ŒSOPHAGOSCOPY, LARYNGOSCOPY, AND BRONCHOSCOPY

66 while

prefer general anaesthesia, ŒSOPHAGOSCOPY, LARYNGOSCOPY, AND general with local ansesthesia

BRONCHOSCOPY AS AN AID TO THE DEFECTION OF DISEASE AND REMOVAL OF FOREIGN BODIES IMPACTED IN THE FOOD AND AIR PASSAGES.1

BY WILLIAM

MILLIGAN, M.D. ABERD.,

AURIST AND LARYNGOLOGIST TO THE MANCHESTER ROYAL INFIRMARY; SURGEON TO THE MANCHESTER EAR HOSPITAL ; LECTURER ON DISEASES OF THE EAR, THE VICTORIA UNIVERSITY, MANCHESTER.

a

is

combination of light advocated by many

experienced observers. Where a simple examination only is to be undertaken, spraying the pharynx and upper laryngeal orifice with cocaine (20 per cent.) and adrenalin (1/1000), equal parts, and swabbing the mucosa of the hypopharynx with the same solution, will as a rule be found sufficiently effective. If, however, any operative interference is contemplated-e.g., the removal of a foreign body, portion of growth, &c.general anaesthesia preceded by an injection of scopolomorphine and atropine is preferable, and is certainly

indicated in nervous individuals and in children. RECENT improvements in endoscopic methods of exaPosition of the patient.-The patient may be examined mination have enormously increased our knowledge of in the If in the former he or in the prone position. morbid affections of the oesophagus, trachea, and upper should sitting sit upright upon a low stool (Brfinings), with the segments of the bronchial tree, and have greatly facilitated head thrown slightly backwards and firmly held by an the detection and removal of impacted foreign bodies. In if in the latter, lying either upon his back (dorsal 1868 Kussmaul read a paper before the Scientific Society assistant ; or upon his side (right or left lateral position), position) of Freiburg upon the Examination of the Normal and with head slightly extended. Should there be an excessive Pathological CEsophagus with Rigid Tubes, making use of flow of saliva it is advisable -to place a saliva pump (conDesormeaux’s apparatus for the purpose of illumination. nected with the main water-supply) in the angle of the A few years later von Miculicz adapted Leiter’s illuminating mouth. The well greased and warmed, oesophagoscope, apparatus-an interior lamp of platinum wire with water- may be introduced with a mandrin by the sense of touch cooling-to Kussmaul’s rigid tubes, with the result that or by ocular inspection without a mandrin. The latter much important physiological and pathological work upon method, although somewhat more difficult, is unquestionthe food and air passages was successfully accomplished. ably the more exact and scientific, as the eye sees and To Kirstein, Killian, von Eicken, and Briinings, however, follows the advance of the tube in its passage downwards. belongs the credit of having systematised and popularised The blind introduction of rigid tubes, bougies, probangs, this important method of examination and means of treatcoin-catchers, &c., is to be condemned, as being highly ment. The problem of how best to illuminate the particular and likely to injure, if not to perforate, the walls dangerous region to be inspected has been notably advanced by the of the cesophagus. It is essential that the tube be kept work of Leiter, Caspar, Kirstein, Guisez, and Brunings, all in the middle line and passed downwards with care and of whom favour the employment of exterior illumination, the patient being meanwhile encouraged to put gentleness, whereas Einhorn, Chevalier Jackson, and Glucksmann prefer up with the temporary discomfort it causes. Where secreinterior illumination. tion wells up into the lumen of the tube, frequent drying of the mucosa with cotton-tipped probes or the use of an (Esophag08coP!! . Endoscopic examination of the oesophagus has demon- aspirator is called for. strated that its course along the front of the vertebral Foreign bodies, unless embedded in the walls of the column is practically straight, the various curvatures so oesophagus or covered with granulation tissue, are as a rule frequently alluded to in anatomical text-books being easily seen. Their extraction is at times, however, difficult, apparently due to post-mortem changes, such as an more especially so in the case of dentures or those with altered position of the diaphragm, the varying weight of sharp points which become embedded in the mucosa, and the stomach according to the amount of its contents, and unless very carefully handled are apt during extraction to the relaxation of the pharyngeal musculature (Mehnert). lacerate, if not to perforate, its walls. To obviate this The hypopharynx or post-cricoidal pharynx, now generally difficulty it may be necessary to "turn"the foreign body conceded as ending at the lower border of the cricoid so that any sharp edges it may possess point downwards, cartilage where the fibres of the inferior constrictor form or to employ some such instrument as Hill’s expanding a prominent fold upon the post-pharyngeal wall, is an oesophagoscope, which when opened out ground the foreign extremely important segment of the alimentary tract, as body enables extraction to be accomplished without injury foreign bodies frequently become impacted at its lower end to the surrounding walls. Impacted foreign bodies should where it is continuous with the oesophagus. The oesophagus be extracted before inflammatory symptoms supervene or proper consists of a cervical and an intrathoracic segment, ulceration takes place. The longer the foreign body remains the former running in the middle line between the vertebral in the food passage the greater the risk of ulceration extendcolumn and the trachea, the latter deviating slightly to ing to adjoining structures-e.g., aorta, mediastinum, pleural the left to reach the extramedian position of the pars cavity, or lung. The following cases illustrate the value of oesophagodiaphragmatica. The length of the oesophagus (from the lower edge of the cricoid cartilage to the cardia) varies scopy as an aid to diagnosis and as an efficient therapeutic considerably according to the measurements of different measure. 1. Brooch in child’s asophagus.-The patient, a female, aged observers. These measurements, as given by von Hacker, 1 CASE and 1 month, was admitted to hospital on account craving year are as follows. The average distance from the upper molar swallowed a brooch. An X ray photograph was taken, The brooch teeth to the mouth of the oesophagus .in males is 14’99 cm., was seen lyingvertically in the oesophagus about an inch below the and in females 13’ 9 cm. ; from the teeth to the bifurca- level of the sterno-clavicular joint. Under general anaesthesia a tube tion of the trachea in males 26 cm., and in females spatula 7 mm. in diameter was passed. After careful cleansing of the walls of the the brooch was seen and was removed with 23-9 cm. ; from the teeth to the cardia in males 39-9 cm., forceps. (Fig.cesophagus 2, A.) Uninterrupted recovery. and in females 37’3cm. For practical purposes, however, CASE 2. Denture in
’

67

From

photographs (actual size) of foreign bodies. A, Brooch removed from child’s œsophagus. B, Portion of toy trumpet from lung. c, Ornamental pin from left bronchus. D, Damson stone in œsophagus. E, Stone from right bronchus.

From a skiagram

showing coins in (esophagus.

FiG. 3.


laid open

showing traumatic ulceration of its wal

Fic,. 4.

Aorta laid open, showing traumatic various coats.

perforation of its

68 which pus oozed. Rectal feeding was ordered. Rapid loss of strength resulted, and death took place seven days later from abscess in the left posterior mediastinum. CASE 5. Denture in hypopharynx.-A female, aged 45 years, had swallowed a denture with four teeth attached ten days before being seen in consultation. Great dysphagia and slight dyspnœa were complained of. The temperature was 1020 F. ; the mucous membrane of the upper laryngeal orifice was much swollen and (jedematous. The denture was seen in the hypopharynx, firmly embedded in oedematous mucosa. It was extracted with great diffioulty. Recovery was slow but uninterrupted. CASE 6. Traumatic perjoration of œsophagus (rabbit bone) into aorta ; necrosis of mediastinal tissues; hæmorrhage into msophagits, stomach, and bowels.-The patient, a female, was admitted to hospital suffering from hsematemesis. She was stated to have vomited half a pint of blood on the day before admission. There was a history of having swallowed a piece of rabbit bone three weeks previously with resulting dysphagia. Examination under- general anaesthesia revealed an ulcerated area at about the level of the tracheal bifurcation with an cedematous granulation sprouting from its base. No trace of any rabbit bone was visible. On the following day the patient had a very severe and prolonged attack of hsematemesis followed by heart failure and death. At the post-mortem examination, at the level of the tracheal bifurcation and on that part of the wall of the oesophagus contiguous to the aorta, was found an irregular ulcer about three-eighths of an inch in maximum diameter with irregular margins, and with a necrotic, blackened and slightly depressed base. (Fig. 3.) The base of the ulcer lay against a blackish mass of necrotic tissue in the mediastinal cellular tissue which connected the cesophagus to the arch of the aorta. There was a perforation (one-eighth of an inch in diameter) in this necrotic area extending through the various coats of the aorta. (Fig. 4.) On the oesophageal wall there was another necrotic patch on the opposite wall to that above affected and about three-quarters of an inch lower down the gullet. This necrosis was confined to the mucous membrane, was not definitely ulcerated, and covered an area of about one eighth of an inch in diameter. CASE 7. Damson stone impacted in œsophagus.-The patient was a boy, aged 14, with a history of having swallowed a caustic alkali four years previously. There had been slight dysphagia ever since. When eating some bread and jam he swallowed a damson stone. (Fig. 2, D.) Complete obstruction for solid food resulted and great difficulty in swallowing fluids. , He was seen three days after the accident. He was pale and exhausted, the skin was moist, and the temperature subnormal. Under general anaesthesia a damson stone was seen at the level of the tracheal bifurcation tightly impacted in circular cicatricial scar tissue. It was removed with forceps. Dilatation of the stricture was effected with bougies. Rapid recovery.

stool,

the

parts

to be

inspected being

cocaine-adrenalin solution,

or

under

a

anæsthetised witlr

general anæthetic,

atropine having been previously injected subcutaneously, or lying either upon the back or upon the side. Many operators prefer the lateral position, the bronchus to be inspected being uppermost and the instrument introduced from the opposite angle of the mouth. The tube-spatula to be used should be well greased and warmed before introduction and passed steadily onwards under ocular inspection, great care being taken to avoid any undue force. When necessary an extension tube is introduced through the tubespatula and passed onwards into whichever bronchus is to be inspected. To diminish the irritability of the bronchial mucosa a 10 per cent. cocaine solution is sprayed into the At timesbronchus by means of a specially long spray. great difficulty is encountered from the presence of large For its removal quantities of secretion, mucus, pus, &c. repeated swabbing or aspiration with a suction-pump is called for. Tilting the end of the table so as to allow the secretion to run towards the mouth helps at times. Foreign bodies with smooth surfaces-e.g., glass beads, difficult to remove on account of marbles, pebbles, &c.-are the inability of the blades of forceps to "hold on"as it At times they may be dislodged with long hooked, were. probes, as was necessary in Case 5. Sharp-pointed foreign bodies also present great practical difficulties on account of the points becoming embedded in the surrounding mucosa and setting up violent inflammation, accompanied by profuse secretion. Before removal is, possible it may be necessary to cut the foreign body into two portions. Bronchoscopy may be either s2upenior or inferior; in other words, the bronchoscopic tube may be passed through the mouth and laryngeal cavity or through a tracheotomy wound made purposely. As a general rule, superior bronchoscopy should be attempted first of all. In the cases about to ba CASE 8. Tra1tmatic cicatricial stenosis of cesophag2es.-The patient, recorded it was found possible to remove the various foreign, a male aged 19, was seen in consultation suffering from almost complete vias naturales (superior bronchoscopy). oesophageal obstruction. There was great emaciation and weakness. bodies per There was a history of having swallowed a caustic alkali three years previously, and there had been more or less dysphagia ever since. Recently the symptoms had been acute. The lumen of the oesophagus

CASE 1. Pin in larynx.-The patient, a female aged 30, inhaled a pin, which she was holding in her mouth, into her larynx. Violent and’ paroxysmal fits of coughing and a feeling of oppression overthe thyroid at the level of the tracheal bifurcation was found to be almost occluded cartilage resulted. The pin was seen to be lying in the laryngeal cavity, was an in cicatricial web. There the centre of the a circular opening by its point embedded in the subglottic mucosa and its head projecting web just large enough to admit bougie No. 4. The opening was above the level of the vocal cords. It was extracted with forceps. and the larger bougies through gradually enlarged by passing larger Rapid recovery. 21 tube until No. Thereafter the passed bougie easily. oesophageal CASE 2. Rib of rabbit in larynx.-The patient, a female aged 65, while stricture was enlarged without the aid of the oesophagoscope. Complete eating a portion of stewed rabbit suddenly felt a sharp pain in the recovery. throat. which was followed immediately by incessant coughmg. There CASE 9. Carcinoma of œsophagus.-The patient, a male aged 49, was no dyspnoea but a feeling as of a foreign body in the larynx. She suffered from increasing dysphagia, deep-seated pain, slight blood- was seen in consultation one week later. The foreign body was found stained expectoration, foetid breath, and loss of weight. On examina- to be lying across the laryngeal cavity just above the level of the vocal tion a cauliflower-looking growth was seen at the commencement of the cords. The mucous membrane was red and cedematous, and there was oesophagus (lower level of cricoid cartilage) with superficial ulceration. much muco-purulent secretion. The foreign body was extracted with A portion was removed with forceps for microscopical examination. forceps. The laryngeal mucous membrane was slightly lacerated Epithelioma. during extraction. Rapid recovery. and CASE 3. Portion of a toy trumpet in right bronchus.-A child, aged T, the reed portion. Severe dyspnoea, To ensure accurate introduction of tubes into the air while blowing a toy trumpet inhaled accompanied by spasmodic cough and expectoration, ensued. Superior certain anatomical measurements should be borne under passages tracheo-bronchoscopy general anæsthesia was performed The in mind. In adults the trachea is from 5 inches in foreign body was located in the right bronchus at the level of the branch. (Fig. 2, B.) Extraction was successfully accomwhile the distance from the upper molars to the eparterial with long forceps. plished rima glottidis is about the same. The carina or bifurcation CASE 4. Top oy pencil (metallic) in right bronchus.-The top of a of the trachea is therefore situated about 9-10 inches from pencil (metallic) while being held in the mouth became letaohed was inhaled. Dyspnoea cough, and expectoration ensued. Air the upper molar teeth. The vocal cords are situated at the and was heard to enter the right lung with a peculiar whistling noise. level of the sixth cervical spine and the carina between the Superior tracheo-bronchoseopy was performed under general anaesthesia, fourth and fifth dorsal spinous processes. The diameter of but with much difficulty from the presence of copious secretion. After and repeated application of cocaine the foreign body was the trachea in adult males may measure from seven-eighths aspiration discovered to be lying crosswise across the bronchus a little below the of an inch to an inch, in females it is about three-fifths of level of the eparterial branch. Removal was effected with long forceps. an inch, while in infants it may not be more than one-sixth Rapid recovery. CASE 5. Smooth pebble in right bronchits.-The patient, a male aged of an inch. The carina is at times situated rather to the 25, while running with the harriers inhaled a smooth pebble whichhe of the but to the middle line, more usually somewhat had in his mouth. It caused sharp pain in the right chest with right Later there was marked shortness of breath upon exertion. left, with the result that the right bronchus is almost a dyspnoea. Under general anaesthesia the ray examination was made. direct continuation of the trachea. The angle formed by An X was stone found to be located in the right bronchus firmly wedged in, the right bronchus with the mid-line of the trachea is an the eparterial branch. The forceps when introduced refused to grasp on account of its smoothness. Repeated but unsuccessful angle of 25°, whereas that formed by the left bronchus is an the pebblewere A made. bent at a right angle at its exlong probe angle of 45°. The diameter of the right bronchus is almost attempts was then introduced and was insinuated behind the tremity gradually equal to that of the trachea, whereas that of the left foreign body. By gentle levering the pebble was coaxed upwards. A bronchus is from 3-4 mm. smaller. Hence foreign bodies are sudden sharp cough forced it into the trachea when it was easilyextracted with a larger pair of forceps. (Fig. 2, E.) Uninterrupted more prone to fall into the right than into the left bronchus. At a distance of one inch from the carina the right recovery. CASE 6. Ornamental pin in left bronchus (second division).-The bronchus gives off its eparterial branch to the upper lobe of patient, a female, inhaled an ornamental pin which she was holding in the right lung. The left bronchus sweeps under the arch of her mouth. (Fig, 2, c.) Sudden sharp pain in left chest resulted with irritable and spasmodic cough, but. there was hardly any dB spnoea. She the aorta and behind the left artery. and at a was seen ten days afterwards. Examination revealed the mn in the left distance of about two inches from the carina gives off a bronchus lying with its point embedded in the mucosa. Much difficulty As a rule four in grasping the pin was experienced owing to the presence of profuse lobe of the left branch to the

Laryngoscopy

Bronchoscopy. rigid

4to

length,

,

slight

pulmonary

lung. upper dorsal and four ventral branches are’given off from both

muco-purulent secretion. Superior tracheo-bronchoscopy was formed. A long forceps was introduced, and the pin was seized

main stems. The patient may be examined

extracted. Uneventful recovery. Manchester.

sitting upright upon

a

low

per--

and