The Roentgenographic Signs Of Expiratory-valve-like Bronchial Obstruction


Categories: FOREIGN BODIES IN THE AIR AND FOOD PASSAGES
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

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).

4. Limitation of the diaphragmatic excursion on the obstructed side

(Manges).



It is very important to note that, as discovered by Manges, the

differential emphysema occurs at the end of expiration and the plate

must be exposed at that time, before inspiration starts. He also noted

that at fluoroscopy the heart moved laterally toward the uninvaded

side during expiration.*



* Dr. Manges has developed such a high degree of skill in the

fluoroscopic diagnosis of non-opaque foreign bodies by the obstructive

emphysema they produce that he has located peanut kernels and other

vegetable substances with absolute accuracy and unfailing certainty in

dozens of cases at the Bronchoscopic Clinic.



[FIG. 74--Expiratory valve-like bronchial obstruction by

non-radiopaque foreign body, producing an acute obstructive emphysema.

Peanut kernel in right main bronchus. Note (a) depression of right

diaphragm; (b) displacement of heart and mediastinum to left; (c)

greater transparency of the invaded side. Ray-plate made by Willis F.

Manges.]



Complete bronchial obstruction shows a density over the whole area

the aeration and drainage of which has been cut off (Fig. 75).

Pulmonary abscess formation and drowned lung (accumulated secretion

in the bronchi and bronchioli) are shown by the definite shadows

produced (Fig. 76).



[140] Dense and metallic objects will usually be readily seen in the

roentgenograms and fluoroscope, but many foreign bodies are of a

nature which will produce no shadow; the roentgenologist should,

therefore, be prepared to interpret the pulmonary pathology, and

should not dismiss the case as negative for foreign body because one

is not seen. Even metallic objects are in rare cases exceedingly

difficult to demonstrate.



[FIG. 75.--Radiograph showing pathology resulting from complete

obstruction of a bronchus with atelectasis and drowned lung resulting.

Foot of an alarm clock in left bronchus of 4 year old child. Present

25 days. Plate made by Johnston and Grier.]



Positive Films of the Tracheo-bronchial Tree as an Aid to

Localization.--In order to localize the bronchus invaded by a small

foreign body the positive film is laid over the negative of the

patient showing the foreign body. The shadow of the foreign body will

then show through the overlying positive film. These positive films

are made in twelve sizes, and the size selected should be that

corresponding to the size of the patient as shown by the

roentgenograph. The dome of the diaphragm and the dome of the pleura

are taken as visceral landmarks for placing the positive films which

have lines indicating these levels. If the shadow of the foreign body

be faint it may be strengthened by an ink mark on the

uncoated side of the plate.



[FIG. 76.--Partial bronchial obstruction for long period of time

Pathology, bronchiectasis and pulmonary abscess, produced by the

presence for 4 years of a nail in the left lung of a boy of 10 years]



Bronchial mapping is readily accomplished by the author's method of

endobronchial insufflation of a roentgenopaque inert powder such as

bismuth subnitrate or subcarbonate (Fig. 77). The roentgenopaque

substance may be injected in a fluid mixture if preferred, but the

walls are better outlined with the powder (Fig. 77).



[FIG. 77.--Roentgenogram showing the author's method of bronchial

mapping or lung-mapping by the bronchoscopic introduction of opaque

substances (in this instance powdered bismuth subnitrate) into the

lung of the patient. Plate made by David R. Bowen. (Illustration,

strengthened for reproduction, is from author's article in American

Journal of Roentgenology, Oct., 1918.)]





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