Bronchoscopy and Esophagoscopy / A Manual of Peroral Endoscopy and Laryngeal Surgery

by Chevalier Jackson

[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.