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


Categories: FOREIGN BODIES IN THE AIR AND FOOD PASSAGES
Sources: 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

air-passages.

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

diseases.

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

esophagoscopy.



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

difficulty.



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.





More

;