purpose Arrowsmith's closer is excellent. In other cases it may prove best to disengage the point of the pin and to bring the pointed shaft into the esophagoscope with the Tucker forceps and withdraw the pin, forceps, and esophagoscope, with the keeper and its shaft sliding alongside the tube. The rounded end of the keeper lying outside the tube allows it to slip along the esophageal walls during withdrawal without inflicting trauma; however, should resistance be felt, withdrawal must immediately cease and the pin must be rotated into a different plane to release the keeper from the fold in which it has probably caught. The sense of touch will aid the sense of sight in the execution of this maneuver (Fig. 87). When the pin reaches the cricopharyngeal level the esophagoscope, forceps, and pin should be turned so that the keeper will be to the right, not so much because of the cricopharyngeal muscle as to escape the posteriorly protuberant cricoid cartilage. In certain cases in which it is found that the pointed shaft of a small safety pin has penetrated the esophageal wall, the pin has been successfully removed by working the keeper into the tube mouth, grasping the keeper with the rotation forceps or side-curved forceps, and pulling the whole pin into the tube by straightening it. This, however, is a dangerous method and applicable in but few cases. It is better to disengage the point by downward and inward rotation with the Tucker forceps.

_Version of a Safety Pin_.--A safety pin of very small size may be turned over in a direction that will cause the point to trail. An advancing point will puncture. This is a dangerous procedure with a large safety pin.

_Endogastric Version_.--A very useful and comparatively safe method is ill.u.s.trated in Figs. 94 and 95. In the execution of this maneuver the pin is seized by the spring with a rotation forceps, and thus pa.s.sed along with the esophagoscope into the stomach where it is rotated so that the spring is uppermost. It can then be drawn into the tube mouth so as to protect the tissues during withdrawal of the pin, forceps, and esophagoscope as one piece. Only very small safety-pins can be withdrawn through the esophagoscope.

_Spatula-protected Method_.--Safety-pins in children, point upward, when lodged high in the cervical esophagus may be readily removed with the aid of the laryngoscope, or esophageal speculum. The keeper end is grasped with the alligator forceps, while the spatular tip of the laryngoscope is worked under the point. Instruments and foreign body are then removed together. Often the pin point will catch in the light-chamber where it is very safely lodged. If the pin be then pulled upon it will straighten out and may be withdrawn through the tube.

[FIG. 94.--Endogastric version. One of the author's methods of removal of upward pointed esophageally lodged open safety-pins by pa.s.sing them into stomach, where they are turned and removed. The first ill.u.s.tration (A) shows the rotation forceps before seizing pin by the ring of the spring end. (Forceps jaws are shown opening in the wrong diameter.) At B is shown the pin seized in the ring by the points of the forceps. At C is shown the pin carried into the stomach and about to be rotated by withdrawal. D, the withdrawal of the pin into the esophagoscope which will thereby close it. If withdrawn by flat-jawed forceps as at F, the esophageal wall would be fatally lacerated.]