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, bismuth 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 passage 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 passage 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 passage 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 Bismuth 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 instituted. 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.