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

by Chevalier Jackson

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.