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Full text of "Diseases Of The Nose Throat And Ear"

INHALED AND SWALLOWED FOREIGN BODIES         217

It cannot be stressed too strongly that the patient or parents must be closely
and directly questioned regarding any such spasm, because once the foreign
body enters a bronchus there may be a silent interval lasting from a few hours
to some weeks with few if any symptoms. Many foreign bodies have been
allowed to lie in a bronchus because the original incident has been concealed
by the child, or gone unnoticed, or been ignored by parents or practitioners,
or because direct questions have not been asked.

In the unconscious patient, whether during sleep or under an anaesthetic or
intoxicated or under the influence of drugs, this spasm may be reduced or
absent, and the occurrence may have passed unnoticed or may not be
remembered clearly.

SYMPTOMS. In the usual case there is a history of a choking incident with a
spluttering spasm of coughing, dyspnoea and perhaps cyanosis, followed by a
relief of acute symptoms. There may be some subsequent stridor or an
expiratory wheeze in children. If advice is not immediately sought the
foreign body may give rise to few symptoms for a matter of weeks, depending
upon its size and nature. In the case of a small object there may be little more
than an occasional tickling spasm of coughing as the object changes its
position in the bronchus or moves peripherally. If the foreign body is larger the
cough is more persistent and is accompanied by an expiratory grunt. Should
the object be organic, such as a peanut, decomposition may begin in a week or
two, resulting in an inflammatory reaction in the surrounding mucosa. This
causes pyrexia and a cough, and gives rise to an acute illness resembling a
lobar pneumonia. By the same token, a patient with an unexplained cough, or
with an apparent lobar collapse which does not respond to the usual thera-
peutic measures, should always be suspected of having inhaled foreign
material.

CLINICAL FEATURES. These depend upon the size and nature of the foreign
body, upon its position in the tracheobronchial tree and upon the length of
time elapsing between inhalation and examination. The immediate signs are
stridor, dyspnoea of varying degree and possibly cyanosis, with a spasmodic,
irritative cough. There may be suprasternal or intercostal indrawing, but
clinical examination of the chest at this stage may be negative.

A foreign body will remain in the trachea if it is too large to enter the bronchi.
If it is very large it may never pass the larynx. A foreign body such as a plug of
wool inhaled during sleep may acquire mucus and enlarge to lie across the
carina and obstruct both main bronchi. Such an incident would give rise to
gross dyspnoea, expiratory stridor, very little air entry into either lung, and
thus cyanosis leading to pallor, unconsciousness and death. A smaller object,
such as an orange pip, in a child's trachea may prove too large to enter the
bronchi, and is moved up and down the trachea with respiration. This is
especially noted if the child is lying flat, when the object may be heard and
felt on palpation to slap gently against the subglottis on each expiration.

If a foreign body enters the bronchial tree, the right bronchi are more
usually involved. The right main bronchus makes an angle of 25 with the
vertical, and is thus nearly continuous with the trachea, while the left main
bronchus is set at an angle of 75 with the vertical. The foreign body penetrates
to a depth varying with its size and shape and consistency. Inhaled vomit or
mucus may reach the smaller bronchi; a small pin may similarly reach the
smaller bronchi if its long axis is in the line of the lumen. A small piece of