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Esophagoscopic Extraction Of Foreign Bodies

Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery

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.

Sponging should be done cautiously lest the foreign body be hidden in
secretions or food accumulation, and dislodged. Small food masses
often lodge above the foreign body and are best removed with forceps.
The folds of the esophagus are to be carefully searched with the aid
of the lip of the esophagoscope. If the mucosa of the esophagus is
lacerated with the forceps all further work is greatly hampered by the
oozing; if the laceration involve the esophageal wall the accident may
be fatal: and at best the tendency of the tube-mouth to enter the
laceration and create a false passage is very great.

Overriding or failure to find a foreign body known to be present
is explained by the collapsed walls and folds covering the object,
since the esophagoscope cannot be of sufficient size to smooth out
these folds, and still be of small enough diameter to pass the
constricted points of the esophagus noted in the chapter on anatomy.
Objects are often hidden just distal to the cricopharyngeal fold,
which furthermore makes a veritable chute in throwing the end of the
tube forward to override the foreign body and to interpose a layer of
tissue between the tube and the object, so that the contact at the
side of the tube is not felt as the tube passes over the foreign body
(Fig. 91). The chief factors in overriding an esophageal foreign body
1. The chute-like effect of the plica cricopharyngeus.
2. The chute-like effect of other folds.
3. The lurking of the foreign body in the unexplored pyriform sinus.
4. The use of an esophagoscope of small diameter.
5. The obscuration of the intruder by secretion or food debris.
6. The obscuration of the intruder by its penetration of the
esophageal wall.
7. The obscuration of the intruder by inflammatory sequelae.

[FIG. 91.--Illustrating the hiding of a coin by the folding downward
of the plica cricopharyngeus. The muscular contraction throws the beak
of the esophagoscope upward while the interposed tissue prevents the
tactile appreciation of contact of the foreign body with the side of
the tube after the tip has passed over the foreign body. Other folds
may in rare instances act similarly in hiding a foreign body from
view. This overriding of a foreign body is apt to cause dangerous
dyspnea by compression of the party wall.]

The esophageal speculum for the removal of foreign bodies is useful
when the object is not more than 2 cm. below the cricoid in a child,
and 3 cm. in the adult. The fold of the cricopharyngeus can be
repressed posteriorward by the forceps which are then in position to
grasp the object when it is found. The author's down-jaw forceps (Fig.
22) are very useful to reach down back of the cricopharyngeal fold,
because of the often small posterior forceps space. The speculum has
the disadvantage of not allowing deeper search should the foreign body
move downward. In infants, the child's size laryngoscope may be used
as an esophageal speculum. General anesthesia is not only unnecessary
but dangerous, because of the dyspnea created by the endoscopic tube.
Local anesthesia is unnecessary as well as dangerous in children; and
its application is likely to dislodge the foreign body unless used as
a troche. Forbes esophageal speculum is excellent.

Next: Mechanical Problems Of Esophagoscopic Removal Of Foreign Bodies

Previous: Contraindications

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