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.