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Mechanical Problems Of Bronchoscopic Foreign Body Extraction*
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Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery
The esophagoscope, like the bronchoscope, is a
hollow brass tube with beveled distal end containing a small
electric light. It differs from the bronchoscope in that it has no
perforations, and has a drainage canal on its upper surface, or next
to the light-carrier canal which opens within the distal end of the
tube. The exact size, position, and shape of the drainage outlets is
important on bronchoscopes, and to an even greater degree on
esophagoscopes. If the proximal edge of the drainage outlet is too
near the distal end of the endoscopic tube, the mucosa will be drawn
into the outlet, not only obstructing it, but, most important,
traumatizing the mucosa. If, for instance, the esophagoscope were to
be pushed upon with a fold thus anchored in the distal end, the
esophageal wall could easily be torn. To admit the largest sizes of
esophagoscopic bougies (Fig. 40), special esophagoscopes (Fig. 5) are
made with both light canal and drainage canal outside the lumen of the
tube, leaving the full area of luminal cross-section unencroached
upon. They can, of course, be used for all purposes, but the slightly
greater circumference is at times a disadvantage. The esophageal and
stomach secretions are much thinner than bronchial secretions, and, if
free from food, are readily aspirated through a comparatively small
canal. If the canal becomes obstructed during esophagoscopy, the
positive pressure tube of the aspirator is used to blow out the
obstruction. Two sizes of esophagoscopes are all that are required--7
mm. X 45 cm. for children, and 10 mm. X 53 cm. for adults (Fig. 3, A
and B); but various other sizes and lengths are used by the author for
special purposes.* Large esophagoscopes cause dangerous dyspnea in
children. If, it is desired to balloon the esophagus with air, the
window plug shown in Fig. 6, is inserted into the proximal end of the
esophagoscope, and air insufflated by means of the hand aspirator or
with a hand bulb. The window can be replaced by a rubber diaphragm
with a perforation for forceps if desired. It will be noted that none
of the endoscopic tubes are fitted with mandrins. They are to be
introduced under the direct guidance of the eye only. Mandrins are
obtainable, but their use is objectionable for a number of reasons,
chief of which is the danger of overriding a foreign body or a lesion,
or of perforating a lesion, or even the normal esophageal wall. The
slanted end on the esophagoscope obviates the necessity of a mandrin
for introduction. The longer the slant, with consequent acuting of the
angle, the more the introduction is facilitated; but too acute an
angle increases the risk of perforating the esophageal wall, and
necessitates the utmost caution. In some foreign-body cases an acute
angle giving a long slant is useful, in others a short slant is
better, and in a few cases the squarely cut-off distal end is best. To
have all of these different slants on hand would require too many
tubes. Therefore the author has settled upon a moderate angle for the
end of both esophagoscopes and bronchoscopes that is easy to insert,
and serves all purposes in the version and other manipulations
required by the various mechanical problems of foreign-body
extraction. He has, however, retained all the experimental models, for
occasional use in such cases as he falls heir to because of a problem
of extraordinary difficulty.
* A 9 mm. X 45 cm. esophagoscope will reach the stomach of almost all
adults and is somewhat easier to introduce than the 10 mm. X 53 cm.,
which may be omitted from the set if economy must be practiced.
[FIG. I.--Author's laryngoscopes. These are the standard sizes and
fulfill all requirements. Many other forms have been devised by the
author, but have been omitted from the list as unnecessary. The infant
diagnostic laryngoscope (C) is not for introducing bronchoscopes,
and is not absolutely necessary, as the larynx of any infant can be
inspected with the child's size laryngoscope (B).
A Adult's size; B, child's size; C, infant's diagnostic size; D,
anterior commissure laryngoscope; E, with drainage canal; 17,
intubating laryngoscope, large lumen. All the laryngoscopes are
preferred without drainage canals.]
[FIG. 2.--The author's bronchoscopes of the sizes regularly used.
Various other lengths and diameters are on hand for occasional use
for special purposes. With the exception of a 6 mm. X 35 cm. size
for older children, these special bronchoscopes are very rarely
used and none of them can be regarded as necessary. For special
purposes, however, special shapes of tube-mouth are useful, as,
for instance, the oval end to facilitate the getting of both
points of a staple into the tube-mouth The illustrated instruments
are as follows:
A, Infant's size, 4 mm. X 30 cm.; B, child's size, 5 mm. X 30 cm.;
C, adolescent's size, 7 mm. X 40 cm.; D, adult's size, 9 mm. X 40 cm.;
E, aspirating bronchoscope made in all the foregoing sizes, and in a
special size, 5 mm. X 45 cm.]
[FIG. 3.--The author's esophagoscopes of the sizes he has standardized
for all ordinary requirements. He uses various other lengths and sizes
for special purposes, but none of them are really necessary. A
gastroscope, 10 mm. X 70 cm., is useful for adults, especially in
cases of gastroptosis. Drainage canals are placed at the top or at the
side of the tube, next to the light-carrier canal.
A, Adult's size, 10 mm. X 53 cm.; B, child's size, 7 mm. X 45 cm.; C
and D, full lumen, with both light canal and drainage canal outside
the wall of the tube, to be used for passing very large bougies. This
instrument is made in adult, child, and adolescent (8 mm. by 45 cm.)
sizes. Gastroscopes and esophagoscopes of the sizes given above (A)
and (B), can be used also as gastroscopes. A small form of C, 5 mm. X
30 cm. is used in infants, and also as a retrograde esophagoscope in
patients of any age. E, window plug for ballooning gastroscope, F.]
[FIG. 4.--Author's short esophagoscopes and esophageal specula
A, Esophageal speculum and hypopharyngoscope, adult's size; B,
esophageal speculum and hypopharyngoscope, child's size; C, heavy
handled short esophagoscope; D, heavy handled short esophagoscope with
[FIG. 5.--Cross section of full-lumen esophagoscope for the use of
largest bourgies. The canals for the light carrier and for drainage
are so constructed that they do not encroach upon the lumen of the
 The special sized esophagoscopes most often useful are the 8 mm.
X 30 cm., the 8 mm. X 45 cm., and the 5 mm. X 45 cm. These are made
with the drainage canal in various positions.
For operations on the upper end of the esophagus, and particularly for
foreign body work, the esophageal speculum shown at A and B, in Fig.
4, is of the greatest service. With it, the anterior wall of the
post-cricoidal pharynx is lifted forward, and the upper esophageal
orifice exposed. It can then be inserted deeper, and the upper third
of the esophagus can be explored. Two sizes are made, the adult's and
the child's size. These instruments serve, very efficiently as
pleuroscopes. They are made with and without drainage canals, the
latter being the more useful form.
[FIG. 6.--Window-plug with glass cap interchangeable with a cap having
a rubber diaphragm with a perforation so that forceps may be used
without allowing air to escape. Valves on the canals (E, F, Fig. 3)