Cases in which foreign bodies have passed from the mouth, and in some instances from the stomach, into the gullet or air-passages, are very serious and often present great difficulties in diagnosis. There may be a distinct history pointing to such an accident, but if there is no such history and the surgeon has to trust alone to the results of his examination the cases are very obscure.<Callout type="warning" title="Be Vigilant">Always consider the possibility of foreign bodies when dealing with sudden respiratory issues.</Callout> The symptoms vary greatly with the position, size, and nature of the foreign body; they may be so severe as to threaten or cause sudden death, or so slight and ambiguous as to be altogether overlooked. In addition to those more or less directly resulting from the impaction of a foreign body, there are those due to the secondary inflammatory changes set up; these may be either acute or very chronic.<Callout type="important" title="Seek Immediate Medical Attention">Do not delay in seeking medical help if you suspect a foreign body is present.</Callout> The diagnosis—In cases of extreme urgency with sudden dyspnoea threatening life, the surgeon will at once thrust his finger to the back of the mouth to feel for and to dislodge any body that may be over or in the upper orifice of the larynx and failing this, will proceed to open the larynx or trachea, without waiting to make an exact diagnosis of the cause and actual position of the obstruction.<Callout type="tip" title="Use Diagnostic Tools">Whenever possible, use Rontgen rays, laryngoscope, bronchoscope, or oesophagoscope for a more accurate diagnosis.</Callout> Foreign bodies in pharynx or oesophagus.—The usual mode of procedure was for the surgeon to pass his right forefinger into the pharynx, and with it to explore the fauces, tonsils, upper orifice of larynx, and as far down the pharynx as he could reach; in many cases this would suffice to determine the presence and position of a foreign body, and even to dislodge it. But it was at the best a rough method, and it gave no information about foreign bodies that had passed through the rima glottidis or into the gullet.<Callout type="risk" title="Be Prepared for Unexpected Findings">Foreign bodies can be smaller than expected and may cause significant harm.</Callout> Whenever possible the diagnosis is to be made by sight, and the exact nature, position, and relations of the foreign body identified. We have two means of doing this: by the Rontgen rays we can obtain a picture of coins and other metallic foreign bodies; and by the laryngoscope, bronchoscope, and oesophagoscope we can see foreign bodies of any kind, whether in the pharynx, gullet, larynx, trachea, or main bronchi.<Callout type="gear" title="Essential Equipment">Ensure you have access to Rontgen equipment, laryngoscopes, and bronchoscopes for accurate diagnosis.</Callout> It is usually easy to determine whether the foreign body is lodged in the air-passages or in the food-passage: dyspnoea and cough indicate the one; dysphagia the other. If the patient can drink off a glass of water quickly and can swallow bread readily it may be accepted that the pharynx and oesophagus are free.<Callout type="important" title="Monitor Symptoms Closely">Continue monitoring for any changes in symptoms, even after initial relief.</Callout> By throwing a strong light from a brow mirror or electric lamp into the mouth, that cavity and the fauces and central region of the pharynx can be well explored. With the laryngoscope the larynx can be examined, and where there is found free and the symptoms point to the air-passages, should be admitted and the bronchoscope carefully passed into the trachea and, if necessary, into each bronchus.<Callout type="tip" title="Be Patient">Examine slowly and carefully to avoid missing small but dangerous foreign bodies.</Callout> Should the food-passage be suspected, the oesophagoscope is passed slowly and carefully, and by this means the lower end of the naso-pharynx can be explored. Sometimes forced every time he swallows. Careful inspection may lead the surgeon to a false diagnosis for if it is in the gullet, and if not followed carefully, pain will continue, whereas, if a foreign body is lodged in one of the main bronchi, e.g., a plum-stone in the right bronchus, the physical examination of the chest gives very characteristic signs. The right side of the chest will make no respiratory movements; it will be resonant on percussion, and there will be an absence of breath-sounds, unless there be a sibilant rhonchus heard over the bronchus and due to incomplete plugging of the bronchus.<Callout type="important" title="Listen for Sibilant Rhonchi">Sibilant rhonchi may indicate partial obstruction in one lung.</Callout> The lung on the unaffected side will be hyper-resonant; its respiratory movements and sounds will be exaggerated. It should be remembered that in such cases there may be no dyspnoea or distress while the patient is quiet. Should an absence of breath-sounds or a loud sonorous or sibilant rale be detected over a part of one lung, the condition may be attributed to the impaction of a foreign body in one of the secondary or tertiary bronchial tubes.<Callout type="risk" title="Be Prepared for Latent Symptoms">Symptoms may subside quickly after initial obstruction, but this does not mean the foreign body has been expelled.</Callout> Cases where foreign bodies have lodged once and have set up suppuration, chronic bronchiectasis, and pulmonary fibrosis are rare unless the history of the onset of the affection is elicited. Unusual localization or exact limitation of the physical signs, however, should always suggest inquiry as to the possibility of the cause being an impacted foreign body. The image may be explored for a foreign body by the finger passed into the pleural sac.<Callout type="important" title="Do Not Ignore Persistent Symptoms">Persistent symptoms after initial relief can indicate ongoing issues.</Callout> There are other cases of injury from foreign bodies getting into the air-passages or gullet viz. those due to hot liquids or caustics. In such cases, the lips, mouth, and tongue may or may not show signs of scalding, or of the caustic effects of acids or alkalis. In some instances the rapid onset of laryngeal obstruction in a child who has shown no previous symptoms is the first and only evidence of scald of the larynx.
Key Takeaways
- Always consider the possibility of foreign bodies when dealing with sudden respiratory issues.
- Use Rontgen rays, laryngoscope, bronchoscope, or oesophagoscope for a more accurate diagnosis.
- Be prepared for unexpected findings; foreign bodies can be smaller than expected and may cause significant harm.
Practical Tips
- Always have access to diagnostic tools such as Rontgen equipment, laryngoscopes, and bronchoscopes in emergency situations.
- Monitor symptoms closely even after initial relief, as symptoms may subside quickly but the foreign body could still be present.
- Be patient during examinations; rushing can lead to missing small but dangerous foreign bodies.
Warnings & Risks
- Do not delay in seeking medical help if you suspect a foreign body is present.
- Be prepared for latent symptoms; initial relief does not mean the foreign body has been expelled.
- Foreign bodies can cause significant harm, especially when they are smaller than expected and lodged in critical areas.
Modern Application
While the specific techniques described in this chapter may be outdated, the principles of recognizing and responding to foreign bodies remain crucial for modern survival preparedness. Understanding how to quickly identify potential hazards and seek appropriate medical attention can save lives in emergency situations.
Frequently Asked Questions
Q: How can a surgeon determine if a foreign body is lodged in the air-passages or food-passage?
The presence of dyspnoea and cough indicates a foreign body in the air-passages, while dysphagia suggests it's in the food-passage. A patient who can drink water quickly and swallow bread easily may indicate that both passages are clear.
Q: What tools should be used for diagnosing foreign bodies in the pharynx or oesophagus?
The chapter recommends using a right forefinger to explore the pharynx, but more accurate methods include Rontgen rays, laryngoscope, bronchoscope, and oesophagoscope. These tools help identify the exact nature, position, and relations of the foreign body.
Q: What are some signs that a patient may have an impacted foreign body in one of their main bronchi?
Signs include the absence of respiratory movements on the affected side, resonance on percussion, and the absence of breath-sounds. A sibilant rhonchus heard over the bronchus due to incomplete plugging can also indicate a partial obstruction.