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

220           THE LARYNX, BRONCHI AND OESOPHAGUS

often of a major nature. Inhaled foreign bodies are potentially fatal, and the
returns of the Registrar-General show many deaths each year attributable to
inhaled objects.

THE OESOPHAGUS

Unlike inhaled foreign bodies, which are most commonly met with in children,
swallowed foreign bodies are frequently found in adults as well. The upper end
of the oesophagus is closed by the cricopharyngeus muscle which opens during
the act of swallowing to allow the food bolus to enter. In children this
sphincter-like muscle will contract rapidly if a foreign body enters the
oesophagus, and the object is held immediately below the muscle at the
upper end of the oesophagus where it may lie for a matter of hours. In adults it
is usual for a sharp object to be similarly arrested, but other foreign bodies
may pass the cricopharyngeus to become held up at a lower level because the
weak oesophageal peristalsis cannot propel them onwards. Once a foreign
body passes the upper end of the oesophagus it may be arrested at the hiatus,
or, less commonly, at the level of the crossing of the left bronchus.

In children the most frequently swallowed objects are coins or small disc-
shaped or irregular playthings. More rarely a child will swallow a sharp
object such as an open safety-pin or a bone. The oesophagus only responds to
the painful stimuli of scratching or stretching, so that the child may be
syrnptomless when first seen. Indeed, a child may have no dysphagia or
stridor, and may be able to swallow fluids with a coin 2-5 cm in diameter held
just below the level of the cricopharyngeus. A larger disc-shaped object may
induce dysphagia or even stridor, while a pointed foreign body will produce
pain on swallowing, so that saliva may dribble from the mouth. It is important
when radiographs are taken to locate the foreign body, that the films include
the mandible or the object may be missed (Fig. 111). The upper end of the
oesophagus lies behind the cricoid cartilage, and a radiograph in which the
clavicles appear at the top of the plate may well have excluded a foreign body.
Deaths have occurred from mediastinitis following perforation of the
oesophagus by sharp foreign bodies which, for this reason, had never been
demonstrated at radiography.

In adults the most commonly swallowed objects are bones of fish, game or
meat. These are often retained in the pyriform fossa or they may be held up
immediately distal to the cricopharyngeus, where they give rise to pain and
dysphagia. Because of the insensitive nature of the oesophagus, localization is
poor. A jagged bone may scratch the mucosa during its passage through the
oesophagus, and such a scratch causes pain on swallowing. In older people
unchewed meat may cause obstruction. This is especially the case if the patient
is edentulous, when meat may not be sufficiently masticated to pass through
the oesophagus and is retained at the hiatus. Patients with an oesophageal
narrowing, whether due to a stenosis or to a carcinoma, will obstruct more
easily, and it is important in certain cases to ensure, once the foreign body has
been removed, that there is no underlying pathology. Such an obstruction is
often complete, resulting in vomiting and even inability to swallow fluids, so
that dehydration ensues, and in children this may be rapid and severe.

CLINICAL FEATURES. There is usually a history of the object having been
swallowed, and this is true even in children. Very often a finger has been