Site Of Lodgment

Categories: FOREIGN BODIES IN THE LARYNX AND TRACHEOBRONCHIAL TREE
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

The majority of foreign bodies in the air

passages occur in children. The right bronchus is more frequently

invaded than the left because of the following factors: I. Its greater

diameter. 2. Its lesser angle of deviation from the tracheal axis. 3.

The situation of the carina to the left of the mid-line of the

trachea. 4. The action of the trachealis muscle. 5. The greater volume

of air going into the right bronchus on inspiration.



The middle lobe bronchus is rarely invaded by foreign body, and,

fortunately, in less than one per cent of the cases is the object in

an upper lobe bronchus.



Spontaneous Expulsion of Foreign Bodies from the Air Passages. A

large, light, foreign body in the larynx or trachea may occasionally

be coughed out, but the frequent newspaper accounts of the sudden

death of children known to have aspirated objects should teach us

never to wait for this occurrence. The cause of death in these cases

is usually the impaction of a large foreign body in the glottis

producing sudden asphyxiation, and in a certain proportion of these

cases the impaction has occurred on the reverse journey, when cough

forced the intruder upward from below. The danger of subglottic

impaction renders it imperative that attempts to aid spontaneous

expulsion by inverting the patient should be discouraged. Sharp

objects, such as pins, are rarely coughed out. The tendency of all

foreign bodies is to migrate down and out to the periphery as their

size and shape will allow. Most of the reported cases of bechic

expulsion of bronchially lodged foreign bodies have occurred after a

prolonged sojourn of the object, associated which much lung pathology;

and in some cases the object has been carried out along with an

accumulation of pus suddenly liberated from an abscess cavity, and

expelled by cough. This is a rare sequence compared to the usual

formation of fibrous stricture above the foreign body that prevents

the possibility of bechic expulsion. To delay bronchoscopy with the

hope of such a solution of the problem is comparable to the former

dependence on nature for the cure of appendiceal abscess.



We do our full duty when we tell the patient or parents that while the

foreign body may be coughed up, it is very dangerous to wait; and,

further, that the difficulty of removal usually increases with the

time the foreign body is allowed to remain in the air passages.



Mortality and morbidity of bronchoscopy vary directly with the

degree of skill and experience of the operator, and the conditions for

which the endoscopies are performed. The simple insertion of the

bronchoscope is devoid of harm if carefully done. The danger lies in

misdirected efforts at removal of the intruder and in repeating

bronchoscopies in children at too frequent intervals, or in prolonging

the procedure unduly. In children under one year endoscopy should be

limited to twenty minutes, and should not be repeated sooner than one

week after, unless urgently indicated. A child of 5 years will bear 40

to 60 minutes work, while the adult offers no unvarying time limit.

More can be ultimately accomplished, and less reaction will follow

short endoscopies repeated at proper intervals than in one long

procedure.



Indications for bronchoscopy for suspected foreign body may be thus

summarized:

1. The appearance of a suspicious shadow in the radiograph, in the

line of a bronchus.

2. In any case in which lung symptoms followed a clear history of

the patient having choked on a foreign body.

3. In any case showing signs of obstruction in the trachea or of a

bronchus.

4. In suspected bronchiectasis.

5. Symptoms of pulmonary tuberculosis with sputum constantly

negative for tubercle bacilli. If the physical signs are at the base,

particularly the right base, the indication becomes very strong even

in the absence of any foreign body circumstance in the history.

6. In all cases of doubt, bronchoscopy should be done anyway.



There is no absolute contraindication to bronchoscopy for foreign

bodies. Extreme exhaustion or reaction from previous efforts at

removal may call for delay for recuperation, but pulmonary abscess and

even the rarer complications, bronchopneumonia and gangrene of the

lung, are improved by the early removal of the foreign body.