Extraction Of Tacks Nails And Large Headed Foreign Bodies From The Tracheobronchial Tree

Categories: MECHANICAL PROBLEMS OF BRONCHOSCOPIC FOREIGN BODY EXTRACTION
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

In cases of this sort the point presents the

same difficulty and requires solution in the same manner as mentioned

in the preceding paragraphs on the extraction of pins. The author's

inward-rotation method when executed with the Tucker forceps is ideal.

The large head, however, presents a special problem because of its

tendency to act as a mushroom anchor when buried in swollen mucosa or

in a fibrous stenosis (Fig. 83) The extraction problems of tacks are

illustrated in Figs. 84, 85, and 86. Nails, stick pins, and various

tacks are dealt with in the same manner by the author's inward

rotation method.



Hollow metallic bodies presenting an opening toward the observer may

be removed with a grooved expansile forceps as shown in Figs 23 and

25, or its edge may be grasped by the regular side-grasping forceps.

The latter hold is apt to be very dangerous because of the trauma

inflicted by the catching of the free edge opposite the forceps; but

with care it is the best method. Should the closed end be uppermost,

however, it may be necessary to insert a hook beyond the object, and

to coax it upward to a point where it may be turned for grasping and

removal with forceps.



[FIG. 83.--Mushroom anchor problem of the upholstery tack. If the

tack has not been in situ more than a few weeks the stenosis at the

level of the darts is simply edematous mucosa and the tack can be

pulled through with no more than slight mucosal trauma, provided

axis-traction only be used. If the tack has been in situ a year or

more the fibrous stricture may need dilatation with the divulsor.

Otherwise traction may rupture the bronchial wall. The stenotic tissue

in cases of a few months' sojourn maybe composed of granulations, in

which case axis-traction will safely withdraw it. The point of a tack

rarely projects freely into the lumen as here shown. More often it is

buried in the wall.]



[168] [FIG. 84.-Schema illustrating the mushroom anchor problem of

the brass headed upholstery tack. At A the tack is shown with the head

bedded in swollen mucosa. The bronchoscopist, looking through the

bronchoscope, E, considering himself lucky to have found the point of

the tack, seizes it and starts to withdraw it, making traction as

shown by the dart in drawing B. The head of the tack catches below a

chondrial ring and rips in, tearing its way through the bronchial wall

(D) causing death by mediastinal emphysema. This accident is still

more likely to occur if, as often happens, the tack-head is lodged in

the orifice of the upper lobe bronchus, F. But if the bronchoscopist

swings the patient's head far to the opposite side and makes

axis-traction, as shown at C, the head of the tack can be drawn

through the swollen mucosa without anchoring itself in a cartilage. If

necessary, in addition, the lip of the bronchoscope can be used to

repress the angle, h, and the swollen mucosa, H. If the swollen

mucosa, H, has been replaced by fibrous tissue from many months'

sojourn of the tack, the stenosis may require dilatation with the

divulsor.]



[FIG. 85.--Problem of the upholstery tack with buried point. If pulled

upon, the imminent perforation of the mediastinum, as shown at A will

be completed, the bronchus will be torn and death will follow even if

the tack be removed, which is of doubtful possibility. The proper

method is gently to close the side curved forceps on the shank of the

tack near the head, push downward as shown by the dart, in B, until

the point emerges. Then the forceps are rotated to bring the point of

the tack away from the bronchial wall.]