Bronchoscopy and Esophagoscopy Part 8

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 pa.s.sages 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 exact.i.tude, 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, a.s.sociated 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 Pa.s.sAGES

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 a.s.sociated 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 inters.p.a.ces 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 pa.s.sage of air during the bronchial dilatation incident to inspiration, const.i.tuting an expiratory valve-like obstruction.

3. Partial bronchial obstruction, allowing to-and-fro pa.s.sage 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 acc.u.mulate. 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 m.u.f.fled 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 pa.s.sage 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 b.a.l.l.s 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 a.s.sociated 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 pa.s.s to and fro with some degree of r.e.t.a.r.dation, 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 pa.s.sage 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 Pa.s.sages. 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 pa.s.sage 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 exact.i.tude 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 a.s.sumed that position by pa.s.sing 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 pa.s.s through the glottic c.h.i.n.k, 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).