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Symptomatology And Diagnosis Of Foreign Bodies In The Air And Food Passages

Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery

Initial symptoms are choking, gagging, coughing, and wheezing, often
followed by a symptomless interval. The foreign body may be in the
larynx, trachea, bronchi, nasal chambers, nasopharynx, fauces, tonsil,
pharynx, hypopharynx, esophagus, stomach, intestinal canal, or may
have been passed by bowel, coughed out or spat out, with or without
the knowledge of the patient. Initial choking, etcetera may have
escaped notice, or may have been forgotten.

Laryngeal Foreign Body.--One or more of the following laryngeal
symptoms may be present: Hoarseness, croupy cough, aphonia,
odynphagia, hemoptysis, wheezing, dyspnea, cyanosis, apnea, subjective
sensation of foreign body. Croupiness in foreign body cases, as in
diphtheria, usually means subglottic swelling. Obstructive foreign
body may be quickly fatal by laryngeal impaction on aspiration, or on
abortive bechic expulsion. Lodgement of a non-obstructive foreign body
may be followed by a symptomless interval. Direct laryngoscopy for
diagnosis is indicated in every child having laryngeal diphtheria
without faucial membrane. (No anesthetic, general or local is needed.)
In the presence of laryngeal symptoms, think of the following:
1. A foreign body in the larynx.
2. A foreign body loose or fixed in the trachea.
3. Digital efforts at removal.
4. Instrumentation.
5. Overflow of food into the larynx from esophageal obstruction due
to the foreign body.
6. Esophagotracheal fistula from ulceration set up by a foreign body
in the esophagus, followed by the leakage of food into the
7. Laryngeal symptoms may persist from the trauma of a foreign body
that has passed on into the deeper air or food passages or that has
been coughed or spat out.
8. Laryngeal symptoms (hoarseness, croupiness, etcetera) may be due
to digital or instrumental efforts at the removal of a foreign body
that never was present.
9. Laryngeal symptoms may be due to acute or chronic laryngitis,
diphtheria, pertussis, infective laryngotracheitis, and many other
10. Deductive decisions are dangerous.
11. If the roentgenray is negative, laryngoscopy (direct in
children, indirect in adults) without anesthesia, general or local, is
the only way to make a laryngeal diagnosis.
12. Before doing a diagnostic laryngoscopy, preparation should be
made for taking a swab-specimen and for bronchoscopy and

Tracheal Foreign Body.--(1) Audible slap, (2) palpatory thud,

and (3) asthmatoid wheeze are pathognomonic. The tracheal flutter
has been observed by McCrae in a case of watermelon seed. Cough,
hoarseness, dyspnea, and cyanosis are often present. Diagnosis is by
roentgenray, auscultation, palpation, and bronchoscopy. Listen long
for audible slap, best heard at open mouth during cough. The
asthmatoid wheeze is heard with the ear or stethoscope bell (McCrae)
at the patient's open mouth. History of initial choking, gagging, and
wheezing is important if elicited, but is valueless negatively.

Bronchial Foreign Body.--Initial symptoms are coughing, choking,
asthmatoid wheeze, etc. noted above. There may be a history of these
or of tooth extraction. At once, or after a symptomless interval,
cough, blood-streaked sputum, metallic taste, or special odor of
foreign body may be noted. Non-obstructive metallic foreign bodies
afford few symptoms and few signs for weeks or months. Obstructive
foreign bodies cause atelectasis, drowned lung, and eventually
pulmonary abscess. Lobar pneumonia is an exceedingly rare sequel.
Vegetable organic foreign bodies as peanut-kernels, beans, watermelon
seeds, etcetera, cause at once violent laryngotracheobronchitis, with
toxemia, cough and irregular fever, the gravity and severity being
inversely to the age of the child. Bones, animal shells and inorganic
bodies after months or years produce changes which cause chills,
fever, sweats, emaciation, clubbed fingers, incurved nails, cough,
foul expectoration, hemoptysis, in fact, all the symptoms of chronic
pulmonary sepsis, abscess, and bronchiectasis. These symptoms and some
of the physical signs may suggest pulmonary tuberculosis, but the
apices are normal and bacilli are absent from the sputum. Every acute
or chronic chest case calls for the exclusion of foreign body.

The physical signs vary with conditions present in different cases
and at different times in the same case. Secretions, normal and
pathologic, may shift from one location to another; the foreign body
may change its position admitting more, less, or no air, or it may
shift to a new location in the same lung or even in the other lung. A
recently aspirated pin may produce no signs at all. The signs of
diagnostic importance are chiefly those of partial or complete
bronchial obstruction, though a non-obstructive foreign body, a pin
for instance, may cause limited expansion (McCrae) or, rarely, a
peculiar rale or a peculiar auscultatory sound. The most nearly
characteristic physical signs are: (1) Limited expansion; (2)
decreased vocal fremitus; (3) impaired percussion note; (4) diminished
intensity of the breath-sounds distal to the foreign body. Complete
obstruction of a bronchus followed by drowned lung adds absence of
vocal resonance and vocal fremitus, thus often leading to an erroneous
diagnosis of empyema. Varying grades of tympany are obtained over
areas of obstructive or compensatory emphysema. With complete
obstruction there may be tympany from the collapsed lung for a time.
Rales in case of complete obstruction are usually most intense on the
uninvaded side. In partial obstruction they are most often found on
the invaded side distal to the foreign body, especially posteriorly,
and are most intense at the site corresponding to that of the foreign
body. A foreign body at the bifurcation of the trachea may give signs
in both lungs. Early in a foreign body case, diminished expansion of
one side, with dulness, may suggest pneumonia in the affected side;
but absence of, or decreased, vocal resonance, and absence of typical
tubular breathing should soon exclude this diagnosis. Bronchial
obstruction in pneumonia is exceedingly rare.

Memorize these signs suggestive of foreign body:
1. Expansion--diminished.
2. Percussion note--impaired (except in obstructive emphysema).
3. Vocal fremitus--diminished.
4. Breath sounds--diminished.

The foregoing is only for memorizing, and must be considered in the
light of the following fundamental note by Prof. McCrae There is no
one description of physical signs which covers all cases. If the
student will remember that complete obstruction of a bronchus leads to
a shutting off of this area, there should be little difficulty in
understanding the signs present. The diagnosis of empyema may be made,
but the outline of the area of dulness, the fact that there is no
shifting dulness, and the greater resistance which is present in
empyema nearly always clear up any difficulty promptly. The absence of
the frequent change in the voice sounds, so significant in an early
small empyema, is of value. A large empyema should give no difficulty.
If difficulty remains the use of the needle should be sufficient. In
thickened pleura vocal fremitus is not entirely absent, and the
breath-sounds can usually be heard, even if diminished. In case of
partial obstruction of a bronchus, it is evident that air will still
be present, hence the dulness may be only slight. The presence of air
and secretion will probably result in the breath-sounds being somewhat
harsh, and will cause a great variety of rales, principally coarse,
and many of them bubbling. Difficulty may be caused by signs in the
other lung or in a lobe other than the one affected by the foreign
body. If it is remembered that these signs are likely to be only on
auscultation, and to consist largely in the presence of rales, while
the signs in the area supplied by the affected bronchus will include
those on inspection, palpation, and percussion, there should be little

The roentgenray is the most valuable diagnostic means; but careful
notation of physical signs by an expert should be made in all cases
preferably without knowledge of ray findings. Expert ray work will
show all metallic foreign bodies and many of less density, such as
teeth, bones, shells, buttons, etcetera. If the ray is negative, a
diagnostic bronchoscopy should be done in all cases of unexplained
bronchial obstruction.

Peanut kernels and watermelon seeds and, rarely, other foreign bodies
in the bronchi produce obstructive emphysema of the invaded side.
Fluoroscopy shows the diaphragm flattened, depressed and of less
excursion on the invaded side; at the end of expiration, the heart and
the mediastinal wall move over toward the uninvaded side and the
invaded lung becomes less dense than the uninvaded lung, from the
trapping of the air by the expiratory, valve-like effect of
obliteration of the forceps spaces that during inspiration afford
air ingress between the foreign body and the swollen bronchial wall.
This partial obstruction causes obstructive emphysema, which must be
distinguished from compensatory emphysema, in which the ballooning is
in the unobstructed lung, because its fellow is wholly out of function
through complete corking of the main bronchus of the invaded side.

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