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 passages 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 passages, 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 passes downward to be arrested at the next narrowing or to pass 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-passages 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.)