,?is book is "o ( ! pione]+ works 9 l>yngology4 ,! orig9al text is f ! libr>y ( ,indiana ,univ]sity ,dep>tm5t ( ,otol>yngology-,head & ,neck ,surg]y1 ,bruce ,matt1 ,,md4 ,x 0 scann$1 conv]t$ to text1 & pro($ by ,alex ,tawadros4 ,,bron*oscopy ,,& ,,esophagoscopy ,a ,manual ( ,p]oral ,endoscopy & ,l>yngeal ,surg]y by ,,*evali] ,,jackson1 ,m4,d41 ,f4,a4,c4,s4 ,pr(essor ( ,l>yngology1 ,jeff]son ,m$ical ,college1 ,philadelphia2 ,pr(essor ( ,bron*oscopy & ,esophagoscopy1 ,graduate ,s*ool ( ,m$ic9e1 ,univ]sity ( ,p5nsylvania2 ,memb] ( ! ,am]ican ,l>yngological ,association2 ,memb] ( ! ,l>yngological1 ,rh9ological1 & ,otological ,society2 ,memb] ( ! ,am]ican ,academy ( ,oph?almology & ,oto-,l>yngology2 ,memb] ( ! ,am]ican ,bron*oscopic ,society2 ,memb] ( ! ,am]ican ,philosophical ,society2 etc41 etc4 ,) #aad ,illu/rations & ,f\r ,color ,plates ,philadelphia ,& ,london ,w4 ,b4 ,saund]s ,company #aibb ,copyrights #aibb1 by ,w4 ,b4 ,saund]s ,company ,made 9 ,u4,s4,a4 ,,to ,,my ,,"m ,,to ,,^: ,,int]e/ ,,9 ,,m$ical ,,sci5ce ,,! ,,au?or ,,owes ,,8 ,,inc5tive1 ,,& ,,to ,,my ,,fa!r ,,^: ,,con/ant ,,advice ,,to ,,educate ,,! ,,eye ,,& ,,! ,,f+]s ,,spurr$ ,,! ,,au?or ,,to ,,cont9ual ,,ef=t1 ,,?is ,,book ,,is ,,affectionately ,,d$icat$4 ,,preface ,?is book is bas$ on an ab/ract ( ! au?or's l>g] "w1 ,p]oral ,endoscopy & ,l>yngeal ,surg]y4 ,! ab/ract 0 prep>$ "u ! au?or's direction by a read]1 9 ord] to get a read]'s po9t ( view on ! pres5tation ( ! subject 9 ! e>li] book4 ,) ?is ab/ract z a />t+ po9t1 ! au?or has endeavor$1 s f> z lay )9 8 limit$ abilities1 to accompli% ! difficult task ( pres5t+ by writt5 ^w ! v>i\s purely manual endoscopic proc$ures4 ,! l>ge numb] ( corrections & revisions f\nd necess>y has confirm$ ! wisdom ( ! plan ( gett+ ! read]'s po9t ( view2 & ^! revisions1 toge!r ) num]\s additions1 h br\ght ! treatm5t ( ! subject up to date s f> z is possible )9 ! limits ( a work+ manual4 ,ackn[l$gm5t is due ! p]sonnel ( ! ,w4 ,b4 ,saund]s ,company = k9dly help4 ,,*evali] ,,jackson4 ,,octob]1 #aibb4 ,,ii ,,cont5ts ,,page ,,*apt] ,i ,,in/rum5t>ium #ag ,,*apt] ,,ii ,,anatomy ,,( ,,l>ynx1 ,,tra*ea1 ,,bron*i ,,& ,,esophagus1 ,,endoscopically ,,consid]$ #eb ,,*apt] ,,iii ,,prep>ation ,,( ,,! ,,pati5t ,,= ,,p]oral ,,endoscopy #fc ,,*apt] ,,iv ,,ane/hesia ,,= ,,p]oral ,,endoscopy #fe ,,*apt] ,v ,,bron*oscopic ,,oxyg5 ,,insufflation #ga ,,*apt] ,,vi ,,position ,,( ,,! ,,pati5t ,,= ,p,e,r,o,r,al ,,endoscopy #gc ,,*apt] ,,vii ,,direct ,,l>yngoscopy #hb ,,*apt] ,,viii ,,direct ,,l>yngoscopy 7,cont9u$7 #ia ,,*apt] ,,ix ,,introduction ,,( ,,! ,,bron*oscope #ig ,,*apt] ,x ,,introduction ,,( ,,! ,,esophagoscope #ajf ,,*apt] ,,xi ,,acquir+ ,,skill #aag ,,*apt] ,,xii ,,=eign ,,bodies ,,9 ,,! ,,air ,,& ,,food ,,passages #abf ,,*apt] ,,xiii ,,=eign ,,bodies ,,9 ,,! ,,l>ynx ,,& ,,tra*eobron*ial ,,tree #adi ,,*apt] ,,xiv ,,removal ,,( ,,=eign ,,bodies ,,f ,,! ,,l>ynx #aef ,,*apt] ,,xv ,,me*anical ,,problems ,,( ,,bron*oscopic ,,=eign ,,body ,,extraction #aeh ,,*apt] ,,xvi ,,=eign ,,bodies ,,9 ,,! ,,bron*i ,,= ,,prolong$ ,,p]iods #agg ,,*apt] ,,xvii ,,unsuccessful ,,bron*oscopy ,,= ,,=eign ,,bodies #aha ,,*apt] ,,xviii ,,=eign ,,bodies ,,9 ,,! ,,esophagus #ahc ,,*apt] ,,xix ,,esophagoscopy ,,= ,,=eign ,,body #ahg ,,*apt] ,,xx ,,pleuroscopy #aii ,,*apt] ,,xxi ,,b5ign ,,gr[?s ,,9 ,,! ,,l>ynx #bja ,,*apt] ,,xxii ,,b5ign ,,gr[?s ,,9 ,,! ,,l>ynx 7,cont9u$7 #bjc ,,*apt] ,,xxiii ,,b5ign ,,gr[?s ,,prim>y ,,9 ,,! ,,tra*eobron*ial ,,tree #bjg ,,*apt] ,,xxiv ,,b5ign ,,neoplasms ,,( ,,! ,,esophagus #bji ,,*apt] ,,xxv ,,endoscopy ,,9 ,,malignant ,,disease ,,( ,,! ,,l>ynx #baj ,,*apt] ,,xxvi ,,bron*oscopy ,,9 ,,malignant ,,gr[?s ,,( ,,! ,,tra*ea #bad ,,*apt] ,,xxvii ,,malignant ,,disease ,,( ,,! ,,esophagus #baf ,,*apt] ,,xxviii ,,direct ,,l>yngoscopy ,,9 ,,diseases ,,( ,,! ,,l>ynx #bba ,,*apt] ,,xxix ,,bron*oscopy ,,9 ,,diseases ,,( ,,! ,,tra*ea ,,& ,,bron*i #bbd ,,*apt] ,,xxx ,,diseases ,,( ,,! ,,esophagus #bce ,,*apt] ,,xxxi ,,diseases ,,( ,,! ,,esophagus 7,cont9u$7 #bde ,,*apt] ,,xxxii ,,diseases ,,( ,,! ,,esophagus 7,cont9u$7 #bea ,,*apt] ,,xxxiii ,,diseases ,,( ,,! ,,esophagus 7,cont9u$7 #bfj ,,*apt] ,,xxxiv ,,diseases ,,( ,,! ,,esophagus 7,cont9u$7 #bfh ,,*apt] ,,xxxv ,,ga/roscopy #bgc ,,*apt] ,,xxxvi ,,acute ,,/5osis ,,( ,,! ,,l>ynx #bgg ,,*apt] ,,xxxvii ,,tra*eotomy #bgi ,,*apt] ,,xxxviii ,,*ronic ,,/5osis ,,( ,,! ,,l>ynx ,,& ,,tra*ea #cjj ,,*apt] ,,xxxix ,,decannulation ,,aft] ,,cure ,,( ,,l>yngeal ,,/5osis #cji ,,bibliography #caa ,,index #cae #ag ,,*apt] ,i--,,in/rum5t>ium ,direct l>yngoscopy1 bron*oscopy1 esophagoscopy & ga/roscopy are proc$ures 9 :i* ! l[] air & food passages are inspect$ & treat$ by ! aid ( electrically light$ tubes :i* s]ve z specula to manipulate ob/ruct+ tissues out ( ! way & to br+ o!rs into ! l9e ( direct vision4 ,illum9ation is suppli$ by a small tung/5-filam5t$1 electric1 cold lamp situat$ at ! di/al extremity ( ! in/rum5t 9 a special groove :i* protects x f any possible injury dur+ ! introduction ( in/rum5ts ?r\gh ! tube4 ,! bron*i & ! esophagus w n all[ dilatation beyond _! normal calib]2 !re=e1 x is necess>y to h tubes ( ! sizes to fit ^! passages at v>i\s developm5tal ages4 ,rupture or ev5 ov]-di/5tion ( a bron*us or ( ! ?oracic esophagus is almo/ inv>iably fatal4 ,! armam5t>ium ( ! endoscopi/ mu/ be complete1 = x is r>ely possible to sub/itute1 or to improvise make%ifts1 :ile ! bron*oscope is 9 situ4 ,fur!rmore1 ! in/rum5ts mu/ be ( ! prop] model & well made2 o!rwise difficulties & dang]s w att5d attempts to see !m4 ,l>yngoscopes4--,! regul> type ( l>yngoscope %[n 9 ,fig4 ,i 7,a1 ,b1 ,c7 is made 9 adult's1 *ild's1 & infant's sizes4 ,! in/rum5ts h a removable slide on ! top ( ! tubul> portion ( ! speculum to all[ ! removal ( ! l>yngoscope aft] ! ins]tion ( ! bron*oscope ?r\gh x4 ,! infant size is made 9 two =ms1 "o )1 ! o!r )\t a removable slide2 ) ei!r =m ! l>ynx ( an infant c be expos$ 9 b a few seconds & a def9ite diagnosis made1 )\t ane/hesia1 g5]al or local2 a ?+ possible by no o!r me?od4 ,= op]ative "w on ! l>ynx ( adults1 su* z ! removal ( b5ign gr[?s1 p>ticul>ly :5 ^! are situat$ 9 ! ant]ior portion ( ! l>ynx1 a special tubul> l>yngoscope hav+ a he>t-%ap$ lum5 & a bevel$ tip is us$4 ,) ?is in/rum5t ! ant]ior commissure is readily expos$1 & because ( ?is x is nam$ ! ant]ior commissure l>yngoscope 7,fig4 #a1 ,d74 ,! tip ( ! ant]ior commissure l>yngoscope c be us$ to expose ei!r v5tricle ( ! l>ynx by lift+ ! v5tricul> b&1 or x may be pass$ ?r\gh ! adult glottis = "w 9 ! subglottic region4 ,?is in/rum5t may also be us$ z an esophageal speculum & z a pleuroscope4 ,a side-slide l>yngoscope1 us$ ) or )\t ! slide1 is occasionally useful4 ,bron*oscopes4--,! regul> bron*oscope is a holl[ brass tube slant$ at its di/al end1 & hav+ a h&le at its proximal or ocul> extremity4 ,an auxili>y canal on its "u surface conta9s ! light c>ri]1 ! electric bulb ( :i* is situat$ 9 a recess 9 ! bevel$ di/al end ( ! tube4 ,num]\s p]=ations 9 ! di/al "p ( ! tube all[ air to ent] f o!r bron*i :5 ! tube-m\? is ins]t$ into "o ^: a]at+ function may be impair$4 ,! accessory tube on ! upp] surface ( ! bron*oscope ends )9 ! lum5 ( ! bron*oscope1 & is us$ = ! insufflation ( oxyg5 or ane/hetics1 7,fig4 #b1 ,a1 ,b1 ,c1 ,d74 ,= c]ta9 "w su* z dra9age ( pulmon>y abscesses1 ! lavage treatm5t ( bron*iectasis & = =eign-body or o!r cases ) abundant secretions1 a dra9age-bron*oscope is useful ,! dra9age canal may be on top1 or on ! "u surface next to ! light-c>ri] canal4 ,= ord9>y "w1 h[ev]1 secretion 9 ! bron*us is be/ remov$ by sponge-pump+ 7,q4,v47 :i* at ! same "t cleans ! lamp4 ,! dra9age bron*oscope may be us$ 9 any case 9 :i* ! v slightly-great] area ( cross section is no disadvantage2 b 9 *ildr5 ! add$ bulk is usually objectionable1 & 9 cases ( rec5t =eign-body1 secretions are n tr\blesome4 ,z be=e m5tion$1 ! l[] air passages w n tol]ate dilatation2 !re=e1 x is necess>y nev] to use tubes l>g] ?an ! size ( ! passages to be exam9$4 ,f\r sizes are suffici5t = any possible case1 f a newborn infant to ! l>ge/ adult4 ,= infants "u "o ye>1 ! prop] tube is ! #d mm4 by #cj cm42 ! *ild's size1 #e mm4 by #cj cm41 is us$ = *ildr5 ag$ f "o to five ye>s4 ,= *ildr5 six ye>s or ov]1 ! #g mm4 by #dj cm4 bron*oscope 7! adolesc5t size7 c be us$ unless ! small] bron*i are to be explor$4 ,! adult bron*oscope measures #i mm4 by #dj cm4 ,! au?or occasionally uses special sizes1 #e mm4 x #de cm41 #f mm4 x #ce cm41 #h mm4 x #dj cm4 ,esophagoscopes4-,! esophagoscope1 l ! bron*oscope1 is a holl[ brass tube ) bevel$ di/al end conta9+ a small electric light4 ,x diff]s f ! bron*oscope 9 t x has no p]=ations1 & has a dra9age canal on its upp] surface1 or next to ! light-c>ri] canal :i* op5s )9 ! di/al end ( ! tube4 ,! exact size1 position1 & %ape ( ! dra9age outlets is important on bron*oscopes1 & to an ev5 great] degree on esophagoscopes4 ,if ! proximal edge ( ! dra9age outlet is too ne> ! di/al end ( ! endoscopic tube1 ! mucosa w be drawn into ! outlet1 n only ob/ruct+ x1 b1 mo/ important1 traumatiz+ ! mucosa4 ,if1 = in/ance1 ! esophagoscope 7 to be pu%$ ^u ) a fold ?us an*or$ 9 ! di/al end1 ! esophageal wall c\ld easily be torn4 ,to admit ! l>ge/ sizes ( esophagoscopic b\gies 7,fig4 #dj71 special esophagoscopes 7,fig4 #e7 are made ) bo? light canal & dra9age canal outside ! lum5 ( ! tube1 leav+ ! full area ( lum9al cross-section un5croa*$ ^u4 ,!y c1 ( c\rse1 be us$ = all purposes1 b ! slightly great] circumf]5ce is at times a disadvantage4 ,! esophageal & /oma* secretions are mu* ?9n] ?an bron*ial secretions1 &1 if free f food1 are readily aspirat$ ?r\gh a comp>atively small canal4 ,if ! canal becomes ob/ruct$ dur+ esophagoscopy1 ! positive pressure tube ( ! aspirator is us$ to bl[ out ! ob/ruction4 ,two sizes ( esophagoscopes are all t are requir$--#g mm4 ,x #de cm4 = *ildr51 & #aj mm4 ,x #ec cm4 = adults 7,fig4 #c1 ,a & ,b72 b v>i\s o!r sizes & l5g?s are us$ by ! au?or = special purposes499 ,l>ge esophagoscopes cause dang]\s dyspnea 9 *ildr54 ,if1 x is desir$ to balloon ! esophagus ) air1 ! w9d[ plug %[n 9 ,fig4 #f1 is ins]t$ into ! proximal end ( ! esophagoscope1 & air insufflat$ by means ( ! h& aspirator or ) a h& bulb4 ,! w9d[ c be replac$ by a rubb] diaphragm ) a p]=ation = =ceps if desir$4 ,x w be not$ t none ( ! endoscopic tubes are fitt$ ) m&r9s4 ,!y are to be introduc$ "u ! direct guidance ( ! eye only4 ,m&r9s are obta9able1 b _! use is objectionable = a numb] ( reasons1 *ief ( :i* is ! dang] ( ov]rid+ a =eign body or a lesion1 or ( p]=at+ a lesion1 or ev5 ! normal esophageal wall4 ,! slant$ end on ! esophagoscope obviates ! necessity ( a m&r9 = introduction4 ,! long] ! slant1 ) consequ5t acut+ ( ! angle1 ! m ! introduction is facilitat$2 b too acute an angle increases ! risk ( p]=at+ ! esophageal wall1 & necessitates ! utmo/ caution4 ,9 "s =eign-body cases an acute angle giv+ a long slant is useful1 9 o!rs a %ort slant is bett]1 & 9 a few cases ! squ>ely cut-(f di/al end is be/4 ,to h all ( ^! diff]5t slants on h& w\ld require too _m tubes4 ,!re=e ! au?or has settl$ ^u a mod]ate angle = ! end ( bo? esophagoscopes & bron*oscopes t is easy to ins]t1 & s]ves all purposes 9 ! v]sion & o!r manipulations requir$ by ! v>i\s me*anical problems ( =eign-body extraction4 ,he has1 h[ev]1 reta9$ all ! exp]im5tal models1 = occasional use 9 su* cases z he falls heir to because ( a problem ( extraord9>y difficulty4 99 ,a #i mm4 ,x #de cm4 esophagoscope w rea* ! /oma* ( almo/ all adults & is some:at easi] to introduce ?an ! #aj mm4 ,x #ec cm41 :i* may be omitt$ f ! set if economy mu/ be practic$4 ,,fig4 ,i4--,au?or's l>yngoscopes4 ,^! are ! /&>d sizes & fulfill all requirem5ts4 ,_m o!r =ms h be5 devis$ by ! au?or1 b h be5 omitt$ f ! li/ z unnecess>y4 ,! infant diagno/ic l>yngoscope 7,c7 is n = introduc+ bron*oscopes1 & is n absolutely necess>y1 z ! l>ynx ( any infant c be inspect$ ) ! *ild's size l>yngoscope 7,b74 ,a ,adult's size2 ,b1 *ild's size2 ,c1 infant's diagno/ic size2 ,d1 ant]ior commissure l>yngoscope2 ,e1 ) dra9age canal2 #ag1 intubat+ l>yngoscope1 l>ge lum54 ,all ! l>yngoscopes are pref]r$ )\t dra9age canals4 ,,fig4 #b4--,! au?or's bron*oscopes ( ! sizes regul>ly us$4 ,v>i\s o!r l5g?s & diamet]s are on h& = occasional use = special purposes4 ,) ! exception ( a #f mm4 ,x #ce cm4 size = old] *ildr51 ^! special bron*oscopes are v r>ely us$ & none ( !m c be reg>d$ z necess>y4 ,= special purposes1 h[ev]1 special %apes ( tube-m\? are useful1 z1 = in/ance1 ! oval end to facilitate ! gett+ ( bo? po9ts ( a /aple into ! tube-m\? ,! illu/rat$ in/rum5ts are z foll[s3 ,a1 ,infant's size1 #d mm4 ,x #cj cm42 ,b1 *ild's size1 #e mm4 ,x #cj cm42 ,c1 adolesc5t's size1 #g mm4 ,x #dj cm42 ,d1 adult's size1 #i mm4 ,x #dj cm42 ,e1 aspirat+ bron*oscope made 9 all ! =ego+ sizes1 & 9 a special size1 #e mm4 ,x #de cm4 ,,fig4 #c4--,! au?or's esophagoscopes ( ! sizes he has /&>diz$ = all ord9>y requirem5ts4 ,he uses v>i\s o!r l5g?s & sizes = special purposes1 b none ( !m are really necess>y4 ,a ga/roscope1 #aj mm4 ,x #gj cm41 is useful = adults1 especially 9 cases ( ga/roptosis4 ,dra9age canals are plac$ at ! top or at ! side ( ! tube1 next to ! light-c>ri] canal4 ,a1 ,adult's size1 #aj mm4 ,x #ec cm42 ,b1 *ild's size1 #g mm4 ,x #de cm42 ,c & ,d1 full lum51 ) bo? light canal & dra9age canal outside ! wall ( ! tube1 to be us$ = pass+ v l>ge b\gies4 ,?is in/rum5t is made 9 adult1 *ild1 & adolesc5t 7#h mm4 by #de cm47 sizes4 ,ga/roscopes & esophagoscopes ( ! sizes giv5 above 7,a7 & 7,b71 c be us$ also z ga/roscopes4 ,a small =m ( ,c1 #e mm4 ,x #cj cm4 is us$ 9 infants1 & also z a retrograde esophagoscope 9 pati5ts ( any age4 ,e1 w9d[ plug = balloon+ ga/roscope1 ,f4 ,,fig4 #d4--;,au?or's %ort esophagoscopes & esophageal specula ,a1 ,esophageal speculum & hypoph>yngoscope1 adult's size2 ,b1 esophageal speculum & hypoph>yngoscope1 *ild's size2 ,c1 heavy h&l$ %ort esophagoscope2 ,d1 heavy h&l$ %ort esophagoscope ) dra9age4 ,,fig4 #e4--;,cross section ( full-lum5 esophagoscope = ! use ( l>ge/ b\rgies4 ,! canals = ! light c>ri] & = dra9age are s con/ruct$ t !y d n encroa* ^u ! lum5 ( ! tube4 #be ,! special siz$ esophagoscopes mo/ (t5 useful are ! #h mm4 ,x #cj cm41 ! #h mm4 ,x #de cm41 & ! #e mm4 ,x #de cm4 ,^! are made ) ! dra9age canal 9 v>i\s positions4 ,= op]ations on ! upp] end ( ! esophagus1 & p>ticul>ly = =eign body "w1 ! esophageal speculum %[n at ,a & ,b1 9 ,fig4 #d1 is ( ! greate/ s]vice4 ,) x1 ! ant]ior wall ( ! po/-cricoidal ph>ynx is lift$ =w>d1 & ! upp] esophageal orifice expos$4 ,x c !n be ins]t$ deep]1 & ! upp] ?ird ( ! esophagus c be explor$4 ,two sizes are made1 ! adult's & ! *ild's size4 ,^! in/rum5ts s]ve1 v effici5tly z pleuroscopes4 ,!y are made ) & )\t dra9age canals1 ! latt] be+ ! m useful =m4 ,,fig4 #f4--,w9d[-plug ) glass cap int]*angeable ) a cap hav+ a rubb] diaphragm ) a p]=ation s t =ceps may be us$ )\t all[+ air to escape4 ,valves on ! canals 7,e1 ,f1 ,fig4 #c7 are pref]able4 ,ga/roscopes4--,! ga/roscope is ( ! same con/ruction z ! esophagoscope1 ) ! exception t x is made long]1 9 ord] to rea* all p>ts ( ! /oma*4 ,9 ord9>y cases1 ! regul> esophagoscopes = adults & *ildr5 respectively w af=d a good view ( ! /oma*1 b !re are cases :i* require long] tubes1 & = ^! a ga/roscope #aj mm4 ,x #gj cm4 is made1 & also "o #aj mm4 ,x #hj cm41 ?\gh ! latt] has nev] be5 ne$$ b once4 #bf ,pleuroscopes4--,z m5tion$ above ! ant]ior commissure l>yngoscope & ! esophageal specula make v effici5t pleuroscopes2 b ?ree diff]5t =ms ( pleuroscopes h be5 devis$ by ! au?or = pleuroscopy4 ,! retrograde esophagoscope s]ves v well = "w ?r\gh small fi/ulae4 ,measur+ ,rule 7,fig4 #g74--;,x is cu/om>y to locate esophageal lesions by d5ot+ _! di/ance f ! incisor tee?4 ,?is is readily done by measur+ ! di/ance f ! proximal end ( ! esophagoscope to ! upp] incisor tee?1 or 9 _! abs5ce1 to ! upp] alveol> process1 & subtract+ ?is measurem5t f ! kn[n l5g? ( ! tube4 ,?us1 if an esophagoscope #de cm4 long be introduc$ & we f9d t ! di/ance f ! incisor tee? to ! ocul> end ( ! esophagoscope z measur$ by ! rule is #bj cm41 we subtract ?is #bj cm4 f ! total l5g? ( ! esophagoscope 7#de cm47 & !n "k t ! di/al end ( ! tube is #be cm4 f ! incisor tee?4 ,graduation m>ks on ! tube h be5 us$1 b are objectionable4 ,,fig4 #g4--,measur+ rule = gaug+ 9 c5timet]s ! dep? ( any location by subtraction ( ! l5g? ( ! un9s]t$ portion ( ! esophagoscope or bron*oscope4 ,?is is pref]able to graduations m>k$ on ! tubes1 ?\gh ! tubes c be m>k$ ) a scale if desir$4 ,batt]ies4--,! simple/1 be/1 & safe/ s\rce ( curr5t is a d\ble dry batt]y arrang$ 9 ?ree gr\ps ( two cells ea*1 connect$ 9 s]ies 7,fig4 #h74 ,ea* set %\ld h two b9d+ po/s & a rheo/at4 ,! b9d+ po/s %\ld h d\ble holes = two additional cords1 to be kept 9 res]ve = use 9 case a cord becomes defective499 ,! comm]cial curr5t r$uc$ ?r\gh a rheo/at %\ld nev] be us$1 because !re is always ! possibility ( gr\nd+ ! circuit ?r\gh ! pati5t2 a highly dang]\s accid5t :5 we consid] t ! tube makes a long moi/ contact 9 tissues close to ! c\rse ( bo? ! vagi & ! he>t4 ,! endoscopi/ %\ld nev] dep5d ^u a pocket batt]y z a s\rce ( illum9ation1 = x is almo/ c]ta9 to fail dur+ ! endoscopy4 ,! wires connect+ ! batt]y & endoscopic in/rum5t are cov]$ ) rubb]1 s t !y may be cleans$ & sup]ficially /]iliz$ ) alcohol4 ,!y may be totally imm]s$ 9 alcohol = any l5g? ( "t )\t injury4 99 ,:5 ?is is done c>e is necess>y to avoid attempt+ to use simultane\sly ! two cords f "o pair ( po/s4 ,,fig #h4--,! au?or's endoscopic batt]y1 heavily built = reliability4 ,x conta9s #f dry cells1 s]ies-connect$ 9 #c gr\ps ( #b cells ea*4 ,ea* gr\p has its own rheo/at & pair ( b9d+ po/s4 ,aspirat+ ,tubes4--,indep5d5t aspirat+ tubes involve delay 9 _! use z comp>$ to aspirat+ canals 9 ! wall ( ! endoscopic tube2 b !re are special cases 9 :i* an indep5d5t tube is invaluable4 ,?ree =ms are us$ by ! au?or4 ,! velvet eye _c traumatize ! mucosa 7,fig4 #i74 ,to hold a =eign body by suction1 a squ>ely cut (f end is necess>y4 ,= use ?r\gh ! tra*eotomic w\nd )\t a bron*oscope a malleable tube 7,fig4 #aj7 is bett]4 ,,fig4 #i4--,! au?or's protect$-ap]ture endoscopic aspirat+ tube = aspiration ( ph>yngeal secretions dur+ direct l>yngoscopy & endotra*eobron*ial secretions at bron*oscopy1 also = dra9+ retroph>yngeal abscesses4 ,! l>yngoscopes are obta9able ) dra9age canals1 b = mo/ purposes ! indep5d5t aspirat+ tube %[n above is m satisfactory4 ,! tubes are made 9 #bj #cj1 #dj1 & #fj cm4 l5g?s4 ,an ap]ture on bo? sides prev5ts draw+ 9 ! mucosa4 ,x c be us$ = insufflation ( e!r if desir$4 ,an aspirat+ tube ( ! same design1 b hav+ a squ>ely cut (f end1 is sometimes useful = remov+ secretions ly+ close to a =eign body2 = remov+ papillomata2 & ev5 = )draw+ =eign bodies ( a s(t surface consi/5cy4 ,x is n (t5 t ! =eign bodies c be ?us )drawn ?r\gh ! glottis1 b closely fitt+ =eign bodies c at lea/ be )drawn to a high] level at :i* ample =ceps spaces w p]mit application ( =ceps4 ,su* aspirat+ tubes1 h[ev]1 are n s safe to use z ! protect$1 d\ble ap]ture tubes4 ,,fig4 #aj4--,! au?or's malleable tra*eotomic aspirat+ tube = removal ( secretions1 exudates1 cru/s1 etc41 f ! tra*eobron*ial tree ?r\gh ! tra*eotomic w\nd )\t a bron*oscope4 ,! tube is made ( copp] s t x c be b5t to any curve1 & ! copp] wire /ylet prev5ts k9k+4 ,! /ylet is remov$ be=e us+ ! tube = aspiration4 #bh ,aspirators4--,! v>i\s electric aspirators s univ]sally us$ 9 ?roat op]ations %\ld be utiliz$ to )draw secretions 9 ! tubes fitt$ ) dra9age canals4 ,!y1 h[ev]1 h ! disadvantages ( n be+ easily transport$1 & ( occasionally be+ out ( ord]4 ,! h& aspirator %[n 9 ,fig4 #aa is1 !re=e1 a necess>y "p ( ! in/rum5tal equipm5t4 ,x nev] fails to "w1 is portable1 & af=ds bo? positive & negative pressures4 ,! positive pressure is sometimes useful 9 cle>+ ! dra9age canal ( any p>ticles ( food1 tissue1 clots1 or secretion :i* may ob/ruct x2 & x also s]ves to fill ! /oma* or esophagus ) air :5 ! balloon+ proc$ure is us$4 ,! me*anical aspirator 7,fig4 #ab7 is highly effici5t & is ! "o us$ 9 ! ,bron*oscopic ,cl9ic4 ,! positive pressure w quickly cle> ob/ruct$ dra9age canals1 & may be us$ :ile ! esophagoscope is 9 situ1 by simply deta*+ ! m9us pressure tube & atta*+ ! plus pressure4 ,9 ! lungs1 h[ev]1 high plus pressures are s dang]\s t ! pressure valve mu/ be l[]$4 ,fig4 #aa--,portable aspirator = endoscopy ) additional tube connect$ ) ! plus pressure side = use 9 case ( occlusion ( ! dra9age canal4 ,?is aspirator has ! advantage ( great p[] ) portability4 ,:]e portability is n requir$ ! electrically op]at$ aspirator is bett]4 ,,fig4 #ab4--,rob9son me*anical aspirator adapt$ = bron*oscopic & esophagoscopic aspiration by ! au?or4 ,! positive pressure is us$ = cle>+ ob/ruct$ dra9age canals & tubes4 ,,fig4 #ac4--;,app>atus = insufflation ( e!r or *lor(orm dur+ bron*oscopy1 = ^? :o may desire to use g5]al ane/hesia4 ,! me*anical me?ods ( intratra*eal insufflation ane/hesia subsequ5tly develop$ by ,meltz] & ,au]1 ,elsb]g1 ,geo4 ,p4 ,mull] & o!rs h rightly sup]s$$ ?is app>atus = all g5]al surgical purposes4 ,sponge-pump+4--,:ile ! usually ?91 wat]y esophageal & ga/ric secretions1 if free f food1 are readily aspirat$ ?r\gh a dra9age canal1 ! secretions ( ! bron*i are (t5 ?ick & mucilag9\s & aspirat$ ) difficulty4 ,fur!r-m1 bron*ial secretions z a rule are n collect$ 9 pools1 b are di/ribut$ ov] ! walls ( ! l>g] bron*i & cont9u\sly well up f small] bron*i dur+ c\gh4 ,! aspirat+ bron*oscopes %\ld be us$ :5ev] _! v slight additional area ( cross-section is unobjectionable4 ,9 mo/ cases1 h[ev]1 ! mo/ advantage\s way to remove bron*ial secretion has be5 f\nd to be by introduc+ a gauze swab on a long sponge c>ri] 7,fig4 #ad71 s t ! sponge ext5ds beyond ! di/al end ( ! bron*oscope1 caus+ c\gh4 ,!n )drawal ( ! sponge c>ri] w remove all ( ! secretion 9 ! tube j z ! plung] 9 a pump w lift all ( ! wat] above x4 ,by ?is maneuv] ! walls ( ! bron*us are wip$ free f secretions1 & ! lamp itself is cleans$4 ,,fig4 #ad4--,sponge c>ri] ) long coll> = c>ry+ ! small sponges %[n 9 ,fig4 #ae4 ,! coll> screws d[n z 9 ! ,coolidge cotton c>ri]4 ,ab\t a doz5 ( ^! are ne$$ & !y %\ld all be small en\gh to g ?r\gh ! #d mm4 7diamet]7 bron*oscope & long en\gh to rea* ?r\gh ! #ec cm4 7l5g?7 esophagoscope1 s t "o set w d = all tubes4 ,! s*ema %[s me?od ( spong+4 ,! c>ri] ,c1 arm$ ) ! sponge1 ,s1 :5 rotat$ z %[n by ! d>t1 ,d1 wipes ! field1 ,p1 at ! same "t wip+ ! lamp1 ,l4 ,! lamp does n ne$ ev] to be )drawn = clean+ dur+ bron*oscopy4 ,x is protect$ 9 a recess s t x does n cat* 9 ! sponges4 ,,fig #ae4--;,exact size to :i* ! b&age-gauze is cut to make endoscopic sponges4 ,ea* rectangle is ! size = ! tubal diamet] giv54 ,! dim5sions ( ! respective rectangles are n giv5 because x is easi] = ! nurse or any "o to cut a c>dbo>d patt]n ( ea* size directly f ?is draw+4 ,! gauze rectangles are fold$ up endwise z %[n at ,a1 !n once 9 ! middle z at ,b1 !n /rung "o doz5 on a safety p94 ,9 ,am]ica gauze b&ages run ab\t #af ?reads to ! c5timet]4 ,diff]5t mat]ial might require a slightly diff]5t size & ! patt]n c\ld be made to suit4 #cb ,! gauze sponges are made by ! in/rum5t nurse z direct$ 9 ,fig4 #ae1 & are /rung on safety p9s1 wrapp$ 9 pap]1 ! size indicat$ by a figure on ! wrapp]1 & !n /]iliz$ 9 an autoclave4 ,! /]ile packages are op5$ only z ne$$4 ,^! bron*oscopic sponges are also made by ,john/on & ,john/on1 ( ,new ,brunswick1 ,n4 ,j4 & are sold 9 ! %ops4 ,m\?-gag4--,wide gagg+ prev5ts prop] exposure ( ! l>ynx by =c+ ! m&ible d[n on ! hyoid bone4 ,! m\? %\ld be g5tly op5$ & a bite block 7,fig4 #af7 ins]t$ betwe5 ! tee? on ! left side ( ! pati5t's m\?1 to prev5t clos+ ( ! jaws on ! delicate bron*oscope or esophagoscope4 ,,fig4 #af4--;,bite block to be ins]t$ betwe5 ! tee? to prev5t closure ( ! jaws on ! endoscopic tube4 ,?is is ! ,mc,kee-,mc,cready modification ( ! ,boyce ?imble ) ! omission ( ! e!riz+ tube1 :i* is no long] ne$$4 ,! block has be5 improv$ by ,dr4 ,w4 ,f4 ,moore ( ! ,bron*oscopic ,cl9ic4 ,=ceps4--,delicacy ( t\* & manipulation are an absolute necessity if ! endoscopi/ is to avoid mortality2 !re=e1 heavily built & spr+-oppos$ =ceps are dang]\s z well z useless4 ,= =eign-body "w 9 ! l>ynx1 & = ! removal ( b5ign l>yngeal gr[?s1 ! alligator =ceps ) r\gh5$ jaws %[n 9 ,fig4 #ag s]ve e purpose4 ,,fig4 #ag4--,l>yngeal grasp+ =ceps design$ by ,mo%]4 ,= my own use ,i h tak5 (f ! rat*et-lock+ device = all g5]al "w1 to be reappli$ on ! r>e occasions :5 x is requir$4 ,bron*oscopic & esophagoscopic grasp+ =ceps are ( ! tubul> type1 t is1 a /ylet c>ry+ ! jaws works 9 a sl5d] tube s t traction on ! /ylet draws ! ,v ( ! op5 jaws into ! lum5 ( ! tube1 ?us caus+ ! blades to approximate4 ,!y are v delicate & light1 yet h great grasp+ p[] & w su/a9 any degree ( traction t x is safe to ex]t4 ,!y p]mit ( ! delicacy ( t\* ( a viol9 b[4 ,! two types ( jaws mo/ frequ5tly us$1 are ^? ) ! =w>d-grasp+ blades %[n 9 ,fig4 #ah1 & ^? hav+ side-grasp+ blades %[n 9 ,fig4 #ai4 ,! side-curv$ =ceps are p]haps ! mo/ g5]ally useful ( all ! endoscopic =ceps2 ! side projection ( ! jaws makes !m readily visible dur+ _! closure on an object2 _! broad] grasp is also an advantage41 ,! projection ( ! blades 9 ! side-curv$ grasp+ =ceps %\ld always be direct$ t[>d ! left4 ,if x is desir$ t !y op5 9 ano!r direction ?is %\ld be accompli%$ by turn+ ! h&le & n by adju/+ ! blade itself4 ,if ?is rule be foll[$ x w always be possible to tell by ! position ( ! h&le exactly :]e ! blades are situat$2 :]eas1 if ! jaws !mselves are turn$1 confusion is sure to result4 ,! =w>d-grasp+ =ceps are always s adju/$ t ! jaws op5 9 an up-&-d[n direction4 ,on r>e occasions x may be deem$ desirable to turn ! /ylet ( ei!r =ceps 9 "s o!r direction relative to ! h&le4 ,,fig4 #ah4--,! au?or's =w>d grasp+ tube =ceps4 ,! h&le me*anism is s simple & delicate t ! mo/ exquisite delicacy ( t\* is possible4 ,two locknuts & a ?umbscrew take up all lo/ motion yet af=d p]fect adju/ability & easy sep>ation = cleans+4 ,at ,a is %[n a small clip = keep+ ! jaws toge!r to prev5t injuri\s b5d+ 9 ! /]iliz]1 or c>ry+ case4 ,at ! left is %[n a h&le-clamp = lock+ ! =ceps on a =eign body 9 ! solution ( c]ta9 r>ely enc\nt]$ me*anical problems4 ,! jaws are s]rat$ & cupp$4 ,,fig4 #ai4--;,jaws ( ! au?or's side-curv$ endoscopic =ceps4 ,^! "w z %[n 9 ! prec$+ illu/ration1 ea* =ceps hav+ its own h&le & tube4 ,orig9ally ! end ( ! cannula & /ylet 7 squ>$ to prev5t rotation ( ! jaws 9 ! cannula4 ,?is 0 f\nd to be unnecess>y ) prop]ly %ap$ jaws1 :i* w$ge tightly4 ,rotation ,=ceps4--,x is sometimes desir$ to make traction on an irregul>ly %ap$ =eign body1 & yet to all[ ! object to turn into ! l9e ( lea/ resi/ance :ile traction is be+ made4 ,?is c be accompli%$ by ! use ( ! rotation =ceps 7,fig4 #bj71 :i* h = blades two po9t$ hooks t meet at _! po9ts & d n ov]lap4 ,rotation =ceps made on ! model ( ! l>yngeal grasp+ =ceps1 b hav+ oppos+ po9ts at ! end ( ! blades1 are sometimes v useful = ! removal ( irregul> =eign bodies 9 ! l>ynx1 or :5 us$ ?r\gh ! esophageal speculum !y are ( great s]vice 9 ! extraction ( su* objects z bones1 p9-buttons1 & too?-plates1 f ! upp] esophagus4 ,^! =ceps are t]m$ l>yngeal rotation =ceps 7,fig4 #ca74 ,all ! v>i\s =ms ( =ceps are made 9 a v delicate size (t5 call$ ! mosquito or extra light =ceps1 #dj cm4 9 l5g?1 = use 9 ! #d mm4 & ! #e mm4 bron*oscopes4 ,= ! #e mm4 bron*oscopes heavi] =ceps ( ! #dj cm4 l5g? are made4 ,= ! l>g] tubes ! =ceps are made 9 #de cm41 #ej cm41 & #fj cm4 l5g?s4 ,a squ>e-cannula =ceps to prev5t turn+ ( ! jaws 0 at "o "t us$ by ! au?or b x has s9ce be5 f\nd t r\nd cannula patt]n s]ves all purposes4 ,,fig4 #bj4--,! au?or's rotation =ceps4 ,useful to all[ turn+ ( an irregul> =eign body to a saf] relation = )drawal & = ! esophagoscopic removal ( safety p9s by ! me?od ( pu%+ !m into ! /oma*1 turn+ & )drawal1 spr+ up4 ,upp]-lobe-bron*us ,=ceps4--,=eign bodies r>ely lodge 9 an upp]-lobe bron*us1 yet ) su* a problem x is necess>y to h =ceps t w rea* ar\nd a corn]4 ,! upp]-lobe-bron*us =ceps %[n 9 ,fig4 #bg h curv$ jaws s made z to /raight5 out :ile pass+ ?r\gh ! bron*oscope & to spr+ back into _! orig9al %ape on up f ! l[] jaw em]g+ f ! di/al end ( ! bron*oscopic tube1 ! radius ( curvature be+ regulat$ by ! ext5t ( em]g5ce p]mitt$4 ,!y are made 9 extra-light patt]n1 #dj cm4 long1 & ! regul> model #de cm4 long4 ,! full-curv$ model1 giv+ #ahj degrees & rea*+ up into ! asc5d+ bran*es1 is made 9 bo? light & heavy patt]ns4 ,=ceps ) less curve1 & )\t ! spiral1 are us$ :5 x is desir$ to rea* only a %ort di/ance ar\nd ! corn] any:]e 9 ! bron*i4 ,^! are also useful1 z sugge/$ by ,willis ,f4 ,manges1 9 deal+ ) safety p9s 9 ! esophagus or tra*eobron*ial tree4 ,,fig4 #ba4--,tuck] jaws = ! au?or's =ceps4 ,! t9y lip project+ d[n f ! upp]1 & up f ! l[] jaw prev5ts sidewise escape ( ! %aft ( a p91 tack1 nail or ne$le4 ,! %aft is automatically ?r[n p>allel to ! bron*oscopic axis4 ,draw+ ab\t f\r times actual size4 #cf ,tuck] ,=ceps--,gabriel ,tuck] modifi$ ! regul> side-curv$ =ceps by add+ a lip 7,fig4 #ba7 to ! left h& side ( bo? upp] & l[] jaws4 ,?is prev5ts ! %aft ( a tack1 nail1 or p91 f spr++ out ( ! grasp ( ! jaws1 & is s effici5t t x has br\ght c]ta9ty ( grasp nev] be=e obta9able4 ,) x ! solution ( ! safety-p9 problem devis$ by ! au?or _m ye>s ago has a facility & c]ta9ty ( execution t makes x ! me?od ( *oice 9 safety-p9 extraction4 ,,fig4 #bb4--,! au?or's d[n-jaw esophageal =ceps4 ,! dropp+ jaw is useful = rea*+ backw>d bel[ ! cricoph>yngeal fold :5 us+ ! esophageal speculum 9 ! removal ( =eign bodies4 ,po/]ior =ceps-spaces are (t5 scanty 9 cases ( =eign bodies lodg$ j bel[ ! cricoph>yngeus4 ,,fig4 #bc4--;,expansile =ceps = ! endoscopic removal ( holl[ =eign bodies su* z intubation tubes1 tra*eal cannulae1 caps1 & c>tridge %ells4 ,screw =ceps4--,= ! secure grasp ( screws ! jaws devis$ by ,dr4 ,tuck] = tacks & p9s are excell5t 7,fig4 #ba74 ,exp&+ ,=ceps4--,holl[ objects may require exp&+ =ceps z %[n 9 ,fig4 #bc4 ,9 us+ !m x is necess>y to be c]ta9 t ! jaws are inside ! holl[ body be=e exp&+ !m & mak+ traction4 ,o!rwise sev]e1 ev5 fatal1 trauma may be inflict$4 ,,fig4 #bd4--,! au?or's f5e/rat$ peanut =ceps4 ,! delicate con/ruction ) long1 spr+y & f5e/rat$ jaws give 9 g5tle h&s a maximum security ) a m9imum ( cru%+ t5d5cy4 ,,fig4 #be--,! au?or's bron*ial dilators1 useful = dilat+ /rictures above =eign bodies4 ,! small] size1 %[n at ! "r is also useful z an exp&+ =ceps = remov+ intubation tubes1 & o!r holl[ objects4 ,! l>g] size w g ov] ! %aft ( a tack4 ,,fig4 #bf4--,! au?or's self-exp&+ bron*ial dilator4 ,! ext5t ( expansion c be limit$ by ! s5se ( t\* or by an adju/able *eck+ me*anism on ! h&le4 ,! au?or frequ5tly us$ smoo? =ceps = ?is purpose1 & f\nd !m s effici5t t ?is dilator 0 devis$4 ,! edges ( =ceps jaws are likely to scrat* ! epi!lium4 ,occasionally ! in/rum5t is useful 9 ! esophagus2 b x is n v safe1 unless us$ ) ! utmo/ caution4 ,tissue ,=ceps4--,) ! =ceps illu/rat$ 9 ,fig4 #bh specim5s ( tissue may be remov$ = biopsy f ! l[] air & food passages ) ease & c]ta9ty4 ,!y h a cross 9 ! out] blade :i* holds ! specim5 remov$4 ,! action is v delicate1 !re be+ no spr+s1 & ! s5se ( t\* imp>t$ is (t5 ( great aid 9 ! diagnosis4 ,,fig4 #bg4--,! au?or's upp]-lobe bron*us =ceps4 ,at ,a is %[n ! full-curv$ =m1 = rea*+ into ! asc5d+ bran*es ( ! upp]-lobe bron*us ,a numb] ( diff]5t =ms ( jaws are made 9 ?is k9d ( =ceps4 ,only #b are %[n4 ,,fig #bh--,! au?or's endoscopic tissue =ceps4 ,! l>yngeal l5g? is #cj cm4 ,= esophageal use !y are made #ej & #fj cm4 long4 ,^! are ! be/ =ceps = cutt+ out small specim5s ( tissue = biopsy4 ,! l>ge basket pun* =ceps %[n 9 ,fig4 #cc are useful 9 remov+ l>g] gr[?s or specim5s ( tissue f ! ph>ynx or l>ynx4 ,a portion or ! :ole ( ! epiglottis may be easily & quickly remov$ ) ^! =ceps1 ! l>yngoscope introduc$ along ! dorsum ( ! tongue into ! glossoepiglottic recess1 br++ ! :ole epiglottis into view4 ,! =ceps may be introduc$ ?r\gh ! l>yngoscope or alongside ! tube4 ,9 ! latt] me?od a great] lat]al action ( ! =ceps is obta9able1 ! tube be+ us$ = vision only4 ,^! =ceps are #cj cm4 long & are made 9 two sizes2 "o ) ! pun* ( ! l>ge/ size t c be pass$ ?r\gh ! adult l>yngoscope1 & a small] "o = use ?r\gh ! ant]ior-commissure l>yngoscope & ! *ild's size l>yngoscope4 ,,fig4 #bi4--,! au?or's papilloma =ceps4 ,! broad blunt nose w scalp (f ! gr[?s )\t any injury to ! normal basal tissues4 ,voice-de/roy+ & /5os+ trauma are ?us easily avoid$4 ,,fig4 #cj4--,! au?or's %ort me*anical spoon 7#cj cm4 long74 ,papilloma ,=ceps4--,papillomata d n infiltrate2 b sup]ficial repullulations 9 _m cases require repeat$ removals4 ,if ! basal tissues are traumatiz$1 an impair$ or ru9$ voice w result4 ,! au?or design$ ^! =ceps 7,fig4 #bi7 to scalp (f ! gr[?s )\t injury to ! normal tissues4 ,,fig4 #ca4--,! au?or's l>yngeal rotation =ceps4 ,,fig4 #cb4--;,enl>g$ view ( ! jaws ( ! au?or's vocal-nodule =ceps4 ,l>g] cups are made = o!r purposes b ^! t9y cups p]mit ( t extreme delicacy requir$ 9 ! excision ( ! nodules f ! vocal cords ( s+]s & o!r voice us]s4 ,,fig #cc4-;,extra l>ge l>yngeal tissue =ceps4 #cj cm4 long1 = remov+ entire gr[?s or l>ge specim5s ( tissue4 ,a small] size is made4 ,bron*ial ,dilators4--,x is n uncommon to f9d a /ricture ( ! bron*us sup]jac5t to a =eign body t has be5 9 situ = a p]iod ( mon?s4 ,9 ord] to remove ! =eign body1 ?is /ricture mu/ be dilat$1 & = ?is ! bron*ial dilator %[n 9 ,fig4 #be 0 devis$4 ,! *annel 9 ea* blade all[s ! clos$ dilator to be pu%$ d[n ov] ! pres5t+ po9t ( su* bodies z tacks1 aft] :i* ! blades are op5$ & ! /ricture /ret*$4 ,a small & a l>ge size are made4 ,= enl>g+ ! bron*ial n>r[+ associat$ ) pulmon>y abscess & sometimes f\nd above a bron*iectatic or =eign body cavity1 ! exp&+ dilator %[n 9 ,fig4 #bf is p]haps less apt to cause injury ?an ord9>y =ceps us$ 9 ! same way4 ,! /ret*+ is "h produc$ by ! spr+ ( ! blades ( ! =ceps & n by manual =ce4 ,! clos$ blades are to be ins]t$ ?r\gh ! /rictur$ area1 op5$1 & !n sl[ly )drawn4 ,= cicatricial /5oses ( ! tra*ea ! metallic b\gies1 ,fig4 #dj1 are useful4 ,= ! l>ynx1 ^? %[n 9 ,fig4 #da are ne$$4 ,,fig4 #cd4--;,a1 ,mo%]'s l>yngeal curette2 ,b1 au?or's flat blade caut]y electrode2 ,c1 po9t$ caut]y electrode2 ,d1 l>yngeal knife4 ,! electrodes are insulat$ ) h>d-rubb] vulcaniz$ onto ! conduct+ wires4 ,,fig4 #ce4--,retrograde esophageal b\gies 9 graduat$ sizes devis$ by ,dr4 ,gabriel ,tuck] & ! au?or = dilatation ( cicatricial esophageal /5osis4 ,!y are drawn upw>d by an endless swall[$ /r+1 & are !re=e only to be us$ 9 ga/ro/omiz$ cases4 ,,fig4 #cf4--;,au?or's bron*oscopic & esophagoscopic me*anical spoon1 made 9 #dj1 #ej & #fj cm4 l5g?s4 ,,fig4 #cg4--,s*ema illu/rat+ ! au?or's me?od ( endoscopic closure ( op5 safety p9s lodg$ po9t upw>d ,! clos] is pass$ d[n "u ocul> control until ! r+1 ,r1 is bel[ ! p94 ,! r+ is !n erect$ to ! position %[n dott$ at ,m1 by mov+ ! h&le1 ,h1 d[nw>d to ,l & lock+ x !re ) ! lat*1 ,z4 ,! =k1 ,a1 is !n ins]t$ &1 engag+ ! p9 at ! spr+ loop1 ,k1 ! p9 is pu%$ into ! r+1 ?us clos+ ! p94 ,slight rotation ( ! p9 ) ! =ceps may be necess>y to get ! po9t into ! keep]4 ,! upp] in/rum5t is sometimes useful z a me*anical spoon = remov+ l>ge1 smoo? =eign bodies f ! esophagus4 ,esophageal ,dilators4--,! dilatation ( cicatricial /5osis ( ! esophagus c be done safely only by endoscopic me?ods4 ,bl9d esophageal b\g9age is highly dang]\s1 = ! lum5 ( ! /ricture is usually ecc5tric & ! b\gie is !re=e apt to p]=ate ! wall r ?an f9d ! small op5+4 ,(t5 !re is pres5t a p\*+ ( ! esophagus above a /ricture1 9 :i* ! b\gie may lodge & p]=ate4 ,b\gies %\ld be introduc$ "u visual guidance ?r\gh ! esophagoscope1 :i* is s plac$ t ! lum5 ( ! /ricture is 9 ! c5t] ( ! endoscopic field4 ,! au?or's endoscopic b\gies 7,fig4 #dj7 are made ) a flexible silk-wov5 tip securely fa/5$ to a /eel %aft4 ,?is %aft l5ds rigidity to ! in/rum5t suffici5t to p]mit its accurate placem5t1 & its small size p]mits ! eye to keep ! silk-wov5 tip 9 view4 ,^! endoscopic b\gies are made 9 sizes f #h to #dj1 ,fr5* scale4 ,! l>g] sizes are us$ especially = ! dilatation ( l>yngeal & tra*eal /5oses4 ,= ! latt] "w x is ess5tial t ! b\gies be inspect$ c>efully be=e !y are us$1 = %\ld a defective tip come (f :ile 9 ! l[] air passages a difficult =eign body problem w\ld be creat$4 ,s(t-rubb] retrograde dilators to be drawn upw>d f ! /oma* by a swall[$ /r+ are useful 9 ga/ro/omiz$ cases 7,fig4 #ce74 ,,fig #ch4--;,half curv$ hook1 #de cm4 & #fj cm4 ,full curv$ patt]ns are made b caution is necess>y to avoid !m becom+ an*or$ 9 ! bron*i4 ,spiral =ms avoid ?is4 ,! au?or makes = himself /eel probe-po9t$ rods out ( :i* he b5ds hooks ( any desir$ %ape4 ,! rod is held 9 a p9-vise to facilitate b5d+ ( ! po9t1 aft] heat+ 9 an alcohol or buns5 flame4 ,hooks4--,no hook great] ?an a "r angle %\ld be us$ ?r\gh endoscopic tubes2 = %\ld x become caught 9 "s ( ! small] bron*i its extraction might result 9 s]i\s trauma4 ,! half curv$ hook %[n 9 ,fig4 #ch is ! safe/ type2 bett] /ill1 a spiral twi/ to ! hook w add to its uses1 & by rev]s+ ! turn+ motion x may be unscrew$ out if x becomes caught4 ,hooks may easily be made f rods ( malleable /eel by heat+ ! end 9 a _s lamp & %ap+ ! curve z desir$ by means ( a p9-vise & pli]s4 ,ab\t #b cm4 ( ! proximal end ( ! rod %\ld be b5t 9 exactly ! opposite direction f t ( ! hook s z to =m a h&le :i* w tell ! position ( ! hook by t\* z well z by sight4 ,coil-spr+ hooks = ! upp]-lobe-bron*us 7,fig4 #ci7 w rea* ar\nd ! corn] into ! asc5d+ bron*us ( ! upp]-lobe-bron*us1 b ! utmo/ skill & c>e are requir$ to make _! use ju/ifiable4 ,,fig4 #ci4--;,au?or's coil-spr+ hook = ! upp]-lobe1 bron*us ,safety-p9 ,clos]4--,!re are a numb] ( me?ods = ! endoscopic removal ( op5 safety-p9s :5 ! po9t is up1 "o ( :i* is by clos+ ! p9 ) ! in/rum5t %[n 9 ,fig4 #cg 9 ! foll[+ mann]4 ,! oval r+ is pass$ ?r\gh ! endoscope until x is beyond ! spr+ ( ! safety-p91 ! r+ is !n turn$ upw>d by depress+ ! h&le1 & by ! aid ( ! prong ! p9 is pu%$ into ! r+1 :i* action approximates ! po9t ( ! p9 & ! keep] & closes ! p94 ,removal is !n less difficult & )\t dang]4 ,?is in/rum5t may also be us$ z a me*anical spoon1 9 :i* case x may be pass$ to ! side ( a difficultly grasp$ =eign body1 su* z a pebble1 ! r+ elevat$ & ! object )drawn4 ,else:]e w be f\nd a description ( ! v>i\s safety-p9 clos]s devis$ by v>i\s endoscopi/s4 ,! au?or has us$ ,arr[smi?'s clos] ) mu* satisfaction4 ,me*anical ,spoon4--,:5 s(t1 friable sub/ances1 su* z a bolus ( meat1 become impact$ 9 ! upp] esophagus1 ! %ort me*anical spoon 7,fig4 #cj7 us$ ?r\gh ! esophageal speculum is ( great aid 9 _! removal4 ,! blade 9 ?is in/rum5t1 z ! "n sugge/s1 is a spoon & is n f5e/rat$ z is ! safety-p9 clos]1 :i* if us$ = friable sub/ances w\ld all[ !m to slip ?r\gh ! f5e/ration4 ,a long] =m = use ?r\gh bron*oscopes & esophagoscopes is %[n 9 ,fig4 #cf4 ,a l>yngeal curette1 caut]y electrodes1 caut]y h&le1 & l>yngeal knife are illu/rat$ 9 ,fig4 #cd4 ,! caut]y is to be us$ ) a trans=m]1 or a /orage batt]y4 ,spectacles4--,if ! op]ator has no refractive error he w ne$ two pairs ( plane protective spectacles ) v l>ge eyes4 ,if ametropic1 corrective l5ses are necess>y1 & duplicate spectacles mu/ be 9 *>ge ( a nurse4 ,= presbyopia two pairs ( spectacles = #dj cm4 di/ance & #fe cm4 di/ance mu/ be at h&4 ,hook temple frames %\ld be us$ s t !y c be easily *ang$ & adju/$ by ! nurse :5 ! l5ses become spatt]$4 ,! spectacle nurse has ready at all times ! extra spectacles1 clean$ & w>m$ 9 a pan ( heat$ wat] s t !y w n be fogg$ by ! pati5t's brea?1 & %e *anges !m )\t delay z (t5 z !y become soil$4 ,! op]ator %\ld "w ) bo? eyes op5 & ) 8 "r eye at ! tube m\?4 ,! op]at+ room %\ld be some:at d>k5$ s z to facilitate ! ignor+ ( ! image 9 ! left eye2 any light+ %\ld be at ! op]ator's back1 & %\ld be insuffici5t to cause reflections f ! inn] surface ( 8 glasses4 ,,fig4 #dj4--,! au?or's endoscopic b\gies4 ,! end consi/s ( a flexible silk wov5 tip atta*$ securely to a /eel %ank4 ,sizes #h to #cj ,fr5* ca!t] scale4 ,a metallic =m ( ?is b\gie is useful 9 ! tra*ea2 b is n s safe = esophageal use4 ,,fig4 #da4--,! au?or's l>yngeal b\gie = ! dilatation ( cicatricial l>yngeal /5osis4 ,made 9 #aj sizes4 ,! %ad$ triangle %[s ! cross-section at ! wide/ "p4 ,,fig4 #db4--,! au?or's bron*oscopic & esophagoscopic table4 #df ,endoscopic ,table4--,any op]at+ table may be us$1 b ! "w is facilitat$ if a special table c be _h :i* all[s ! plac+ ( ! pati5t 9 all requir$ positions4 ,! table illu/rat$ 9 fig4 #db is s arrang$ t :5 ! false top is drawn =w>d on ! railroad1 ! head piece drops & ! pati5t is plac$ 9 ! correct 7,boyce7 position = esophagoscopy or bron*oscopy1 i4e41 ) ! head & %\ld]s ext5d+ ov] ! end ( ! table4 ,by means ( ! :eel ! plane ( ! table may be alt]$ to any desir$ angle ( incl9ation or height ( head4 ,op]at+ ,room4--,all endoscopic proc$ures %\ld be p]=m$ 9 a some:at d>k5$ op]at+ room :]e all ! desir$ mat]ials are at h&4 ,an endoscopic team consi/s ( ?ree p]sons3 ! op]ator1 ! assi/ant :o holds ! head1 & ! in/rum5t assi/ant4 ,ano!r p]son is requir$ to hold ! pati5t's arms & /ill ano!r = ! *ang+ ( ! op]ator's glasses :5 !y become spatt]$4 ,! endoscopic team ( ?ree ma9ta9 surgical asepsis 9 ! matt] ( h&s & g[ns1 etc4 ,! batt]y1 on a small table ( its own1 is plac$ at ! left h& ( ! op]ator4 ,beyond x is ! table = ! me*anical aspirator1 if "o is us$4 ,all extra in/rum5ts are plac$ on a /]ile table1 )9 rea*1 b n 9 ! way1 :ile ^? in/rum5ts = use 9 ! p>ticul> op]ation are plac$ on a small in/rum5t table back ( ! endoscopi/4 ,only ^? in/rum5ts likely to be want$ %\ld be plac$ on ! work+ table1 s t !re %all be no confusion 9 _! selection by ! in/rum5t nurse :5 call$ =4 ,ea* mom5t ( "t %\ld be utiliz$ :5 ! endoscopic proc$ure has be5 />t$1 no "t %\ld be lo/ 9 ! hunt+ or sep>at+ ( in/rum5ts4 ,to h ! respective tables always 9 ! same position relative to ! op]ator prev5ts confusion & avoids delay4 ,,fig #dc4--,! au?or's retrograde esophagoscope4 ,oxyg5 ,tank & ,tra*eotomy ,in/rum5ts4--,respiratory arre/ may occur f %ift+ ( a =eign body1 pressure ( ! esophagoscope1 tumor1 or div]ticulum full ( food4 ,r>e z ^! cont+5cies are1 x is ess5tial t means = resuscitation be at h&4 ,no endoscopic proc$ure %\ld be und]tak5 )\t a set ( tra*eotomy in/rum5ts on ! /]ile table )9 in/ant rea*4 ,9 respiratory arre/ f ! above m5tion$ causes1 respiratory ef=ts are n apt to return unless oxyg5 & amyl nitrite are bl[n into ! tra*ea ei!r ?r\gh a tra*eotomy op5+ or bett] /ill by means ( a bron*oscope introduc$ ?r\gh ! l>ynx4 ,! limpness ( ! pati5t r5d]s bron*oscopy s easy t ! well-drill$ bron*oscopi/ %\ld h no difficulty 9 ins]t+ a bron*oscope 9 #aj or #ae seconds1 if prop] prep>$ness has be5 obs]v$4 ,x is p]haps relatively r>ely t su* accid5ts occur1 yet if prep>ations are made = su* a cont+5cy1 a life may be sav$ :i* w\ld o!rwise be inevitably lo/4 ,! oxyg5 tank cov]$ ) a /]ile musl9 cov] %\ld /& to ! left ( ! op]at+ table4 ,asepsis4--,/rict aseptic te*nic mu/ be obs]v$ 9 all endoscopic proc$ures4 ,! op]ator1 fir/ assi/ant1 & in/rum5t nurse mu/ use ! same precautions z to h& /]ilization & /]ile g[ns z w\ld be ex]cis$ 9 any surgical op]ation4 ,! op]ator & fir/ assi/ant %\ld we> masks & /]ile gloves4 ,! pati5t is in/ruct$ to cleanse ! m\? ?or\ghly ) ! too? bru% & a #bj p] c5t alcohol m\? wa%4 ,any d5tal defects %\ld1 if "t p]mit1 z 9 a c\rse ( repeat$ treatm5ts1 be rem$i$ by ! d5tal surgeon4 ,:5 plac$ on ! table ) neck b>e & ! %\ld]s unhamp]$ by clo?+1 ! pati5t is cov]$ ) a /]ile %eet & ! head is enfold$ 9 a /]ile t[el4 ,! face is wip$ ) #gj p] c5t alcohol4 ,x is to be rememb]$ t :ile ! pati5t is relatively immune to ! bact]ia he himself h>bors1 ! implantation ( diff]5t /ra9s ( p]haps ! same type ( organisms may prove virul5t to him4 ,fur!rmore ! transf]5ce ( lues1 tub]culosis1 diph!ria1 pneumonia1 erysipelas & o!r infective diseases w\ld be inevitable if /]ile precautions 7 n tak54 ,all ( ! tubes & =ceps are /]iliz$ by boil+4 ,! light-c>ri]s & lamps may be /]iliz$ by imm]sion 9 #ie p] c5t alcohol or by prolong$ exposure to =maldehyde gas4 ,cont9u\s /]ilization by keep+ !m put away 9 a metal box ) =mal9 pa/illes or o!r s\rce ( =maldehyde gas is an ideal me?od4 ,knives & scissors are imm]s$ 9 #ie p] c5t alcohol1 & ! rubb] cov]$ conduct+ cords are wip$ ) ! same solution4 ,li/ ( ,in/rum5ts4--,! foll[+ li/ has be5 compil$ z a conv5i5t basis = equipm5t1 to :i* su* special in/rum5ts z may be ne$$ = special cases c be add$ f "t to "t4 ,! in/rum5ts li/$ are ( ! au?or's design4 #a adult's l>yngoscope4 #a *ild's l>yngoscope4 #a infant's diagno/ic l>yngoscope4 #a ant]ior commissure l>yngoscope4 #a bron*oscope1 #d mm4 ,x #cj cm4 #a bron*oscope1 #e mm4 ,x #cj cm4 #a bron*oscope1 #g mm4 ,x #dj cm4 #a bron*oscope1 #i mm4 ,x #dj cm4 #a esophagoscope1 #g mm4 ,x #de cm4 #a esophagoscope1 #aj mm4 ,x #ec cm4 #a esophagoscope1 full lum51 #g mm4 ,x #de cm4 #a esophagoscope1 full lum51 #i mm4 ,x #de cm4 #a esophageal speculum1 adult4 #a esophageal speculum1 *ild4 #a =w>d-grasp+ =ceps1 delicate1 #dj cm4 #a =w>d-grasp+ =ceps1 regul>1 #ej cm4 #a =w>d-grasp+ =ceps1 regul>1 #fj cm4 #a side-grasp+ =ceps1 delicate1 #dj cm4 #a side-grasp+ =ceps1 regul>1 #ej cm4 #a side-grasp+ =ceps1 regul>1 #fj cm4 #a rotation =ceps1 delicate1 #dj cm4 #a rotation =ceps1 regul>1 #ej cm4 #a rotation =ceps1 regul>1 #fj cm4 #a l>yngeal alligator =ceps4 #a l>yngeal papilloma =ceps4 #aj esophageal b\gies1 ,nos4 #h to #ag ,fr5* 7l>g] sizes to ,no4 #cf may be add$74 #a special measur+ rule4 #f light sponge c>ri]s4 #a aspirator ) d\ble tube = m9us & plus pressure4 #b endoscopic aspirat+ tubes #cj & #ej cm4 #a half curv$ hook1 #fj cm4 #a triple circuit bron*oscopy batt]y4 #f rubb] cov]$ conduct+ cords = batt]y4 #a box bron*oscopic sponges1 size #d4 #a box bron*oscopic sponges1 size #e4 #a box bron*oscopic sponges1 size #g4 #a box bron*oscopic sponges1 size #aj4 #a bite block1 #a adult4 #a bite block1 *ild4 #b doz5 extra lamps = light$ in/rum5ts4 #a extra light c>ri] = ea* in/rum5t499 #d y>ds ( pipe-clean+1 wor/$-cov]$ wire4 99 ,messrs4 ,george ,p4 ,pill+ & ,sons :o are n[ mak+ ^! in/rum5ts supply an extra light c>ri] & #b extra lamps ) ea* in/rum5t4 ,c>e ( ,in/rum5ts4--,! endoscopi/ mu/ ei!r p]sonally c>e = 8 in/rum5ts1 or h an in/rum5t nurse 9 8 own employ1 = if !y are intru/$ to ! g5]al op]at+ room r\t9e he w f9d t small p>ts w be lo/2 blades ( =ceps b5t1 brok51 or ru/$2 tubes d+$2 dra9age canals *ok$ ) blood or secretions :i* h be5 coagulat$ by boil+1 & electric atta*m5ts r5d]$ un/able or uns]vicable1 by boil+1 etc4 ,! tubes %\ld be cleans$ by =c+ cold wat] ?r\gh ! dra9age canals ) ! aspirat+ syr+e1 !n dri$ by =c+ pipe-clean+ wor/$-cov]$ wire ?r\gh ! light & dra9age canals4 ,gauze on a sponge c>ri] is us$ to clean ! ma9 canal4 ,=ceps /ylets %\ld be remov$ f _! cannulae1 & ! cannulae cleans$ ) cold wat]1 !n dri$ & oil$ ) ! pipe-clean+ mat]ial4 ,! /ylet %\ld h any r\gh places smoo!d ) f9e em]y clo? & its blades c>efully inspect$2 ! p>ts are !n oil$ & reassembl$4 ,nickle plat+ on ! tubes is apt to peel & ^! scales h %>p1 cutt+ edges :i* may injure ! mucosa4 ,all tubes1 !re=e1 %\ld be unplat$4 ,r\gh places on ! tubes %\ld be smoo!d ) ! f9e/ em]y clo?1 or1 bett]1 on a buff+ :eel4 ,! dry cells 9 ! batt]y %\ld be r5ew$ ab\t e #d mon?s :e!r us$ or n4 ,lamps1 light c>ri]s1 & cords1 aft] cleans+1 are wip$ ) #ie p] c5t alcohol1 & ! light-c>ri]s ) ! lamps 9 place are kept 9 a cont9u\s /]ilization box conta9+ =maldehyde pa/illes4 ,x is ( ! utmo/ importance t in/rum5ts be always put away 9 p]fect ord]4 ,n only are clean+ & oil+ imp]ative1 b any ne$$ repairs %\ld be att5d$ to at once4 ,o!rwise x w be inevitable t :5 gott5 out 9 an em]g5cy !y w fail4 ,9 g5]al surg]y1 a spoon w s]ve = a retractor & good "w c be done ) make%ifts2 b 9 endoscopy1 especially 9 ! small1 delicate1 natural passages ( *ildr51 ! h&icap ( a defective or insuffici5t armam5t>ium may make all ! diff]5ce betwe5 a success & a fatal failure4 ,a bron*oscopic cl9ic %\ld at all times be 9 ! same /ate ( prep>$ness = em]g5cy z is ev]y:]e requir$ ( a fire-eng9e h\se4 ,,plate ,i--,a ,,work+ ,,set ,,( ,,! ,,au?or',s ,,endoscopic ,,tubes ,,= ,,l>yngoscopy1 ,,bron*oscopy1 ,,esophagoscopy1 ,,& ,,ga/roscopy3 ,a1 ,adult's l>yngoscope2 ,b1 *ild's l>yngoscope2 ,c1 ant]ior commissure l>yngoscope2 ,d1 esophageal speculum1 *ild's size2 ,e1 esophageal speculum1 adult's size2 ,f1 bron*oscope1 infant's size1 #d mm4 ,x #cj cm42 ,g1 bron*oscope1 *ild's size1 #e mm4 ,x #cj cm42 ,h1 aspirat+ bron*oscope = adults1 #g mm4 ,x #dj cm42 ,i1 bron*oscope1 adolesc5t's size1 #g mm4 x #dj cm41 us$ also = ! deep] bron*i ( adults2 ,j1 bron*oscope1 adult size1 g mm4 x #dj cm42 ,k1 *ild's size esophagoscope1 #g mm4 ,x #de cm42 ,l1 adult's size esophagoscope1 full lum5 con/ruction1 #i mm4 x #de cm42 ,m1 adult's size ga/roscope4 ,c1 ,i1 & ,e are also hypoph>yngoscopes4 ,c is an excell5t esophageal speculum = *ildr51 & a long] model is made = adults4 ,if ! utmo/ economy mu/ be practis$ ,d1 ,e1 & ,m may be omitt$4 ,! balance ( ! in/rum5ts are indisp5sable if adults & *ildr5 are to be dealt )4 ,! in/rum5ts are made by ,*>les ,j4 ,pill+ ,sons1 ,philadelphia4 #eb ,,*apt] ,,ii--,,anatomy ,,( ,,l>ynx1 ,,tra*ea1 ,,bron*i ,,& ,,esophagus1 ,,endoscopically ,,consid]$ ,! l>ynx is a c>tilag9\s box1 triangul> 9 cross-section1 ) ! apex ( ! triangle direct$ ant]iorly4 ,x is readily felt 9 ! neck & is a l&m>k = ! op]ation ( tra*eotomy4 ,we are conc]n$ endoscopically ) f\r ( its c>tilag9\s /ructures3 ! epiglottis1 ! two aryt5oid c>tilages1 & ! cricoid c>tilage4 ,! epiglottis1 ! fir/ l&m>k 9 direct l>yngoscopy1 is a leaf-l projection spr++ f ! ant]o9t]nal surface ( ! l>ynx & hav+ = its function ! direct+ ( ! bolus ( food into ! pyri=m s9uses4 ,x does n close ! l>ynx 9 ! trap-door mann] =m]ly taught2 a fact easily demon/rat$ by ! simple ins]tion ( ! direct l>yngoscope & fur!r demon/rat$ by ! abs5ce ( dysphagia :5 ! epiglottis is surgically remov$1 or is de/roy$ by ulc]ation4 ,closure ( ! l>ynx is accompli%$ by ! approximation ( ! v5tricul> b&s1 aryt5oids & aryepiglottic folds1 ! latt] hav+ a sph9ct]-l action1 & by ! rais+ & tilt+ ( ! l>ynx4 ,! aryt5oids =m ! upp] po/]ior b\nd>y ( ! l>ynx & our p>ticul> int]e/ 9 !m is direct$ t[>d _! motility1 = ! rotation ( ! aryt5oids at ! crico>yt5oid articulations det]m9es ! movem5ts ( ! cords & ! production ( voice4 ,approximation ( ! aryt5oids is a "p ( ! me*anism ( closure ( ! l>ynx4 ,! cricoid c>tilage 0 reg>d$ by esophagoscopi/s z ! *ief ob/ruction enc\nt]$ on ! introduction ( ! esophagoscope4 ,z %[n by ! au?or1 x is ! cricoph>yngeal fold1 & ! inconceivably p[]ful pull ( ! cricoph>yngeal muscle on ! cricoid c>tilage1 t causes ! difficulty4 ,! cricoid is pull$ s p[]fully back aga9/ ! c]vical sp9e1 t x is h>d to believe t ?is muscles is ins]t$ into ! m$ian raphe & n into ! sp9e itself 7,fig4 #fh74 ,! v5tricul> b&s or false vocal cords vic>i\sly phonate 9 ! abs5ce ( ! true cords1 & assi/ 9 ! protective function ( ! l>ynx4 ,!y =m ! floor ( ! v5tricles ( ! l>ynx1 :i* are recesses on ei!r side1 betwe5 ! false & true cords1 & conta9 num]\s muc\s gl&s ! secretion f :i* lubricates ! cords4 ,! v5tricles are n visible by mirror l>yngoscopy1 b are readily expos$ 9 _! dep?s by lift+ ! respective v5tricul> b&s ) ! tip ( ! l>yngoscope4 ,! vocal cords1 :i* appe> :ite1 flat1 & ribbon-l 9 ! mirror1 :5 view$ directly assume a r$di% color1 & reveal _! true %elf-l =mation4 ,9 ! subglottic area ! tissues are vascul>1 &1 9 *ildr5 especially1 !y are prone to swell :5 traumatiz$1 a fact :i* %\ld be always 9 m9d to emphasize ! importance ( g5tl5ess 9 bron*oscopy1 & fur!rmore1 ! necessity ( avoid+ ?is region 9 tra*eotomy because ( ! dang] ( produc+ *ronic l>yngeal /5osis by ! reaction ( ^! tissues to ! pres5ce ( ! tra*eotomic cannula4 ,! tra*ea j bel[ its entrance into ! ?orax deviates slightly to ! "r1 to all[ room = ! aorta4 ,at ! level ( ! second co/al c>tilage1 ! ?ird 9 *ildr51 x bifurcates into ! "r & left ma9 bron*i4 ,po/]iorly ! bifurcation corresponds to ab\t ! f\r? or fif? ?oracic v]tebra1 ! tra*ea be+ ela/ic1 & displac$ by v>i\s movem5ts4 ,! endoscopic appe>ance ( ! tra*ea is t ( a tube flatt5$ on its po/]ior wall4 ,9 two locations x normally (t5 assumes a m or less oval outl9e2 9 ! c]vical region1 due to pressure ( ! ?yroid gl&2 & 9 ! intra?oracic portion j above ! bifurcation :]e x is cross$ by ! aorta4 ,?is latt] flatt5+ is rhy?mically increas$ ) ea* pulsation4 ,"u pa?ological conditions1 ! tra*eal outl9e may be v>i\sly alt]$1 ev5 to oblit]ation ( ! lum54 ,! mucosa ( ! tra*ea & bron*i is moi/ & gli/5+1 :iti% 9 circul> ridges correspond+ to ! c>tilag9\s r+s1 & r$di% 9 ! int]v5+ grooves4 ,! "r bron*us is %ort]1 wid]1 & m ne>ly v]tical ?an its fell[ ( ! opposite side1 & is practically ! cont9uation ( ! tra*ea1 :ile ! left bron*us might be consid]$ z a bran*4 ,! deviation ( ! "r ma9 bron*us is ab\t #be degrees1 & its l5g? unbran*$ 9 ! adult is ab\t #b4e cm4 ,! deviation ( ! left ma9 bron*us is ab\t #ge degrees & its adult l5g? is ab\t #e cm4 ,! "r bron*us consid]$ z a /em1 may be said to give (f ?ree bran*es1 ! epi>t]ial1 upp]- or sup]ior-lobe bron*us2 ! middle-lobe bron*us2 & ! cont9uation d[nw>d1 call$ ! l[]- or inf]ior-lobe bron*us1 :i* gives (f dorsal1 v5tral & lat]al bran*es4 ,! left ma9 bron*us gives (f fir/ ! upp]-or sup]ior-lobe bron*us1 ! cont9uation be+ ! l[]-or inf]ior-lobe bron*us1 consi/+ ( a /em ) dorsal1 v5tral & lat]al bran*es4 ,,fig4 #dd4--,tra*eo-bron*ial tree4 ,,lm1 ,left ma9 bron*us2 ,,sl1 sup]ior lobe bron*us2 ,,ml1 middle lobe bron*us2 ,,il1 inf]ior lobe bron*us4 ,! septum betwe5 ! "r & left ma9 bron*i1 t]m$ ! c>9a1 is situat$ to ! left ( ! midtra*eal l9e4 ,x is recogniz$ endoscopically z a %ort1 %9+ ridge runn+ sagitally1 or1 z ! pati5t lies 9 ! recumb5t position1 we speak ( x z be+ v]tical4 ,on ei!r side are se5 ! op5+s ( ! "r & left ma9 bron*i4 ,9 ,fig4 #dd1 x w be se5 t ! l[] bord] ( ! c>9a is on a level ) ! upp] portion ( ! orifice ( ! "r sup]ior-lobe bron*us2 ) ! c>9a z a l&m>k & by displac+ ) ! bron*oscope ! lat]al wall ( ! "r ma9 bron*us1 a second1 small]1 v]tical spur appe>s1 & a view ( ! orifice ( ! "r upp]-lobe bron*us is obta9$1 ?\gh a lum5 image _c be pres5t$4 ,on pass+ d[n ! "r /em bron*us 7pati5t recumb5t7 a horizontal p>tition or spur is f\nd ) ! lum5 ( ! middle-lobe bron*us ext5d+ t[>d ! v5tral surface ( ! body4 ,all bel[ ?is op5+ ( ! "r middle-lobe bron*us con/itutes ! l[]-lobe bron*us & its bran*es4 ,,fig4 #de4--;,bron*oscopic views4 ,s2 ,sup]ior lobe bron*us2 ,,sl1 sup]ior lobe bron*us2 ,i1 inf]ior lobe bron*us2 ,m1 middle lobe bron*us4 #ef ,com+ back to ! c>9a & pass+ d[n ! left bron*us1 ! relatively great di/ance f ! c>9a to ! upp]-lobe bron*us is not$4 ,! spur divid+ ! orifices ( ! left upp]- & l[]-lobe bron*i is oblique 9 direction1 & x is possible to see m ( ! lum5 ( ! left upp]-lobe bron*us ?an ( its homologue on ! "r4 ,bel[ ?is are se5 ! l[]-lobe bron*us & its divisions 7,fig4 #de74 ,dim5sions ( ! ,tra*ea & ,bron*i4--,x w be not$ t ! bron*i divide monopodially1 n di*otom\sly4 ,:ile ! lum9a ( ! individual bron*i dim9i% z ! bron*i divide1 ! sum ( ! areas %[s a progressive increase 9 total tubul> area ( cross-section4 ,?us1 ! sum ( ! areas ( cross-section ( ! two ma9 bron*i1 "r & left1 is great] ?an ! area ( cross section ( ! tra*ea4 ,?is foll[s ! well kn[n dynamic law4 ,! relative increase 9 surface z ! tubes bran* & dim9i% 9 size increases ! friction ( ! pass+ air1 s t an actual increase 9 area ( cross section is necess>y1 to avoid increas+ resi/ance to ! passage ( air4 ,! cadav]ic dim5sions ( ! tra*eobron*ial tree may be epitomiz$ approximately z foll[s3 ,adult ,male ,female ,*ild ,infant ,diamet] tra*ea1 #ad ,x #bj #ab ,x #af #h ,x #aj #f ,x #g ,l5g? tra*ea1 cm4 #ab4j #aj4j #f4j #d4j ,l5g? "r bron*us #b4e #b4e #b4j #a4e ,l5g? left bron*us #e4j #e4j #c4j #b4e ,l5g? upp] tee? to tra*ea #ae4j #bc4j #aj4j #i4j ,l5g? total to second>y bron*us #cb4j #bh4j #ai4j #ae4j ,9 consid]+ ! =ego+ table x is to be rememb]$ t 9 life muscle tonus v>ies ! lum5 & on ! :ole r5d]s x small]4 ,9 ! selection ( tubes x mu/ be rememb]$ t ! full diamet] ( ! tra*ea is n available on acc\nt ( ! glottic ap]ture :i* 9 ! adult is a triangle measur+ approximately #ab ,x #bb ,x #bb mm4 & p]mitt+ ! passage ( a tube n ov] #aj mm4 9 diamet] )\t risk ( injury4 ,fur!rmore a tube :i* fill$ ! tra*ea w\ld be too l>ge to ent] ei!r ma9 bron*us4 ,! normal movem5ts ( ! tra*ea & bron*i are respiratory1 pulsatory1 be*ic1 & deglutitory4 ,! two =m] are rhy?mic :ile ! two latt] are int]mitt5tly not$ dur+ bron*oscopy4 ,x is readily obs]v$ t ! bron*i elongate & exp& dur+ inspiration :ile dur+ expiration !y %ort5 & contract4 ,! bron*oscopi/ mu/ le>n to "w 9 spite ( ! fact t ! bron*i dilate1 contract1 elongate1 %ort51 k9k1 & are d+$ & pu%$ ?is way & t4 ,x is ?is resili5cy & movability t make bron*oscopy possible4 ,! inspiratory enl>gem5t ( lum5 op5s up ! =ceps spaces1 & ! facile bron*oscopi/ avails himself ( ! opportunity to seize ! =eign body4 ,,! ,,esophagus ,a few ( ! anatomical details mu/ be kept especially 9 m9d :5 x is desir$ to introduce /raight & rigid in/rum5ts d[n ! lum5 ( ! gullet4 ,fir/ & mo/ important is ! fact t ! esophageal walls are exce$+ly ?9 & delicate & require ! mo/ c>eful manipulation4 ,because ( ?is delicacy ( ! walls & because ! esophagus1 be+ a con/ant passageway = bact]ia f ! m\? to ! /oma*1 is nev] /]ile1 surgical proc$ures are associat$ ) infective risks4 ,= "s o!r & n fully und]/ood reason1 ! esophagus is1 surgically speak+1 "o ( ! mo/ intol]ant ( all human visc]a4 ,! ant]ior wall ( ! esophagus is 9 a "p ( its c\rse1 9 close relation to ! po/]ior wall ( ! tra*ea1 & ?is portion is call$ ! p>ty wall4 ,x is ?is p>ty wall t conta9s ! lymph dra9age sy/em ( ! po/]ior portion ( ! l>ynx1 & x is l>gely by ?is r\te t po/]iorly locat$ malignant l>yngeal neoplasms e>ly meta/asize to ! m$ia/9um4 #eh ,,fig #df4--;,esophagoscopic & ,ga/roscopic ,*>t ,,bir? #a yr4 #c yrs4 #f yrs4 #aj yrs4 #ad yrs4,,adults #bc #bg #cj #cc #cf #dc #ec ,cm4 ,,great] ,,curvature #ah #bj #bb #be #bg #cd #dj ,cm4 ,,c>dia #ai #ba #bc #bd #be #ca #cf ,cm4 ,,hiatus #ac #ae #af #ah #bj #bd #bg ,cm4 ,,left ,,bron*us #ab #ad #ae #af #ag #ba #bc ,cm4 ,,aorta #g #i #aj #aa #ab #ad #af ,cm4 ,,cricoph>y+eus #j #j #j #j #j #j #j ,cm4 ,,incisors ,,fig4 #df4--,! au?or's esophagoscopic *>t ( approximate di/ances ( ! esophageal n>r[+s f ! upp] incisor tee?1 arrang$ = conv5i5t ref]5ce dur+ esophagoscopy 9 ! dorsally recumb5t pati5t4 ,! l5g?s ( ! esophagus at diff]5t ages are %[n diagrammatically 9 ,fig4 #df4 ,! diamet] ( ! esophageal lum5 v>ies greatly ) ! ela/icity ( ! esophageal walls2 its diamet] at ! f\r po9ts ( anatomical con/riction is %[n 9 ! foll[+ table3 ,con/riction ,diamet] ,v]tebra ,cricoph>yngeal ,transv]se #bc mm4 7#a 947 ,six? c]vical ,ant]o-po/]ior #ag mm4 7#c_/d 947 ,aortic ,transv]se #bd mm4 7#a 947 ,f\r? ?oracic ,ant]o-po/]ior #ai mm4 7#c_/d 947 ,left-bron*ial ,transv]se #bc mm4 7#a 947 ,fif? ?oracic ,ant]o-po/]ior #ag mm4 7#c_/d 947 ,diaphragmatic ,transv]se #bc mm4 7#a 97 ,t5? ?oracic ,ant]o-po/]ior #bc mm4 794--7 ,= practical endoscopic purposes x is only necess>y to rememb] t 9 a normal esophagus1 /raight & rigid tubes ( #g mm4 diamet] %\ld pass freely 9 infants1 & 9 adults1 tubes ( #aj mm4 ,! #d demon/rable con/rictions f above d[nw>d are at #a4 ,! crico-ph>yngeal fold4 #b4 ,! cross+ ( ! aorta4 #c4 ,! cross+ ( ! left bron*us4 #d4 ,! hiatus esophageus4 ,!re is a def9ite fif? n>r[+ ( ! esophageal lum5 n easily demon/rat$ esophagoscopically & n se5 dur+ dissection1 b readily %[n functionally by ! fact t almo/ all =eign bodies lodge at ?is po9t4 ,?is n>r[+ occurs at ! sup]ior ap]ture ( ! ?orax & is probably produc$ by ! cr[d+ ( ! num]\s organs :i* ent] or leave ! ?orax ?r\gh ?is orifice4 ,! crico-ph>yngeal con/riction1 z already m5tion$1 is produc$ by ! tonic contraction ( a specializ$ b& ( ! orbicul> fib]s ( ! l[]mo/ portion ( ! inf]ior ph>yngeal con/rictor muscle1 call$ ! cricoph>yngeal muscle4 ,z %[n by ! au?or x is ?is muscle & n ! cricoid c>tilage alone t causes ! difficulty 9 ! ins]tion ( an esophagoscope4 ,?is muscle is atta*$ lat]ally to ! edges ( ! signet ( ! cricoid :i* x pulls ) an incompreh5sible p[] aga9/ ! po/]ior wall ( ! hypoph>ynx1 ?us clos+ ! m\? ( ! esophagus4 ,its o!r atta*m5t is 9 ! m$ian po/]ior raphe4 ,betwe5 ^! circul> fib]s 7! cricoph>yngeal muscle7 & ! oblique fib]s ( ! inf]ior con/rictor muscle !re is a weakly support$ po9t ?r\gh :i* ! esophageal wall may h]niate to =m ! s-call$ pulsion div]ticulum4 ,x is at ?is weak po9t t fatal esophagoscopic p]=ation by inexp]i5c$ op]ators is mo/ likely to occur4 ,! aortic n>r[+ ( ! esophagus may n be notic$ at all if ! pati5t is plac$ 9 ! prop] sequ5tial high-l[ position4 ,x is only :5 ! tube-m\? is direct$ aga9/ ! left ant]ior wall t ! actively pulsat+ aorta is felt4 ,! bron*ial n>r[+ ( ! esophagus is due to backw>d displacem5t caus$ by ! passage ( ! left bron*us ov] ! ant]ior wall ( ! esophagus at ab\t #bg cm4 f ! upp] tee? 9 ! adult4 ,! ridge is q prom95t 9 "s pati5ts1 especially ^? ) dilatation f /5oses l[] d[n4 ,! hiatal n>r[+ is bo? anatomic & spasmodic4 ,! peculi> arrangem5t ( ! t5d9\s & muscul> /ructure ( ! diaphragm acts on ?is hiatal op5+ 9 a sph9ct]-l fa%ion4 ,!re are also special bundles ( muscle fib]s ext5d+ f ! crura ( ! diaphragm & surr\nd+ ! esophagus1 :i* contribute to tonic closure 9 ! same way t a p9*-cock closes a rubb] tube4 ,! au?or has call$ ! hiatal closure ! diaphragmatic p9*cock4 ,direction ( ! ,esophagus4--,! esophagus ent]s ! *e/ 9 a decid$ly backw>d z well z d[nw>d direction1 p>allel to t ( ! tra*ea1 foll[+ ! curves ( ! c]vical & upp] dorsal sp9e4 ,bel[ ! left bron*us ! esophagus turns =w>d1 pass+ ?r\gh ! hiatus 9 ! diaphragm ant]ior to & to ! left ( ! aorta4 ,! l[] ?ird ( ! esophagus 9 addition to its ant]ior curvature turns /rongly to ! left1 s t an esophagoscope ins]t$ f ! "r angle ( ! m\?1 :5 introduc$ into ! /oma*1 po9ts 9 ! direction ( ! ant]ior sup]ior sp9e ( ! left ileum4 ,x is necess>y to keep ?is g5]al c\rse con/antly 9 m9d 9 all cases ( esophagoscopy1 b p>ticul>ly 9 ^? cases 9 :i* !re is m>k$ dilatation ( ! esophagus foll[+ spasm at ! diaphragm level4 ,9 su* cases ! aid ( ?is k ( direction w greatly simplify ! f9d+ ( ! hiatus esophageus 9 ! floor ( ! dilatation4 ,! extr9sic or transmitt$ movem5ts ( ! esophagus are respiratory & pulsatory1 & to a slight ext5t1 be*ic4 ,! respiratory movem5ts consi/ 9 a dilatation or op5+ up ( ! ?oracic esophageal lum5 dur+ inspiration1 due to ! negative intra?oracic pressure4 ,! normal pulsatory movem5ts are due to ! pulsatile pressure ( ! aorta1 f\nd at ! #d? ?oracic v]tebra 7#bd cm4 f ! upp] tee? 9 ! adult71 & ( ! he>t itself1 mo/ m>k$ly felt at ! level ( ! #g? & #h? ?oracic v]tebrae 7ab\t #cj cm4 f ! upp] tee? 9 adults74 ,z ! di/ances ( all ! n>r[+s v>y ) age1 x is useful to frame & hang up = ref]5ce a copy ( ! *>t 7,fig4 #df74 ,! intr9sic movem5ts ( ! esophagus are involunt>y muscul> contractions1 z 9 deglutition & regurgitation2 spasmodic1 ! latt] usually hav+ "s pa?ologic cause2 & tonic1 z ! normal hiatal closure1 9 ! au?or's op9ion may be consid]$4 ,swall[+ may be involunt>y or volunt>y4 ,! con/rictors are anatomically n consid]$ "p ( esophagus prop]4 ,:5 ! con/rictors volunt>ily deliv] ! bolus pa/ ! cricoph>yngeal fold1 ! involunt>y or p]i/altic contractions ( ! esophageal mural musculature c>ry ! bolus on d[nw>d4 ,!re is no sph9ct] at ! c>diac end ( ! esophagus4 ,! site ( spasmodic /5osis 9 ! l[] ?ird1 ! s-call$ c>diospasm1 0 fir/ demon/rat$ by ! au?or to be locat$ at ! hiatus esophageus & ! spasmodic contractions are ( ! specializ$ muscle fib]s !re encircl+ ! esophagus1 & might be t]m$ phr5ospasm1 or hiatal esophagismus4 ,regurgitation ( food f ! /oma* is normally prev5t$ by ! hiatal muscul> diaphragmatic closure 7call$ by ! au?or ! diaphragmatic p9*cock7 plus ! k9k+ ( ! abdom9al esophagus4 ,9 ! au?or's op9ion !re is no spasm 9 ! disease call$ c>diospasm4 ,x is simply ! failure ( ! diaphragmatic p9*cock to op5 normally 9 ! deglutitory cycle4 ,a bett] "n is functional hiatal /5osis4 ,at retrograde esophagoscopy ! c>dia & abdom9al esophagus d n seem to exi/4 ,! top ( ! /oma* seems to be clos$ by ! diaphragmatic p9*cock 9 ! same way t ! top ( a bag is clos$ by a puck]+ /r+4 #fc ,,*apt] ,,iii--,,prep>ation ,,( ,,! ,,pati5t ,,= ,,p]oral ,,endoscopy ,! sugge/ions ( ! au?or 9 ! e>li] volumes 9 reg>d to prep>ation ( ! pati5t1 z = any op]ation1 by a ba?1 laxative1 etc41 & especially by special cleans+ ( ! m\? ) #be p] c5t alcohol1 h receiv$ g5]al endorsem5t4 ,c>e %\ld be tak5 n to set up undue reaction by vigor\s scrubb+ ( gums unaccu/om$ to x4 ,artificial d5tures %\ld be remov$4 ,ev5 if no ane/hetic is to be us$1 ! pati5t %\ld be fa/$ = five h\rs if possible1 ev5 = direct l>yngoscopy 9 ord] to =e/all vomit+4 ,except 9 em]g5cy cases e pati5t %\ld be gone ov] by an int]ni/ = organic disease 9 any =m4 ,if an endol>yngeal op]ation is ne$$ by a nephritic1 prep>atory treatm5t may prev5t l>yngeal edema or o!r complications4 ,hemophilia %\ld be ?\ght (4 ,x is q common = ! fir/ symptom ( an aortic aneurysm to be an impair$ p[] to swall[1 or ! lodgm5t ( a bolus ( meat or o!r =eign body4 ,if aneurysm is pres5t & esophagoscopy is necess>y1 z x always is 9 =eign body cases1 to be =e-w>n$ is to be =e>m$4 ,pulmon>y tub]culosis is (t5 unsuspect$ 9 v "y *ildr54 ,!re is great dang] f tra*eal pressure by an esophageal div]ticulum or dilatation di/5d$ ) food2 or ! food maybe regurgitat$ & aspirat$ into ! l>ynx & tra*ea4 ,!re=e1 9 all esophageal cases ! esophagus %\ld be empti$ by regurgitation induc$ by titillat+ ! fauces ) ! f+] aft] swall[+ a tumbl]ful ( wat]1 pressure on ! neck1 etc4 ,aspiration w succe$ 9 "s cases4 ,9 o!rs x is absolutely necess>y to remove food ) ! esophagoscope4 ,if ! aspirat+ tube becomes clogg$ by solid food1 ! me?od ( swab aspiration m5tion$ "u bron*oscopy w succe$4 ,( c\rse !re is usually no c\gh to aid1 b ! involunt>y abdom9al & ?oracic compression helps4 ,%\ld a pati5t arrive 9 a s]i\s /ate ( wat]-hung]1 z "p ( ! prep>ation ! pati5t mu/ be giv5 wat] by hypod]moclysis & ent]oclysis1 & if necess>y ! endoscopy1 except 9 dyspneic cases1 mu/ be delay$ until ! dang] ( wat]-/>vation is pa/4 ,z po9t$ out by ,ell5 ,j4 ,patt]son ! size ( ! ?ymus gl& %\ld be /udi$ be=e an esophagoscopy is done on a *ild4 ,e pati5t %\ld be exam9$ by indirect1 mirror l>yngoscopy z a prelim9>y to p]oral endoscopy = any purpose :atsoev]4 ,?is becomes d\bly necess>y 9 cases t are to be ane/hetiz$4 #fe ,,*apt] ,,iv--,,ane/hesia ,,= ,,p]oral ,,endoscopy ,a dyspneic pati5t %\ld nev] be giv5 a g5]al ane/hetic4 ,coca9e %\ld n be us$ on *ildr5 "u t5 ye>s ( age because ( its extreme toxicity4 ,to ^! two po/ulates always 9 m9d1 a ?ird "o1 applicable to bo? g5]al & local ane/hesia1 is to be add$--total abolition ( ! c\gh-reflex %\ld be = %ort p]iods only4 ,g5]al ane/hesia is nev] us$ 9 ! ,bron*oscopic ,cl9ic = endoscopic proc$ures4 ,! *oice = ea* op]ator mu/1 h[ev]1 be a matt] = individual decision1 & w dep5d ^u ! p]sonal equation1 & degree ( skill ( ! op]ator1 & 8 ability to quiet ! appreh5sions ( ! pati5t4 ,9 o!r words1 ! op]ator mu/ decide :at is be/ = 8 p>ticul> pati5t "u ! conditions !n exi/+4 ,*ildr5 9 ! ,bron*oscopic ,cl9ic receive nei!r local nor g5]al ane/hesia1 nor s$ative1 = l>yngoscopic op]ations or esophagoscopy4 ,bron*oscopy 9 ! old] *ildr5 :5 no dyspnea is pres5t has 9 rec5t ye>s1 at ! sugge/ion ( ,pr(4 ,h>e1 be5 prec$$ by a full dose ( morph9 sulphate 7i4e41 #a_/h gra9 = a *ild ( six ye>s7 or a full physiologic dose ( sodium bromide4 ,! appreh5sion is ?us some:at allay$ & ! excessive c\gh-reflex quiet$4 ,! morph9e %\ld be giv5 n less ?an an h\r & a half be=e bron*oscopy to all[ "t = ! onset ( ! soporific & antispasmodic effects :i* are ! desid]ata1 n ! analgesic effects4 ,dosage is m dep5d5t on temp]am5t ?an on age or body weight4 ,atrop9e is advantage\sly add$ to morph9e 9 bron*oscopy = =eign bodies1 n only = ! usual reasons b = its effect z an antispasmodic1 & especially = its dim9ution ( endobron*ial secretions4 ,true1 x does n dim9i% pus1 b by dim9i%+ ! outp\r+ ( normal secretions t dilute ! pus ! total quantity ( fluid enc\nt]$ is less ?an x o!rwise w\ld be4 ,9 cases ( l>ge quantities ( pus1 z 9 pulmon>y abscess & bron*iectasis1 h[ev]1 no dim9ution is noticeable4 ,no food or wat] is all[$ = #e h\rs prior to any endoscopic proc$ure1 :e!r s$atives or ane/hetics are to be giv5 or n4 ,if ! /oma* is n empty vomit+ f contact ( ! tube 9 ! ph>ynx w int]f]e ) "w4 ,) adults no ane/hesia1 g5]al or local1 is giv5 = esophagoscopy4 ,= l>yngeal op]ation & bron*oscopy ! foll[+ te*nic is us$3 ,"o h\r be=e op]ation ! pati5t is giv5 hypod]matically a full physiologic dose ( morph9 sulphate 7f #a_/d1 to #c_/h gr47 gu>d$ ) atrop9 sulphate 7gr4 #a_/aej74 ,c>e mu/ be tak5 t ! injection be n giv5 into a ve94 ,on ! op]at+ table ! epiglottis & ph>ynx are pa9t$ ) #aj p] c5t solution ( coca94 ,two applications are usually suffici5t completely to ane/hetize ! ext]ior & int]ior ( ! l>ynx by block+ ( ! sup]ior l>yngeal n]ve )\t any endol>yngeal applications4 ,! l>yngoscope is n[ introduc$ & if f\nd necess>y a #bj p] c5t coca9 solution is appli$ to ! int]ior ( ! l>ynx & subglottic region1 by means ( gauze swabs fa/5$ to ! sponge c>ri]s4 ,"h also two applications are q suffici5t to produce complete ane/hesia 9 ! l>ynx4 ,if bron*oscopy is to be done ! gauze swab is c>ri$ d[n ?r\gh ! expos$ glottis to ! c>9a1 ?us ane/hetiz+ ! tra*eal mucosa4 ,if fur!r ane/hetization ( ! bron*ial mucosa is requir$1 coca9 may be appli$ 9 ! same mann] ?r\gh ! bron*oscope4 ,9 all ^! local applications prolong$ contact ( ! swab is mu* m effici5t ?an simply pa9t+ ! surface4 #fg ,9 cases 9 :i* coca9 is deem$ contra9dicat$ morph9 alone is us$4 ,if giv5 9 suffici5t dosage coca9 c be altoge!r disp5s$ ) 9 any case4 ,x is p]haps saf] = ! beg9n] 9 8 e>ly cases ( esophagoscopy to h ! pati5t relax$ by an e!r ane/hesia1 provid$ ! pati5t is n dyspneic to beg9 )1 or made s by faulty position or by pressure ( ! esophagoscopic tube m\? on ! tra*eoesophageal p>ty wall4 ,z pr(ici5cy develops1 h[ev]1 he w f9d ane/hesia unnecess>y4 ,local ane/hesia is ne$less = esophagoscopy1 & if us$ at all %\ld be limit$ to ! l>yngoph>ynx & nev] appli$ to ! esophagus1 = ! esophagus is )\t s5sation1 z anyone may obs]ve 9 dr9k+ hot liquids4 ,direct l>yngoscopy 9 *ildr5 requires nei!r local nor g5]al ane/hesia1 ei!r = diagnosis or = removal ( =eign bodies or gr[?s f ! l>ynx4 ,g5]al ane/hesia is contra9dicat$ because ( ! dyspnea apt to be pres5t1 & because ! /ruggles ( ! pati5t might cause a dislodgm5t ( ! l>yngeal intrud] & aspiration to a l[] level4 ,! latt] accid5t is also prone to foll[ attempts to coca9ize ! l>ynx4 ,te*nic = ,g5]al ,ane/hesia4--,= esophagoscopy & ga/roscopy1 if g5]al ane/hesia is desir$1 e!r may be />t$ by ! usual me?od & cont9u$ by dropp+ ^u fold$ gauze laid ov] ! m\? aft] ! tube is introduc$4 ,endo-tra*eal adm9i/ration ( e!r is1 h[ev]1 f> saf] ?an p]oral adm9i/ration1 = x ov]comes ! dang] ( respiratory arre/ f pressure ( ! esophagoscope1 =eign body1 or bo?1 on ! tra*ea4 ,*lor(orm %\ld n be us$ = esophagoscopy or ga/roscopy because ( its depressant action on ! respiratory c5t]4 ,= bron*oscopy1 e!r or *lor(orm may be />t$ 9 ! usual way & cont9u$ by insufflat+ ?r\gh ! bran* tube ( ! bron*oscope by means ( ! app>atus %[n 9 ,fig4 #ac4 ,9 case ( p>alysis ( ! l>ynx1 ev5 if only monolat]al1 a g5]al ane/hetic if ne$$ %\ld be giv5 by intratra*eal insufflation4 ,if ! app>atus = ?is is n available ! pati5t %\ld be tra*eotomiz$4 ,h5ce1 e adult pati5t %\ld be exam9$ ) a ?roat mirror be=e g5]al ane/hesia = any purpose1 & ! necessity becomes d\bly imp]ative be=e goit] op]ations4 ,a numb] ( fatalities h occurr$ f neglect ( ?is precaution4 ,ane/hetiz+ a tra*eotomiz$ pati5t is free f dang] s long z ! cannula is kept free f secretion4 ,e!r is dropp$ on gauze laid ov] ! tra*eotomic cannula & ! ane/hesia wat*$ 9 ! usual mann]4 ,if ! l>yngeal /5osis is n complete1 e!r-saturat$ gauze is to be plac$ ov] ! m\? z well z ov] ! tra*eotomy tube4 ,endo-tra*eal ane/hesia is by f> ! safe/ way = ! adm9i/ration ( e!r = any purpose4 ,by means ( ! silk-wov5 ca!t] introduc$ into ! tra*ea1 e!r-lad5 air f an insufflation app>atus is pip$ d[n to ! lungs cont9u\sly1 & ! /rong return-fl[ prev5ts blood & secretions f ent]+ ! l[] air-passages4 ,! ca!t] %\ld be ( a size1 relative to t ( ! glottic *9k1 to p]mit a free return-fl[4 ,a numb] #bd ,fr5* is readily accommodat$ by ! adult l>ynx & lies well out ( ! way along ! po/]ior wall ( ! l>ynx4 ,because ( ! little room occupi$ by ! insufflation ca!t] ?is me?od af=ds ideal ane/hesia = ext]nal l>yngeal op]ations4 ,op]ations on ! nose1 accessory s9uses & ! ph>ynx1 apt to be att5d$ by consid]able ble$+1 are r5d]$ free f ! dang] ( aspiration pneumonia by endotra*eal ane/hesia4 ,x is ! safe/ ane/hesia = goit] op]ations4 ,endo-tra*eal ane/hesia has r5d]$ ne$less ! intricate negative pressure *amb] =m]ly requir$ = ?oracic surg]y1 = by prop] regulation ( ! pressure "u :i* ! e!r lad5$ air is deliv]$1 a lung may be held 9 any desir$ degree ( expansion :5 ! pleural cavity is op5$4 ,x is indicat$ 9 op]ations ( ! head1 neck1 or ?orax1 9 :i* !re is dang] ( respiratory arre/ by c5tric inhibition or p]iph]al pressure2 9 op]ations 9 :i* !re is a possibility ( excessive ble$+ & aspiration ( blood or secretions2 & 9 op]ations :]e x is desir$ to keep ! ane/heti/ away f ! op]at+ field4 ,v>i\s =ms ( app>atus = ! deliv]y ( ! e!r-lad5 vapor are suppli$ by in/rum5t mak]s ) explicit directions z to _! me*anical managem5t4 ,we are conc]n$ "h ma9ly ) ! te*nic ( ! ins]tion ( ! intratra*eal tube4 ,! l>ynx %\ld be exam9$ ) ! mirror1 pref]ably be=e ! day ( op]ation1 = evid5ce ( disease1 & incid5tally to det]m9e ! size ( ! ca!t] to be introduc$1 ?\gh ! latt] c be det]m9$ aft] ! l>ynx is l>yngoscopically expos$4 ,! foll[+ li/ ( rules = ! introduction ( ! ca!t] w be ( s]vice 7see ,fig4 #ei74 ,,rules ,,= ,,ins]tion ,,( ,,! ,,ca!t] ,,= ,,insufflation ,,ane/hesia #a4 ,! pati5t %\ld be fully "u ! ane/hetic by ! op5 me?od s z to get full relaxation ( ! muscles ( ! neck4 #b4 ,! pati5t's head mu/ be 9 full ext5sion ) ! v]tex firmly pu%$ d[n t[>d ! feet ( ! pati5t1 s z to ?r[ ! neck upw>d & br+ ! occiput d[n z close z possible b5ea? ! c]vical v]tebrae4 #c4 ,no gag %\ld be us$1 because ! pati5t %\ld be suffici5tly ane/hetiz$ n to ne$ a gag1 & because wide gagg+ defeats ! exposure ( ! l>ynx by jamm+ d[n ! m&ible4 #d4 ,! epiglottis mu/ be id5tifi$ be=e x is pass$4 #e4 ,! speculum mu/ pass suffici5tly f> bel[ ! tip ( ! epiglottis s t ! latt] w n slip4 #f4 ,too deep ins]tion mu/ be avoid$1 z 9 ?is case ! speculum goes po/]ior to ! cricoid1 & ! cricoid is lift$1 expos+ ! m\? ( ! esophagus1 :i* is bewild]+ until suffici5t education ( ! eye enables ! op]ator to recognize ! l&m>ks4 #g4 ,! pati5t's head is lift$ (f ! table by ! spatul> tip ( ! l>yngoscope4 ,actual lift+ ( ! head w n be necess>y if ! pati5t is fully relax$2 b ! idea ( lift+ conveys ! prop] conception ( l>yngeal exposure 7,fig4 #ee74 #ga ,,*apt] ,v--,,bron*oscopic ,,oxyg5 ,,insufflation ,bron*oscopic oxyg5 insufflation is a life-sav+ measure equall$ by no o!r me?od kn[n to ! sci5ce ( m$ic9e1 9 all cases ( asphyxia1 or apnea1 pres5t or imp5d+4 ,its especial sph]e ( usefulness is 9 sev]e cases ( electric %ock1 hang+1 smoke asphyxia1 /rangulation1 suffocation1 ?oracic or abdom9al pressure1 apnea1 acute traumatic pneumo?orax1 respiratory arre/ f abs5ce ( suffici5t oxyg51 or apnea f ! pres5ce ( quantities ( irrespirable or irritant gases4 ,comb9$ ) bron*oscopic aspiration ( secretions x is ! be/ me?od ( treatm5t = poison+ by *lor9e gas1 asphyxiat+1 & o!r w> gases4 ,bron*oscopic oxyg5 insufflation %\ld be taught to e int]ne 9 e hospital4 ,! em]g5cy or accid5t w>d ( e hospital %\ld h ! necess>y equipm5t & an int]ne famili> ) its use4 ,! me?od is simple1 once ! knack is acquir$4 ,! pati5t be+ limp & recumb5t on a table1 ! l>ynx is expos$ ) ! l>yngoscope1 & ! bron*oscope is ins]t$ z h]e9aft] describ$4 ,! oxyg5 is turn$ on at ! tank & ! fl[ regulat$ be=e ! rubb] tube f ! wa%-bottle ( tank is atta*$ to ! side-outlet ( ! bron*oscope4 ,x is necess>y to be c]ta9 t ! fl[ is g5tle1 s t1 ) a free return fl[ ! introduc$ pressure does n exce$ ! capill>y pressure2 o!rwise ! blood w be =c$ out ( ! capill>ies & ! is*emia ( ! lungs w be fatal4 ,ano!r dang] is t ov]di/5sion causes inhibition ( inspiration result+ 9 apnea cont9u+ z long z ! di/5sion is ma9ta9$1 if n long]4 ,! return fl[ f ! bron*oscope %\ld be int]rupt$ = #b or #c seconds sev]al times a m9ute to inflate ! lungs1 b ! fl[ mu/ n be occlud$ long] ?an #c seconds1 because ! intrapulmon>y pressure w\ld rise4 ,a pe>l ( amyl nitrite may be brok5 9 ! wa% bottle4 ,sl[ rhy?mic artificial respiratory movem5ts are a useful adjunct1 & unless ! op]ator is v skillful 9 gaug+ ! alt]nate pressures & releases ) ! ?umb accord+ to ! oxyg5 pressure1 x is vitally necess>y to fill & deflate ! lungs rhy?mically by "o ( ! well kn[n me?ods ( artificial respiration4 ,anyone skill$ 9 ! introduction ( ! bron*oscope c d bron*oscopy 9 a few seconds1 & x is especially easy 9 cases ( respiratory arre/1 because ( ! limp condition ( ! pati5t4 ,! =ego+ applies to cases 9 :i* a pulmotor w\ld be us$1 su* z apnea f electric %ocks1 etc4 ,= ob/ructive dyspnea & asphyxia1 tra*eotomy is ! proc$ure ( *oice1 & ! skillful tra*eotomi/ w\ld be ju/ifi$ 9 pref]r+ tra*eotomy = ! o!r class ( cases1 insufflat+ ! oxyg5 & amyl nitrite ?r\gh ! tra*eotomic w\nd4 ,! pulmotor & simil> me*anisms are1 p]haps1 ! be/ ?+s ! use ( :i* c be taught to laym52 b z comp>$ to bron*oscopic oxyg5 insufflation !y are woefully ineffici5t1 because ! intraoral pressure =ces ! tongue back ov] ! l>yngeal orifice1 ob/ruct+ ! airway 9 ?is dea? zone4 ,by ! introduction ( ! bron*oscope ?is dea? zone is entirely elim9at$1 & a free airway e/abli%$ = pip+ ! oxyg5 directly into ! lungs4 #gc ,,*apt] ,,vi--,,position ,,( ,,! ,,pati5t ,,= ,,p]oral ,,endoscopy ,x is ! au?or's inv>iable practice to place ! pati5t 9 ! dorsally recumb5t position4 ,! sitt+ position is less favorable4 ,:ile ly+ on a well-padd$1 flat table ! pati5t is readily controll$1 ! head is freely movable1 secretions c be easily remov$1 ! view obta9$ by ! endoscopi/ is truly direct 7)\t rev]sal ( sides71 &1 mo/ important1 ! employm5t ( "o position only favors smoo!r & m effici5t team "w1 & a bett] endoscopic te*nic4 ,g5]al ,pr9ciples ( ,position4--,z w be se5 9 ,fig4 #dg ! tra*ea & esophagus are n horizontal 9 ! ?orax1 b _! long axes foll[ ! curves ( ! c]vical & dorsal sp9e4 ,!re=e1 if we are to br+ ! buccal cavity & ph>ynx 9 a /raight l9e ) ! tra*ea & esophagus x w be f\nd necess>y to elevate ! :ole head above ! plane ( ! table1 & at ! same "t make ext5sion at ! occipito-atloid jo9t4 ,by ?is maneuv] ! c]vical sp9e is br\ght 9 l9e ) ! upp] portion ( ! dorsal sp9e z %[n 9 ,fig4 #ee4 ,x 0 =m]ly taught1 & (t5 9 spite ( my bett] k ,i am /ill unconsci\sly prone to all[ ! head & c]vical sp9e to assume a l[] position ?an ! plane ( ! table1 ! s-call$ ,rose position4 ,) ! head s plac$1 x is impossible to ent] ! l[] air or food passages ) a rigid tube1 z w be %[n by a /udy ( ! radiograph %[n 9 ,fig4 #di4 ,ext5sion ( ! head on ! occipito-atloid jo9t is = ! purpose ( free+ ! tube f ! tee?1 & ! am\nt requir$ w v>y ) ! degree to :i* ! m\? c be op5$4 ,:e!r ! head be ext5d$1 flex$1 or kept mid-way1 ! fundam5tal pr9ciple 9 ! introduction ( all endoscopic tubes is ! ant]ior plac+ ( ! c]vical sp9e & ! high elevation ( ! head4 ,! esophagus1 j beh9d ! he>t1 turns v5trally & to ! left4 ,9 ord] to pass a rigid tube ?r\gh ?is v5tral curve ! dorsal sp9e is n[ ext5d$ by l[]+ ! head & %\ld]s bel[ ! plane ( ! table4 ,?is w be fur!r expla9$ 9 ! *apt] on esophagoscopy4 ,9 all ( ^! proc$ures1 ! nose ( ! pati5t %\ld be direct$ t[>d ! z5i?1 & ! assi/ant %\ld prev5t rotation ( ! head z well z prev5t l[]+ ( ! head4 ,! pati5t %\ld be urg$ z foll[s3 ,don't hold y\rself s rigid4 ,let y\r head & neck g loose4 ,let y\r head re/ 9 my h&4 ,don't try to hold x4 ,let me hold x4 ,relax4 ,don't raise y\r *e/4 ,,fig4 #dg4--,s*ematic illu/ration ( normal position ( ! intra-?oracic tra*ea & esophagus & also ( ! entire tra*ea :5 ! pati5t is 9 ! correct position = p]oral bron*oscopy4 ,:5 ! head is ?r[n backw>d 7z 9 ! ,rose position7 ! ant]ior convexity ( ! c]vical sp9e is transmitt$ to ! tra*ea & esophagus & _! axes deviat$4 ,! ant]ior deviation ( ! l[] ?ird ( ! esophagus %[s ! anatomical basis = ! high l[ position = esophagoscopy ,,fig4 #dh4--;,correct position ( ! c]vical sp9e = esophagoscopy & bron*oscopy4 7,illu/ration reproduc$ f au?or's article ,j\r4 ,am4 ,m$4 ,assoc41 ,sept4 #be1 #aiji7 ,,fig4 #di4--;,curv$ position ( ! c]vical sp9e1 ) ant]ior convexity1 9 ! ,rose position1 r5d]+ esophagoscopy & bron*oscopy difficult or impossible4 ,! devi\s c\rse ( ! ph>ynx1 l>ynx & tra*ea are pla9ly visible4 ,! ext5sion is incorrectly imp>t$ to ! :ole c]vical sp9e in/ead ( only to ! occipito-atloid jo9t4 ,?is is ! usual & v faulty conception ( ! ext5d$ position4 7,illu/ration reproduc$ f au?or's article1 ,j\r4 ,am4 ,m$4 ,assoc41 ,sept4 #be1 #aiji47 #gf ,= direct l>yngoscopy ! pati5t's head is rais$ above ! plane ( ! table by ! fir/ assi/ant1 :o /&s to ! "r ( ! pati5t1 hold+ ! bite block on 8 "r ?umb ins]t$ 9 ! left corn] ( ! pati5t's m\?1 :ile 8 ext5d$ "r h& lies along ! left side ( ! pati5t's *eek & head1 & prev5ts rotation4 ,8 left h&1 plac$ "u ! pati5t's occiput1 elevates ! head & ma9ta9s ! desir$ degree ( ext5sion at ! occipito-atloid jo9t 7,fig4 #ej74 ,,fig #ej4--;,direct l>yngoscopy1 recumb5t pati5t4 ,! second assi/ant is sitt+ hold+ ! head 9 ! ,boyce position1 8 left =e>m on 8 left ?igh 8 left foot on a /ool ^: top is #fe cm4 l[] ?an ! table-top4 ,8 left h& is on ! pati5t's /]ile-cov]$ scalp1 ! ?umb on ! =ehead1 ! f+]s "u ! occiput1 mak+ =c$ ext5sion4 ,! "r =e>m passes "u ! neck ( ! pati5t1 s t ! index f+] ( ! "r h& holds ! bite-block 9 ! left corn] ( ! pati5t's m\?4 ,! f+]s ( ! op]ator's "r h& pulls ! upp] lip out ( all dang] ( gett+ p9*$ betwe5 ! tee? & ! l>yngoscope4 ,?is is a precaution ( ! utmo/ importance & ! tra9$ habit ( do+ x mu/ be develop$ by ! p]oral endoscopi/4 ,position = ,bron*oscopy & ,esophagoscopy4--,! dorsally recumb5t pati5t is s plac$ t ! head & %\ld]s ext5d beyond ! table1 ! edge ( :i* supports ! ?orax at ab\t ! level ( ! scapulae4 ,dur+ introduction1 ! head mu/ be ma9ta9$ 9 ! same relative position to ! table z t describ$ = direct l>yngoscopy1 t is1 elevat$ & ext5d$4 ,! fir/ assi/ant1 9 ?is case1 sits on a /ool to ! "r ( ! pati5t's head1 8 left foot re/+ on a box ab\t #ad in*es 9 height1 ! left knee support+ ! assi/ant's left h&1 :i* be+ plac$ "u ! occiput ( ! pati5t ma9ta9s elevation & ext5sion4 ,! "r arm ( ! assi/ant passes "u ! neck ( ! pati5t1 ! bite block be+ c>ri$ on ! middle f+] ( ! "r h& & ins]t$ into ! left side ( ! pati5t's m\?4 ,! "r h& also prev5ts rotation ( ! head 7,fig4 #ea74 ,z ! bron*oscope or esophagoscope is fur!r ins]t$1 ! head mu/ be plac$ s t ! tube corresponds to ! axis ( ! lum5 ( ! passage to be exam9$4 ,if ! left bron*us is be+ explor$1 ! head mu/ be br\ght /rongly to ! "r4 ,if ! "r middle lobe bron*us is be+ se>*$1 ! head w\ld require "s left lat]al deflection & a consid]able degree ( l[]+1 = ?is bron*us1 z be=e m5tion$1 ext5ds ant]iorly4 ,dur+ esophagoscopy :5 ! level ( ! he>t is rea*$1 ! head & upp] ?orax mu/ be /rongly depress$ bel[ ! plane ( ! table 9 ord] to foll[ ! axis ( ! lum5 ( ! v5trally turn+ esophagus2 at ! same "t ! head mu/ be br\ght some:at to ! "r1 s9ce ! esophagus 9 ?is region deviates /rongly to ! left4 ,,fig4 #ea4--,position ( pati5t & assi/ant = introduction ( ! bron*oscope & esophagoscope4 ,! middle ( ! scapulae re/ on ! edge ( ! table2 ! head & %\ld]s1 free to move1 are support$ by ! assi/ant1 ^: "r arm passes "u ! neck2 ! "r middle f+] ins]ts ! bite block into ! left side ( ! m\?4 ,! left h&1 re/+ on ! left knee ma9ta9s ! desir$ degree ( elevation1 ext5sion & lat]al deflection requir$ by ! op]ator4 ,! pati5t's v]tex %\ld be #aj cm4 high] ?an ! level ( ! top ( ! table4 ,?is is ! ,boyce position1 :i* has nev] be5 improv$ ^u = bron*oscopy & esophagoscopy4 ,,fig4 #eb4--,s*ema ( position = endoscopy4 ,a4 ,normal recumb5cy on ! table ) pill[ support+ ! head4 ,! l>ynx c be directly exam9$ 9 ?is position1 b a bett] position is obta9able4 ,b4 ,head is rais$ to prop] position ) head flex$4 ,muscles ( front ( neck are relax$ & exposure ( l>ynx ?us r5d]$ easi]2 b1 = mo/ endoscopic "w1 a c]ta9 am\nt ( ext5sion is desir$4 ,! elevation is ! important ?+4 ,c4 ,! neck be+ ma9ta9$ 9 position ,b1 ! desir$ am\nt ( ext5sion ( ! head is obta9$ by a movem5t limit$ to ! occipito-atloid articulation by ! assi/ant's h& plac$ z %[n by ! d>t 7,b74 ,d4 ,faulty position4 ,unless prev5t$1 almo/ all pati5ts w heave up ! *e/ & ar* ! lumb> sp9e s z to defeat ! object & to r5d] endoscopy difficult by br++ ! *e/ up to ! high-held head1 ?us assum+ ! same relation ( ! head to ! *e/ z exi/s 9 ! ,rose position 7a faulty "o = endoscopy7 z w be und]/ood by assum+ t ! dott$ l9e1 ,e1 repres5ts ! table4 ,if ! pelvis be n held d[n to ! table ! pati5t may ev5 assume ! opi/hoton\s position by support+ 8 weight on 8 heels on ! table & 8 head on ! assi/ant's h&4 ,9 obta9+ ! position ( high head ) occipito-atloid ext5sion1 ! easie/ & mo/ c]ta9 me?od1 z po9t$ out to me by my assi/ant1 ,gabriel ,tuck]1 is fir/ to raise ! head1 /rongly flex$1 z %[n 9 ,fig4 #eb2 !n :ile ma9ta9+ x !re1 make ! occipito-atloid ext5sion4 ,?is has prov5 bett] ?an to elevate & ext5d 9 a comb9$ simultane\s movem5t4 ,if ! pati5t w\ld relax to limpness exposure ( ! l>ynx w\ld be easily obta9$1 simply by lift+ ! head ) ! lip ( ! l>yngoscope pass$ bel[ ! tip ( ! epiglottis 7z 9 ,fig4 #ee7 & no hold+ ( ! head w\ld be necess>y4 ,b only r>ely is a pati5t f\nd :o c d ?is4 ,?is degree ( relaxation is ( c\rse1 pres5t 9 pr(\nd g5]al e!r ane/hesia1 :i* is n to be ?\ght ( = direct l>yngoscopy1 except :5 x is us$ = ! purpose ( ins]tion ( intratra*eal insufflation ane/hetic tubes4 ,= ?is1 ( c\rse1 ! pati5t is already to be deeply ane/hetiz$4 ,! muscul> t5sion ex]t$ by "s pati5ts 9 assum+ & hold+ a faulty position is almo/ z mu* ( a h9drance to p]oral endoscopy z is ! position itself4 ,! t5d5cy ( ! pati5t to heave up 8 *e/ & assume a false position simulat+ ! opi/hoton\s position 7,fig4 #eb7 mu/ be ov]come by p]suasion4 ,?is position has all ! disadvantages ( ! ,rose position = endoscopy4 ,,fig4 #ec4--,! au?or's position = ! removal ( =eign bodies f ! l>ynx or f any ( ! upp] air or food passages4 ,if dislodg$1 ! intrud] w n be aid$ by gravity to rea* a deep] lodgem5t4 ,! "o exception to ^! g5]al positions is f\nd 9 proc$ures = ! removal ( =eign bodies f ! l>ynx4 ,9 su* cases1 :ile ! same relative position ( ! head to ! plane ( ! table is ma9ta9$1 ! :ole table top is s incl9$ z to elevate ! feet & l[] ! head1 kn[n z ,jackson's position4 ,?is semi-inv]sion ( ! pati5t all[s ! =eign body to drop into ! ph>ynx if x %\ld be dislodg$1 or slip f ! =ceps 7,fig4 #ec74 #hb ,,*apt] ,,vii--,,direct ,,l>yngoscopy ,importance ( ,mirror ,exam9ation ( ! ,l>ynx4--,! pres5ce ( ! direct l>yngoscope incites spasmodic l>yngeal reflexes1 & ! traction ex]t$ some:at di/orts ! tissues1 s t accurate obs]vations ( v>iations 9 l>yngeal mobility are difficult to obta94 ,! function ( ! l>yngeal muscles & /ructures1 !re=e1 c be/ be /udi$ ) ! l>yngeal mirror1 except 9 infants & small *ildr5 :o w n tol]ate ! proc$ure ( indirect l>yngoscopy4 ,a true idea ( ! dep? ( ! l>ynx is n obta9$ ) ! mirror1 & a view ( ! v5tricles is r>ely _h4 ,) ! introduction ( ! direct l>yngoscope x is f\nd t ! l>ynx is funnel %ap$1 & t ! adult cords are situat$ ab\t #c cm4 bel[ ! aryepiglottic folds2 ! cords also assume _! true %elf-l "* & take on a p9ki% or yell[i% t+e1 r ?an ! pe>ly :ite se5 9 ! mirror4 ,!y are n to any ext5t diff]5tiat$ by color f ! neighbor+ /ructures4 ,_! recognition dep5ds almo/ :olly on =m1 position & movem5t4 ,accurate obs]vation is /imulat$ 9 all pa?ologic cases by mak+ color$ crayon sket*es1 h[ev] crude1 ( ! mirror image ( ! l>ynx4 ,! location ( a gr[? may be ?us graphically record$1 s t at ! "t ( op]ation a glance w s]ve to refre% ! memory z to its site4 ,x is to be con/antly kept 9 m9d1 h[ev]1 t 9 ! mirror image ! sides are rev]s$ because ( ! fac+ positions ( ! exam9] & pati5t4 ,direct l>yngoscopy is ! only me?od by :i* ! l>ynx ( *ildr5 c be se54 ,! proc$ure ne$ require less ?an a m9ute ( "t1 & an accurate diagnosis ( ! condition pres5t1 :e!r papilloma1 =eign body1 diph!ria1 p>alysis1 etc41 may be ?us obta9$4 ,! po/]ior ph>yngeal wall %\ld be exam9$ 9 all dyspneic *ildr5 = ! possible exi/5ce ( retroph>yngeal abscess4 ,,plate ,,ii--,,direct ,,& ,,indirect ,,l>yngeal ,,views ,,f ,,au?or',s ,,oil-,,color ,,draw+s ,,f ,,life3 #a1 ,epiglottis ( *ild z se5 by direct l>yngoscopy 9 ! recumb5t position4 #b1 ,normal l>ynx spasmodically clos$1 z is usual on fir/ exposure )\t ane/hesia4 #c1 ,same on inspiration4 #d1 ,supraglottic papillomata z se5 on direct l>yngoscopy 9 a *ild ( two ye>s4 #e1 ,cy/ ( ! l>ynx 9 a *ild ( f\r ye>s1 se5 on direct l>yngoscopy )\t ane/hesia4 #f1 ,indirect view ( l>ynx eight weeks aft] ?yrotomy = canc] ( ! "r cord 9 a man ( fifty ye>s4 #g1 ,same aft] two ye>s4 ,an adv5titi\s b& indi/+ui%able f ! orig9al "o has replac$ ! lo/ cord4 #h1 ,condition ( ! l>ynx ?ree ye>s aft] hemil>yngectomy = epi!lioma 9 a pati5t fifty-"o ye>s ( age4 ,?yrotomy reveal$ su* ext5sive involvem5t1 ) an op5 ulc]ation :i* _h rea*$ ! p]i*ondrium1 t ! entire left w+ ( ! ?yroid c>tilage 0 remov$ ) ! left aryt5oid4 ,a suffici5tly wide removal 0 accompli%$ )\t remov+ any "p ( ! esophageal wall bel[ ! level ( ! crico-aryt5oid jo9t4 ,!re is no attempt on ! "p ( nature to =m an adv5titi\s cord on ! left side4 ,! normal aryt5oid drew ! normal cord ov]1 approximately to ! edge ( ! cicatricial tissue ( ! op]at$ side4 ,! voice1 at fir/ a v ho>se :isp]1 ev5tually 0 fairly l\d1 ?\gh slightly husky & inflexible4 #i1 ,! ph>ynx se5 "o ye> aft] l>yngectomy = endo!lioma 9 a man ag$ sixty-eight ye>s4 ,! purple papilla2 ant]iorly are at ! base ( ! tongue1 & f ?is ! mucosa slopes d[nw>d & backw>d smoo?ly into ! esophagus4 ,!re are "s slight folds t[>d ! left & "s ( ^! are q cicatricial4 ,! epiglottis 0 remov$ at op]ation4 ,! tra*ea 0 sutur$ to ! sk9 & did n communicate ) ! ph>ynx4 7,direct view47 ,contra9dications to ,direct ,l>yngoscopy4--,!re are no absolute contra9dications to direct l>yngoscopy 9 any case :]e direct l>yngoscopy is really ne$$ = diagnosis or treatm5t4 ,9 extremely dyspneic pati5ts1 if ! op]ator is n confid5t 9 8 ability = a prompt & sure introduction ( a bron*oscope1 x may be wise to d a tra*eotomy fir/4 ,in/ructions to ! ,pati5t4--,be=e beg9n+ endoscopy ! pati5t %\ld be told t he w feel a v disagreeable pressure on 8 neck & t he may feel z ?\gh he 7 ab\t to *oke4 ,he mu/ be g5tly b positively made to und]/& 7#a7 t :ile ! proc$ure is al>m+1 x is absolutely free f dang]2 7#b7 t y "k j h[ x feels2 7#c7 t y w n all[ 8 brea? to be %ut (f completely2 7#d7 t he c help y & himself v mu* by pay+ close att5tion to brea?+ deeply & regul>ly2 7#e7 & t he mu/ n draw himself up rigidly z ?\gh walk+ on ice1 b mu/ be easy & relax$4 ,direct ,l>yngoscopy4 ,adult ,pati5t4--,be=e />t+1 e detail 9 reg>d to in/rum5tal equipm5t & op]at+ room assi/ants1 7includ+ an assi/ant to hold ! arms & legs ( ! pati5t7 mu/ be complete4 ,prep>ation ( ! pati5t & ! te*nic ( local ane/hesia h be5 discuss$ 9 _! respective *apt]s4 ,! dorsally recumb5t pati5t is drap$ ) 7n p9n$ 97 a /]ile %eet4 ,! head1 cov]$ by /]ile t[els1 is elevat$1 & slight ext5sion is made at ! occipitoatloid jo9t by ! left h& ( ! fir/ assi/ant4 ,! bite block plac$ on ! assi/ant's "r ?umb is ins]t$ into ! left angle ( ! pati5t's op5 m\? 7see ,fig4 #ej74 ,! l>yngoscope mu/ always & inv>iably be held 9 ! left h&1 & 9 su* a mann] t ! greate/ am\nt ( traction is made at ! swell ( ! horizontal b> ( ! h&le1 r ?an on ! v]tical b>4 ,! "r h& is !n free = ! manipulation ( =ceps1 & ! ins]tion ( ! bron*oscope or o!r in/rum5t4 ,dur+ introduction1 ! f+]s ( ! "r h& retract ! upp] lip s z to prev5t its be+ p9*$ betwe5 ! l>yngoscope & ! tee?4 ,! introduction ( ! direct l>yngoscope & exposure ( ! l>ynx is be/ describ$ 9 two /ages4 #a4 ,exposure & id5tification ( ! epiglottis4 #b4 ,elevation ( ! epiglottis & all ! tissues atta*$ to ! hyoid bone1 s z to expose ! l>ynx to direct view4 ,fir/ ,/age4--,! spatul> end ( ! l>yngoscope is introduc$ 9 ! "r side ( ! pati5t's m\?1 along ! "r side ( ! ant]ior two-?irds ( ! tongue4 ,x 0 ! ,g]man me?od to introduce ! l>yngoscope ov] ! dorsum ( ! tongue b 9 ord] to elevate ?is sometimes p[]ful muscul> organ consid]able =ce may be requir$1 :i* ex]cise ( =ce may be entirely avoid$ by cr[d+ ! tongue ov] to ! left4 ,:5 ! po/]ior ?ird /age ( ! tongue is rea*$1 ! tip ( ! l>yngoscope is direct$ t[>d ! midl9e & ! dorsum ( ! tongue is elevat$ by a lift+ motion imp>t$ to ! l>yngoscope4 ,! epiglottis w !n be se5 to project into ! endoscopic field1 z se5 9 ,fig4 #ed4 ,,fig4 #ed4--;,end ( ! fir/ ( direct l>yngoscopy1 recumb5t adult pati5t4 ,! epiglottis is expos$ by a lift+ motion ( ! spatul> tip on ! tongue ant]ior to ! epiglottis4 ,second ,/age4--,! spatul> end ( ! l>yngoscope %\ld n[ be tipp$ back t[>d ! po/]ior wall ( ! ph>ynx1 pass$ po/]ior to ! epiglottis1 & advanc$ ab\t #a cm4 ,! l>ynx is n[ expos$ by a motion t is be/ describ$ z a susp5sion ( ! head & all ! /ructures atta*$ to ! hyoid bone on ! tip ( ! spatul> end ( ! l>yngoscope 7,fig4 #ee74 ,p>ticul> c>e mu/ be tak5 at ?is /age n to pry on ! upp] tee?2 b r to imp>t a lift+ motion ) ! tip ( ! speculum )\t depress+ ! proximal tubul> orifice4 ,x is to be emphasiz$ t :ile "s pressure is necess>y 9 ! lift+ motion1 great =ce %\ld nev] be us$2 ! art is a g5tle "o4 ,! fir/ view is apt to f9d ! l>ynx 9 /ate ( spasm1 & af=ds an excell5t demon/ration ( ! fact t ! l>ynx c he completely clos$ )\t ! aid ( ! epiglottis4 ,usually little m is se5 ?an ! two r\nd$ aryt5oid masses1 &1 ant]ior to !m1 ! v5tricul> b&s 9 m or less close apposition hid+ ! cords 7,fig4 #ef74 ,) deep g5]al ane/hesia or ?or\gh local ane/hesia ! spasm may n be pres5t4 ,by ask+ ! pati5t to take a deep brea? & ma9ta9 /eady brea?+1 or p]haps by reque/+ a phonatory ef=t1 ! l>ynx w op5 widely & ! cords be reveal$4 ,if ! ant]ior commissure ( ! l>ynx is n readily se51 ! lift+ motion & elevation ( ! head %\ld be increas$1 & if !re is /ill difficulty 9 expos+ ! ant]ior commissure ! assi/ant hold+ ! head %\ld ) ! index f+] ext]nally on ! neck depress ! ?yroid c>tilage4 ,if by ?is te*nic ! l>ynx fails to be reveal$ ! endoscopi/ %\ld ask himself :i* ( ! foll[+ rules he has violat$4 ,,fig4 #ee4--,s*ema illu/rat+ ! te*nic ( direct l>yngoscopy on ! recumb5t pati5t4 ,! motion is imp>t$ to ! tip ( ! l>yngoscope z if to lift ! pati5t by 8 hyoid hone4 ,! portion ( ! table indicat$ by ! dott$ l9e may be dropp$ or n1 b ! back ( ! head mu/ nev] g l[] ?an "h %[n1 = direct l>yngoscopy2 & x is bett] to h x at lea/ #aj cm4 above ! level ( ! table4 ,! table may be us$ z a re/ = ! op]ator's left elb[ to take ! weight ( ! head4 7,note t 9 bron*oscopy & esophagoscopy ! head section ( ! table mu/ be dropp$1 s z to leave ! head & neck ( ! pati5t out 9 ! air1 support$ by ! second assi/ant47 ,,fig4 #ef4--;,endoscopic view at ! end ( ! second /age ( direct l>yngoscopy4 ,recumb5t pati5t4 ,l>ynx expos$ wait+ = l>ynx to relax its spasmodic contraction4 ,,rules ,,= ,,direct ,,l>yngoscopy #a4 ,! l>yngoscope mu/ always be held 9 ! left h&1 nev] 9 ! "r4 #b4 ,! op]ator's "r index f+] 7nev] ! left7 %\ld be us$ to retract ! pati5t's upp] lip s t !re is no dang] ( p9*+ ! lip betwe5 ! in/rum5t & ! tee?4 #c4 ,! pati5t's head mu/ always be exactly 9 ! middle l9e1 n rotat$ to ! "r or left1 nor b5t ov] sidewise2 & ! entire head mu/ be =w>d ) ext5sion at ! occipitoatloid jo9t only4 #d4 ,! l>yngoscope is ins]t$ to ! "r side ( ! ant]ior two-?irds ( ! tongue1 ! tip ( ! spatula be+ direct$ t[>d ! midl9e :5 ! po/]ior ?ird ( ! tongue is rea*$4 #e4 ,! epiglottis mu/ always be id5tifi$ be=e any attempt is made to expose ! l>ynx4 #f4 ,:5 fir/ ins]t+ ! l>yngoscope to f9d ! epiglottis1 great c>e %\ld be tak5 n to ins]t too deeply le/ ! epiglottis be ov]ridd5 & ?us hidd54 #g4 ,aft] id5tification ( ! epiglottis1 too deep ins]tion ( ! l>yngoscope mu/ be c>efully avoid$ le/ ! spatula be ins]t$ back ( ! aryt5oids into ! hypo-ph>ynx4 #h4 ,exposure ( ! l>ynx is accompli%$ by pull+ =w>d ! epiglottis & ! tissues atta*$ to ! hyoid bone1 & n by pry+ ^! tissues =w>d ) ! upp] tee? z a fulcrum4 #i4 ,c>e mu/ be tak5 to avoid mi/ak+ ! ary-epiglottic fold = ! epiglottis itself4 7,mo/ likely to occur z ! result ( rotation ( ! pati5t's head47 #aj4 ,! tube %\ld n be reta9$ too long 9 place1 b %\ld be remov$ & ! pati5t p]mitt$ to swall[ ! accumulat$ saliva1 :i*1 if ! l>yngoscope is too long 9 place1 w trickle d[n ! tra*ea & cause c\gh4 7,swall[+ is almo/ impossible :ile ! l>yngoscope is 9 position47 ,! secretions may be remov$ ) ! aspirator4 #aa4 ,! pati5t mu/ be in/ruct$ to brea! deeply & quietly )\t mak+ a s\nd4 #hh ,difficulties ( ,direct ,l>yngoscopy4--,! l>ynx c be directly expos$ 9 any pati5t ^: m\? c be op5$1 al?\gh ! ease v>ies greatly ) ! type ( pati5t4 ,failure to expose ! epiglottis is usually due to too great ha/e to ent] ! speculum all ! way d[n4 ,! spatula %\ld glide sl[ly along ! po/]ior ?ird ( ! tongue until x rea*es ! glossoepiglottic fossa1 :ile at ! same "t ! tongue is lift$2 :5 ?is is done ! epiglottis w /& out 9 /rong relief4 ,! beg9n] is apt to ins]t ! speculum too f> & expose ! hypoph>ynx r ?an ! l>ynx4 ,! elusiv5ess ( ! epiglottis & its t5d5cy to retreat d[nw>d are v mu* acc5tuat$ 9 pati5ts :o h worn a tra*eotomic cannula2 & if /ill we>+ x1 ! pati5t c wait indef9itely be=e op5+ 8 glottis4 ,ov] ext5sion ( ! pati5t's head is a frequ5t cause ( difficulty4 ,if ! head is held high en\gh ext5sion is n necess>y1 & ! less ! ext5sion ! less muscul> t5sion !re is 9 ! ant]ior c]vical muscles4 ,only "o aryt5oid em95ce may be se54 ,! "r & ! left look diff]5t4 ,practice w facilitate id5tification1 s t ! endoscopi/ w at once "k :i* way to look = ! glottis4 ,( ! difficulties t p]ta9 to ! op]ator himself ! greate/ is lack ( practice4 ,he mu/ le>n to recognize ! l&m>ks ev5 ?\gh a high degree ( spasm be pres5t4 ,! epiglottis & ! two r\nd$ em95ces correspond+ to ! aryt5oids mu/ be 9 ! m9d's eye1 = x is only on deep1 relax$ inspiration t any?+ l a typical picture ( ! l>ynx w be se54 ,he mu/ "k also ! "r f ! left aryt5oid :5 only "o is se5 9 ord] to "k :e!r to move ! lip ( ! l>yngoscope to ! "r or ! left = exposure ( ! int]ior ( ! l>ynx4 ,in/rum5ts = ,direct ,l>yngoscopy4--,9 und]tak+ direct l>yngoscopy "o mu/ always be prep>$ = bron*oscopy1 esophagoscopy1 & tra*eotomy1 z well4 ,prep>ations = bron*oscopy are necess>y because ! pa?ological condition may n be f\nd 9 ! l>ynx1 & fur!r se>* ( ! tra*ea or bron*i may be requir$4 ,a =eign body 9 ! l>ynx may be aspirat$ to a deep] location & c\ld only be foll[$ ) ! bron*oscope4 ,sudd5 respiratory arre/ might occur1 f pa?ology or =eign body1 necessitat+ ! ins]t+ ( ! bron*oscope = brea?+ purposes1 & ! insufflation ( oxyg5 & amyl nitrite4 ,tra*ectomy might be requir$ = dyspnea or o!r reasons4 ,x might be necess>y to explore ! esophagus = conditions associat$ ) l>yngeal lesions1 z = in/ance a =eign body 9 ! esophagus caus+ dyspnea by pressure4 ,9 %ort1 :5 plann+ = direct l>yngoscopy1 bron*oscopy1 or esophagoscopy1 prep>e = all ?ree1 & = tra*eotomy4 ,a prop]ly done direct l>yngoscopy w\ld nev] precipitate a tra*eotomy 9 an unane/hetiz$ pati5t2 b direct l>yngoscopy has to deal s frequ5tly ) l>yngeal /5osis1 t r\t9e prep>ation = tra*eotomy a hundr$ unnecess>y times is fully comp5sat$ = by ! c]ta9ty ( prep>$ness :5 ! r>e b urg5t occasion arises4 ,direct ,l>yngoscopy 9 ,*ildr54--,! epiglottis 9 *ildr5 is usually /rongly curl$1 (t5 omega %ap$1 & is v elusive & slipp]y4 ,! l>ynx ( a *ild is v freely movable 9 ! neck dur+ respiration & deglutition1 & has a /rong t5d5cy to retreat d[nw>d dur+ exam9ation1 & ?us )draw ! epiglottis aft] ! aryt5oids h be5 expos$4 ,9 foll[+ d[n ) ! l>yngoscope ! speculum is prone to ent] ! hypoph>ynx4 ,lift+ 9 ?is location w expose ! m\? ( ! esophagus & %ut (f ! l>ynx1 & may cause respiratory arre/4 ,practice1 h[ev]1 w soon develop a te*nic & ability to recognize ! l&m>ks 9 /ate ( spasm1 s t on expos+ ! approximat$ aryt5oid em95ces ! endoscopi/ w ma9ta9 8 position & wait = ! l>ynx to op54 ,! proc$ure %\ld be done )\t any =m ( ane/hesia = ! foll[+ reasons3 #a4 ,ane/hesia is unnecess>y4 #b4 ,x is extremely dang]\s 9 a dyspneic pati5t4 #c4 ,x is inadmissable 9 a pati5t ) diph!ria4 #d4 ,if ane/hesia is to be us$1 direct l>yngoscopy w nev] rea* its full degree ( usefulness1 because ane/hesia makes a major proc$ure out ( a m9or "o4 #e4 ,coca9 9 *ildr5 is dang]\s1 & its application m annoy+ ?an ! exam9ation4 ,induc+ a ,*ild to ,op5 its ,m\? 7,au?or's ,me?od74--,! w\nd+ ( ! *ild's m\?1 gums1 & lips1 9 ! (t5 inefficaci\s me?ods ) gags1 hemo/ats1 raspatories1 etcet]a1 are entirely unnecess>y4 ,! m\? ( any *ild n unconsci\s c be op5$ quickly & )\t ! slighte/ h>m by pass+ a curv$ probe betwe5 ! cl5*$ jaws back ( ! mol>s & d[n back ( ! tongue t[>d ! l>yngoph>ynx4 ,?is w cause ! *ild to gag1 :5 its m\? inv>iably op5s4 #ia ,,*apt] ,,viii--,,direct ,,l>yngoscopy 7,cont9u$7 ,te*nic ( ,l>yngeal ,op]ations4--,prep>ation ( ! pati5t & ane/hesia h be5 m5tion$ "u _! respective *apt]s4 ,! prime ess5tial ( successful l>yngeal op]ations is p]fect ma/]y ( cont9u\s left-h&$ l>yngeal exposure4 ,! "r h& mu/ be equally tra9$ 9 ! manipulation ( =ceps1 & ! "r eye to gauge dep?4 ,blood & secretions are be/ remov$ by a suction tube 7,fig4 #i7 ins]t$ ?r\gh ! l>yngoscope1 or directly into ! ph>ynx outside ! l>yngoscope4 ,= ! removal ( b5ign gr[?s ! au?or's papilloma =ceps1 ,fig4 #bi1 or ! l>yngeal grasp+ =ceps %[n 9 ,fig4 #ag w prove m satisfactory ?an any =m ( cutt+ =ceps4 ,^! gr[?s %\ld be remov$ sup]ficially flu% ) ! normal /ructure4 ,! cru%+ ( ! base incid5t to ! pluck+ (f ( ! gr[? causes its recession4 ,by ?is cons]vative me?od damage to ! cords & impairm5t ( ! voice are avoid$4 ,= gr[?s 9 ! ant]ior portion ( ! l>ynx1 & 9 fact = ! removal ( mo/ small b5ign gr[?s1 ! ant]ior commissure l>yngoscope is especially adapt$4 ,its %ape all[s its introduction into ! ve/ibule ( ! l>ynx1 & if desir$ x may be introduc$ ?r\gh ! glottic *9k = ! treatm5t ( subglottic conditions4 ,x w n infrequ5tly be obs]v$ t a p$unculat$ subglottic gr[? :i* is f\nd ) difficulty w be pull$ upw>d into view by ! gauze swab introduc$ to remove secretions4 ,! gr[? is !n (t5 held tightly betwe5 ! approximat$ cords = a few seconds--p]haps long en\gh to grasp x ) =ceps4 #ib ,removal ( ,gr[? f ! ,l>yngeal ,v5tricle4--,aft] expos+ ! l>ynx 9 ! usual mann]1 if ! head is turn$ /rongly to ! "r1 ! tip ( ! l>yngoscope1 direct$ f ! "r side ( ! m\?1 may be us$ to lift ! left v5tricul> h& & ?us expose ! v5tricle1 f :i* a gr[? may be remov$ 9 ! usual mann] 7,fig4 #eg74 ,! "r v5tricle is expos$ by work+ f ! left side ( ! m\?4 ,,fig4 #eg4-,s*ema illu/rat+ ! lat]al me?od ( expos+ a gr[? 9 ! v5tricle ( ,morgagni1 by b5d+ ! pati5t's head to ! opposite side1 :ile ! second assi/ant ext]nally fixes ! l>ynx ) 8 h&4 ,m1 ,pati5t's m\?2 ,t1 ?yroid c>tilage2 ,r1 "r side2 ,l1 left4 ,v1 ,b1 v5tricul> b&4 ,c1 ,c1 vocal cord4 ,! circul> draw+ indicates ! endoscopic view obta9able by ?is me?od4 ,! tube1 ,e1 is dropp$ to ! corn] ( ! m\?1 ,b1 & ! tube is ins]t$ d[n to ,r4 ,! lip ( ! spatula c !n be us$ to lift ! v5tricul> b& s z to expose m ( ! v5tricle4 ,! draw+ %[s an unusually %all[ v5tricle4 ,tak+ a ,l>yngeal ,specim5 = ,diagnosis4--,! diagnosis ( c>c9oma1 s>coma1 & "s o!r conditions c be made c]ta9 only by microscopic /udy ( tissue remov$ f ! gr[?4 ,! specim5 %\ld be ample b w necess>ily be small4 ,if ! suspect$ gr[? be small x %\ld be remov$ entire1 toge!r ) "s ( ! basal tissues4 ,if x is a l>ge gr[?1 & !re are objections to its entire removal1 ! edge ( ! gr[?1 includ+ app>5tly normal z well z neopla/ic tissue1 is necess>y4 ,if x is a diffuse infiltrative process1 a specim5 %\ld be tak5 f at lea/ two locations4 ,tissue = biopsy is to be tak5 ) ! pun* =ceps %[n 9 ,fig4 #bh or t 9 ,fig4 #cc4 ,! =ceps may be ins]t$ ?r\gh ! tube or f ! angle ( ! m\?2 ! extubal me?od 7see ,fig4 #eh74 ,,fig4 #eh4--,s*ema illu/rat+ removal ( a tumor f ! upp] "p ( ! l>ynx by ! au?or's extubal me?od = l>ge tumors4 ,! l>ge alligator basket pun* =ceps1 ,f1 is ins]t$ f ! "r corn] ( ! m\? & ! jaws are plac$ ov] ! tumor1 ,t1 "u guidance ( ! eye look+ ?r\gh ! l>yngoscope1 ,l4 ,?is me?od is n us$ = small tumors4 ,x is excell5t = amputation ( ! epiglottis ) ^! same pun* =ceps or ) ! heavy sn>e4 ,removal ( l>ge b5ign tumors above ! cords may be done ) ! sn>e or ) ! l>ge l>yngeal pun* =ceps4 ,bo? are us$ 9 ! extubal me?od4 ,amputation ( ! epiglottis = palliation ( odynophagia or dysphagia 9 tub]cul\s or malignant disease1 is ( b5efit :5 ! ulc]ation is conf9$ to ?is region2 ?\gh z to tub]culosis ! au?or feels r cons]vat+ly incl9$4 ,e>ly malignancy ( ! extreme tip c be cur$ by su* means4 ,! function ( ! epiglottis seems to be to split ! food bolus & direct its portions lat]ally into ! pyri=m s9uses1 r ?an to take any important "p 9 ! closure ( ! l>ynx4 ,foll[+ ! removal ( ! epiglottis !re is r>ely compla9t ( food ent]+ ! l>ynx4 ,! project+ portion ( ! epiglottis may be amputat$ ) a heavy sn>e1 or by means ( ! l>ge l>yngeal pun* =ceps 7,fig4 #cc74 ,endoscopic ,op]ations = ,l>yngeal ,/5osis4--,web =mations may be excis$ ) slid+ pun* =ceps1 or if ! web is due to contraction only1 incision ( ! true b& may all[ its retraction4 ,9 "s in/ances lib]ation ( adhesions w favor ! =mation ( adv5titi\s vocal cords4 ,a %>p ant]ior commissure is a l>ge factor 9 good phonation4 ,endoscopic evisc]ation ( ! l>ynx w cure a few cases ( l>yngeal cicatricial /5osis1 & %\ld be tri$ be=e resort+ to l>yngo/omy4 ,a slid+ pun* =ceps is us$ to remove all ! tissue 9 ! l>ynx out to ! p]i*ondrium1 b c>e %\ld be tak5 9 cicatricial cases to avoid remov+ any "p ( ei!r aryt5oid c>tilage4 ,9 cases ( po/icus p>alysis ! excision may include portions ( ! vocal processes ( ! aryt5oids4 ,v5triculocordectomy is pref]able to evisc]ation4 ,! v5tricul> floor is remov$ ) pun* =ceps 7,fig4 #cc7 fir/ on "o side1 !n aft] two mon?s1 on ! o!r4 ,vocal ,results4--,a :isp]+ voice c always be _h z long z air c pass ?r\gh ! l>ynx1 & ?is may be develop$ to a v l\d p5etrat+ /age :isp]4 ,if ! aryt5oid motility has be5 un9jur$ ! repeat$ pulls on ! sc> tissue may draw out adv5titi\s b&s & develop a l\d1 useful1 ?\gh p]haps r\gh & inflexible voice4 ,galvano-caut]ization is ! be/ me?od ( treatm5t = *ronic subglottic edema or hyp]plasia su* z is se5 9 *ildr5 foll[+ diph!ria1 :5 ! /5osis produc$ prev5ts extubation or decannulation4 ,! utmo/ caution %\ld be us$ to avoid deep caut]izations2 !y are almo/ c]ta9 to set up p]i*ondritis :i* w increase ! /5osis4 ,"s ( ! mo/ difficult cases t h come to ! au?or h be5 previ\sly caut]iz$ too deeply4 ,galvano-caut]y puncture ( tub]cul\s infiltrations ( ! l>ynx at times yields excell5t results 9 cases ) mild pulmon>y lesions1 & has q replac$ ! use ( ! curette1 lactic acid1 & o!r cau/ics4 ,! direct me?od ( expos+ ! l>ynx r5d]s ! application ( ! caut]y po9t easy & accurate4 ,9 sev]ely /5os$ tub]cul\s l>ynges a tra*eotomy %\ld fir/ be done1 = ?\gh ! reaction is slight x might be suffici5t to close a n>r[$ glottis4 ,! te*nic is ! usual "o = l>yngeal op]ations4 ,local ane/hesia suffices4 ,! l>ynx is expos$4 ,! rheo/at hav+ be5 previ\sly adju/$ to heat ! electrode to ne>ly :ite heat1 ! circuit is brok5 & ! electrode introduc$ cold4 ,:5 ! po9t is 9 contact ) ! desir$ location ! curr5t is turn$ on & ! po9t ?ru/ 9 z deeply z desir$4 ,usually x %\ld p5etrate until a firm resi/ance is felt2 b c>e mu/ be us$ n to damage ! crico>yt5oid jo9t4 ,! circuit is brok5 at ! in/ant ( )drawal4 ,punctures %\ld be made z ne>ly z possible p]p5dicul> to ! surface1 s z to m9imize ! de/ruction ( epi!lium & ?us less5 ! reaction4 ,a m9ute gray fibr\s sl\gh deta*es itself 9 a few days4 ,caut]y puncture %\ld be repeat$ e two or ?ree weeks1 select+ a new location ea* "t1 until ! desir$ result is obta9$4 ,great caution1 z m5tion$ above1 mu/ be us$ to avoid sett+ up p]i*ondritis4 ,_m cases ( l>yngeal tub]culosis w recov] z quickly by sil5ce & a g5]al antitub]cul\s regime4 ,radium1 9 =m ( capsules or ( ne$les ins]t$ 9 ! tissues may be appli$ ) great accuracy2 b ! au?or is /rongly impress$ ) pyri=m s9us applications by ! ,fre] me?od4 ,aft]-c>e ( endol>yngeal op]ations includes c>eful cleans+ ( ! tee? & m\?2 & if ! extr9sic area ( ! l>ynx is involv$ 9 ! w\nd1 /]ile liquid food & wat] %\ld be giv5 = f\r days4 ,! pati5t %\ld be wat*$ = complications by a special nurse :o is famili> ) ! signs ( l>yngeal dyspnea 7q4v474 ,complications dur+ endol>yngeal op]ations are r>e4 ,dyspnea may require tra*eotomy4 ,idiosyncrasy to coca91 or ! sight or ta/e ( blood may nauseate ! pati5t & cause syncope4 ,s]i\s hemorrhage c\ld occur only 9 a hemophile4 ,! c>eless h&l+ ( a bite block might damage a frail tool or d5tal fixture4 ,complications aft] endol>yngeal op]ations are unusual4 ,c>elessness 9 asepsis has be5 kn[n to cause c]vical cellulitis4 ,emphysema ( ! neck has occurr$4 ,edema ( ! l>ynx occasionally occurs1 & might necessitate tra*eotomy4 ,s]i\s ble$+ aft] op]ation is v r>e except 9 ble$]s4 ,hemorrhage )9 ! l>ynx c be /opp$ by ! introduction ( a roll ( gauze f above1 tra*eotomy hav+ be5 previ\sly p]=m$4 ,morph9 subcutane\sly adm9i/]$1 has a con/rict+ action on ! vessels :i* r5d]s x ( value 9 controll+ hemorrhage4 #ig ,,*apt] ,,ix--,,introduction ,,( ,,! ,,bron*oscope ,no "o %\ld d bron*oscopy until he is able to expose ! glottis by left-h&$ direct l>yngoscopy 9 less ?an "o m9ute4 ,:5 he has ma/]$ ?is1 "o m9ute m %\ld be suffici5t to introduce ! bron*oscope into ! tra*ea4 ,,te*nic ,,( ,,bron*oscopy ,local ane/hesia is usually employ$ 9 ! adult4 ,! pati5t is plac$ 9 ! ,boyce position %[n 9 ,fig4 #ea1 ) head & %\ld]s project+ ov] ! edge ( ! table & support$ by an assi/ant4 ,! glottis is expos$ by left-h&$ l>yngoscopy4 ,! in/rum5t-assi/ant n[ ins]ts ! di/al end ( ! bron*oscope into ! lum5 ( ! l>yngoscope1 ! h&le be+ direct$ to ! "r 9 a horizontal position4 ,! op]ator n[ grasps ! bron*oscope1 8 eye is transf]r$ f ! l>yngoscope to ! bron*oscope1 & ! bron*oscope is advanc$ & s direct$ t a good view ( ! glottis is obta9$4 ,! slant$ end ( ! bron*oscope %\ld !n be direct$ to ! left1 s z cle>ly to expose ! left cord4 ,9 ?is position x w be f\nd t ! tip ( ! slant$ end is 9 ! c5t] ( ! glottic *9k & w slip readily into ! tra*ea4 ,no great =ce %\ld be us$1 because if ! bron*oscope does n g ?r\gh readily1 ei!r ! tube is too l>ge a size or x is n correctly plac$ 7,fig4 #fj74 ,normally1 h[ev]1 !re is "s slight resi/ance1 :i* 9 cases ( subglottic l>yngitis may be consid]able4 ,! tra9$ l>yngologi/ w readily det]m9e by s5se ( t\* ! degree ( pressure necess>y to ov]come x4 ,:5 ! bron*oscope has be5 ins]t$ to ab\t ! second or ?ird tra*eal r+1 ! heavy l>yngoscope is remov$ by rotat+ ! h&le to ! left1 remov+ ! slide1 & )draw+ ! in/rum5t4 ,c>e mu/ be tak5 t ! bron*oscope is n )drawn or c\gh$ out dur+ ! removal ( ! l>yngoscope2 ?is c be avoid$ by all[+ ! ocul> end to re/ aga9/ ! g[n-cov]$ *e/ ( ! op]ator4 ,if pref]r$ ! op]ator may tra9 8 in/rum5tal assi/ant to take (f ! l>yngoscope1 :ile ! op]ator devotes 8 att5tion to prev5t+ ! )drawal ( ! bron*oscope by hold+ ! h&le ) 8 "r h&4 ,at ! mom5t ( ins]tion ( ! bron*oscope ?r\gh ! glottis1 an especially /rong upw>d lift on ! beak ( ! spatula w facilitate ! passage4 ,x is necess>y to be c]ta9 t ! axis ( ! bron*oscope corresponds to ! axis ( ! tra*ea1 9 ord] to avoid injury to ! subglottic tissue :i* might be foll[$ by subglottic edema 7,fig4 #dg74 ,if ! subglottic region is already edemat\s & causes resi/ance1 slight rotation to ! l>yngoscope1 & bron*oscope w cause ! bron*oscope to ent] m easily4 ,,fig4 #ei4--;,insufflation ane/hesia ) ,elsb]g app>atus4 ,ane/heti/ has expos$ ! l>ynx & is ab\t to introduce ! silk-wov5 ca!t]4 ,note ! full ext5sion ( ! head on ! table4 ,,fig4 #fj4--,s*ema illu/rat+ ! introduction ( ! bron*oscope ?r\gh ! glottis1 recumb5t pati5t4 ,! h&le1 ,h1 is always horizontally to ! "r4 ,:5 ! glottis is fir/ se5 ?r\gh ! tube x %\ld be c5trally locat$ z at ,k4 ,at ! next inspiration ! end ,b1 is mov$ horizontally to ! left z %[n by ! d>t1 ,m1 until ! glottis %[s at ! "r edge ( ! field1 ,c4 ,?is means t ! po9t ( ! lip1 ,b1 is at ! m$ian l9e1 & x is !n quickly 7n viol5tly7 pu%$ ?r\gh into ! tra*ea4 ,at ?is same mom5t or ! in/ant be=e1 ! hyoid bone is giv5 a quick additional lift ) ! tip ( ! l>yngoscope4 ,,fig4 #fa4--,s*ema illu/rat+ oral bron*oscopy4 ,! portion ( ! table "h %[n "u ! head is1 9 actual "w1 dropp$ all ! way d[n p]p5dicul>ly4 ,x appe>s 9 ^! draw+s z a dott$ l9e to emphasize ! fact t ! head mu/ be above ! level ( ! table dur+ introduction ( ! bron*oscope into ! tra*ea4 ,a1 ,exposure ( l>ynx2 ,b1 bron*oscope introduc$2 ,c1 slide remov$2 ,d1 l>yngoscope remov$ leav+ bron*oscope alone 9 position4 ,difficulties 9 ! ,introduction ( ! ,bron*oscope4--,! beg9n] may ent] ! esophagus in/ead ( ! tra*ea3 ?is might be a dang]\s accid5t 9 a dyspneic case1 = ! tube c\ld1 by pressure on ! tra*ea1 cause respiratory arre/4 ,a bron*oscope ?us misplac$ %\ld be re/]iliz$ be=e introduc+ x into ! air passages1 = :ile ! l[] air passages are usually free f bact]ia1 ! esophagus is a septic canal4 ,if ! giv5 te*nic is c>efully c>ri$ out ! bron*oscope w n be contam9at$ ) m\? secretions4 ,! tra*ea is recogniz$ z an op5 tube1 ) :iti% r+s1 & ! expiratory bla/ c be felt & tubul> brea?+ he>d2 :ile if by mi/ake ! bron*oscope has ent]$ ! gullet x w be obs]v$ t ! c]vical esophagus has collaps$ walls4 ,a puff ( air may be felt & a flutt]+ s\nd he>d :5 ! tube is 9 ! esophagus1 b ^! lack ! int5sity ( ! tra*eal bla/4 ,usually a free fl[ ( secretion is met ) 9 ! esophagus4 ,9 diseas$ /ates ! tra*eal r+s may n be visible because ( swoll5 mucosa1 or ! tra*ea itself may be 9 p>tial collapse f ext]nal pressure4 ,! true expiratory bla/ w1 h[ev]1 always be recogniz$ :5 ! tube is 9 ! tra*ea4 ,wide gagg+ ( ! m\? r5d]s exposure ( ! l>ynx difficult4 ,,fig4 #fb4--;,ins]tion ( ! bron*oscope4 ,note direction ( ! tra*ea z indicat$ by ! bron*oscope4 ,note t ! pati5t's head is held above ! level ( ! table4 ,! assi/ant's left h& %\ld be at ! pati5t's m\? hold+ ! bite-block4 ,?is is remov$ & ! assi/ant is on ! wrong side ( ! table 9 ! illu/ration 9 ord] n to hide ! position ( ! op]ator's h&s4 ,note ! h&le ( ! bron*oscope is to ! "r4 ,,fig4 #fc4--,! heavy l>yngoscope has be5 remov$ leav+ ! light bron*oscope 9 position4 ,! op]ator is ins]t+ =ceps4 ,note h[ ! left h& ( ! op]ator holds ! tube lightly betwe5 ! ?umb & fir/ two f+]s ( ! left h&1 :ile ! la/ two f+]s are hook$ ov] ! upp] tee? ( ! pati5t an*or+ ! tube to prev5t x mov+ 9 or out or o!rwise *ang+ ! relation ( ! di/al tube-m\? to a =eign body or a gr[? :ile =ceps are be+ us$4 ,?us1 also1 any desir$ location ( ! tube c be ma9ta9$ 9 sy/ematic exploration4 ,! assi/ant's left h& is dropp$ out ( ! way to %[ ! op]ator's me?od4 ,! assi/ant dur+ bron*oscopy holds ! bite-block l a ?imble on ! index f+] ( ! left h&1 & ! assi/ant %\ld be on ! "r side ( ! pati5t4 ,he is "h put wrongly on ! left side s z n to hide ! in/rum5ts & ! mann] ( hold+ !m4 ,exam9ation ( ! ,tra*ea & ,bron*i4--,all bron*ial orifices mu/ be id5tifi$ s]iatim2 because ?is is ! only way by :i* ! bron*oscopi/ c "k :at "p ( ! tree he is exam9+4 ,appe>ances alone are n en\gh4 ,x is ! ord] 9 :i* !y are expos$ t enables ! inexp]i5c$ op]ator to "k ! orifices4 ,aft] ! removal ( ! l>yngoscope1 ! bron*oscope is to be held by ! left h& l a billi>d cue1 ! t]m9al phalanges ( ! left middle & r+ f+]s hook+ ov] ! upp] tee?1 :ile ! ?umb & index f+] hold ! bron*oscope1 clamp+ x to ! tee? tightly or loosely z requir$ 7,fig4 #fc74 ,?us ! tube may be an*or$ 9 any position1 or at any dep?1 & ! "r h& :i* 0 direct+ ! tube may be us$ = ! manipulation ( in/rum5ts4 ,! grasp ( ! bron*oscope 9 ! "r h& %\ld be simil> to t ( hold+ a p51 t is1 ! ?umb1 fir/1 & second f+]s1 encircle ! %aft ( ! tube4 ,! bron*oscope %\ld nev] be held by ! h&le 7,fig4 #fd7 = ?is grasp does n all[ ( tactile s5se transmission1 is rigid1 awkw>d1 & r5d]s rotation ( ! tube a wri/ motion in/ead ( b a g5tle f+] action4 ,any secretion 9 ! tra*ea is to be remov$ by sponge pump+ be=e ! bron*oscope is advanc$4 ,! inspection ( ! walls ( ! tra*ea is accompli%$ by weav+ f side to side &1 if necess>y1 up & d[n2 ! head be+ deflect$ z requir$ dur+ ! se>* ( ! passages1 s t ! l>ynx be n made ! fulcrum 9 ! lev]-l action4 ,,fig4 #fd4--;,at ,a is %[n an incorrect mann] ( hold+ ! bron*oscope4 ,! grasp is too rigid & ! position ( ! h& is awkw>d4 ,b1 ,correct mann]1 ! coll> be+ held lightly betwe5 ! f+] & ! ?umb ,! ?umb mu/ n occlude ! tube m\?4 ,! ,fulcrum ( ! ,bron*oscopic ,lev] is at ! ,upp] ,?oracic ,ap]ture2 ,nev] at ! ,l>ynx4--,disreg>d ( ?is rule w cause subglottic edema & w limit ! lat]al motion ( ! tip ( ! bron*oscope4 ,x is ! function ( ! assi/ant to make ! head & neck foll[ ! direction ( ! proximal end ( ! bron*oscope & ?us avoid any pressure on ! l>ynx 7see ,p]oral ,endoscopy1 ,fig4 #ace1 p4 #afd74 ,9 pass+ d[n ! tra*ea ! foll[+ two rules mu/ be kept 9 m9d3 #a4 ,be=e attempt+ to ent] ei!r ma9 bron*us ! c>9a mu/ be id5tifi$4 #b4 ,be=e ent]+ ei!r ma9 bron*us ! orifices ( bo? %\ld be id5tifi$ & inspect$4 ,! c>9a is id5tifi$ z a %>p v]tical spur 7recumb5t pati5t7 at ! di/al end ( ! tra*ea1 on ei!r side ( :i* are ! op5+s ( ! ma9 bron*i4 ,z ! c>9a is situat$ to ! left ( ! midl9e ( ! tra*ea1 ! lip ( ! bron*oscope %\ld be turn$ t[>d ! left1 & slight lat]al pressure %\ld be made on ! left tra*eal wall :ile ! head ( ! pati5t is held slightly to ! "r4 ,?is w expose ! left bron*ial orifice & c>9a4 ,ent]+ ! ,bron*i4--,! lip ( ! bron*oscope %\ld be turn$ 9 ! direction ( ! bron*us to be explor$1 & ! axis ( ! bron*oscope %\ld be made to correspond z ne>ly z possible to ! axis ( ?is bron*us4 ,! position ( ! lip is designat$ by ! direction tak5 by ! h&le4 ,^u ent]+ ! "r bron*us1 ! h&le ( ! bron*oscope is turn$ horizontally to ! "r1 & at ! same "t ! assi/ant deflects ! head to ! left4 ,! "r upp]-lobe bron*us is recogniz$ by its v]tical spur2 ! orifice is expos$ by displac+ ! "r lat]al wall ( ! "r ma9 bron*us at ! level ( ! c>9a4 ,usually ?is orifice w be ?us br\ght into view4 ,if n ! bron*oscope may be advanc$ d[nw>d #a or #b cm41 c>efully to avoid ov]rid+4 ,?is bran* is sometimes f\nd com+ (f ! tra*ea itself1 & ev5 if x does n1 ! ov]rid+ ( ! orifice is c]ta9 if ! "r bron*us is ent]$ be=e se>* is made = ! upp]-lobe-bron*ial orifice4 ,! head mu/ be mov$ /rongly to ! left 9 ord] to view ! orifice4 ,a lum5 image ( ! "r upp]-lobe bron*us is n obta9able because ( ! %>p angles at :i* x is giv5 (f4 ,! left upp]-lobe bron*us is ent]$ by keep+ ! h&le ( ! bron*oscope 7& consequ5tly ! lip7 to ! left1 &1 by keep+ ! head ( ! pati5t /rongly to ! "r z ! bron*oscopi/ goes d[n ! left ma9 bron*us4 ,?is causes ! lip ( ! bron*oscope to be> /rongly on ! left wall ( ! left ma9 bron*us1 consequ5tly ! left upp]-lobe-bron*ial orifice w n be ov]ridd54 ,! spur sep>at+ ! upp]-lobe-bron*ial orifice f ! /em bron*us is at an angle approximately f two to eight o'clock1 z usually se5 9 ! recumb5t pati5t4 ,a lum5 image ( a desc5d+ bran* ( ! upp]-lobe bron*us is (t5 obta9$1 if ! pati5t's head be borne /rongly en\gh to ! "r4 ,,fig4 #fe4--,s*ema illu/rat+ ! ent]+ ( ! ant]iorly bran*+ middle lobe bron*us4 ,t1 ,tra*ea2 ,b1 orifice ( left ma9 bron*us at bifurcation ( tra*ea4 ,! bron*oscope1 ,s1 is 9 ! "r ma9 bron*us1 po9t+ 9 ! direction ( ! "r inf]ior lobe bron*us1 ,i4 ,9 ord] to cause ! lip to ent] ! middle lobe bron*us1 ,m1 x is necess>y to drop ! head s t ! bron*oscope 9 ! tra*ea ,,tt1 w po9t prop]ly to enable ! lip ( ! tube m\? to ent] ! middle lobe bron*us1 z x is se5 to h done at ,,ml4 ,bran*es ( ! /em bron*us 9 ei!r lung are expos$1 or _! respective lum9a pres5t$1 by manipulation ( ! lip ( ! bron*oscope1 ) movem5t ( ! head 9 ! requir$ direction4 ,po/]ior bran*es require ! head q high4 ,a l>ge "o 9 ! left /em j bel[ ! left upp]-lobe bron*us is (t5 invad$ by =eign bodies4 ,ant]ior bran*es require l[]+ ! head4 ,! middle-lobe bron*us is ! l>ge/ ( all ant]ior bran*es4 ,its almo/ horizontal spur is br\ght into view by direct+ ! lip ( ! bron*oscope upw>d1 & dropp+ ! head ( ! pati5t until ! lip be>s /rongly on ! ant]ior wall ( ! "r bron*us 7see ,fig4 #fe74 #ajf ,,*apt] ,x--,,introduction ,,( ,,! ,,esophagoscope ,! esophagoscope is to be pass$ only ) ocul> guidance1 nev] bl9dly ) a m&r9 or obturator1 z 0 done be=e ! bevel-end$ esophagoscope 0 develop$4 ,bl9d introduction ( ! esophagoscope is equally z dang]\s z bl9d b\g9age4 ,x is almo/ c]ta9 to cause ov]-rid+ ( =eign bodies & disease4 ,9 ei!r condition p]=ation ( ! esophagus is possible by pu%+ a %>p =eign body ?r\gh ! normal wall or by p5etrat+ a wall weak5$ by disease4 ,l&m>ks mu/ be id5tifi$ z rea*$1 9 ord] to "k ! locality rea*$4 ,! secretions pres5t =m suffici5t lubrication = ! in/rum5t4 ,a cle> conception ( ! endoscopic anatomy1 ! n>r[+s1 direction1 & *anges ( direction ( ! axis ( ! esophagus1 are necess>y4 ,! s]vices ( a tra9$ assi/ant to place ! head 9 ! prop] sequ5tial high-l[ positions are indisp5sible 7,figs4 #eb & #gj74 ,introduction may be divid$ into f\r /ages4 #a4 ,ent]+ ! "r pyri=m s9us4 #b4 ,pass+ ! cricoph>yngeus4 #c4 ,pass+ ?r\gh ! ?oracic esophagus4 #d4 ,pass+ ?r\gh ! hiatus4 ,! pati5t is plac$ 9 ! ,boyce position z describ$ 9 ,*apt] ,,vi4 ,z previ\sly /at$1 ! esophagus 9 its upp] portion foll[s ! curves ( ! c]vical & dorsal sp9e4 ,x is necess>y1 !re=e1 to br+ ! c]vical sp9e into a /raight l9e ) ! upp] portion ( ! dorsal sp9e & ?is is accompli%$ by elevation ( ! head--! high position 7,figs4 #ff-ga74 ,,plate ,,iii--,,esophagoscopic ,,views ,,f ,,oil-,,color ,,draw+s ,,f ,,life1 ,,by ,,! ,,au?or3 #a1 ,direct view ( ! l>ynx & l>yngoph>ynx 9 ! dorsally recumb5t pati5t1 ! epiglottis & hyoid bone be+ lift$ ) ! direct l>yngoscope or ! esophageal speculum4 ,! spasmodically adduct$ vocal cords are p>tially hidd5 by ! ov]-hang ( ! spasmodically prom95t v5tricul> h&s4 ,po/]ior to ?is ! aryepiglottic folds end+ po/]iorly 9 ! aryt5oid em95ces are se5 9 apposition4 ,! esophagoscope %\ld be pass$ to ! "r ( ! m$ian l9e into ! "r pyri=m s9us1 repres5t$ "h by ! "r arm ( ! d>k cresc5t4 #b1 ,! "r pyri=m s9us 9 ! dorsally recumb5t pati5t1 ! em95ce at ! upp] left bord]1 corresponds to ! edge ( ! cricoid c>tilage4 #c1 ,! cricoph>yngeal con/riction ( ! esophagus 9 ! dorsally recumb5t pati5t1 ! cricoid c>tilage be+ lift$ =w>d ) ! esophageal speculum4 ,! l[] 7po/]ior7 half ( ! lum5 is clos$ by ! fold correspond+ to ! orbicul> fib]s ( ! cricoph>yngeus :i* advances spasmodically f ! po/]ior wall4 7,comp>e ,fig4 #aj47 ,?is view is n obta9$ ) an esophagoscope4 #d1 ,pass+ ?r\gh ! "r pyri=m s9us ) ! esophagoscope2 dorsally recumb5t pati5t4 ,! walls seem 9 tight apposition1 &1 at ! edges ( ! slit-l lum51 bulge t[>d ! obs]v]4 ,! direction ( ! axis ( ! slit v>ies1 & 9 "s in/ances x is l a rosette1 dep5d+ on ! degree ( spasm4 #e1 ,c]vical esophagus4 ,! lum5 is n s patul5t dur+ inspiration z l[] d[n2 & x closes completely dur+ expiration4 #f1 ,?oracic esophagus2 dorsally recumb5t pati5t4 ,! ridge cross+ above ! lum5 corresponds to ! left bron*us4 ,x is seldom s prom95t z 9 ?is pati5t1 b c always be f\nd if se>*$ =4 #g1 ,! normal esophagus at ! hiatus4 ,?is is (t5 mi/ak5 = ! c>dia by esophagoscopi/s4 ,x is m truly a sph9ct] ?an ! c>dia itself4 ,9 ! au?or's op9ion !re is no truly sph9ct]ic action at ! c>dia4 ,x is ! failure ( ?is hiatal sph9ct] to op5 z 9 ! normal deglutitory cycle t produces ! syndrome call$ c>diospasm4 #h1 ,view 9 ! /oma* ) ! op5-tube ga/roscope4 ,! =m ( ! folds v>ies cont9ually4 #i1 ,s>coma ( ! po/]ior wall ( ! upp] ?ird ( ! esophagus 9 a woman ( ?irty-"o ye>s4 ,se5 ?r\gh ! esophageal speculum1 pati5t sitt+4 ,! lum5 ( ! m\? ( ! esophagus1 mu* encroa*$ ^u by ! s>comat\s infiltration1 is se5 at ! l[] "p ( ! circle4 #aj1 ,co9 7half-doll>7 w$g$ 9 ! upp] ?ird ( ! esophagus ( a boy ag$ f\rte5 ye>s4 ,se5 ?r\gh ! esophageal speculum1 recumb5t pati5t4 ,=ceps are retract+ ! po/]ior lip ( ! esophageal m\? prep>atory to removal4 #aa1 ,fungat+ squam\s-cell$ epi!lioma 9 a man ( sev5ty-f\r ye>s4 ,fungations are n always pres5t1 & are (t5 pale & edemat\s4 #ab1 ,cicatricial /5osis ( ! esophagus due to ! swall[+ ( lye 9 a boy ( f\r ye>s4 ,bel[ tile upp] /ricture is se5 a second /ricture4 ,an ulc] surr\nd$ by an inflammatory areola & ! granulation tissue toge!r illu/rates ! etiology ( cicatricial tissue4 ,! fan-%ap$ sc> is really almo/ l9e>1 b x is view$ 9 p]spective4 ,pati5t 0 cur$ by esophagoscopic dilatation4 #ac1 ,angioma ( ! esophagus 9 a man ( =ty ye>s4 ,! pati5t _h hemorrhoids & v>icose ve9s ( ! legs4 #ad1 ,luetic ulc] ( ! esophagus #bf cm4 f ! upp] tee? 9 a woman ( ?irty-eight ye>s4 ,two sc>s f heal$ ulc]ations are se5 9 p]spective on ! ant]ior wall4 ,bran*+ vessels are se5 9 ! livid areola ( ! ulc]s4 #ae1 ,tub]culosis ( ! esophagus 9 a man ( ?irty-f\r ye>s4 #af1 ,leukoplakia ( ! esophagus ne> ! hiatus 9 a man ag$ fifty-six ye>s4 ,! hypoph>ynx tap]s d[n to ! gullet l a funnel1 & ! l>ynx is susp5d$ 9 its lum5 f ! ant]ior wall4 ,! l>ynx is atta*$ only to ! ant]ior wall1 b is held closely aga9/ ! po/]ior ph>yngeal wall by ! action ( ! inf]ior con/rictor ( ! ph>ynx1 & p>ticul>ly by its specializ$ portion--! cricoph>yngeus muscle4 ,a bolus ( food is split by ! epiglottis & ! two portions drift$ lat]ally into ! pyri=m s9uses1 ! recesses se5 on ei!r side ( ! l>ynx4 ,b little ( ! food bolus passes po/]ior to ! l>ynx dur+ ! act ( swall[+4 ,x is ?r\gh ! pyri=m s9us t ! esophagoscope is to be ins]t$1 !reby foll[+ ! natural food passage4 ,to ins]t ! esophagoscope 9 ! midl9e1 po/]ior to ! aryt5oids1 requires a degree ( =ce dang]\s to ex]t & almo/ c]ta9 to produce damage to ! crico>yt5oid jo9t or to ! ph>yngeal wall1 or to bo?4 ,! esophagoscope is /eadi$ by ! left h& l a billi>d cue1 ! t]m9al phalanges ( ! left middle & r+ f+]s hook$ ov] ! upp] tee?1 :ile ! left index f+] & ?umb encircle ! tube & retract ! upp] lip to prev5t its be+ p9*$ betwe5 ! tube & upp] tee?4 ,! "r h& holds ! tube 9 p5 fa%ion at ! coll> ( ! h&le1 n by ! h&le4 ,dur+ introduction ! h&le is to be po9t$ upw>d t[>d ! z5i?4 ,/age ,i4 ,ent]+ ! ,"r ,pyri=m ,s9us4--,! op]ator /&+ 7z 9 ,fig4 #ff71 ins]ts ! esophagoscope along ! "r side ( ! tongue z f> z & d[n ! po/]ior ph>yngeal wall4 ,a lift+ motion imp>t$ to ! tip ( ! esophagoscope by ! left ?umb w br+ ! r\nd$ "r aryt5oid em95ce into view 7,a1 ,fig4 #fi74 ,?is is ! l&m>k ( ! pyri=m s9us1 & c>e mu/ be tak5 to avoid injury by hook+ ! tube m\? ov] x or its fell[4 ,! tip ( ! tube %\ld n[ be direct$ some:at t[>d ! midl9e1 rememb]+ ! funnel %ape ( ! hypoph>ynx4 ,x w !n be f\nd to glide readily ?r\gh ! "r pyri=m s9us = #b or #c cm41 :5 x comes to a full /op1 & ! lum5 disappe>s4 ,?is is ! spasmodically clos$ cricoph>yngeal con/riction4 ,,fig4 #ff4--;,esophagoscopy by ! au?or's high-l[ me?od4 ,fir/ /age4 ,high position4 ,f9d+ ! "r pyri=m s9us4 ,9 ?is & ! second /age ! pati5t's v]tex is ab\t #ae cm4 above ! level ( ! table4 ,/age #b4 ,pass+ ! cricoph>yngeus is ! mo/ difficult "p ( esophagoscopy1 especially if ! pati5t is unane/hetiz$4 ,local ane/hesia helps little1 if at all4 ,! h&le ( ! esophagoscope is /ill po9t+ upw>d & consequ5tly we are sure t ! lip ( ! esophagoscope is direct$ ant]iorly4 ,=ce mu/ n be us$1 b /eady firm pressure aga9/ ! tonically contract$ cricoph>yngeus is made1 :ile at ! same "t ! di/al end ( ! esophagoscope is lift$ by ! left ?umb4 ,at ! fir/ inspiration a lum5 w usually appe> 9 ! upp] portion ( ! endoscopic field4 ,! tip ( ! esophagoscope ent]s ?is lum5 & ! slant$ end slides ov] ! fold ( ! cricoph>yngeus into ! c]vical esophagus4 ,!re is usually f #a to #c cm4 ( ?is con/rict$ lum5 at ! level ( ! cricoph>yngeus & ! subjac5t orbicul> esophageal fib]s4 #aji ,,fig4 #fg4--,s*ematic illu/ration ( ! au?or's high-l[ me?od ( esophagoscopy4 ,9 ! fir/ & second /ages ! pati5t's head fully ext5d$ is held high s z to br+ x 9 l9e ) ! ?oracic esophagus1 z %[n above4 ,! ,rose position is %[n by way ( acc5tuation4 ,,fig4 #fh4--,s*ematic illu/ration ( ! anatomic basis = difficulty 9 introduction ( ! esophagoscope4 ,! cricoid c>tilage is pull$ backw>d aga9/ ! c]vical sp9e1 by ! cricoph>yngeus1 s /rongly t x is difficult to realize t ! cricoph>yngeus is n ins]t$ into ! v]tebral p]io/eum in/ead ( into ! m$ian raphe4 ,,fig4 #fi4--,! upp] illu/ration %[s movem5ts necess>y = pass+ ! cricoph>yngeus4 ,! l[] illu/ration %[s s*ematically ! me?od ( f9d+ ! pyri=m s9us 9 ! au?or's me?od ( esophagoscopy4 ,! l>ge circle repres5ts ! cricoid c>tilage4 ,g1 ,glottic *9k1 spasmodically clos$2 ,,vb1 v5tricul> b&2 ,a1 "r aryt5oid em95ce2 ,p1 "r pyri=m s9us1 ?r\gh :i* ! tube is pass$ 9 ! recumb5t po/ure4 ,! pyri=m s9uses are ! normal food passages4 ,/age #c4 ,pass+ ,?r\gh ! ,?oracic ,esophagus4--,! ?oracic esophagus w be se5 to exp& dur+ inspiration & contract dur+ expiration1 due to ! *ange 9 ?oracic pressure4 ,! esophagoscope usually glides easily ?r\gh ! ?oracic esophagus if ! pati5t's position is correct4 ,aft] ! levels ( ! aorta & left bron*us are pass$ ! lum5 ( ! esophagus seems to h a t5d5cy to disappe> ant]iorly4 ,! lum5 mu/ be kept 9 axial view & ! head l[]$ z requir$ = ?is purpose4 ,/age #d4 ,pass+ ,?r\gh ! ,hiatus ,esophageus4--,:5 ! head is dropp$1 x mu/ at ! same "t be mov$ horizontally to ! "r 9 ord] t ! axis ( ! tube %all correspond to ! axis ( ! l[] ?ird ( ! esophagus1 :i* deviates to ! left & turns ant]iorly4 ,! head & %\ld]s at ?is "t w be f\nd to be consid]ably bel[ ! plane ( ! table top 7,fig4 #ga74 ,! hiatal con/riction may assume ! =m ( a slit or rosette4 ,if ! rosette or slit _c be promptly f\nd1 z may be ! case 9 v>i\s degrees ( diffuse dilatation1 ! tube m\? mu/ be %ift$ f>!r to ! left & ant]iorly4 ,:5 ! tube m\? is c5t]$ ov] ! hiatal con/riction mod]ately firm pressure cont9u$ = a %ort "t w cause x to yield4 ,!n ! tube1 ma9ta9+ ?is same direction w1 )\t fur!r tr\ble glide into & ?r\gh ! abdom9al esophagus4 ,! c>dia w n be notic$ z a con/riction1 b its appe>ance w be ann\nc$ by ! roll+ 9 ( r$di% ga/ric mucosal folds1 & by a gu% ( fluid f ! /oma*4 ,,fig4 #gj4--,s*ematic illu/ration ( ! au?or's high-l[ me?od ( esophagoscopy1 f\r? /age4 ,pass+ ! hiatus4 ,! head is dropp$ f ! position ( ! #a/ & #bnd /ages1 ,,cl1 to ! position ,t1 & at ! same "t ! head & %\ld]s are mov$ to ! "r 7)\t rotation7 :i* gives ! necess>y direction = pass+ ! hiatus4 ,,fig4 #ga4--;,esophagoscopy by ! au?or's high-l[ me?od4 ,/age #d4 ,pass+ ! hiatus ,! pati5t's v]tex is ab\t #e cm4 bel[ ! top ( ! table4 ,normal esophageal mucosa "u prop] illum9ation is gli/5+ & ( a yell[i% or blui% p9k4 ,! folds are s(t & velvety1 r5d]+ infiltration quickly noticeable4 ,! cricoid c>tilage %[s :ite ?r\gh ! mucosa4 ,! ga/ric mucosa is a d>k] p9k ?an t ( ! esophagus & :5 actively secret+1 its color 9 "s cases t5ds t[>d crimson4 ,secretions 9 ! esophagus are readily aspirat$ ?r\gh ! dra9age canal by a negative pressure pump4 ,food p>ticles are be/ remov$ by sponge pump+1 or ) =ceps4 ,%\ld ! dra9age canal become ob/ruct$ positive pressure f ! pump w cle> ! canal4 ,difficulties ( ,esophagoscopy4--,! beg9n] may f9d ! esophagoscope seem+ly rigidly fix$1 s t x c be nei!r introduc$ nor )drawn4 ,?is usually results f a w$g+ ( ! tube 9 ! d5tal angle1 & is ov]come by a wid] op5+ ( ! jaws1 or p]haps by eas+ up ( ! bite block1 b mo/ (t5 by correct+ ! position ( ! pati5t's head4 ,if ! beg9n] _c />t ! tube into ! pyri=m s9us 9 an adult1 x is a good plan to expose ! aryt5oid em95ce ) ! l>yngoscope & !n to ins]t ! #g mm4 esophagoscope into ! "r pyri=m s9us by direct vision4 ,pass+ ! cricoph>yngeal & hiatal spasmodically contract$ n>r[+s w prove ! mo/ try+ "p ( esophagoscopy2 b ) ! head prop]ly held1 & ! tube prop]ly plac$ & direct$1 pati5t wait+ = relaxation ( ! spasm ) g5tle cont9u\s pressure w usually expose ! lum5 ahead4 ,9 8 fir/ few esophagoscopies ! novice _h be/ use g5]al ane/hesia to avoid ^! difficulties & to accu/om himself to ! esophageal image4 ,9 ! fir/ favorable subject--an emaciat$ individual ) no tee?--esophagoscopy )\t ane/hesia %\ld be tri$4 ,9 cases ( kyphosis x is a mi/ake to try to /raight5 ! sp9e4 ,! head %\ld be held correspond+ly high] at ! beg9n+1 & %\ld be v sl[ly & cauti\sly l[]$4 ,once ins]t$1 ! esophagoscope %\ld n be remov$ until ! completion ( ! proc$ure1 unless respiratory arre/ dem&s x4 ,occasionally 9 /5otic conditions ! light may become cov]$ by ! upwell+ ( a flood ( fluid1 & x w be ?\ght ! light has gone out4 ,z soon z ! fluid has be5 aspirat$ ! light w be f\nd burn+ z brightly z be=e4 ,if a lamp %\ld fail x is unnecess>y to remove ! tube1 z ! light c>ri] & light c be )drawn & quickly adju/$4 ,a complete in/rum5t equipm5t ) prop] selection ( in/rum5ts = ! p>ticul> case are necess>y = smoo? work+4 ,balloon+ ,esophagoscopy4--,by ins]t+ ! w9d[ plug %[n 9 ,fig4 #f ! esophagus may be inflat$ & /udi$ 9 ! di/5d$ /ate4 ,! folds are ?us smoo!d out & con/rictions r5d]$ m m>k$4 ,e!r ane/hesia is advocat$ by ,mo%]4 ,! dang] ( respiratory arre/ f pressure1 %\ld ! pati5t be dyspneic1 is always pres5t unless ! ane/hetic be giv5 by ! intratra*eal me?od4 ,if necess>y to use =ceps ! w9d[ cap is remov$4 ,if ! p]=at$ rubb] diaphragm cap be sub/itut$ ! esophagus c be reballoon$1 b "w is no long] ocul>ly guid$4 ,! fluoroscope may be us$ b is s mislead+ z to r5d] p]=ation & false passage likely4 ,specul> ,esophagoscopy4--,inspection ( ! hypoph>ynx & upp] esophagus is readily made ) ! esophageal speculum %[n 9 ,fig4 #d4 ,high lesions & =eign bodies lodg$ beh9d ! l>ynx are ?us discov]$ ) ease1 & su* a condition z a retroph>yngeal abscess :i* has burr[$ d[nw>d is mu* less apt to be ov]look$ ?an ) ! esophagoscope4 ,high /rictures ( ! esophagus may be expos$ & treat$ by direct visual b\g9age until ! lum5 is suffici5tly dilat$ to all[ ! passage ( ! esophagoscope = b\g9age ( ! deep] /rictures4 ,te*nic ( ,specul> ,esophagoscopy4--,recumb5t pati5t4 ,boyce position4 ,! l>ynx is to be expos$ z 9 direct l>yngoscopy1 ! "r pyri=m s9us id5tifi$1 ! tip ( ! speculum ins]t$ !re91 & g5tly ins9uat$ to ! cricoph>yngeal con/riction4 ,too great ext5sion ( ! head is to be avoid$--ev5 slight flexion at ! occipito-atloid jo9t may be f\nd useful at times4 ,mod]ate ant]ior or upw>d traction pulls ! cricoid away f ! po/]ior ph>yngeal wall & ! lum5 ( ! esophagus op5s above a cresc5tic fold 7! cricoph>yngeus74 ,! speculum readily slides ov] ?is fold & ent]s ! c]vical esophagus4 ,9 se>*+ = =eign bodies 9 ! esophagus ! speculum has ! disadvantage ( limit$ l5g?1 s t %\ld ! =eign body move d[nw>d x c\ld n be foll[$4 ,complications ,foll[+ ,esophagoscopy4--,^! are to be avoid$ 9 l>ge measure by ! ex]cise ( g5tl5ess1 c>e1 & skill t are acquir$ by practice4 ,if ! in/ructions h]e9 giv5 are foll[$1 esophagoscopy is absolutely )\t mortality ap>t f ! conditions = :i* x is done4 ,injury to ! crico-aryt5oid jo9t may simulate recurr5t p>alysis4 ,po/icus p>alysis may occur f recurr5t or vagal pressure by a misdirect$ esophagoscope4 ,^! conditions usually recov] b may p]si/4 ,p]=ation ( ! esophageal wall may cause dea? f septic m$ia/9itis4 ,! pleura may be ent]$1--pyopneumo?orax w result & dem& imm$iate ?oracotomy & ga/ro/omy4 ,aneurysm ( ! aorta may be ruptur$4 ,pati5ts ) tub]culosis1 decomp5sat+ c>diovascul> lesions1 or o!r advanc$ organic disease1 may h s]i\s complications precipitat$ by esophagoscopy4 ,retrograde ,esophagoscopy4--,! fir/ /ep is to get rid ( ! ga/ric secretions4 ,!re is always fluid 9 ! /oma*1 & ?is keeps p\r+ out ( ! tube 9 a /eady /ream4 ,fold aft] fold is empti$ ( fluid4 ,once ! /oma* is empty1 ! se>* beg9s = ! c>dial op5+4 ,! be/ l&m>k is a m>k ) a d]mal p5cil on ! sk9 at a po9t correspond+ to ! level ( ! hiatus esophageus4 ,:5 x is desir$ to d a retrograde esophagoscopy & ! ga/ro/omy is done = ?is special purpose1 x is wise to h x v high4 ,once ! c>dia is locat$ & ! esophagus ent]$1 ! rema9d] ( ! "w is v easy4 ,b\g9age c be c>ri$ out f bel[ ! same z f above & may be ( advantage 9 "s cases4 ,/rictural lum9a are mu* m apt to be conc5tric z approa*$ f bel[ because !re has be5 no di/ortion by pressure dilatation due to /agnation ( ! food op]at+ ?r\gh a long p]iod ( "t4 ,at retrograde esophagoscopy !re seems to be no abdom9al esophagus & no c>dia4 ,! esophagoscope enc\nt]s only ! diaphragmatic p9*cock :i* seems to be at ! top ( ! /oma* l ! puck]+ /r+ at ! top ( a bag4 ,retrograde esophagoscopy is sometimes useful = /r++ ! esophagus 9 cases 9 :i* ! pati5t is unable to swall[ a /r+ because he is too "y or because ( an epi!lial scal+ ov] ( ! upp] entrance ( ! /ricture4 ,9 su* cases ! smalle/ size ( ! au?or's fili=m b\gies 7,fig4 #dj7 is ins]t$ ?r\gh ! retrograde esophagoscope 7,fig4 #dc7 & ins9uat$ upw>d ?r\gh ! /ricture4 ,:5 ! tip rea*es ! ph>ynx c\gh+1 *ok+ & gagg+ are notic$4 ,! fili=m end is br\ght out ! m\? suffici5tly f> to atta* a silk braid$ cord :i* is !n pull$ d[n & out ( ! ga/ro/omic op5+4 ,! braid$ silk /r+ mu/ be long en\gh s t ! oral & ! abdom9al ends c be ti$ toge!r to make x endless2 b be=e do+ s ! oral end %\ld be drawn ?r\gh nose :]e x w be less annoy+ ?an 9 ! m\?4 ,! purpose ( ! /r+ is to pull up ! retrograde b\gies 7,fig4 #ce7 #aag ,,*apt] ,,xi--,,acquir+ ,,skill ,endoscopic ability _c be b\ght ) ! in/rum5ts4 ,z ) all me*anical proc$ures1 facility c be obta9$ only by educat+ ! eye & ! f+]s 9 repeat$ ex]cise ( a p>ticul> s]ies ( maneuv]s4 ,z ) le>n+ to play a musical in/rum5t1 a fundam5tal k ( te*nic1 positions1 & l&m>ks is necess>y1 aft] :i* only cont9u$ manual practice makes = pr(ici5cy4 ,= in/ance1 effici5t use ( =ceps requires t !y be s famili> to ! grasp t _! use is automatic4 ,endoscopy is a purely manual proc$ure1 h5ce to "k h[ is n en\gh3 manual practice is necess>y4 ,ev5 9 ! h&l+ ( ! electrical equipm5t1 practice 9 quickly locat+ tr\ble is z ess5tial z !oretic k4 ,!re is no my/]y ab\t electric light+4 ,no s\rce ( illum9ation o!r ?an electricity is possible = endoscopy4 ,!re=e a small am\nt ( electrical k1 r5d]$ practical by practice1 is ess5tial to ma9ta9 ! simple light+ sy/em 9 work+ ord]4 ,x is an insult to ! intellig5ce ( ! physician to say t he _c ma/] a simple problem ( electric te/+ involv+ ! locat+ ( "o or m ( five possibilities4 ,x is simply a matt] ( memoriz+ five te/s4 ,x is repeat$ = emphasis t a comm]cial curr5t r$uc$ by means ( a rheo/at %\ld nev] be us$ z a s\rce ( curr5t = endoscopy ) any k9d ( in/rum5t1 because ( ! dang] to ! pati5t ( a possible gr\nd+ ( ! circuit dur+ ! ext5sive moi/ contact ( a metallic endoscopic tube 9 ! m$ia/9um4 ,! batt]y %[n 9 ,fig4 #h %\ld be us$4 ,! mo/ frequ5t cause ( tr\ble is ! mi/ake ( ov]-illum9at+ ! lamps4 ,! lamp %\ld n be ov]-illum9at$ to ! dazzl+ :it5ess usually us$ 9 fla% lights4 ,excessive illum9ation alt]s ! prop] p]ception ( ! color+ ( ! mucosa1 besides %ort5+ ! life ( ! lamps4 ,! prop] degree ( brightness is obta9$ :51 z ! curr5t is increas$1 ! fir/ *ange f yell[ to :ite light is obta9$4 ,nev] turn up ! rheo/at )\t wat*+ ! lamp4 ,te/+ = ,electric ,defects4--,^! te/s %\ld be made be=eh&2 n :5 ab\t to comm5ce introduction4 ,if ! fir/ lamp lights up prop]ly1 use x ) its light-c>ri] to te/ out ! o!r cords4 ,if ! lamp lights up1 b flick]s1 locate ! tr\ble be=e attempt+ to d an endoscopy4 ,if %ak+ ! c>ri] cord-t]m9al produces flick]+ !re may be a film ( corrosion on ! c5tral contact ( ! light c>ri] t goes into ! c>ri] cord-t]m9al4 ,if ! lamp fails to %[ a light1 ! tr\ble may be 9 "o ( five places :i* %\ld be te/$ = 9 ! foll[+ ord] & mann]4 #a4 ,! lamp may n be firmly screw$ into ! light-c>ri]4 ,)draw ! light-c>ri] & try screw+ x 91 ?\gh n too /rongly1 le/ ! c5tral wire t]m9al 9 ! lamp be b5t ov]4 #b4 ,! light-c>ri] may be defective4 #c4 ,! cord may be defective or its t]m9als n tight 9 ! b9d+ po/s4 ,if screw+ d[n ! ?umb nuts does n produce a light1 te/ ! light-c>ri] ) lamp on ! o!r cords4 ,res]ve cords 9 ea* pair ( b9d+ po/s are = use in/ead ( ! defective cords4 ,! two sets ( cords f "o pair ( b9d+ po/s %\ld n be us$ simultane\sly4 #d4 ,! lamp may be defective4 ,try ano!r lamp4 #e4 ,! batt]y may be defective4 ,take a cord & light-c>ri] ) lamp t lights up1 deta*+ ! cord-t]m9als at ! b9d+ po/s1 & atta* ! t]m9als to ! b9d+ po/s ( ! batt]y to be te/$4 ,effici5t use ( =ceps requires previ\s practice 9 h&l+ ( ! =ceps until x has become z natural & free f ?\ght z ! use ( knife & =k4 ,inde$ ! coord9ate use ( ! bron*oscopic tube-m\? & ! =ceps v mu* resembles ! use ( knife & =k4 ,yet only too (t5 a practition] w telegraph = a bron*oscope & =ceps1 & )\t any practice />t 9 to remove an entangl$ or impact$ =eign body f ! t9y bron*i ( a *ild4 ,failure & mortality are almo/ inevitable4 ,a few hundr$ h\rs sp5t 9 work+ out1 on a bit ( rubb] tub+1 ! v>i\s me*anical problems giv5 9 ! section on t subject w save lives & r5d] easily successful _m removals t w\ld o!rwise be impossible4 ,x is (t5 difficult = ! beg9n] to judge ! di/ance ! =ceps h be5 ins]t$ into ! tube4 ,?is difficulty is readily solv$ if ^u ins]t+ ! =ceps sl[ly into ! tube1 he obs]ves t z ! blades pass ! light !y become brightly illum9at$4 ,by ?is light reflex x is kn[n1 !re=e1 t ! =ceps blades are at ! tube-m\?1 & di/ance f ?is po9t c be readily gaug$4 ,excell5t practice may be _h by pick+ up ?r\gh ! bron*oscope or esophagoscope black ?reads f a :ite backgr\nd1 !n :ite ?reads f a black backgr\nd1 & f9ally :ite ?reads on a :ite backgr\nd & black ?reads on a black backgr\nd4 ,?is %\ld be done fir/ ) ! #i mm4 bron*oscope4 ,x is to be rememb]$ t ! majority ( =eign body accid5ts occur 9 *ildr51 ) :om small tubes mu/ be us$2 !re=e1 practice "w1 aft] say ! fir/ #ajj h\rs1 %\ld be done ) ! #e mm4 bron*oscope & correspond+ =ceps r ?an adult size tubes1 s t ! op]ator w be accu/om$ to "w ?r\gh a small calibre tube :5 ! actual case pres5ts itself4 #abj ,cadav] ,practice4--,! fundam5tal pr9ciples ( p]oral endoscopy are be/ taught on ! cadav]4 ,x is necess>y t a specially prep>$ subject be _h1 9 ord] to obta9 ! requir$ degree ( flexibility4 ,inject+ fluid ( ! foll[+ =mula work$ out by ,pr(4 ,j4 ,p>sons ,s*aeff] = ! ,bron*oscopic ,cl9ic c\rses1 has prov$ v satisfactory3 ,sodium c>bonate--#a #a_/b lbs4 ,:ite ars5ic--#b #a_/b lbs4 ,potassium nitrate--#c lbs4 ,wat]--#e gal4 ,boil until ars5ic is dissolv$4 ,:5 cold add3 ,c>bolic acid #aejj c4c4 ,glyc]9 #abej c4c4 ,alcohol 7#ie7 #abej c4c4 ,= ea* body use ab\t #c gal4 ( fluid4 ,! me?od ( introduction ( ! endoscopic tube1 & its v>i\s positions c be demon/rat$ & repeat$ly practic$ on ! cadav] until a p]fect$ te*nic is develop$ 9 bo? ! op]ator & assi/ant :o holds ! head1 & ! "o :o passes ! in/rum5ts to ! op]ator4 ,9 no o!r mann] c ! l&m>ks & endoscopic anatomy be /udi$ s ?or\ghly & practically1 & 9 no o!r way c ! pupil be taught to avoid kill+ 8 pati5t4 ,! dang]-po9ts 9 esophagoscopy are n demon/rable on ! liv+ )\t actually incurr+ mortality4 ,l>yngeal gr[?s may be simulat$1 =eign body problems creat$ & _! me*anical difficulties solv$ & practice "w ) ! =ceps & tube p]fect$4 ,practice on ! ,rubb]-tube ,manik94--,?is mu/ be c>ri$ out 9 two ways4 #a4 ,g5]al practice ) all sorts ( objects = ! education ( ! eye & ! f+]s4 #b4 ,be=e und]tak+ a =eign body case1 practice %\ld be _h ) a duplicate ( ! =eign body4 ,x is n possible to h a cadav] = daily practice1 b =tunately ! eye & f+]s may be tra9$ q z effectually by simulat+ =eign body conditions 9 a small r$ rubb] tube & solv+ ^! me*anical problems ) ! bron*oscope & =ceps4 ,! tub+ may be plac$ on ! desk & held by a small vise 7,fig4 #gb7 s t at odd mom5ts dur+ ! day or ev5+ ! fasc9at+ "w may be pick$ up & put aside )\t loss ( "t4 ,complicat$ rubb] manik9s are ( no value 9 ! practice ( introduction1 & =eign body problems c be equally well /udi$ 9 a piece ( rubb] tub+ ab\t #aj in*es long4 ,no endoscopi/ has en\gh practice on ! liv+ subject1 because ! cases are too infrequ5t & fur!rmore ! tube is ins]t$ = too %ort a space ( "t4 ,practice on ! rubb] tube tra9s ! eye to recognize objects & to gauge di/ance2 x develops ! tactile s5se s t a k ( ! "* ( ! object grasp$ or ! nature ( ! tissues palpat$ may be acquir$4 ,be=e attempt+ ! removal ( a p>ticul> =eign body f a liv+ pati5t1 ! anticipat$ problem %\ld be simulat$ ) a duplicate ( ! =eign body 9 a rubb] tube4 ,9 ?is way ! endoscopi/ may prec$e ea* case ) a practical exp]i5ce equival5t to any numb] ( cases ( precisely ! same k9d ( =eign body4 ,if ! object _c be remov$ f ! rubb] tube )\t viol5ce1 x is obvi\s t no attempt %\ld be made on ! pati5t until fur!r practice has %[n a def9ite me?od ( h>mless removal4 ,dur+ practice "w ! value ( ! bevel$ lip ( ! bron*oscope & esophagoscope 9 solv+ me*anical problems w be evid5c$4 ,) x alone1 a =eign body may be turn$ into favorable positions = extraction1 & folds c always be held out ( ! way4 ,suffici5t comb9$ practice ) ! bron*oscope & ! =ceps enable ! endoscopi/ easily to d ?+s t at fir/ seem impossible4 ,x is to be rememb]$ t lat]al motion ( ! long sl5d] tube-=ceps _c be controll$ accurately by ! h&le1 ?is is obta9$ by a *ange 9 position ( ! endoscopic tube1 ! object be+ s c5t]$ t x is grasp$ )\t side motion ( ! =ceps4 ,:5 necess>y1 ! di/al end ( ! =ceps may be pu%$ lat]ally by ! manipulation ( ! bron*oscope4 ,,fig4 #gb4--;,a simple manik94 ,! weight ( ! small vise s]ves to /eady ! rubb] tub+4 ,by ! use ( tub+ ( ! size ( ! invad$ bron*us & a duplicate ( ! =eign body1 any me*anical problem c he simulat$ = solution or = practice1 /udy ( all possible pres5tations1 etc4 ,practice on ! ,dog4--,hav+ ma/]$ ! te*nic ( introduction on ! cadav] & tra9$ ! eye & f+]s by practice "w on ! rubb] tube1 exp]i5ce %\ld be _h 9 ! liv+ l[] air & food passages ) _! pulsatory1 respiratory1 be*ic & deglutitory movem5ts1 & ev]-pres5t secretions4 ,x is n only inhuman b impossible to obta9 ?is exp]i5ce on *ildr54 ,=tunately ! dog (f]s a mo/ ready subject & ne$ 9 no way be h>m$ nor pa9$ by ?is invaluable & life-sav+ practice4 ,a small dog ! size ( a t]ri] 7say #f to #aj p\nds 9 weight7 %\ld be *os5 & ane/hetiz$ by ! hypod]mic injection ( morph9 sulphate 9 dosage ( approximately "o-six? ( a gra9 p] p\nd ( body weight1 giv5 ab\t #de m9utes be=e ! "t ( practice4 ,dogs /& l>ge doses ( morph9 )\t app>5t ill effect1 s t repeat$ injection may be giv5 9 small] dosage until ! desir$ degree ( relaxation results4 ,! fir/ effect is vomit+ :i* gives an empty /oma* = esophagoscopy & ga/roscopy4 ,vomit+ is soon foll[$ by relaxation & /upor4 ,! dog is normal & hungry 9 a few h\rs4 ,dosage mu/ be gov]n$ 9 ! clog z 9 ! human be+ by ! susceptibility to ! drug & by ! temp]am5t ( ! animal4 ,o!r =ms ( ane/hesia h be5 tri$ 9 my tea*+1 & none has prov5 s safe & satisfactory4 ,phonation may be prev5t$ dur+ esophagoscopy by prev5t+ approximation ( ! cords1 ?r\gh ins]t+ a silk-wov5 ca!!r 9 ! tra*ea4 ,! l>ynx & tra*ea may be pa9t$ ) coca9 solution if x is f\nd necess>y = bron*oscopy4 ,a v com=table & safe m\? gag is %[n 9 ,fig4 #gc4 ,great g5tl5ess %\ld be ex]cis$1 & no =ce %\ld be us$1 = none is requir$ 9 endoscopic "w2 & ! endoscopi/ w lose mu* ( ! value ( 8 dog practice if he fails to reg>d ! dog z a *ild4 ,he %\ld rememb] he is n le>n+ h[ to d endoscopy on ! dog2 b le>n+ on ! dog h[ safely to d bron*oscopy on a human be+4 ,! degree ( resi/ance dur+ introduction c be gaug$ & ! color ( ! mucosa /udi$1 :ile t int]e/+ ph5om5on1 ! dilatation & l5g!n+ ( ! bron*i dur+ inspiration & _! contraction & %ort5+ dur+ expiration1 is readily obs]v$ & always =ms subject = ?\ght 9 its possible connection ) pa?ological conditions4 ,=eign body problems are n[ to be solv$ "u ^! liv+ conditions1 & x is my feel+ t no "o %\ld attempt ! removal ( a =eign body f ! bron*us ( a *ild until he has remov$ at lea/ #ajj =eign bodies f ! dog )\t h>m+ ! animal4 ,dogs h ! faculty ( easily ridd+ _! air-passages ( =eign objects1 s t "o ne$ n be al>m$ if a =eign body is lo/ dur+ practice removal4 ,x is to be rememb]$ t dogs swall[ v l>ge objects ) app>5t ease4 ,! dog's esophagus is relatively mu* l>g] ?an t ( human be+s4 ,!re=e a small dog 7( six to eight p\nds' weight7 mu/ be us$ = esophagoscopic practice1 if practice is to be _h ) objects ( ! size usually enc\nt]$ 9 human be+s4 ,! bron*i ( a dog ( ?is weight w be ab\t ! size ( ^? ( a *ild4 ,,fig4 #gc4--;,au?or's m\? gag = use on ! dog4 ,! ?umb-nut s]ves to prev5t an uncom=table degree ( expansion ( ! gag4 ,a b&age may be w\nd ar\nd ! dog's jaws to prev5t undue spread ( ! jaws4 ,endoscopy on ! ,human ,be+4--,dog "w (f]s b little practice 9 l>yngoscopy4 ,because ( ! slight angle at :i* ! dog's head jo9s 8 sp9e1 ! l>ynx is 9 a direct l9e ) ! op5 m\?2 h5ce little displacem5t ( ! ant]ior c]vical tissues is necess>y4 ,moreov] ! int]ior ( ! l>ynx ( ! dog is q diff]5t f t ( ! human l>ynx4 ,! te*nic ( l>yngoscopy 9 ! human subject is be/ p]fect$ by a r\t9e direct exam9ation ( ! l>ynx ( ane/hetiz$ pati5ts aft] su* an op]ation z1 = in/ance1 tonsillectomy1 to see t ! l>ynx & l>yngoph>ynx are free ( clots4 ,to p]=m a bron*oscopy or esophagoscopy "u ^! conditions w\ld be repreh5sible2 b direct l>yngoscopy = ! seek+ & removal ( clots s]ves a useful purpose z a prev5tative ( pulmon>y abscess & simil> complications499 ,diagnosis ( l>yngeal conditions 9 "y *ildr5 is possible only by direct l>yngoscopy & is neglect$ 9 almo/ all ( ! cases4 ,no ane/hesia1 g5]al or local1 is requir$4 ,mu* cl9ical mat]ial is neglect$4 ,all cases ( dyspnea or dysphagia %\ld be /udi$ endoscopically if ! cause ( ! condition _c be def9itely f\nd & treat$ by o!r means4 ,invaluable practice 9 esophagoscopy is f\nd 9 ! treatm5t ( /rictures ( ! esophagus by weekly or biweekly esophagoscopic b\g9age4 99 ,dr4 ,william ,fr$]ick ,moore1 ( ! ,bron*oscopic ,cl9ic1 has rec5tly collect$ /ati/ics ( #bjb cases ( po/-tonsillectomic pulmon>y abscess t po9t /rongly to aspiration ( infect$ clots & o!r infective mat]ials z ! mo/ frequ5t etiologic me*anism 7,moore1 ,w4 ,f41 ,pulmon>y ,abscess4 ,j\rn4 ,am4 ,m$4 ,assn41 ,april #bi1 #aibb1 ,vol4 #gh1 pp4 #abgi-abha74 ,9 acquir+ skill z an endoscopi/ ! foll[+ p>aphras$ aphorisms af=d food = ?\ght4 ,,aphorisms ,educate y\r eye & y\r f+]s4 ,be sure y are "r1 b n too sure4 ,foll[ y\r judgm5t1 nev] y\r impulse4 ,cry ov] spill$ milk en\gh to memorize h[ y spill$ x4 ,let y\r mi/akes worry y en\gh to prev5t repetition4 ,let y\r left h& "k :at y\r "r h& does & h[ to d x4 ,nature helps1 b %e is no m int]e/$ 9 ! survival ( y\r pati5t ?an 9 ! survival ( ! attack+ pa?og5ic bact]ia4 #abf ,,*apt] ,,xii--,,=eign ,,bodies ,,9 ,,! ,,air ,,& ,,food ,,passages ,! air & food passages may be invad$ by any =eign sub/ance ( solid1 liquid or gase\s nature1 f ! animal1 vegetable1 or m9]al k+doms4 ,its orig9 may be f )9 ! body 7blood1 pus1 secretion1 bron*oli?s1 seque/ra1 worms72 introduc$ f )\t by way ( ! natural passages 7aspirat$ or swall[$ objects72 or x may ent] by p5etration 7bullet1 d>t1 dra9age tube f ! neck74 ,prophylaxis4--,if "o put into 8 m\? no?+ b food1 =eign body accid5ts w\ld be r>e4 ,! habit ( hold+ tacks1 p9s & :atnot 9 ! m\? is q univ]sal & deplorable4 ,*ildr5 are prone to foll[ ! bad example ( _! eld]s4 ,no small objects su* z safety p9s1 buttons1 & co9s %\ld be left )9 a baby's rea*2 *ildr5 %\ld be wat*$ & taught n to place ?+s 9 _! m\?s4 ,mo!rs %\ld be specially caution$ n to give nuts or nut c&y ( any k9d to a *ild ^: p[]s ( ma/ication are imp]fect1 because ! mol> tee? are n erupt$4 ,x might be made a dictum t3 ,no *ild "u #c ye>s ( age %\ld be all[$ to eat nuts1 unless gr\nd f9ely z 9 peanut butt]4 ,digital ef=ts at removal ( =eign bodies frequ5tly =ce ! object d[nw>d1 or may hook x =w>d into ! l>ynx1 :]eas if n m$dl$ ) digitally ! intrud] might be spat out4 ,be=e g5]al ane/hesia ! m\? %\ld be se>*$ = loose tee?1 removable d5tures1 etc41 & all unconsci\s individuals %\ld be likewise exam9$4 ,:5 work+ 9 ! m\? precautions %\ld be tak5 aga9/ ! possible inhalation or swall[+ ( loose objects or in/rum5ts4 #abf ,objects t h lodg$ 9 ! esophagus1 l>ynx1 tra*ea1 or bron*i %\ld be endoscopically remov$4 ,=eign ,bodies 9 ! ,insane4--,=eign bodies may be introduc$ volunt>ily & 9 great numb]s by ! insane4 ,hy/]ical individuals may ass]t ! pres5ce ( a =eign body1 or may ev5 volitionally swall[ or aspirate objects4 ,x is a mi/ake to d a bron*oscopy 9 ord] to cure by sugge/ion ! delusion ( =eign body pres5ce4 ,su* cures are ephem]al4 ,=eign ,bodies 9 ! ,/oma*4--,ga/roscopy is indicat$ 9 cases ( a =eign body t refuses to pass aft] a mon? or two4 ,=eign bodies 9 v l>ge numb]s 9 ! /oma*1 z 9 ! insane1 may be remov$ by ga/ro/omy4 ,! symptomatology ( =eign bodies may be epitomiz$ z giv5 bel[2 b x mu/ be kept 9 m9d1 t c]ta9 symptoms may n be manife/ imm$iately aft] intrusion1 & o!rs may p]si/ = a "t aft] ! passage1 removal1 or expulsion ( a =eign body4 ,,esophageal ,,=eign ,,body ,,symptoms #a4 ,!re are no absolutely diagno/ic symptoms4 #b4 ,dysphagia1 h[ev]1 is ! mo/ con/ant compla9t1 v>y+ ) ! size ( ! =eign body1 & ! degree ( inflammatory or spasmodic reaction produc$4 #c4 ,pa9 may be caus$ by p5etration ( a %>p =eign body1 by inflammation second>y !reto1 by impaction ( a l>ge object1 or by spasmodic closure ( ! hiatus esophageus4 #d4 ,! subjective s5sation ( =eign body is usually pres5t1 b _c be reli$ ^u z assur+ ! pres5ce ( a =eign body = ?is s5sation (t5 rema9s = a "t aft] ! passage onw>d ( ! intrud]4 #e4 ,all ( ^! symptoms may exi/1 (t5 9 ! mo/ int5se degree1 z ! result ( previ\s viol5t attempts at removal2 & ! =eign body may or may n be pres5t4 ,,symptoms ,,( ,,l>yngeal ,,=eign ,,body #a4 ,initial l>yngeal spasm foll[$ by :eez+ respiration1 cr\py c\gh1 & v>y+ degrees ( impairm5t ( phonation4 #b4 ,pa9 may be a symptom4 ,if s1 x is usually locat$ 9 ! l>yngeal region1 ?\gh 9 "s cases x is ref]r$ to ! e>s4 #c4 ,! l>ynx may tol]ate a ?91 flat1 =eign body = a relatively long p]iod ( "t1 a mon? or m2 b ! developm5t ( increas+ dyspnea r5d]s e>ly removal imp]ative 9 ! majority ( cases4 ,,symptoms ,,( ,,tra*eal ,,& ,,bron*ial ,,=eign ,,body #a4 ,tra*eal =eign bodies are usually movable & _! movem5ts c usually be felt by ! pati5t4 #b4 ,c\gh is usually pres5t at once1 may disappe> = a "t & recur1 or may be cont9u\s1 & may be s viol5t z to induce vomit+4 ,9 rec5t cases fix$ =eign bodies cause little c\gh2 %ift+ =eign bodies cause viol5t c\gh+4 #c4 ,sudd5 %utt+ (f ( ! expiratory bla/ & ! phonation dur+ p>oxysmal c\gh is almo/ pa?ognomonic ( a movable tra*eal =eign body4 #d4 ,dyspnea is usually pres5t 9 tra*eal =eign bodies1 & is due to ! bulk ( ! =eign body plus ! subglottic swell+ caus$ by ! traumatism ( ! %ift+s ( ! intrud]4 #e4 ,dyspnea is usually abs5t 9 bron*ial =eign bodies4 #f4 ,! respiratory rate is increas$ only if a consid]able portion ( lung is out ( function1 by ! ob/ruction ( a ma9 bron*us1 or if inflammatory sequelae are ext5sive4 #g4 ,! a/hmatoid :eeze is usually pres5t 9 tra*eal =eign bodies1 & is (t5 l\d] & ( l[] pit* ?an ! a/hmatoid :eeze ( bron*ial =eign bodies4 ,x is he>d at ! op5 m\?1 n at ! *e/ wall2 & prolong$ expiration z ?\gh to rid ! lungs ( all residual air1 may be necess>y to elicit x4 #h4 ,pa9 is n a common symptom1 b may occur & be accurately localiz$ by ! pati5t1 9 case ( ei!r tra*eal or bron*ial =eign body4 ,,e>ly ,,symptoms ,,( ,,irritat+ ,,=eign ,,body ,,su* ,,z ,a ,,peanut ,,k]nel ,,9 ,,! ,,bron*us #a4 ,initial l>yngeal spasm is almo/ inv>iably pres5t ) =eign bodies ( organic nature1 su* z nut k]nels1 peas1 beans1 maize1 etc4 #b4 ,a diffuse purul5t l>yngo-tra*eo-bron*itis develops )9 #bd h\rs 9 *ildr5 "u #b ye>s4 #c4 ,fev]1 toxemia1 cyanosis1 dyspnea & p>oxysmal c\gh are promptly %[n4 #d4 ,! *ild is unable to c\gh up ! ?ick mucilag9\s pus ?r\gh ! swoll5 l>ynx & may dr[n 9 its own secretions unless ! (f5d] be remov$4 #e4 ,dr[n$ lung1 t is to say natural passages idl$ ) pus & secretions1 rapidly =ms4 #f4 ,pulmon>y abscess develops soon] ?an 9 case ( m9]al =eign bodies4 #g4 ,! old] ! *ild ! less sev]e ! reaction4 ,,symptoms ,,( ,,prolong$ ,,=eign ,,body ,,soj\rn ,,9 ,,! ,,bron*us #a4 ,! "t ( inhalation ( a =eign body may be unkn[n or =gott54 #b4 ,c\gh & purul5t expectoration ultimately result1 al?\gh !re may be a delusive protract$ symptomless int]val4 #acj #c4 ,p]iodic attacks ( fev]1 ) *ills & sweats1 & foll[$ by increas$ c\gh+ & ! expulsion ( a l>ge am\nt ( purul5t1 usually m or less f\l mat]ial1 are s ne>ly diagno/ic ( =eign body z to call = exclusion ( ?is probability ) ! utmo/ c>e4 #d4 ,emaciation1 clubb+ ( ! f+]s & toes1 night sweats1 hemoptysis1 9 fact all ( ! symptoms ( tub]culosis are 9 mo/ cases simulat$ ) exactitude1 ev5 to ! ga9 9 weight by an out-door regime4 #e4 ,tub]cle bacilli h nev] be5 f\nd1 9 ! cases at ! ,bron*oscopic ,cl9ic1 associat$ ) =eign body 9 ! bron*us499 ,9 cases ( prolong$ soj\rn ?is has be5 ! only elem5t lack+ 9 a complete cl9ical picture ( advanc$ tub]culosis4 ,"o po9t ( diff]5ce 0 ! almo/ inv>iably rapid recov]y aft] removal ( ! =eign body4 ,! /atem5t 9 all ( ! text-books1 t =eign body is foll[$ by ph?isis pulmonalis is a relic ( ! days :5 ! bacill>y orig9 ( true tub]culosis 0 unkn[n1 h5ce ! =eign-body ph?isis pulmonalis1 or pseudo tub]culosis1 0 confus$ ) ! true pulmon>y tub]culosis ( bacill>y orig94 #f4 ,! subjective s5sation ( pa9 may all[ ! pati5t accurately to localize a =eign body4 #g4 ,=eign bodies ( metallic or organic nature may cause _! peculi> ta/e 9 ! sputum4 #h4 ,(f5sive odor$ sputum %\ld always sugge/ bron*ial =eign body2 b abs5ce ( sputum1 odor\s or n1 %\ld n exclude =eign body4 #i4 ,sudd5 complete ob/ruction ( "o ma9 bron*us does n cause noticeable dyspnea provid$ its fell[ is functionat+4 #aca #aj4 ,complete ob/ruction ( a bron*us is foll[$ by rapid onset ( symptoms4 #aa4 ,! physical signs usually %[ limitation ( expansion on ! affect$ side1 impairm5t ( p]cussion1 & less5$ trans-mission or abs5ce ( brea?-s\nds di/al to ! =eign body4 99 ,! exceptional case has at la/ be5 enc\nt]$4 ,a boy ) a tack 9 ! bron*us 0 f\nd to h pulmon>y tub]culosis4 ,,symptoms ,,( ,,ga/ric ,,=eign ,,body ,=eign body 9 ! /oma* ord9>ily produces no symptoms4 ,! ro5tg5ogram & ! fluoroscopic /udy ) an opaque mixture are ! *ief means ( diagnosis4 ,,diagnosis ,,( ,,=eign ,,body ,,9 ,,! ,,air ,,or ,,food ,,passages ,! que/ions aris+ are3 ,i4 ,is a =eign body pres5t8 #b4 ,:]e is x locat$8 #c4 ,is a p]oral endoscopic proc$ure indicat$8 #d4 ,are !re any contra9dications to endoscopy8 ,9 ord] to answ] ^! que/ions ! def9ite r\t9e giv5 bel[ is foll[$ unv>y+ly 9 ! ,bron*oscopic ,cl9ic4 #a4 ,hi/ory4 #b4 ,complete physical exam9ation1 includ+ mirror l>yngoscopy4 #c4 ,ro5tg5ologic /udy4 #d4 ,endoscopy4 ,! hi/ory %\ld note ! date (1 & %\ld delve into ! details ( ! accid5t2 special note be+ made ( ! occurr5ce ( l>yngeal spasm1 :eez+ respiration he>d by ! pati5t or o!rs 7a/hmatoid :eeze71 fev]1 c\gh1 pa91 dyspnea1 dysphagia1 odynphagia1 regurgitation1 etc4 ,! am\nt1 "* & odor ( sputum are important4 ,increas+ am\nts ( purul5t1 f\l-odor$1 sometimes blood-t+$ sputum /rongly sugge/ prolong$ bron*ial =eign body soj\rn4 ,! mode ( onset ( ! p]si/+ symptoms1 :e!r imm$iately foll[+ ! suppos$ accid5t or delay$ 9 _! occurr5ce1 is to be not$4 ,d attacks ( sudd5 dyspnea & cyanosis occur8 ,:at has be5 ! previ\s treatm5t & :at attempts at removal h be5 made8 ,! nature ( ! =eign body is to be det]m9$1 & if possible a duplicate !re( obta9$4 ,g5]al physical exam9ation %\ld be complete includ+ inspection ( ! eyes1 e>s1 nose1 ph>ynx1 & mirror inspection ( ! naso-ph>ynx & l>ynx4 ,special att5tion is paid to ! *e/ = ! localization ( ! object4 ,9 ord] to discov] conditions r5d]+ endoscopy unusually haz>d\s1 all p>ts ( ! body are to be exam9$4 ,aneurysm ( ! aorta1 excessive blood pressure1 s]i\s c>diac & r5al conditions1 ! pres5ce ( a h]nia & ! exi/5ce ( c5tral n]v\s disease1 z tabes dorsalis1 %\ld be at lea/ kn[n be=e attempt+ any endoscopic proc$ure4 ,dysphagia might result f ! pressure ( an unkn[n aneurysm1 ! symptoms be+ attribut$ to a =eign body1 & aortic aneurysm is a def9ite contra9dication to esophagoscopy unless !re be =eign body pres5t also4 ,!re is no absolute contra9dication to ! endoscopic removal ( a =eign body1 ?\gh _m conditions may r5d] x wise to po/-pone endoscopy4 ,l>yngeal crises ( tabes might1 because ( _! sudd5 onset1 be ?\ght due to =eign body4 ,,physical ,,signs ,,9 ,,esophageal ,,=eign ,,body ,!re are no con/ant physical signs associat$ ) uncomplicat$ impaction ( a =eign body 9 ! esophagus4 ,%\ld p]=ation ( ! c]vical esophagus occur1 subcutane\s emphysema1 & p]haps cellulitis1 may be f\nd2 :ile a p]=ation ( ! ?oracic region caus+ m$ia/9itis is manife/$ by toxemia1 fev]1 & rapid s9k+4 ,p]=ation ( ! pleura1 ) ! developm5t ( pyopneumo?orax1 is manife/$ by ! usual signs4 ,x is to be emphasiz$ t bl9d b\g9age has no place 9 ! diagnosis ( any esophageal condition4 ,! ro5tg5ologi/ w give ! in=mation we desire )\t dang] to ! pati5t1 & ) f> great] accuracy4 ,,=eign ,,bodies ,,9 ,,! ,,l>ynx ,l>yngeally lodg$ =eign bodies produce a :eez+ respiration1 ! quality ( :i* is peculi> to ! l>ynx & is readily localiz$ to ?is organ4 ,if swell+ or ! size ( ! =eign body be suffici5t to produce dyspnea1 inspiratory indraw+ ( ! supra/]nal not*1 supraclavicul> fossae1 co/al int]spaces & l[] /]num w be pres5t4 ,cyanosis is only an accompanim5t ( sudd5ly produc$ dyspnea2 ! facies w !re=e usually be anxi\s & pale1 unless ! pati5t is se5 imm$iately aft] ! aspiration ( ! =eign body4 ,if labor$ brea?+ has be5 prolong$1 & exhau/ion ?reat5$1 ! he>t's action w be irregul> & weak4 ,! =eign body c be se5 ) ! mirror1 b a ro5tg5ograph mu/ nev]!less be made1 = ! object may be ( ano!r nature ?an 0 fir/ ?\ght4 ,! ro5tg5ograph w %[ its position1 & f ?is k ! plan ( removal c be =mulat$4 ,= example1 a /raight p9 may be s plac$ 9 ! l>ynx t only a portion ( its %aft w be visible1 ! ro5tg5ogram w tell :]e ! head & po9t are locat$1 & :i* ( ^! w be ! m readily dis5gag$4 7,see ,*apt] on ,me*anical ,problems47 ,,physical ,,signs ,,( ,,tra*eal ,,=eign ,,body ,if fix$ 9 ! tra*ea ! only objective sign ( =eign body may be a :eez+ respiration1 ! site ( :i* may be localiz$ ) ! /e?oscope1 by ! int5sity ( ! s\nd4 ,movable =eign bodies may produce a palpatory ?rill1 & ! rumble & sudd5 /op c be he>d ) ! /e?oscope & (t5 ) ! nak$ e>4 ,! lungs w %[ equal a]ation1 b !re may be m>k$ dyspnea )\t ! indraw+ ( ! fossae1 if ! object be ( l>ge size & locat$ bel[ ! manubrium4 ,to ! peculi> s\nd ( ! sudd5 subglottic1 expiratory or be*ic arre/ ( ! =eign body ! au?or has giv5 ! "n audible slap2 :5 felt by ! ?umb on ! tra*ea he calls x ! palpatory ?ud4 ,^! signs c be produc$ by no condition o!r ?an ! arre/ ( "s sub/ance by ! subglottic tap]4 ,once he>d & felt !y are unmi/akable4 ,,physical ,,signs ,,( ,,bron*ial ,,=eign ,,body ,9 mo/ cases !re w be limitation ( expansion on ! invad$ side1 ev5 ?\gh ! =eign body is ( su* a %ape z to cause no bron*ial ob/ruction4 ,x has be5 not$ frequ5tly 9 conjunction ) ! pres5ce ( su* objects z a common /raight p9 9 a small bran* bron*us4 ,?is peculi> ph5om5on 0 fir/ not$ by ,?omas ,mc,crae 9 "o ( ! au?or's cases & has s9ce be5 abundantly corroborat$ by ,mc,crae & o!rs z "o ( ! mo/ con/ant physical signs4 ,to und]/& ! peculi> physical f9d+s 9 ^! cases x is necess>y to rememb] t ! bron*i are n tubes ( con/ant calib]2 !re occurs a dilatation dur+ inspiration1 & a contraction ( ! lum5 dur+ expiration2 fur!rmore1 ! lum5 may be n>r[$ by swoll5 mucosa if ! =eign body be ( an irritant nature4 ,! signs v>y ) ! degree ( ob/ruction ( ! bron*us1 & ) ! consequ5t degree ( int]f]5ce ) a]ation & dra9age ( ! subjac5t portion ( ! lung4 ,we h ?ree def9ite types :i* %[ practically con/ant signs 9 ! e>li] /ages ( =eign body invasion4 #a4 ,complete bron*ial occlusion4 #b4 ,ob/ruction complete dur+ expiration1 b all[+ ! passage ( air dur+ ! bron*ial dilatation incid5t to inspiration1 con/itut+ an expiratory valve-l ob/ruction4 #c4 ,p>tial bron*ial ob/ruction1 all[+ to-&-fro passage ( air4 #a4 ,complete bron*ial ob/ruction is manife/$ by limitation ( expansion1 m>k$ly impair$ p]cussion note1 p>ticul>ly at ! base1 abs5ce ( brea?-s\nds1 & rales on ! invad$ side4 ,an atelectasis "h exi/s2 ! air imprison$ 9 ! lung is soon absorb$1 & secretions rapidly accumulate4 ,on ! free side a comp5satory emphysema is pres5t4 #b4 ,expiratory ,valve-l ,ob/ruction4--,! ob/ruct$ side %[s m>k$ limitation ( expansion4 ,p]cussion is ( a tympanitic "*4 ,! duration ( ! vibrations may be %ort5$ giv+ a muffl$ tympany4 ,v>i\s grades & degrees ( tympany may be not$4 ,brea? s\nds are m>k$ly dim9i%$ or abs5t4 ,no rales are he>d on ! invad$ side1 al?\gh rales ( all types may be pres5t on ! free side4 ,9 "s cases x is possible to he> a %ort inspiratory s\nd4 ,vocal resonance & fremitus are b little alt]$4 ,! he>t w be f\nd displac$ some:at to ! opposite side4 ,^! signs are expla9$ by ! passage ( "s air pa/ ! =eign body dur+ inspiration ) its trapp+ dur+ expiration1 s t !re is air "u pressure con/antly ma9ta9$ 9 ! ob/ruct$ area4 ,?is type ( ob/ruction is mo/ frequ5tly obs]v$ :5 ! =eign body is ( an organic nature su* z nut k]nels1 beans1 corn1 se$1 etc4 ,! localiz$ swell+ ab\t ! irritat+ =eign body completes ! expiratory ob/ruction4 ,x may also be pres5t ) any =eign body ^: size & %ape are su* z to occlude ! lum5 ( ! bron*us dur+ its contract$ expiratory phase4 ,x 0 pres5t 9 cases ( pebbles1 cyl9drical metallic objects1 ?ick t\gh balls ( secretion etcet]a4 ,! valvul> action is "h produc$ mo/ (t5 by a *ange 9 ! size ( ! valve seat & n by a movem5t ( ! =eign body plug4 ,9 o!r cases ,i h f\nd at bron*oscopy1 a regul> ball-valve me*anism4 ,pneumo?orax is ! only pa?ologic condition associat$ ) signs simil> to ^? ( expiratory1 valve-l bron*ial ob/ruction by a =eign body4 #c4 ,p>tial bron*ial ob/ruction by an object su* z a nail all[s air to pass to & fro ) "s degree ( ret>dation1 & impairs ! dra9age ( ! subjac5t lung4 ,limitation ( expansion w be f\nd on ! invad$ side4 ,! area bel[ ! =eign body w give an impair$ p]cussion note4 ,brea?-s\nds are dim9i%$ 9 ! area ( dullness1 & vocal resonance & fremitus are impair$4 ,rales are ( great diagno/ic import2 ! passage ( air pa/ ! =eign body is accompani$ by bl[+1 h>% brea?+1 & snor+2 snapp+ rales are he>d usually ) greate/ int5sity po/]iorly ov] ! site ( ! =eign body 7usually ab\t ! scapul> angle74 ,a k ( ! topographical lung anatomy1 ! bron*ial tree1 & ( endoscopic pa?ology99 %\ld enable ! exam9] ( ! *e/ to locate v accurately a bron*ial =eign body by physical signs alone1 = all ! significant signs occur di/al to ! =eign body lodgm5t4 99 ,jackson1 ,*evali]4 ,pa?ology ( ,=eign ,bodies 9 ! ,air & ,food ,passages4 ,mutt] ,lecture1 #aiah4 ,surg]y1 ,gynecology & ,ob/etrics1 ,m>*1 #aiai4 ,also1 by ! same au?or1 ,me*anism ( ! ,physical ,signs ( ,=eign ,bodies 9 ! ,lungs4 ,proce$+s ( ! ,college ( ,physicians1 ,philadelphia1 #aibb4 ,! a/hmatoid :eeze has be5 f\nd by ! au?or a valuable confirmatory sign ( bron*ial =eign body4 ,x is a :eez+ he>d by plac+ ! obs]v]'s e> at ! op5 m\? ( ! pati5t 7n at ! *e/ wall7 dur+ a prolong$ =c$ expiration4 ,?omas ,mc,crae elicits ?is sign by plac+ ! /e?oscope bell at ! pati5t's op5 m\?4 ,! quality ( ! s\nd is dry] ?an t he>d 9 a/hma & ! :eeze is cle>e/ aft] all secretion has be5 remov$ by c\gh+4 ,! me*anism ( production is1 probably1 ! passage ( air by a =eign body :i* n>r[s ! lum5 ( a l>ge bron*us4 ,z ! =eign body works d[nw>d ! :eeze less5s4 ,! :eeze is (t5 s l\d z to be he>d at "s di/ance f ! pati5t4 ,x is ( greate/ value 9 ! diagnosis ( non-ro5tg5opaque =eign body b its abs5ce 9 no way negates =eign body4 ,its pres5ce or abs5ce %\ld be record$ 9 e case4 ,prolong$ bron*ial ob/ruction by =eign body is foll[$ by bron*iectasis & lung abscess usually 9 a l[] lobe4 ,! symptoms may ) exactitude simulate tub]culosis1 b ?is disease %\ld be readily exclud$ by ! basal1 unilat]al site ( ! lesion1 abs5ce ( tub]cle bacilli 9 ! sputum1 & ro5tg5ographic /udy4 ,*e/ exam9ation 9 ! =eign body cases reveals limitation ( expansion1 (t5 "s retraction1 flat p]cussion note1 & greatly dim9i%$ or abs5t brea?-s\nds ov] ! site ( ! pulmon>y lesion4 ,rales v>y ) ! am\nt ( secretion pres5t4 ,^! physical signs sugge/ empyema2 & rib resection _h be5 done be=e admission 9 a numb] ( cases only to f9d ! pleura normal4 ,,ro5tg5ray ,,/udy ,,9 ,,=eign ,,body ,,cases ,ro5tg5ography4--,all cases ( *e/ disease %\ld h ! b5efit ( a ro5tg5ologic /udy to exclude bron*ial =eign body z an etiological factor4 ,negative op9ions %\ld nev] be bas$ ^u any plates except ! be/ t ! wond]ful mod]n developm5t ( ! art & sci5ce ( ro5tg5ology c produce4 ,9 d\btful cases1 ! negative op9ion %\ld n be conclusive until a ro5tg5ologi/ ( long exp]i5ce 9 *e/ "w1 & especially 9 =eign body cases1 has be5 call$ 9 consultation4 ,ev5 !n !re w be an occasional case call+ = diagno/ic bron*oscopy4 ,ant]o-po/]ior & lat]al ro5tg5ograms %\ld always be made4 ,9 an ant]o-po/]ior film a flat =eign body ly+ 9 ! lat]al body plane might be invisible 9 ! %ad[ ( ! sp9e1 he>t1 & great vessels2 b w\ld be reveal$ 9 ! lat]al view because ( ! great] edgewise d5sity ( ! intrud] & ! abs5ce ( o!r confus+ %ad[s4 ,fluoroscopic exam9ation w (t5 discov] ! be/ angle f :i* to make a plate2 b =eign bodies ca/+ a v fa9t %ad[ on a plate may be totally invisible on ! fluoroscopic scre54 ,! value ( a ro5tg5ogram aft] ! removal ( a =eign body _c be too /rongly emphasiz$4 ,x is evid5ce ( removal & w exclude ! pres5ce ( a second intrud] :i* might h be5 ov]look$ 9 ! fir/ /udy4 ,fluoroscopic /udy ( ! swall[+ function ) b>ium mixture1 or a b>ium-fill$ capsule1 w give ! location ( a nonro5tg5opaque object 7su* z bone1 meat1 etc47 9 ! esophagus4 ,if a flat or disc-%ap$ object locat$ 9 ! c]vical region is se5 to be ly+ 9 ! lat]al body plane1 x w be f\nd to be 9 ! esophagus1 = x assum$ t position by pass+ d[n flatwise beh9d ! l>ynx4 ,if1 h[ev]1 ! object is se5 to be 9 ! sagittal plane x mu/ lie 9 ! tra*ea4 ,?is position 0 necess>y = x to pass ?r\gh ! glottic *9k1 & c be ma9ta9$ because ( ! yield+ ( ! po/]ior membran\s wall ( ! tra*ea4 ,,! ,,ro5tg5ographic ,,signs ,,( ,,expiratory-,,valve-,,l ,,bron*ial ,,ob/ruction ,! ro5tg5ray signs 9 expiratory valve-l ob/ruction ( a bron*us are ^? ( an acute ob/ructive emphysema 7,fig4 #gd71 namely1 #a4 ,great] transp>5cy on ! ob/ruct$ side 7,iglau]74 #b4 ,displacem5t ( ! he>t to ! free side 7,iglau]74 #c4 ,depression & flatt5+ ( ! dome ( ! diaphragm on ! invad$ side 7,iglau]74 #d4 ,limitation ( ! diaphragmatic excursion on ! ob/ruct$ side 7,manges74 ,x is v important to note t1 z discov]$ by ,manges1 ! diff]5tial emphysema occurs at ! end ( expiration & ! plate mu/ be expos$ at t "t1 be=e inspiration />ts4 ,he also not$ t at fluoroscopy ! he>t mov$ lat]ally t[>d ! un9vad$ side dur+ expiration499 99 ,dr4 ,manges has develop$ su* a high degree ( skill 9 ! fluoroscopic diagnosis ( non-opaque =eign bodies by ! ob/ructive emphysema !y produce t he has locat$ peanut k]nels & o!r vegetable sub/ances ) absolute accuracy & unfail+ c]ta9ty 9 doz5s ( cases at ! ,bron*oscopic ,cl9ic4 ,,fig4 #gd--;,expiratory valve-l bron*ial ob/ruction by non-radiopaque =eign body1 produc+ an acute ob/ructive emphysema4 ,peanut k]nel 9 "r ma9 bron*us4 ,note 7a7 depression ( "r diaphragm2 7b7 displacem5t ( he>t & m$ia/9um to left2 7c7 great] transp>5cy ( ! invad$ side4 ,ray-plate made by ,willis ,f4 ,manges4 ,complete bron*ial ob/ruction %[s a d5sity ov] ! :ole area ! a]ation & dra9age ( :i* has be5 cut (f 7,fig4 #ge74 ,pulmon>y abscess =mation & dr[n$ lung 7accumulat$ secretion 9 ! bron*i & bron*ioli7 are %[n by ! def9ite %ad[s produc$ 7,fig4 #gf74 #adj ,d5se & metallic objects w usually be readily se5 9 ! ro5tg5ograms & fluoroscope1 b _m =eign bodies are ( a nature :i* w produce no %ad[2 ! ro5tg5ologi/ %\ld1 !re=e1 be prep>$ to int]pret ! pulmon>y pa?ology1 & %\ld n dismiss ! case z negative = =eign body because "o is n se54 ,ev5 metallic objects are 9 r>e cases exce$+ly difficult to demon/rate4 ,,fig4 #ge4--,radiograph %[+ pa?ology result+ f complete ob/ruction ( a bron*us ) atelectasis & dr[n$ lung result+4 ,foot ( an al>m clock 9 left bron*us ( #d ye> old *ild4 ,pres5t #be days4 ,plate made by ,john/on & ,gri]4 ,positive ,films ( ! ,tra*eo-bron*ial ,tree z an ,aid to ,localization4--,9 ord] to localize ! bron*us invad$ by a small =eign body ! positive film is laid ov] ! negative ( ! pati5t %[+ ! =eign body4 ,! %ad[ ( ! =eign body w !n %[ ?r\gh ! ov]ly+ positive film4 ,^! positive films are made 9 twelve sizes1 & ! size select$ %\ld be t correspond+ to ! size ( ! pati5t z %[n by ! ro5tg5ograph4 ,! dome ( ! diaphragm & ! dome ( ! pleura are tak5 z visc]al l&m>ks = plac+ ! positive films :i* h l9es indicat+ ^! levels4 ,if ! %ad[ ( ! =eign body be fa9t x may be /r5g!n$ by an ink m>k on ! uncoat$ side ( ! plate4 ,,fig4 #gf4--,p>tial bron*ial ob/ruction = long p]iod ( "t ,pa?ology1 bron*iectasis & pulmon>y abscess1 produc$ by ! pres5ce = #d ye>s ( a nail 9 ! left lung ( a boy ( #aj ye>s ,bron*ial mapp+ is readily accompli%$ by ! au?or's me?od ( endobron*ial insufflation ( a ro5tg5opaque in]t p[d] su* z bismu? subnitrate or subc>bonate 7,fig4 #gg74 ,! ro5tg5opaque sub/ance may be inject$ 9 a fluid mixture if pref]r$1 b ! walls are bett] outl9$ ) ! p[d] 7,fig4 #gg74 ,,fig4 #gg4--,ro5tg5ogram %[+ ! au?or's me?od ( bron*ial mapp+ or lung-mapp+ by ! bron*oscopic introduction ( opaque sub/ances 79 ?is in/ance p[d]$ bismu? subnitrate7 into ! lung ( ! pati5t4 ,plate made by ,david ,r4 ,b[54 7,illu/ration1 /r5g!n$ = reproduction1 is f au?or's article 9 ,am]ican ,j\rnal ( ,ro5tg5ology1 ,oct41 #aiah47 ,,errors ,,to ,,avoid ,,9 ,,suspect$ ,,=eign ,,body ,,cases #a4 ,d n rea* = ! =eign body ) ! f+]s1 le/ ! =eign body be !reby pu%$ into ! l>ynx1 or ! l>ynx be ?us traumatiz$4 #b4 ,d n hold up ! pati5t by ! heels1 le/ a tra*eally lodg$ =eign body be dislodg$ & asphyxiate ! pati5t by becom+ jamm$ 9 ! glottis4 #adc #c4 ,d n fail to h a ro5tg5ogram made1 if possible1 :e!r ! =eign body 9 "q is ( a k9d d5se to ! ray or n4 #d4 ,d n fail to se>* endoscopically = a =eign body 9 all cases ( d\bt4 #e4 ,d n pass bl9dly an esophageal b\gie1 probang1 or o!r in/rum5t4 #f4 ,d n tell ! pati5t he has no =eign body until aft] ro5tg5ray exam9ation1 physical exam9ation1 indirect exam9ation1 & endoscopy h all prov5 negative4 ,,summ>y ,,symptomatology ,,& ,,diagnosis ,,( ,,=eign ,,bodies ,,9 ,,! ,,air ,,& ,,food ,,passages ,initial symptoms are *ok+1 gagg+1 c\gh+1 & :eez+1 (t5 foll[$ by a symptomless int]val4 ,! =eign body may be 9 ! l>ynx1 tra*ea1 bron*i1 nasal *amb]s1 nasoph>ynx1 fauces1 tonsil1 ph>ynx1 hypoph>ynx1 esophagus1 /oma*1 inte/9al canal1 or may h be5 pass$ by b[el1 c\gh$ out or spat out1 ) or )\t ! k ( ! pati5t4 ,initial *ok+1 etcet]a may h escap$ notice1 or may h be5 =gott54 ,l>yngeal ,=eign ,body4--,"o or m ( ! foll[+ l>yngeal symptoms may be pres5t3 ,ho>s5ess1 cr\py c\gh1 aphonia1 odynphagia1 hemoptysis1 :eez+1 dyspnea1 cyanosis1 apnea1 subjective s5sation ( =eign body4 ,cr\p9ess 9 =eign body cases1 z 9 diph!ria1 usually means subglottic swell+4 ,ob/ructive =eign body may be quickly fatal by l>yngeal impaction on aspiration1 or on abortive be*ic expulsion4 ,lodgem5t ( a non-ob/ructive =eign body may be foll[$ by a symptomless int]val4 ,direct l>yngoscopy = diagnosis is indicat$ 9 e *ild hav+ l>yngeal diph!ria )\t faucial membrane4 7,no ane/hetic1 g5]al or local is ne$$47 ,9 ! pres5ce ( l>yngeal symptoms1 ?9k ( ! foll[+3 #a4 ,a =eign body 9 ! l>ynx4 #b4 ,a =eign body loose or fix$ 9 ! tra*ea4 #c4 ,digital ef=ts at removal4 #d4 ,in/rum5tation4 #e4 ,ov]fl[ ( food into ! l>ynx f esophageal ob/ruction due to ! =eign body4 #f4 ,esophagotra*eal fi/ula f ulc]ation set up by a =eign body 9 ! esophagus1 foll[$ by ! leakage ( food into ! air-passages4 #g4 ,l>yngeal symptoms may p]si/ f ! trauma ( a =eign body t has pass$ on into ! deep] air or food passages or t has be5 c\gh$ or spat out4 #h4 ,l>yngeal symptoms 7ho>s5ess1 cr\p9ess1 etcet]a7 may be due to digital or in/rum5tal ef=ts at ! removal ( a =eign body t nev] 0 pres5t4 #i4 ,l>yngeal symptoms may be due to acute or *ronic l>yngitis1 diph!ria1 p]tussis1 infective l>yngotra*eitis1 & _m o!r diseases4 #aj4 ,d$uctive decisions are dang]\s4 #aa4 ,if ! ro5tg5ray is negative1 l>yngoscopy 7direct 9 *ildr51 indirect 9 adults7 )\t ane/hesia1 g5]al or local1 is ! only way to make a l>yngeal diagnosis4 #ab4 ,be=e do+ a diagno/ic l>yngoscopy1 prep>ation %\ld be made = tak+ a swab-specim5 & = bron*oscopy & esophagoscopy4 ,tra*eal ,=eign ,body4--7#a7 ,audible slap1 7#b7 palpatory ?ud1 & 7#c7 a/hmatoid :eeze are pa?ognomonic4 ,! tra*eal flutt] has be5 obs]v$ by ,mc,crae 9 a case ( wat]melon se$4 ,c\gh1 ho>s5ess1 dyspnea1 & cyanosis are (t5 pres5t4 ,diagnosis is by ro5tg5ray1 auscultation1 palpation1 & bron*oscopy4 ,li/5 long = audible slap1 be/ he>d at op5 m\? dur+ c\gh4 ,! a/hmatoid :eeze is he>d ) ! e> or /e?oscope bell 7,mc,crae7 at ! pati5t's op5 m\?4 ,hi/ory ( initial *ok+1 gagg+1 & :eez+ is important if elicit$1 b is valueless negatively4 ,bron*ial ,=eign ,body4--,initial symptoms are c\gh+1 *ok+1 a/hmatoid :eeze1 etc4 not$ above4 ,!re may be a hi/ory ( ^! or ( too? extraction4 ,at once1 or aft] a symptomless int]val1 c\gh1 blood-/reak$ sputum1 metallic ta/e1 or special odor ( =eign body may be not$4 ,non-ob/ructive metallic =eign bodies af=d few symptoms & few signs = weeks or mon?s4 ,ob/ructive =eign bodies cause atelectasis1 dr[n$ lung1 & ev5tually pulmon>y abscess4 ,lob> pneumonia is an exce$+ly r>e sequel4 ,vegetable organic =eign bodies z peanut-k]nels1 beans1 wat]melon se$s1 etcet]a1 cause at once viol5t l>yngotra*eobron*itis1 ) toxemia1 c\gh & irregul> fev]1 ! gravity & sev]ity be+ inv]sely to ! age ( ! *ild4 ,bones1 animal %ells & inorganic bodies aft] mon?s or ye>s produce *anges :i* cause *ills1 fev]1 sweats1 emaciation1 clubb$ f+]s1 incurv$ nails1 c\gh1 f\l expectoration1 hemoptysis1 9 fact1 all ! symptoms ( *ronic pulmon>y sepsis1 abscess1 & bron*iectasis4 ,^! symptoms & "s ( ! physical signs may sugge/ pulmon>y tub]culosis1 b ! apices are normal & bacilli are abs5t f ! sputum4 ,e acute or *ronic *e/ case calls = ! exclusion ( =eign body4 ,! physical signs v>y ) conditions pres5t 9 diff]5t cases & at diff]5t times 9 ! same case4 ,secretions1 normal & pa?ologic1 may %ift f "o location to ano!r2 ! =eign body may *ange its position admitt+ m1 less1 or no air1 or x may %ift to a new location 9 ! same lung or ev5 9 ! o!r lung4 ,a rec5tly aspirat$ p9 may produce no signs at all4 ,! signs ( diagno/ic importance are *iefly ^? ( p>tial or complete bron*ial ob/ruction1 ?\gh a non-ob/ructive =eign body1 a p9 = in/ance1 may cause limit$ expansion 7,mc,crae7 or1 r>ely1 a peculi> rale or a peculi> auscultatory s\nd4 ,! mo/ ne>ly *>act]i/ic physical signs are3 7#a7 ,limit$ expansion2 7#b7 decreas$ vocal fremitus2 7#c7 impair$ p]cussion note2 7#d7 dim9i%$ int5sity ( ! brea?-s\nds di/al to ! =eign body4 ,complete ob/ruction ( a bron*us foll[$ by dr[n$ lung adds abs5ce ( vocal resonance & vocal fremitus1 ?us (t5 lead+ to an errone\s diagnosis ( empyema4 ,v>y+ grades ( tympany are obta9$ ov] areas ( ob/ructive or comp5satory emphysema4 ,) complete ob/ruction !re may be tympany f ! collaps$ lung = a "t4 ,rales 9 case ( complete ob/ruction are usually mo/ int5se on ! un9vad$ side4 ,9 p>tial ob/ruction !y are mo/ (t5 f\nd on ! invad$ side di/al to ! =eign body1 especially po/]iorly1 & are mo/ int5se at ! site correspond+ to t ( ! =eign body4 ,a =eign body at ! bifurcation ( ! tra*ea may give signs 9 bo? lungs4 ,e>ly 9 a =eign body case1 dim9i%$ expansion ( "o side1 ) dulness1 may sugge/ pneumonia 9 ! affect$ side2 b abs5ce (1 or decreas$1 vocal resonance1 & abs5ce ( typical tubul> brea?+ %\ld soon exclude ?is diagnosis4 ,bron*ial ob/ruction 9 pneumonia is exce$+ly r>e4 ,memorize ^! signs sugge/ive ( =eign body3 #a4 ,expansion--dim9i%$4 #b4 ,p]cussion note--impair$ 7except 9 ob/ructive emphysema74 #c4 ,vocal fremitus--dim9i%$4 #d4 ,brea? s\nds--dim9i%$4 ,! =ego+ is only = memoriz+1 & mu/ be consid]$ 9 ! light ( ! foll[+ fundam5tal note by ,pr(4 ,mc,crae ,!re is no "o description ( physical signs :i* cov]s all cases4 ,if ! /ud5t w rememb] t complete ob/ruction ( a bron*us leads to a %utt+ (f ( ?is area1 !re %\ld be little difficulty 9 und]/&+ ! signs pres5t4 ,! diagnosis ( empyema may be made1 b ! outl9e ( ! area ( dulness1 ! fact t !re is no %ift+ dulness1 & ! great] resi/ance :i* is pres5t 9 empyema ne>ly always cle> up any difficulty promptly4 ,! abs5ce ( ! frequ5t *ange 9 ! voice s\nds1 s significant 9 an e>ly small empyema1 is ( value4 ,a l>ge empyema %\ld give no difficulty4 ,if difficulty rema9s ! use ( ! ne$le %\ld be suffici5t4 ,9 ?ick5$ pleura vocal fremitus is n entirely abs5t1 & ! brea?-s\nds c usually be he>d1 ev5 if dim9i%$4 ,9 case ( p>tial ob/ruction ( a bron*us1 x is evid5t t air w /ill be pres5t1 h5ce ! dulness may be only slight4 ,! pres5ce ( air & secretion w probably result 9 ! brea?-s\nds be+ some:at h>%1 & w cause a great v>iety ( rales1 pr9cipally co>se1 & _m ( !m bubbl+4 ,difficulty may be caus$ by signs 9 ! o!r lung or 9 a lobe o!r ?an ! "o affect$ by ! =eign body4 ,if x is rememb]$ t ^! signs are likely to be only on auscultation1 & to consi/ l>gely 9 ! pres5ce ( rales1 :ile ! signs 9 ! area suppli$ by ! affect$ bron*us w include ^? on inspection1 palpation1 & p]cussion1 !re %\ld be little difficulty4 ,! ro5tg5ray is ! mo/ valuable diagno/ic means2 b c>eful notation ( physical signs by an exp]t %\ld be made 9 all cases pref]ably )\t k ( ray f9d+s4 ,exp]t ray "w w %[ all metallic =eign bodies & _m ( less d5sity1 su* z tee?1 bones1 %ells1 buttons1 etcet]a4 ,if ! ray is negative1 a diagno/ic bron*oscopy %\ld be done 9 all cases ( unexpla9$ bron*ial ob/ruction4 ,peanut k]nels & wat]melon se$s &1 r>ely1 o!r =eign bodies 9 ! bron*i produce ob/ructive emphysema ( ! invad$ side4 ,fluoroscopy %[s ! diaphragm flatt5$1 depress$ & ( less excursion on ! invad$ side2 at ! end ( expiration1 ! he>t & ! m$ia/9al wall move ov] t[>d ! un9vad$ side & ! invad$ lung becomes less d5se ?an ! un9vad$ lung1 f ! trapp+ ( ! air by ! expiratory1 valve-l effect ( oblit]ation ( ! =ceps spaces t dur+ inspiration af=d air +ress betwe5 ! =eign body & ! swoll5 bron*ial wall4 ,?is p>tial ob/ruction causes ob/ructive emphysema1 :i* mu/ be di/+ui%$ f comp5satory emphysema1 9 :i* ! balloon+ is 9 ! unob/ruct$ lung1 because its fell[ is :olly out ( function ?r\gh complete cork+ ( ! ma9 bron*us ( ! invad$ side4 ,esophageal ,=eign ,body4--,aft] initial *ok+ & gagg+1 or )\t ^!1 !re may be a subjective s5se ( a =eign body1 con/ant or1 m (t51 on swall[+4 ,odynphagia & dysphagia or aphagia may or may n be pres5t4 ,pa91 sub-/]nal or ext5d+ to ! back is sometimes pres5t4 ,hematemesis & fev] may occur f ! =eign body or f r\gh in/rum5tation4 ,symptoms ref]able to ! air-passages may be pres5t due to3 7#a7 ,ov]fl[ ( ! secretions on attempts to swall[ ?r\gh ! ob/ruct$ esophagus2 7#b7 erosion ( ! =eign body ?r\gh f ! esophagus into ! tra*ea2 or 7#c7 trauma inflict$ on ! l>ynx dur+ attempts at removal1 digital or in/rum5tal1 ! =eign body /ill be+ pres5t or n4 ,diagnosis is by ! ro5tg5ray1 fir/ )\t1 !n1 if necess>y1 ) a capsule fill$ ) an opaque mixture4 ,flat objects1 l co9s1 always lie ) _! greate/ diamet] 9 ! coronal plane ( ! body1 :5 9 ! esophagus2 9 ! sagittal plane1 :5 9 ! tra*ea or l>ynx4 ,lat]al1 ant]opo/]ior1 & sometimes also qu>t]+ ro5tg5ograms are necess>y4 ,"o tak5 lat]ally1 l[ d[n on ! neck b cle> ( ! %\ld]1 w (t5 %[ a bone or o!r semiopaque object invisible 9 ! ant]opo/]ior exposure4 #adi ,,*apt] ,,xiii--,,=eign ,,bodies ,,9 ,,! ,,l>ynx ,,& ,,tra*eobron*ial ,,tree ,! protective reflexes prev5t+ ! entrance ( =eign bodies into ! l[] air passages are3 7#a7 ,! l>yngeal clos+ reflex & 7#b7 ! be*ic reflex4 ,l>yngeal clos+ = normal swall[+ consi/s *iefly 9 ! tilt+ & ! closure ( ! upp] l>yngeal orifice4 ,! v5tricul> b&s help b slightly2 & ! epiglottis & ! vocal cords little1 if at all4 ,! gauntlet to be run by =eign bodies ent]+ ! tra*eobron*ial tree is compos$ (3 #a4 ,epiglottis4 #b4 ,upp] l>yngeal orifice4 #c4 ,v5tricul> b&s4 #d4 ,vocal cords4 #e4 ,be*ic bla/4 ,! epiglottis acts some:at z a f5d]4 ,! sup]ior l>yngeal ap]ture1 compos$ ( a pair ( movable ridges ( tissue1 has almo/ a sph9ct]ic action1 9 addition to a tilt+ movem5t4 ,! v5tricul> b&s c approximate "u p[]ful /imuli4 ,! vocal cords act simil>ly4 ,! "o defect 9 ! effici5cy ( ?is b>ri]1 is ! t5d5cy to take a deep inspiration prep>atory to ! c\gh excit$ by ! contact ( a =eign body4 ,site ( ,lodgm5t4--,! majority ( =eign bodies 9 ! air passages occur 9 *ildr54 ,! "r bron*us is m frequ5tly invad$ ?an ! left because ( ! foll[+ factors3 ,i4 ,its great] diamet]4 #b4 ,its less] angle ( deviation f ! tra*eal axis4 #c4 ,! situation ( ! c>9a to ! left ( ! mid-l9e ( ! tra*ea4 #d4 ,! action ( ! tra*ealis muscle4 #e4 ,! great] volume ( air go+ into ! "r bron*us on inspiration4 ,! middle lobe bron*us is r>ely invad$ by =eign body1 &1 =tunately1 9 less ?an "o p] c5t ( ! cases is ! object 9 an upp] lobe bron*us4 ,spontane\s ,expulsion ( ,=eign ,bodies f ! ,air ,passages4 ,a l>ge1 light1 =eign body 9 ! l>ynx or tra*ea may occasionally be c\gh$ out1 b ! frequ5t newspap] acc\nts ( ! sudd5 dea? ( *ildr5 kn[n to h aspirat$ objects %\ld tea* u nev] to wait = ?is occurr5ce4 ,! cause ( dea? 9 ^! cases is usually ! impaction ( a l>ge =eign body 9 ! glottis produc+ sudd5 asphyxiation1 & 9 a c]ta9 proportion ( ^! cases ! impaction has occurr$ on ! rev]se j\rney1 :5 c\gh =c$ ! intrud] upw>d f bel[4 ,! dang] ( subglottic impaction r5d]s x imp]ative t attempts to aid spontane\s expulsion by inv]t+ ! pati5t %\ld be disc\rag$4 ,%>p objects1 su* z p9s1 are r>ely c\gh$ out4 ,! t5d5cy ( all =eign bodies is to migrate d[n & out to ! p]iph]y z _! size & %ape w all[4 ,mo/ ( ! report$ cases ( be*ic expulsion ( bron*ially lodg$ =eign bodies h occurr$ aft] a prolong$ soj\rn ( ! object1 associat$ :i* mu* lung pa?ology2 & 9 "s cases ! object has be5 c>ri$ out along ) an accumulation ( pus sudd5ly lib]at$ f an abscess cavity1 & expell$ by c\gh4 ,?is is a r>e sequ5ce comp>$ to ! usual =mation ( fibr\s /ricture above ! =eign body t prev5ts ! possibility ( be*ic expulsion4 ,to delay bron*oscopy ) ! hope ( su* a solution ( ! problem is comp>able to ! =m] dep5d5ce on nature = ! cure ( app5diceal abscess4 ,we d our full duty :5 we tell ! pati5t or p>5ts t :ile ! =eign body may be c\gh$ up1 x is v dang]\s to wait2 &1 fur!r1 t ! difficulty ( removal usually increases ) ! "t ! =eign body is all[$ to rema9 9 ! air passages4 ,mortality & morbidity ( bron*oscopy v>y directly ) ! degree ( skill & exp]i5ce ( ! op]ator1 & ! conditions = :i* ! endoscopies are p]=m$4 ,! simple ins]tion ( ! bron*oscope is devoid ( h>m if c>efully done4 ,! dang] lies 9 misdirect$ ef=ts at removal ( ! intrud] & 9 repeat+ bron*oscopies 9 *ildr5 at too frequ5t int]vals1 or 9 prolong+ ! proc$ure unduly4 ,9 *ildr5 "u "o ye> endoscopy %\ld be limit$ to tw5ty m9utes1 & %\ld n be repeat$ soon] ?an "o week aft]1 unless urg5tly indicat$4 ,a *ild ( #e ye>s w be> #dj to #fj m9utes "w1 :ile ! adult (f]s no unv>y+ "t limit4 ,m c be ultimately accompli%$1 & less reaction w foll[ %ort endoscopies repeat$ at prop] int]vals ?an 9 "o long proc$ure4 ,indications = bron*oscopy = suspect$ =eign body may be ?us summ>iz$3 #a4 ,! appe>ance ( a suspici\s %ad[ 9 ! radiograph1 9 ! l9e ( a bron*us4 #b4 ,9 any case 9 :i* lung symptoms foll[$ a cle> hi/ory ( ! pati5t hav+ *ok$ on a =eign body4 #c4 ,9 any case %[+ signs ( ob/ruction 9 ! tra*ea or ( a bron*us4 #d4 ,9 suspect$ bron*iectasis4 #e4 ,symptoms ( pulmon>y tub]culosis ) sputum con/antly negative = tub]cle bacilli4 ,if ! physical signs are at ! base1 p>ticul>ly ! "r base1 ! indication becomes v /rong ev5 9 ! abs5ce ( any =eign body circum/ance 9 ! hi/ory4 #f4 ,9 all cases ( d\bt1 bron*oscopy %\ld be done anyway4 ,!re is no absolute contra9dication to bron*oscopy = =eign bodies4 ,extreme exhau/ion or reaction f previ\s ef=ts at removal may call = delay = recup]ation1 b pulmon>y abscess & ev5 ! r>] complications1 bron*opneumonia & gangr5e ( ! lung1 are improv$ by ! e>ly removal ( ! =eign body4 ,*oice ( ,"t to d ,bron*oscopy = ,=eign ,body4--,! difficulties ( removal usually increase f ! "t ( aspiration ( ! object4 ,x t5ds to "w d[nw>d & outw>d1 :ile ! mucosa becomes edemat\s1 p>tly clos+ ov] ! =eign body1 & ev5 completely oblit]at+ ! lum5 ( small] bron*i4 ,lat]1 granulation tissue & ! =mation ( /ricture fur!r hide ! object4 ,! pati5t's heal? det]iorates ) ! onset ( pulmon>y pa?ology1 & r5d]s him a less favorable subject = bron*oscopy4 ,organic =eign bodies1 :i* produce e>ly & int5se inflammatory reaction & are liable to swell1 call = prompt bron*oscopy4 ,:5 a bron*us is completely ob/ruct$ by ! bulk ( ! =eign body itself imm$iate removal is urg5tly dem&$ to prev5t s]i\s lung *anges1 result+ f atelectasis & want ( dra9age4 ,9 %ort1 removal ( ! =eign body %\ld be accompli%$ z soon z possible aft] its entrance4 ,?is1 h[ev]1 does n ju/ify ha/y1 ill-plann$1 & poorly equipp$ bron*oscopy1 :i* 9 mo/ cases is doom$ to failure 9 removal ( ! object4 ,! bron*oscopi/ %\ld n p]mit himself to be /amp$$ into a bron*oscopy late at night1 :5 he is fatigu$ aft] a h>d day's "w4 ,bron*oscopic f9d+ ( a =eign body is n especially difficult if ! aspiration has be5 rec5t4 ,if second>y processes h develop$1 or ! object be small & 9 a bron*us too small to admit ! tube-m\?1 consid]able exp]i5ce may be necess>y to discov] x4 ,!re is usually inflammatory reaction ar\nd ! orifice ( ! invad$ bron*us1 :i* 9 a measure s]ves to localize ! intrud]4 ,we mu/ n =get1 h[ev]1 t objects may h mov$ to ano!r location1 & also t ! irritation may h be5 ! result ( previ\s ef=ts at removal4 ,c>e mu/ be ex]cis$ n to mi/ake ! %>p1 %9+1 int]bron*ial spurs = bright ?9 objects l new p9s j aspirat$2 aft] a few days p9s become black5$4 ,if ^! spurs be torn pneumo?orax may ensue4 ,if a numb] ( small bron*i are to be se>*$1 ! bron*oscope mu/ be br\ght into ! l9e ( ! axis ( ! bron*us to be exam9$1 & any int]v5+ tissue g5tly pu%$ aside ) ! lip ( ! bron*oscope4 ,bl9d prob+ = exploration is v dang]\s unless c>efully done4 ,! /raight =ceps1 introduc$ clos$1 =m ! be/ probe & are ready = grasp+ if ! object is felt4 ,once ! bron*oscope has be5 introduc$1 x %\ld n be )drawn until ! proc$ure is complet$4 ,! light c>ri] alone may be remov$ f its canal if ! illum9ation be faulty4 ,,complications ,,& ,,aft]-,,effects ,,( ,,bron*oscopy ,all =eign body cases %\ld be wat*$ day & night by special nurses until all dang] ( complications is pass$4 ,complications are r>e aft] c>eful "w1 b if !y d occur1 !y may require imm$iate att5tion4 ,?is applies especially to ! subglottic edema associat$ ) ara*idic bron*itis 9 *ildr5 "u #b ye>s ( age4 ,g5]al ,reaction4--,!re is usually no elevation 9 temp]ature foll[+ a %ort bron*oscopy = ! removal ( a rec5tly lodg$ metallic =eign body4 ,if1 h[ev]1 an inflammatory condition ( ! bron*i exi/$ previ\s to ! bron*oscopy1 z = in/ance ! int5se diffuse1 purul5t l>yngotra*eobron*itis associat$ ) ! aspiration ( nut k]nels1 or 9 ! pres5ce ( pulmon>y abscess f long reta9$ =eign bodies1 a mod]ate tempor>y rise ( temp]ature may be expect$4 ,^! cases almo/ always h _h irregul> fev] be=e bron*oscopy4 ,di/urbance ( ! epi!lium 9 ! pres5ce ( pus )\t abscess usually p]mits en\gh absorption to elevate ! temp]ature slightly = a few days4 ,surgical %ock 9 its true =m has nev] foll[$ a c>efully p]=m$ & "t-limit$ bron*oscopy4 ,sev]e fatigue result+ 9 deep sleep may be se5 9 *ildr5 aft] prolong$ "w4 ,local reaction is ord9>ily not$ by slight l>yngeal conge/ion caus+ "s ho>s5ess & disappe>+ 9 a few days4 ,if dyspnea occur x is usually due to 7#a7 ,dr[n+ ( ! pati5t 9 8 own secretions4 7#b7 ,subglottic edema4 7#c7 ,l>yngeal edema4 ,dr[n+ ( ! ,pati5t 9 ,8 ,own ,secretions4--,! accumulation ( secretions 9 ! bron*i due to faulty be*ic p[]s & se5 mo/ frequ5tly 9 *ildr51 is quickly relievable by bron*oscopic sponge-pump+ or aspiration ?r\gh ! tra*eotomic w\nd1 9 cases 9 :i* ! tra*eotomy may be deem$ necess>y4 ,9 o!r cases1 ! aspirat+ bron*oscope ) side dra9age canal 7,fig4 #a1 ,e7 may be us$ ?r\gh ! l>ynx4 ,frequ5t p]oral passage ( ! bron*oscope = ?is purpose is contra9dicat$ only 9 case ( *ildr5 "u #c ye>s ( age1 because ( ! likelihood ( provok+ subglottic edema4 ,9 su* cases in/ead ( ins]t+ a bron*oscope ! aspirat+ tube 7,fig4 #i7 %\ld be ins]t$ ?r\gh ! direct l>yngoscope1 or a l[ tra*eotomy %\ld be done4 ,supraglottic edema is r>ely responsible = dyspnea except :5 associat$ ) advanc$ nephritis4 ,subglottic edema is a complication r>ely se5 except 9 *ildr5 "u #c ye>s ( age4 ,!y h a peculi> hi/ologic /ructure 9 ?is region1 z is %[n by ,logan ,turn]4 ,ev5 at ! pr$ispos+ age subglottic edema is a v unusual sequ5ce to bron*oscopy if ?is region 0 previ\sly normal4 ,! passage ( a bron*oscope ?r\gh an already inflam$ subglottic area is liable to be foll[$ by a tempor>y increase 9 ! swell+4 ,if ! =eign body be associat$ ) b slight am\nt ( secretion1 ! *ild c usually obta9 suffici5t air ?r\gh ! tempor>ily n>r[$ lum54 ,if1 h[ev]1 z 9 cases ( ara*idic bron*itis1 l>ge am\nts ( purul5t secretion mu/ be expell$1 x w be f\nd 9 c]ta9 cases t ! decreas$ glottic lum5 & impair$ l>yngeal motility w r5d] tra*eotomy necess>y to dra9 ! lungs & prev5t dr[n+ 9 ! reta9$ secretions4 ,subglottic edema occurr+ 9 a previ\sly normal l>ynx may result f3 #a4 ,! use ( ov]-siz$ tubes4 #b4 ,prolong$ bron*oscopy4 #c4 ,faulty position ( ! pati5t1 ! axis ( ! tube n be+ 9 t ( ! tra*ea4 #d4 ,trauma f undue =ce or improp] direction 9 ! ins]tion ( ! bron*oscope4 #e4 ,! manipulation ( in/rum5ts4 #f4 ,trauma inflict$ 9 ! extraction ( ! =eign body4 ,diagnosis mu/ be made )\t wait+ = cyanosis :i* may nev] appe>4 ,pallor1 re/lessness1 />tl$ awak5+ aft] a few m9utes sleep1 occurr+ 9 a *ild ) cr\py c\gh1 indraw+ ar\nd ! clavicles1 9 ! int]co/al spaces1 at ! supra/]nal not* & at ! epiga/rium1 call = tra*eotomy :i* %\ld always be l[4 ,su* a case %\ld n be left unwat*$4 ,! *ild w become exhau/$ 9 its fight = air & w give up & die4 ,! respiratory rate naturally increases because ( air hung]1 accumulat+ secretions t _c be expell$ because ( impair$ glottic motility give signs wrongly int]pret$ z pneumonia4 ,_m *ildr5 ^: lives c\ld h be5 sav$ by tra*eotomy h di$ "u ?is errone\s diagnosis4 ,treatm5t4--,intubation is n s safe because ! secretions _c easily be expell$ ?r\gh ! tube & po/9tubational /5osis may be produc$4 ,l[ tra*eotomy1 ! tra*eal incision always bel[ ! second r+1 is ! safe/ & be/ me?od ( treatm5t4 #aef ,,*apt] ,,xiv--,,removal ,,( ,,=eign ,,bodies ,,f ,,! ,,l>ynx ,symptoms & ,diagnosis4--,! hi/ory ( a sudd5 *ok+ attack foll[$ by impairm5t ( voice1 :eez+1 & m or less dyspnea c be usually elicit$4 ,l>yngeal diph!ria is ! condition mo/ frequ5tly ?\ght ( :5 ^! symptoms are pres5t1 & antitox9 is rightly giv5 :ile wait+ = a positive diagnosis4 ,extreme dyspnea may r5d] tra*eotomy urg5tly dem&$ be=e any attempts at diagnosis are made4 ,fur!r consid]ation ( ! symptomatology & diagnosis ( l>yngeal =eign body w be f\nd on pages #abh1 #acc & #adc4 ,prelim9>y ,exam9ation4--,9 ! adult1 mirror exam9ation ( ! l>ynx %\ld be done1 ! pati5t be+ plac$ 9 ! recumb5t position4 ,:5ev] "t p]mits ro5tg5ograms1 lat]al & ant]opo/]ior1 %\ld be made1 ! lat]al "o z l[ 9 ! neck z possible4 ,"o might ?9k ?is an unnecess>y proc$ure because ( ! visibility ( ! l>ynx 9 ! mirror2 b a *ild's l>ynx _c usually be indirectly exam9$1 & ev5 9 ! adult a p9 may be s situat$ t nei!r head nor po9t is visible1 only a portion ( ! %aft be+ se54 ,! ro5tg5ogram w give accurate in=mation z to ! position1 & w ?us all[ a plann+ ( ! be/ me?od = removal ( ! =eign body4 ,a bone 9 ! l>ynx usually is visible 9 a good ro5tg5ogram4 ,accurate diagnosis 9 *ildr5 is made by direct l>yngoscopy )\t ane/hesia1 b direct l>yngoscopy %\ld n be done until "o is prep>$ to remove a =eign body if f\nd1 to foll[ x into ! bron*us & remove x if x %\ld be dislodg$ & aspirat$1 & to d tra*eotomy if sudd5 respiratory arre/ occur4 #aeg ,te*nic ( ,removal ( ,=eign ,bodies f ! ,l>ynx4--,! pati5t is to be plac$ 9 ! au?or's position1 %[n 9 ,fig4 #ec4 ,no g5]al ane/hesia %\ld be giv51 & ! application ( local ane/hesia is usually unnecess>y & fur!r1 is liable to dislodge & pu% d[n ! =eign body499 ,because ( ! risk ( loss d[nw>d x is be/ to seize ! =eign body z soon z se52 !n to det]m9e h[ be/ to disimpact x4 ,! fundam5tal pr9ciples are t a po9t$ object mu/ ei!r h its po9t protect$ by ! =ceps grasp or be br\ght out po9t trail+1 & t a flat object mu/ be s rotat$ t its plane corresponds to ! sagittal plane ( ! glottic *9k4 ,! l>yngeal grasp+ =ceps 7,fig4 #ec7 w be f\nd ! mo/ useful1 al?\gh ! alligator rotation =ceps 7,fig4 #ca7 may occasionally be requir$4 99 ,9 adolesc5ts or adults a few drops ( a #d p] c5t solution ( coca9 appli$ to ! l>yngoph>ynx ) an atomiz] or a dropp] w af=d ! m9imum risk ( dislodgem5t2 b ! au?or's p]sonal pref]5ce is = no ane/hesia1 g5]al or local4 #aeh ,,*apt] ,,xv--,,me*anical ,,problems ,,( ,,bron*oscopic ,,=eign ,,body ,,extraction99 99 ,= m ext5sive consid]ation ( me*anical problems ?an is "h possible ! read] is ref]r$ to ! ,bibliography1 page #caa1 especially ref]5ce numb]s #a1 #aa1 #cg & #ef4 ,! endoscopic extraction ( a =eign body is a me*anical problem pure & simple1 & mu/ be /udi$ f ?is viewpo9t4 ,ha/y1 ill-equipp$1 ill-plann$1 or viol5t endoscopy on ! errone\s pr9ciple t if n imm$iately remov$ ! =eign body w be fatal1 is nev] ju/ifiable4 ,:ile ! lodgem5t ( an organic =eign body 7su* z a nut k]nel7 9 ! bron*us calls = prompt removal & might be includ$ "u ! li/ ( em]g5cy op]ations1 "t is always available = complete prep>ation1 = ?or\gh /udy ( ! pati5t1 & localization ( ! intrud]4 ,! pati5t is bett] (f ) ! =eign body 9 ! lung ?an if 9 its removal a m$ia/9itis1 rupture into ! pleura1 or te>+ ( a ?oracic blood vessel has result$4 ,! motto ( ! endoscopi/ %\ld be ,i w d no h>m4 ,if no h>m be inflict$1 any numb] ( bron*oscopies c be done at suitable int]vals1 & ev5tually success w be a*iev$1 :]eas if mortality results1 all opportunity ceases4 ,! fir/ /ep 9 ! solution ( ! me*anical problem is ! /udy ( ! ro5tg5ograms made 9 at lea/ ?ree planes2 7#a7 ant]opo/]ior1 7#b7 lat]al1 & 7#c7 ! plane correspond+ to ! greate/ plane ( ! =eign body4 ,! next /ep is to put a duplicate ( ! =eign body into ! rubb]-tube manik9 previ\sly ref]r$ to1 & try to simulate ! probable position %[n by ! ray1 s z to get an idea ( ! bron*oscopic appe>ance ( ! probable pres5tation4 ,!n ! duplicate =eign body is turn$ into z _m diff]5t positions z possible1 s z to educate ! eye to assi/ 9 ! compreh5sion ( ! l>ge/ possible numb] ( pres5tations t may be enc\nt]$ at ! bron*oscopy on ! pati5t4 ,= ea* ( ^! pres5tations a me?od ( disimpaction1 dis5gagem5t1 dis5tanglem5t or v]sion & seizure is work$ out1 accord+ to ! k9d ( =eign body4 ,prep>$ by ?is practice & ! radiographic /udy1 ! bron*oscope is introduc$ into ! pati5t4 ,! location ( ! =eign body is approa*$ sl[ly & c>efully to avoid ov]rid+ or displacem5t4 ,a /udy ( ! pres5tation is z necess>y = ! bron*oscopi/ z = ! ob/etrician4 ,x %\ld be made ) a view to det]m9+ ! foll[+ po9ts3 #a4 ,! relation ( ! pres5t+ "p to ! surr\nd+ tissues4 #b4 ,! probable position ( ! unse5 portion1 z det]m9$ by ! appe>ance ( ! pres5t+ "p tak5 9 connection ) ! k obta9$ by ! previ\s ray /udy1 & by inspection ( ! ray plate upside d[n on view 9 front ( ! bron*oscopi/4 #c4 ,! v]sion or o!r manipulation necess>y to conv]t an unfavorable into a favorable pres5tation = grasp+ & dis5gagem5t4 #d4 ,! be/ in/rum5ts to use1 & :i* to use fir/1 z1 hook1 p9clos]1 =ceps1 etc4 #e4 ,! pres5ce & position ( ! =ceps spaces ( :i* !re mu/ be two = all ord9>y =ceps1 "o = ea* jaw1 or ! ins]tion space = any o!r in/rum5t4 ,until all ( ^! po9ts are det]m9$ x is a grave error to ins]t any k9d ( in/rum5t4 ,if possible ev5 swabb+ ( ! =eign body %\ld be avoid$ by swabb+ out ! bron*us1 :5 necess>y1 be=e ! region ( ! intrud] is rea*$4 ,:5 ! op]ator has det]m9$ ! in/rum5t to be us$1 & ! me?od ( us+ x1 ! in/rum5t is cauti\sly ins]t$1 "u guidance ( ! eye4 #afj ,! lip ( ! bron*oscope is "o ( ! mo/ valuable aids 9 ! solution ( =eign-body problems4 ,) x p>tial or complete v]sion ( an object c be accompli%$ s z to conv]t an unfavorable pres5tation into "o favorable = grasp+ ) ! =ceps2 edemat\s mucosa may be displac$1 angles /raight5$ & space made at ! side ( ! =eign body = ! =ceps' jaw4 ,x =ms a %ield or protector t c be slipp$ "u ! po9t ( a %>p =eign body & c make c\nt]pressure on ! tissues :ile ! =ceps are disemb$d+ ! po9t ( ! =eign body4 ,) ! bron*oscopic lip & ! =ceps or o!r in/rum5t ins]t$ ?r\gh ! tube1 ! bron*oscopi/ has bimanual1 eye-guid$ control1 :i* if x has be5 suffici5tly practic$ to af=d ! facility 9 coord9ate use common to ev]yone ) knife & =k1 w accompli% maneuv]s t seem m>vel\s to anyone :o has n develop$ facility 9 ?is coord9ate use ( ! bron*oscopic in/rum5ts4 ,! relation ( ! tube m\? & =eign body is ( vital importance4 ,g5]ally consid]$1 ! tube m\? %\ld be z ne> ! =eign body z possible1 & ! object mu/ be plac$ 9 ! c5t] ( ! bron*oscopic field1 s t ! ends ( ! op5 jaws ( ! =ceps w pass suffici5tly f> ov] ! object4 ,b little lat]al control is _h ( ! long in/rum5ts ins]t$ ?r\gh ! tube2 sidewise motion is obta9$ by a %ift+ ( ! end ( ! bron*oscope4 ,:5 ! =eign body has be5 c5t]$ 9 ! bron*oscopic field & plac$ 9 a position favorable = grasp+1 x is important t ?is position be ma9ta9$ by an*or+ ! tube to ! upp] tee? ) ! left1 ?ird1 & f\r? f+]s hook$ ov] ! pati5t's upp] alveolus 7,fig4 #fc7 ,! ,light ,reflex on ! ,=ceps4--,x is (t5 difficult = ! beg9n] to judge to :at dep? an in/rum5t has be5 ins]t$ ?r\gh ! tube4 ,on sl[ly ins]t+ a =ceps ?r\gh ! tube1 z ! blades come opposite ! di/al light !y w appe> brightly illum9at$2 or %\ld ! blades lie close to ! light bulb1 a %ad[ w be se5 9 ! previ\sly brilliantly light$ opposite wall4 ,x is !n kn[n t ! =ceps are at ! tube m\?1 & ! endoscopi/ has b to gauge ! di/ance f ?is to ! =eign body4 ,?is assi/ance 9 gaug+ dep? is "o ( ! great advances 9 =eign body bron*oscopy obta9$ by ! developm5t ( di/al illum9ation4 ,hooks are useful 9 ! solution ( v>i\s me*anical problems1 & may be turn$ by ! op]ator himself into v>i\s %apes by heat+ small probe-po9t$ /eel rods 9 a _s lamp1 ! proximal end be+ turn$ ov] at a "r angle = a controll+ h&le4 ,hooks ) a great] curve ?an a "r angle are prone to engage 9 small orifices f :i* !y are ) difficulty remov$4 ,a "r angle curve ( ! di/al end is usually suffici5t1 & a corkscrew spiral is (t5 advantage\s1 r5d]+ removal easy by a rev]sal ( ! twi/+ motion 7,bib4 #aa1 p4 #caa74 ,! ,use ( ,=ceps 9 ,endoscopic ,=eign ,body ,extraction4--,two diff]5t /r5g?s ( =ceps are suppli$1 z w be se5 9 ! li/ 9 ,*apt] #a4 ,! regul> =ceps h a p[]ful grasp & are us$ on d5se =eign bodies :i* require consid]able pressure on ! object to prev5t ! =ceps f slipp+ (f4 ,= m delicate manipulation1 & p>ticul>ly = friable =eign bodies1 ! light] =ceps are us$4 ,spr+-oppos$ =ceps r5d] any delicacy ( t\* impossible4 ,=ceps are to be held 9 ! "r h&1 ! ?umb 9 "o r+1 & ! ?ird1 or r+ f+]1 9 ! o!r r+4 ,^! f+]s are us$ to op5 & close ! =ceps1 :ile all traction is to be made by ! "r index f+]1 :i* has its position on ! =ceps h&le ne> ! /ylet1 z %[n 9 ,fig4 #gh4 ,x is absolutely ess5tial = accurate "w1 t ! =ceps jaws be se5 to close ^u ! =eign body4 ,! impulse to seize ! object z soon z x is discov]$ mu/ be /rongly resi/$4 ,a c>eful /udy ( its size1 %ape1 & position & relation to surr\nd+ /ructures mu/ be made be=e any attempt at extraction4 ,! mo/ favorable po9t & position = grasp+ hav+ be5 obta9$1 ! clos$ =ceps are ins]t$ ?r\gh ! bron*oscope1 ! light reflex obta9$1 ! =ceps blades n[ op5$ are turn$ 9 su* a position t1 on advanc+1 ! =eign body w ent] ! op5 ,v1 a suffici5t di/ance to af=d a good grasp4 ,! blades are !n clos$ & ! =eign body is drawn aga9/ ! tube m\?4 ,few =eign bodies are suffici5tly small to all[ )drawal ?r\gh ! tube1 s t tube1 =ceps & =eign body are usually )drawn toge!r4 ,,fig4 #gh4--,prop] hold ( =ceps4 ,! "r ?umb & ?ird f+]s are ins]t$ into ! r+s :ile ! "r index f+] has its place high on ! h&le4 ,all traction is made ) ! index f+]1 ! r+ f+]s be+ us$ only to op5 & close ! =ceps4 ,if any pu%+ is deem$ safe x may be done by plac+ ! index f+] back ( ! ?umb-nut on ! /ylet4 ,an*or+ ! ,=eign ,body ,aga9/ ! ,tube ,m\?4--,if )drawal be made a bimanual proc$ure x is almo/ c]ta9 t ! =eign body w trail a c5timet] or m beyond ! tube m\?1 & t ! closure ( ! glottic *9k z soon z ! di/al end ( ! bron*oscope em]ges w /rip ! =eign body f ! =ceps grasp1 :5 ! =eign body rea*es ! cords4 ,?is is avoid$ by an*or+ ! =eign body aga9/ ! tube m\? z soon z ! =eign body is grasp$1 z %[n 9 ,fig4 #gi4 ,! left index f+] & ?umb grasp ! %aft ( ! =ceps close to ! ocul> end ( ! tube1 :ile ! o!r f+]s encircle ! tube2 closure ( ! =ceps is ma9ta9$ by ! f+]s ( ! "r h&1 :ile all traction = )drawal is made ) ! left h&1 :i* firmly clamps =ceps & bron*oscope z "o piece4 ,?us ! ?ree units are br\ght out z "o2 ! bron*oscope keep+ ! cords ap>t until ! =eign body has ent]$ ! glottis4 ,,fig4 #gi--,me?od ( an*or+ ! =eign body aga9/ ! tube m\? ,aft] ! object has be5 drawn firmly aga9/ ! lip ( ! endoscopic tube ! left f+] & ?umb grasp ! =ceps cannula & lock x aga9/ ! ocul> end ( ! tube1 ! o!r f+]s ( ! left h& encircle ! tube4 ,)drawal is !n done ) ! left h&2 ! f+]s ( ! "r h& ma9ta9+ closure ( ! =ceps4 #afd ,br++ ! ,=eign ,body ,?r\gh ! ,glottis4--,/ripp+ ( ! =eign body f ! =ceps at ! glottis may be due to3 #a4 ,n keep+ ! object aga9/ ! tube m\? z j m5tion$4 #b4 ,n br++ ! greate/ diamet] ( ! =eign body into ! sagittal plane ( ! glottic *9k4 #c4 ,faulty application ( ! =ceps on ! =eign body4 #d4 ,me*anically imp]fect =ceps4 ,%\ld ! =eign body be lo/ at ! glottis x may1 if l>ge become impact$ & ?reat5 asphyxia4 ,prompt ins]tion ( ! l>yngoscope w usually all[ removal ( ! object by means ( ! l>yngeal grasp+ =ceps4 ,! object may be dropp$ or expell$ into ! ph>ynx & be swall[$4 ,x may ev5 be c\gh$ into ! naso-ph>ynx or x may be re-aspirat$4 ,9 ! latt] ev5t ! bron*oscope is to be re-ins]t$ & ! tra*ea c>efully se>*$4 ,c>e mu/ be us$ n to ov]ride ! object4 ,if mu* inflammatory reaction has occurr$ 9 ! fir/ invad$ bron*us1 tempor>ily susp5d+ ! a]at+ function ( ! correspond+ lung1 reaspiration ( a dislodg$ =eign body is liable to c>ry x into ! opposite ma9 bron*us1 by reason ( ! great] inspiratory volume ( air ent]+ t side4 ,?is may produce sudd5 dea? by block+ ! only a]at+ organ4 ,extraction ( ,p9s1 ,ne$les & ,simil> ,long ,po9t$ ,objects4--,:5 se>*+ = su* objects especial c>e mu/ be tak5 n to ov]ride !m4 ,p9s are almo/ always f\nd po9t upw>d1 & ! dictum c !re=e be made1 ,se>* n = ! p91 b = ! po9t ( ! p94 ,if ! po9t be f\nd free1 x %\ld be work$ into ! lum5 ( ! bron*oscope by manipulation ) ! lip ( ! tube4 ,x may !n be seiz$ ) ! =ceps & )drawn4 ,%\ld ! p9 be grasp$ by ! %aft1 x is almo/ c]ta9 to turn crosswise ( ! tube m\?1 :]e "o pull may cause ! po9t to p]=ate1 enorm\sly increas+ ! difficulties by transfixation1 & p]haps result+ fatally 7,fig4 #hj74 ,,fig4 #hj4--,s*ematic illu/ration ( a s]i\s phase ( ! error ( ha/ily seiz+ a transfix$ p9 ne> its middle1 :5 fir/ se5 z at ,m4 ,traction ) ! =ceps 9 ! direction ( ! d>t 9 ,s*ema ,b w rip op5 ! esophagus or bron*us inflict+ fatal trauma1 & probably ! p9 w be /ripp$ (f at ! glottic or ! cricoph>yngeal level1 respectively4 ,! po9t ( ! p9 mu/ be disemb$d$ & gott5 into ! tube m\? z at ,a1 to make =ceps traction safe4 ,,fig4 #ha4--,s*ema illu/rat+ ! me*anical problem ( extract+ a p91 a l>ge "p ( ^: %aft is buri$ 9 ! bron*ial wall1 ,b4 ,! p9 mu/ be pu%$ d[nw>d & if ! orifice ( ! bran*es1 ,c1 ,d1 are too small to admit ! head ( ! p9 "s o!r orifice 7z at ,a7 mu/ be f\nd by palpation 7n by viol5t pu%+7 to admit ! head1 s t ! p9 c be pu%$ d[nw>d p]mitt+ ! po9t to em]ge 7,e74 ,! po9t is !n manipulat$ into ! bron*oscopic tube-m\? by means ( co-ord9at$ movem5ts ( ! bron*oscopic lip & ! side-curv$ =ceps1 z %[n at ,f4 ,inw>d ,rotation ,me?od4--,:5 ! po9t is f\nd to be buri$ 9 ! mucosa1 ! be/ & usually successful me?od is to grasp ! p9 z ne> ! po9t z possible ) ! side-grasp+ =ceps1 !n ) a spiral motion to pu% ! p9 d[nw>d :ile rotat+ ! =ceps ab\t n9ety degrees4 ,! po9t is ?us dis5gag$1 & ! %aft ( ! p9 is br\ght p>allel ) t ( ! =ceps1 aft] :i* ! po9t may be drawn into ! tube m\?4 ,! lips add$ to ! side-curv$ =ceps by my assi/ant ,dr4 ,gabriel ,tuck] ,i n[ use exclusively = ?is inw>d rotation me?od4 ,!y are invaluable 9 prev5t+ ! escape ( ! p9 dur+ ! manipulation4 ,a hook is sometimes useful 9 dis5gag+ a buri$ po9t4 ,! me?od ( its use is illu/rat$ 9 ,fig4 #hb4 ,,fig4 #hb4--,me*anical problem ( p91 ne$le1 tack or nail ) emb$d$ po9t4 ,if ! =ceps are pull$ ^u ! p9 po9t w be buri$ /ill deep]4 ,! side curv$ =ceps grasp ! p9 z ne> ! po9t z possible !n ) a corkscrew motion ! p9 is pu%$ d[nw>d & rotat$ to ! "r :5 ! p9 w be f\nd to be p>allel ) ! %aft ( ! =ceps & c be drawn into ! tube4 ,if ! p9 is prev5t$ by its head f be+ pu%$ d[nw>d ! po9t may be extract$ by ! hook z %[n above ,! side curv$ =ceps may be us$ in/ead ( ! hook = free+ ! po9t1 ! au?or's inw>d rotation me?od4 ,! v be/ in/rum5t = ! purpose is ! =ceps devis$ by my assi/ant1 ,dr4 ,gabriel ,tuck] 7,fig4 #ba74 ,! lips prev5t all risk ( los+ ! p9 f ! grasp1 & at ! same "t br+ ! long axis ( ! p9 p>allel to t ( ! bron*oscope4 ,p9s are v prone to drop into ! small] bron*i & disappe> completely f ! ord9>y field ( endoscopic exploration4 ,at o!r times1 p9s n dropp+ s deeply may %[ ! po9t only dur+ expiration or c\gh1 at :i* times ! bron*i are %ort5$4 ,9 su* in/ances ! invad$ bron*ial orifice %\ld be cle>ly expos$ z ne> ! axis ( its lum5 z possible2 ! =ceps are n[ ins]t$1 op5$1 & ! next em]g5ce wat*$ =1 ! po9t be+ grasp$ z soon z se54 ,extraction ( ,tacks1 ,nails & ,l>ge ,head$ ,=eign ,bodies f ! ,tra*eobron*ial ,tree4--,9 cases ( ?is sort ! po9t pres5ts ! same difficulty & requires solution 9 ! same mann] z m5tion$ 9 ! prec$+ p>agraphs on ! extraction ( p9s4 ,! au?or's inw>d-rotation me?od :5 execut$ ) ! ,tuck] =ceps is ideal4 ,! l>ge head1 h[ev]1 pres5ts a special problem because ( its t5d5cy to act z a mu%room an*or :5 buri$ 9 swoll5 mucosa or 9 a fibr\s /5osis 7,fig4 #hc74 ,! extraction problems ( tacks are illu/rat$ 9 ,figs4 #hd1 #he1 & #hf4 ,nails1 /ick p9s1 & v>i\s tacks are dealt ) 9 ! same mann] by ! au?or's inw>d rotation me?od4 ,holl[ metallic bodies pres5t+ an op5+ t[>d ! obs]v] may be remov$ ) a groov$ expansile =ceps z %[n 9 ,figs #bc & #be1 or its edge may be grasp$ by ! regul> side-grasp+ =ceps4 ,! latt] hold is apt to be v dang]\s because ( ! trauma inflict$ by ! cat*+ ( ! free edge opposite ! =ceps2 b ) c>e x is ! be/ me?od4 ,%\ld ! clos$ end be upp]mo/1 h[ev]1 x may be necess>y to ins]t a hook beyond ! object1 & to coax x upw>d to a po9t :]e x may be turn$ = grasp+ & removal ) =ceps4 ,,fig4 #hc4--,mu%room an*or problem ( ! uphol/]y tack4 ,if ! tack has n be5 9 situ m ?an a few weeks ! /5osis at ! level ( ! d>ts is simply edemat\s mucosa & ! tack c be pull$ ?r\gh ) no m ?an slight mucosal trauma1 provid$ axis-traction only be us$4 ,if ! tack has be5 9 situ a ye> or m ! fibr\s /ricture may ne$ dilatation ) ! divulsor4 ,o!rwise traction may rupture ! bron*ial wall4 ,! /5otic tissue 9 cases ( a few mon?s' soj\rn maybe compos$ ( granulations1 9 :i* case axis-traction w safely )draw x4 ,! po9t ( a tack r>ely projects freely into ! lum5 z "h %[n4 ,m (t5 x is buri$ 9 ! wall4 #afh ,,fig4 #hd4-,s*ema illu/rat+ ! mu%room an*or problem ( ! brass head$ uphol/]y tack4 ,at ,a ! tack is %[n ) ! head b$d$ 9 swoll5 mucosa4 ,! bron*oscopi/1 look+ ?r\gh ! bron*oscope1 ,e1 consid]+ himself lucky to h f\nd ! po9t ( ! tack1 seizes x & />ts to )draw x1 mak+ traction z %[n by ! d>t 9 draw+ ,b4 ,! head ( ! tack cat*es bel[ a *ondrial r+ & rips 91 te>+ its way ?r\gh ! bron*ial wall 7,d7 caus+ dea? by m$ia/9al emphysema4 ,?is accid5t is /ill m likely to occur if1 z (t5 happ5s1 ! tack-head is lodg$ 9 ! orifice ( ! upp] lobe bron*us1 ,f4 ,b if ! bron*oscopi/ sw+s ! pati5t's head f> to ! opposite side & makes axis-traction1 z %[n at ,c1 ! head ( ! tack c be drawn ?r\gh ! swoll5 mucosa )\t an*or+ itself 9 a c>tilage4 ,if necess>y1 9 addition1 ! lip ( ! bron*oscope c be us$ to repress ! angle1 h1 & ! swoll5 mucosa1 ,h4 ,if ! swoll5 mucosa1 ,h1 has be5 replac$ by fibr\s tissue f _m mon?s' soj\rn ( ! tack1 ! /5osis may require dilatation ) ! divulsor4 ,,fig4 #he4--,problem ( ! uphol/]y tack ) buri$ po9t4 ,if pull$ ^u1 ! imm95t p]=ation ( ! m$ia/9um1 z %[n at ,a w be complet$1 ! bron*us w be torn & dea? w foll[ ev5 if ! tack be remov$1 :i* is ( d\btful possibility4 ,! prop] me?od is g5tly to close ! side curv$ =ceps on ! %ank ( ! tack ne> ! head1 pu% d[nw>d z %[n by ! d>t1 9 ,b1 until ! po9t em]ges4 ,!n ! =ceps are rotat$ to br+ ! po9t ( ! tack away f ! bron*ial wall4 #afi ,removal ( ,op5 ,safety ,p9s f ! ,tra*ea & ,bron*i4-- ,removal ( a clos$ safety p9 pres5ts no difficulty if x is grasp$ at "o or ! o!r end4 ,a grasp 9 ! middle produces a toggle & r+ action :i* w\ld prev5t extraction4 ,:5 ! safety p9 is op5 ) ! po9t d[nw>d c>e mu/ be ex]cis$ n to ov]ride x ) ! bron*oscope or to pu% ! po9t ?r\gh ! wall4 ,! spr+ or ne> end is to be grasp$ ) ! side-curv$ or ! rotation =ceps 7,figs4 #ai1 #bj & #ca7 & pull$ into ! bron*oscope1 ?us clos+ ! p94 ,an op5 safety p9 lodg$ po9t up pres5ts an entirely diff]5t & a v difficult problem4 ,if traction is made )\t clos+ ! p9 or protect+ ! po9t sev]e & probably fatal trauma w be produc$4 ,! p9 may be clos$ ) ! p9-clos] z illu/rat$ 9 ,fig4 #cg1 & !n remov$ ) =ceps4 ,arr[smi?'s p9-clos] is excell5t4 ,ano!r me?od 7,fig4 #hg7 consi/s 9 br++ ! po9t ( ! safety p9 into ! bron*oscope1 aft] dis5gag+ ! po9t ) ! side curv$ =ceps1 by ! au?or's inw>d rotation me?od4 ,! =ceps-jaws 7,fig4 #ba7 devis$ rec5tly by my assi/ant1 ,dr4 ,gabriel ,tuck]1 are ideal = ?is maneuv]4 ,z ! po9t is n[ protect$1 ! spr+1 se5 j (f ! tube m\?1 is be/ grasp$ ) ! rotation =ceps1 :i* af=d ! secure/ hold4 ,! keep] & its %aft are outside ! bron*oscope1 b its r\nd$ portion is upp]mo/ & w glide ov] ! tissues )\t trauma ^u c>eful )drawal ( ! tube & safety p94 ,c>e mu/ be tak5 to rotate ! p9 s t x lies 9 ! sagittal plane ( ! glottis ) ! keep] plac$ po/]iorly1 = ! reason t ! base ( ! glottic triangle is po/]ior1 & t ! po/]ior wall ( ! l>ynx is membran\s above ! cricoid c>tilage1 & w yield4 ,a small safety-p9 may be remov$ by v]sion1 ! po9t be+ turn$ into a bran* bron*ial orifice4 ,no "o %\ld ?9k ( attempt+ ! extraction ( a safety p9 lodg$ po9t upw>d )\t hav+ practic$ = at lea/ a hundr$ h\rs on ! rubb] tube manik94 ,?is practice %\ld be c>ri$ out by anyone expect+ to d endoscopy1 because x af=ds excell5t education ( ! eye & ! f+]s 9 ! endoscopic manipulation ( any k9d ( =eign body4 ,!n1 :5 a safety p9 case is enc\nt]$1 ! bron*oscopi/ w be prep>$ to cope ) its difficulties1 & he w be able to det]m9e :i* ( ! me?ods w be be/ suit$ to 8 p]sonal equation 9 ! p>ticul> case4 ,,fig4 #hf4--,s*ema illu/rat+ ! upp]-lobe-bron*us problem1 comb9$ ) ! mu%room-an*or problem & ! au?or's me?od = _! solution4 ,! pati5t be+ recumb5t1 ! bron*oscopi/ look+ d[n ! "r ma9 bron*us1 ,m1 sees ! po9t ( ! tack project+ f ! "r upp]-lobe-bron*us1 ,a4 ,he seizes ! po9t ) ! side-curv$ =ceps2 !n slides d[n ! bron*oscope to ! position %[n dott$ at ,b4 ,next he pu%es ! bron*oscopic tube-m\? d[nw>d & m$ianw>d1 simultane\sly mov+ ! pati5t's head to ! "r1 ?us sw++ ! bron*oscopic level on its fulcrum1 & dragg+ ! tack d[nw>d & inw>d out ( its b$1 to ! position1 #a74 ,traction1 z %[n at ,c1 w !n safely & easily )draw ! tack4 ,a v small bron*oscope is ess5tial4 ,! lip ( ! bron*oscopic tube-m\? mu/ be us$ to pry ! =ceps d[n & ov]1 & ! lip mu/ be br\ght close to ! tack j be=e ! pry+-pu%+ movem5t4 ,s1 "r /em-bron*us4 ,,fig4 #hg4--,"o me?od ( deal+ ) an op5 safety p9 )\t clos+ x4 ,removal ( ,d\ble ,po9t$ ,tacks4--,if ! tack or /aple be small1 & lodg$ 9 a relatively l>ge tra*ea a v]sion may be done4 ,t is1 ! /aple may be turn$ ov] ) ! hook or rotation =ceps & br\ght out ) ! po9ts trail+4 ,) a long /aple 9 a *ild's tra*ea ! be/ me?od is to coax ! intrud] along g5tly "u ocul> guidance1 nev] mak+ traction en\gh to bury ! po9t deeply1 & lift+ ! po9t ) ! hook :5ev] x %[s any incl9ation to ent] ! wall4 ,great c>e & dext]ity are requir$ to get ! intrud] ?r\gh ! glottis4 ,9 c]ta9 locations1 "o or bo? po9ts may be turn$ into bran* bron*i z illu/rat$ 9 ,fig4 #hh1 or ov] ! c>9a into ! opposite ma9 bron*us4 ,ano!r me?od is to get bo? po9ts into ! tube-m\?4 ,?is may be favor$1 z demon/rat$ by my assi/ant1 ,dr4 ,gabriel ,tuck]1 by tilt+ ! /aple s z to get bo? po9ts into ! longe/ diamet] ( ! tube-m\?4 ,9 "s cases ,i h squeez$ ! bron*oscope 9 a vise to create an oval tube-m\?4 ,9 o!r cases ,i h us$ exp&+ =ceps ) groov$ blades4 ,,fig4 #hh4-,s*ema illu/rat+ podalic v]sion ( bron*ially-lodg$ /aples or d\ble-po9t$ tacks4 ,h1 bron*oscope4 ,a1 swoll5 mucosa cov]+ po9ts ( /aple4 ,at ,e ! /aple has be5 manipulat$ upw>d ) bron*oscopic lip & hooks until ! po9ts are opposite ! bran* bron*ial orifices1 ,b1 ,c4 ,traction be+ made 9 ! direction ( ! d>t 7,f71 by means ( ! rotation =ceps1 & c\nt]pressure be+ made ) ! bron*oscopic lip on ! po9ts ( ! /aple1 ! po9ts ent] ! bran* bron*i & p]mit ! /aple to be turn$ ov] & remov$ ) po9ts trail+ h>mlessly beh9d 7,k74 ,! ,extraction ( ,tightly ,fitt+ ,=eign ,bodies f ! ,bron*i4 ,annul> ,edema4--,su* objects z m>bles1 pebbles1 corks1 etc41 are drawn deeply & ) =ce by ! inspiratory bla/ into ! smalle/ bron*us !y c ent]4 ,! air di/al to ! impact$ =eign body is soon absorb$1 & ! negative pressure ?us produc$ increases ! impaction4 ,a r+ ( edemat\s mucosa quickly =ms & cov]s ! pres5t+ "p ( ! object1 leav+ visible only a small surface 9 ! c5t] ( an acute edemat\s /5osis4 ,a =ceps ) n>r[1 /iff1 expansive-spr+ jaws may press back a portion ( ! edema & may all[ a grasp on ! sides ( ! =eign body2 b usually ! attempt to apply =ceps :5 !re are no spaces betwe5 ! pres5t+ "p ( ! =eign body & ! bron*ial wall1 w result only 9 pu%+ ! =eign body deep]499 ,a bett] me?od is to use ! lip ( ! bron*oscope to press back ! swoll5 mucosa at "o po9t1 s t a hook may be introduc$ bel[ ! =eign body1 :i* !n c be work$ up to a wid] place :]e =ceps may be appli$ 7,fig4 #hi74 ,sometimes ! object may ev5 be held firmly aga9/ ! tube m\? ) ! hook & ?us extract$4 ,= ?is ! unslant$ tube-m\? is us$4 99 ,! au?or's new ball =ceps are v successful ) ball-be>+ balls & m>bles4 ,,fig4 #hi4--,s*ema illu/rat+ ! use ( ! lip ( ! bron*oscope 9 disimpaction ( =eign bodies4 ,a & ,b %[ an annul> edema above ! =eign body1 ,f4 ,at ,c ! edemat\s mucosa is be+ repress$ by ! lip ( ! tube m\?1 p]mitt+ ins9uation ( ! hook1 ,h1 pa/ "o side ( ! =eign body1 :i* is !n )drawn to a conv5i5t place = application ( ! =ceps4 ,?is repression by ! lip is (t5 us$ = purposes o!r ?an ! ins]tion ( hooks4 ,! lip ( ! esophagoscope c be us$ 9 ! same way4 ,extraction ( ,s(t ,friable ,=eign ,bodies f ! ,tra*eobron*ial ,tree4--,! difficulties "h consi/ 9 ! liability ( cru%+ or fragm5t+ ! object1 & scatt]+ portions into m9ute bron*i1 z well z ! problem ( disimpaction f a r+ ( annul> edema1 ) little or no =ceps space4 ,!re is usually 9 ^! cases an abundance ( purul5t secretion :i* fur!r h9d]s ! "w4 ,! great dang] ( pu%+ ! =eign body d[nw>d s t ! swoll5 mucosa hides x completely f view1 mu/ always be kept 9 m9d4 ,extremely delicate =ceps ) r broad blades are requir$ = ?is "w4 ,! f5e/rat$ peanut =ceps are be/ = l>ge pieces 9 ! l>ge bron*i4 ,! op]ator %\ld develop 8 tactile s5se ) =ceps by repeat$ practice 9 ord] to acquire ! skill to grasp peanut k]nels suffici5tly firmly to hold !m dur+ )drawal1 yet n s firmly z to cru% !m4 ,nipp+ (f an edge by n ins]t+ ! =ceps f> en\gh is also to be avoid$4 ,small fragm5ts "u #b mm4 9 diamet] may be expell$ ) ! secretions & fragm5ts may be f\nd on ! sponges & 9 ! secretions aspirat$ or remov$ by sponge pump+4 ,x is1 h[ev]1 nev] ju/ifiable delib]ately to break a friable =eign body ) ! hope t ! fragm5ts w be expell$1 = ^! may be aspirat$ into small bron*i1 & cause multiple abscesses4 ,a hook may be f\nd useful 9 deal+ ) r\nd1 friable1 =eign bodies2 & 9 "s cases ! me*anical spoon or safety-p9 clos] may be us$ to advantage4 ,! =eign body is !n br\ght close to1 b n cru%$ aga9/ ! tube m\?4 #agd ,removal ( animal objects f ! tra*eobron*ial tree is readily accompli%$ ) ! side-curv$ =ceps4 ,lee*es are n uncommon intrud]s 9 ,european c\ntries4 ,small insects are usually c\gh$ out4 ,worms & l>vae may be f\nd4 ,coca9e or salt solution w cause a lee* to loos5 its hold4 ,=eign bodies 9 ! upp]-lobe bron*i are =tunately n common4 ,if ! object is n too f> out to ! p]iph]y x may be grasp$ by ! upp]-lobe-bron*us =ceps 7,fig4 #ij71 guid$ by ! collaboration ( ! fluoroscopi/4 ,^! =ceps are made s z to rea* high into ! asc5d+ bran*es ( ! upp]-lobe bron*us4 ,full-curv$ coil-spr+ hooks w rea* high1 b mu/ be us$ ) ! utmo/ caution1 & ! me?od ( _! dis5gagem5t mu/ be practic$ be=eh&4 ,p5etrat+ ,projectiles4--,=eign bodies t h p5etrat$ ! *e/ wall & lodg$ 9 ! lung may be remov$ by oral bron*oscopy if ! intrud] is n l>g] ?an ! lum5 ( ! correspond+ ma9 bron*us 7see ,bibliography1 #dc7 ,,fig4 #ij4--,s*ematic illu/ration ( ! au?or's upp]-lobe-bron*us =ceps 9 position grasp+ a p9 9 an ant]iorly asc5d+ bran* ( ! upp]-lobe bron*us4 ,t1 ,tra*ea2 ,,ul1 upp]-lobe bron*us2 ,,lb1 left bron*us2 ,,sb1 /em bron*us4 ,^! =ceps are made to ext5d ar\nd #ahj degrees4 ,,rules ,,= ,,endoscopic ,,=eign ,,body ,,extraction #a4 ,nev] endoscope a =eign body case unprep>$1 ) ! idea ( tak+ a prelim9>y look4 #b4 ,approa* c>efully ! suspect$ location ( a =eign body1 s z n to ov]ride any portion ( x4 #age #c4 ,avoid grasp+ a =eign body ha/ily z soon z se54 #d4 ,! %ape1 size & position ( a =eign body1 & its relations to surr\nd+ /ructures1 %\ld be /udi$ be=e attempt+ to apply ! =ceps4 7,exception cit$ 9 ,rule #aj47 #e4 ,prelim9>y /udy ( a =eign body %\ld be f a di/ance4 #f4 ,z ! fir/ grasp ( ! =ceps is ! be/1 x %\ld be well plann$ be=eh& s z to seize ! prop] "p ( ! intrud]4 #g4 ,) all long =eign bodies ! motto %\ld be ,se>*1 n = ! =eign body1 b = its ne>] end4 ,) p9s1 ne$les1 & ! l1 ) po9t upw>d1 se>* always = ! po9t4 ,try to see x fir/4 #h4 ,rememb] t a long =eign body grasp$ ne> ! middle becomes1 me*anically speak+1 a toggle & r+4 #i4 ,rememb] t ! mortality to foll[ failure to remove a =eign body does n ju/ify probably fatal viol5ce dur+ its removal4 #aj4 ,l>yngeally lodg$ =eign bodies1 because ( ! likelihood ( dislodgm5t & loss1 may be seiz$ by any "p fir/ pres5t$1 & plan ( )drawal c be det]m9$ aft]w>d4 #aa4 ,= simil> reasons1 l>yngeal cases %\ld be dealt ) only 9 ! au?or's position 7,fig4 #ec74 #ab4 ,an esophagoscopy may be ne$$ 9 a bron*oscopic case1 or a bron*oscopy 9 an esophageal case4 ,9 e case bo? k9ds ( tubes %\ld be /]ile & ready be=e />t+4 ,x is ! unexpect$ t happ5s 9 =eign body endoscopy4 #ac4 ,d n pull on a =eign body unless x is prop]ly grasp$ to come away readily )\t trauma4 ,!n d n pull h>d4 #ad4 ,d no h>m1 if y _c remove ! =eign body4 #ae4 ,full-curv$ hooks are to be us$ 9 ! bron*i ) greate/ caution1 if us$ at all1 le/ !y cat* inextricably 9 bran* bron*i4 #agf #af4 ,don't =ce a =eign body d[nw>d4 ,coax x back4 ,! deep] x gets ! great] y\r difficulties4 #ag4 ,! wat*word ( ! bron*oscopi/ %\ld be1 ,if ,i c d no good1 ,i w at lea/ d no h>m4 ,fluoroscopic bron*oscopy is s deceptively easy f a sup]ficial1 !oretical1 po9t ( view t x has be5 us$ unsuccessfully 9 cases easily h&l$ 9 ! regul> endoscopic way ) ! eye at ! proximal tube-m\?4 ,9 a collect$ s]ies ( cases by v>i\s op]ators ! object 0 remov$ 9 #ff4g p] c5t ) a mortality ( #da4f p] c5t4 ,9 ! problem ( a p9 locat$ out ( ! field ( bron*oscopic vision1 ! fluoroscopi/ w yield invaluable aid4 ,an extremely delicate =ceps is to be ins]t$ clos$ into ! invad$ bron*us1 ! grasp on ! object be+ confirm$ by ! fluoroscopi/4 ,x is to be kept 9 m9d t :ile ! object itself may be 9 ! grasp ( ! =ceps1 ! fluoroscope w n %[ :e!r !re may n be includ$ 9 ! =ceps' grasp a bron*ial spur or o!r tissue1 ! te>+ ( :i* may be fatal4 ,!re=e traction mu/ n be suffici5t to lac]ate tissue4 ,if ! =eign body does n come readily x mu/ be releas$1 & a new grasp may !n be tak54 ,all ( ! cautions 9 faulty seizure already m5tion$1 apply ) p>ticul> =ce to fluoroscopic bron*oscopy4 ,! fluoroscope is ( aid 9 f9d+ =eign bodies held 9 abscess cavities4 ,! fluoroscope %\ld %[ bo? ! lat]al & ant]opo/]ior planes4 ,to accompli% ?is quickly1 two ,coolidge tubes & two scre5s are necess>y4 ,fluoroscopic bron*oscopy1 because ( its high mortality & l[ p]c5tage ( successes1 %\ld be tri$ only aft] regul>1 ocul>ly guid$1 p]oral bron*oscopy has fail$1 & only by ^? :o h _h exp]i5ce 9 ocul>ly guid$ bron*oscopy4 #agg ,,*apt] ,,xvi--,,=eign ,,bodies ,,9 ,,! ,,bron*i ,,= ,,prolong$ ,,p]iods ,! soj\rn ( an inorganic =eign body 9 ! bron*us = a ye> or m is foll[$ by ! developm5t ( bron*iectasis1 pulmon>y abscess1 & fibr\s *anges4 ,! symptoms ( tub]culosis may all be pres5t$1 b tub]cle bacilli h nev] be5 f\nd associat$ ) any ( ! _m cases t h come to ! ,bron*oscopic ,cl9ic499 ,! hi/ory ( repeat$ attacks ( malaise1 fev]1 *ills1 & sweats la/+ = a few days & t]m9at$ by ! expulsion ( an am\nt ( f\l pus1 sugge/s ! int]mitt5t dra9age ( an abscess cavity1 & special /udy %\ld be made to elim9ate =eign body z ! cause ( ! condition1 9 all su* cases1 :e!r !re is any hi/ory ( a =eign body accid5t or n4 ,bron*oscopy = diagnosis is to be done unless ! etiology c be def9itely prov5 by o!r means4 ,9 all cases ( *ronic *e/ disease =eign body %\ld be elim9at$ z a matt] ( r\t9e4 99 ,"o exception has rec5tly come to ! ,cl9ic4 #ab ,! "t ( aspiration ( a =eign body may be unkn[n1 hav+ possibly occurr$ 9 infancy1 dur+ n>cosis1 or ! object may ev5 ent] ! l[] air passages )\t ! pati5t be+ aw>e ( ! accid5t1 z happ5$ ) a p>ticul>ly intellig5t bus9ess man :o unkn[+ly aspirat$ ! tip ( an atomiz] :ile spray+ 8 ?roat4 ,9 _m o!r cases ! accid5t _h be5 =gott54 ,9 /ill o!rs1 9 spite ( ! pati5t's /atem5t ( a conviction t ! tr\ble 0 due to a =eign body he _h aspirat$1 ! physician did n consid] x wor?y ( suffici5t consid]ation to w>rant a ro5tg5ray exam9ation4 ,x is curi\s to note ! v>i\s op9ions held 9 reg>d to ! gravity ( ! pres5ce ( a bron*ial =eign body4 ,"o pati5t 0 told by 8 physician t ! pres5ce ( a /aple 9 8 bron*us 0 an impossibility1 = he w\ld n h liv$ five m9utes aft] ! accid5t4 ,o!rs consid] ! pres5ce ( a =eign body 9 ! bron*us z comp>atively h>mless1 9 spite ( ! repeat$ reports ( invalidism & fatality 9 ! m$ical lit]ature ( c5turies4 ,! old] au?orities /ate t all cases ( prolong$ bron*ial =eign body soj\rn di$ f ph?isis pulmonalis1 & x is /ill ! op9ion ( "s practition]s t ! pres5ce ( a =eign body 9 ! lung pr$isposes to ! developm5t ( true tub]culosis4 ,) ! dissem9ation ( k reg>d+ ! possibility ( bron*ial =eign body1 & ! m>vell\s success 9 _! removal by bron*oscopy1 ! cases ( prolong$ =eign body soj\rn %\ld decrease 9 numb]4 ,x %\ld be ! recogniz$ rule1 & n ! exception1 t all *e/ conditions1 acute or *ronic1 %\ld h ! b5efit ( ro5tg5ographic /udy1 ev5 ap>t f ! possibility ( =eign body4 ,(t5 ev5 ) ! cle> hi/ory ( =eign-body aspiration1 bo? pati5t & physician are delud$ by a relatively long p]iod ( quiesc5ce 9 :i* no symptoms are app>5t4 ,?is symptomless int]val is foll[$ soon] or lat] by ev] increas+ c\gh & expectoration ( sputum1 f9ally by bron*iectasis & pulmon>y abscess1 *ronic sepsis1 & invalidism4 ,pa?ology4--,if ! =eign body completely ob/ructs a ma9 bron*us1 prev5t+ bo? a]ation & dra9age1 su* rapid de/ruction ( lung tissue foll[s t ext5sive pa?ologic *anges may result 9 a few mon?s1 or ev5 9 a few weeks1 9 ! case ( irritat+ =eign bodies su* z peanut k]nels & s(t rubb]4 ,v m9ute1 inorganic =eign bodies may become ency/$ z 9 an?racosis4 ,l>ge objects1 h[ev]1 d n become ency/$4 ,! object is drawn d[n by gravity & aspirat$ into ! smalle/ bron*us x c ent]4 ,lat] ! negative pressure bel[ f absorption ( air impacts x /ill fur!r4 ,swell+ ( ! bron*ial mucosa f irritation plus infection completes ! occlusion ( ! bron*us4 ,ret5tion ( secretions & bact]ial decomposition !re( produces fir/ a dr[n$ lung 7natural passages full ( pus72 !n sl\gh+ or ulc]ation 9 ! tissues plus ! pressure ( ! pus1 causes bron*iectasis2 fur!r de/ruction ( ! c>tilag9\s r+s results 9 true abscess =mation bel[ ! =eign body4 ,! productive inflammation at ! site ( lodgem5t ( ! =eign body results 9 cicatricial contraction & ! =mation ( a /ricture at ! top ( ! cavity1 9 :i* ! =eign body is usually held4 ,! abscess may ext5d to ! p]iph]y & rupture into ! pleural cavity4 ,x may dra9 int]mitt5tly into a bron*us4 ,c]ta9 irritat+ =eign bodies1 su* z s(t rubb]1 may produce gangr5\s bron*itis & multiple abscesses4 ,= obs]vations on pa?ology 7see ,bibliography1 #ch74 ,prognosis4--,if ! =eign body be n remov$1 ! result+ *ronic sepsis or pulmon>y hemorrhage w prove fatal4 ,removal ( ! =eign body usually results 9 complete recov]y )\t fur!r local treatm5t4 ,occasionally1 second>y dilatation ( a bron*ial /ricture may be requir$4 ,all cases w ne$1 besides removal ( ! =eign body1 an antitub]cul\s regim51 & (f] a good prognosis if ?is be foll[$4 ,treatm5t4--,bron*oscopy %\ld be done 9 all cases ( *ronic pulmon>y abscess & bron*iectasis ev5 ?\gh radiographic /udy reveals no %ad[ ( =eign body4 ,! pati5t by assum+ a po/ure ) ! head l[]$ is urg$ to expel spontane\sly all ! pus possible1 be=e ! bron*oscopy4 ,! aspirat+ bron*oscope 7,fig4 #b1 ,e7 is (t5 useful 9 cases :]e l>ge am\nts ( secretion may be anticipat$4 ,granulations may require removal ) =ceps & spong+4 ,di/urb$ granulations result 9 ble$+ :i* fur!r hamp]s ! op]ation2 !re=e1 !y %\ld n be t\*$ until ready to apply ! =ceps1 unless x is impossible to /udy ! pres5tation )\t di/urb+ !m4 ,= ?is reason secretions hid+ a =eign body %\ld be remov$ ) ! aspirat+ tube 7,fig4 #i7 r ?an by swabb+ or sponge-pump+1 :5 ! bron*oscopic tube-m\? is close to ! =eign body4 ,x is inadvisable1 h[ev]1 to ins]t a =ceps into a mass ( granulations to grope bl9dly = a =eign body1 ) no k ( ! pres5tation1 ! =ceps spaces1 or ! location ( bran*-bron*ial orifices into :i* "o blade ( ! =ceps may g4 ,dilatation ( a /ricture may be necess>y1 & may be accompli%$ by ! =ms ( bron*ial dilators %[n 9 ,fig4 #be4 ,! holl[ type ( dilator is to be us$ 9 cases 9 :i* ! =eign body is held 9 ! /ricture 7,fig4 #hc74 ,?is dilator may be pu%$ d[n ov] ! /em ( su* an object z a tack1 & ! /ricture dilat$ )\t ! risk ( pu%+ ! object d[nw>d4 ,x is only r>ely1 h[ev]1 t ! po9t ( a tack is free4 ,d5se cicatricial tissue may require incision or excision4 ,int]nal bron*otomy is d\btless1 a v dang]\s proc$ure1 ?\gh no fatalities h occurr$ 9 any ( ! ?ree cases 9 ! ,bron*oscopic ,cl9ic4 ,x is advisable only z a la/ resort4 #aha ,,*apt] ,,xvii--,,unsuccessful ,,bron*oscopy ,,= ,,=eign ,,bodies ,! limitations ( bron*oscopic removal ( =eign bodies are usually manife/$ 9 ! failure to f9d a small =eign body :i* has ent]$ a m9ute bron*us f> d[n & out t[>d ! p]iph]y4 ,:5 localization by means ( transp>5t films1 fluoroscopy1 & endobron*ial bismu? insufflation has fail$1 ! "q arises z to ! advisability ( endoscopic excision ( ! tissue int]v5+ betwe5 ! =eign body & bron*oscope ) ! aid ( two fluoroscopes1 "o = ! lat]al & ! o!r ! v]tical plane4 ,) =eign bodies 9 ! l>g] bron*i ne> ! root ( ! lung su* a proc$ure is unnecess>y1 & injury to a l>ge vessel w\ld be almo/ c]ta94 ,at ! extreme p]iph]y ( ! lung ! dang] is less1 = ! vessels are small] & s]i\s hemorrhage less probable1 ?r\gh ! ret5tion & decomposition ( blood 9 small bron*i ) lat] abscess =mation is a cont+5cy4 ,! nature ( ! bridge ( tissue is to be consid]$2 %\ld x be cicatricial1 ! result ( prolong$ inflammatory processes1 x may be c>efully excis$ )\t v great risk ( s]i\s complications4 ,! blood vessels are dim9i%$ 9 size & numb] by ! *ronic productive inflammation1 :i* m ?an (fsets _! less5$ contractility4 ,! possibility ( ! =eign body be+ c\gh$ out aft] suppurative processes h loos5$ its impaction is too remote2 & ! lesions e/abli%$ may result fatally ev5 aft] ! expulsion ( ! object4 ,pulmon>y abscess =mation & rupture into ! pleura %\ld n be await$1 = ! =eign body does n (t5 foll[ ! pus into ! pleural cavity4 ,x rema9s 9 ! lung1 held 9 a b$ ( granulation tissue4 ,fur!rmore1 to await ! developm5t is to subject ! pati5t to a prolong$ & p]haps fatal sepsis1 or a fatal pulmon>y hemorrhage f ! erosion ( a vessel by ! suppurative process4 ,! rec5t developm5ts 9 ?oracic surg]y h greatly decreas$ ! op]ative mortality ( ?oracotomy1 s t ?is op]ation is to be consid]$ :5 bron*oscopy has fail$4 ,bron*oscopy c be consid]$ z hav+ fail$1 = ! "t be+1 :5 two or m exp]t bron*oscopi/s on repeat$ se>* h be5 unable to f9d ! =eign body or to dis5tangle x2 b ! art ( bron*oscopy is develop+ s rapidly t ! failures ( a few ye>s ago w\ld be easy successes today4 ,be=e consid]+ ?oracotomy mon?s ( /udy ( ! me*anical problem are advisable4 ,x is probable t any =eign body ( appreciable size t has gone d[n ! natural passages c be br\ght back ! same way4 ,9 ! ev5t ( a =eign body rea*+ ! pleura1 ei!r ) or )\t pus1 x %\ld be remov$ imm$iately by pleuroscopy or by ?oracotomy1 )\t wait+ = adhesive pleuritis4 ,! problem may be summ>iz$ ?us3 #a4 ,l>ge =eign bodies 9 ! tra*ea or l>ge bron*i c always be remov$ by bron*oscopy4 #b4 ,! developm5t ( bron*oscopy hav+ subsequ5tly solv$ ! problems pres5t$ by previ\s failures1 x seems probable t by pati5t developm5tal endeavor1 any =eign body ( appreciable size t has gone d[n ?r\gh ! natural passages1 c be bron*oscopically remov$ ! same way1 provid$ fatal trauma is avoid$4 ,at ! au?or's ,bron*oscopic ,cl9ics #ih4g p] c5t ( =eign bodies h be5 remov$4 ,,*apt] ,,xviii--,,=eign ,,bodies ,,9 ,,! ,,esophagus ,etiology4--,! lodgem5t ( =eign bodies 9 ! esophagus is influ5c$ by3 #a4 ,! %ape ( ! =eign body 7disc-%ap$1 po9t$1 irregul>74 #b4 ,resili5cy ( ! object 7safety p9s74 #c4 ,! size ( ! =eign body4 #d4 ,n>r[+ ( ! esophagus1 spasmodic or organic1 normal1 or pa?ologic4 #e4 ,p>alysis ( ! normal esophageal propulsory me*anism4 ,! lodgem5t ( a bolus ( ord9>y food 9 ! esophagus is /rongly sugge/ive ( a preexi/+ n>r[+ ( ! lum5 ( ei!r a spasmodic or organic nature2 a l>ge bolus ( food1 poorly ma/icat$ & hurri$ly swall[$1 may1 h[ev]1 become impact$ 9 a p]fectly normal esophagus4 ,c>elessness is ! cause ( ov] #hj p] c5t ( ! =eign bodies 9 ! esophagus 7see ,bibliography1 #bi74 ,site ( ,lodgem5t4--,almo/ all =eign bodies are arre/$ 9 ! c]vical esophagus at ! level ( ! sup]ior ap]ture ( ! ?orax4 ,a physiologic n>r[+ is pres5t at ?is level1 produc$ 9 "p by muscul> contraction1 & ma9ly by ! cr[d+ ( ! adjac5t visc]a into ! fix$ & n>r[ upp] ?oracic ap]ture4 ,if dislodg$ f ?is position ! =eign body usually passes d[nw>d to be arre/$ at ! next n>r[+ or to pass into ! /oma*4 ,! esophagoscopi/ :o enc\nt]s ! difficulty ( introduction at ! cricoph>yngeal fold expects to f9d ! =eign body above ! fold4 ,su*1 h[ev]1 is almo/ nev] ! case4 ,! cricoph>yngeus muscle functionates 9 />t+ ! =eign body d[nw>d z if x 7 food2 b ! n>r[+ at ! upp] ?oracic ap]ture arre/s x because ! esophageal p]i/altic musculature is feeble z comp>$ to ! p[]ful inf]ior con/rictor4 ,symptoms4--,dysphagia is ! mo/ frequ5t compla9t 9 cases ( esophageally lodg$ =eign bodies4 ,a v small object may excite suffici5t spasm to cause aphagia1 :ile a relatively l>ge =eign body may be tol]at$1 aft] a "t1 s t ! swall[+ function may seem normal4 ,int]mitt5t dysphagia sugge/s ! tilt+ or %ift+ ( a =eign body 9 a valve-l fa%ion2 b may be due to occlusion ( ! by-passages by food arre/$ by ! =eign body4 ,dyspnea may be pres5t if ! =eign body is l>ge en\gh to compress ! tra*ea4 ,c\gh may be excit$ by reflex irritation1 ov]fl[ ( secretions into ! l>ynx1 or by p]=ation ( ! po/]ior tra*eal wall1 traumatic or ulc]ative1 all[+ leakage ( food or secretion into ! tra*ea4 7,see ,*apt] ,,xii = discussion ( symptomatology & diagnosis47 ,prognosis4--,a =eign body lodg$ 9 ! esophagus may prove quickly fatal f hemorrhage due to p]=ation ( a l>ge vessel2 f asphyxia by pressure on ! tra*ea2 or f p]=ation & septic m$ia/9itis4 ,sl[] fatalities may result f suppuration ext5d+ to ! tra*ea or bron*i ) consequ5t edema & asphyxia4 ,soon] or lat]1 if n remov$1 ! =eign body causes dea?4 ,x may be tol]at$ = a long p]iod ( "t1 caus+ abscess1 c]vical cellulitis1 fi/ul\s tracts1 & ultimately extreme /5osis f cicatricial contraction4 ,p]i*ondritis ( ! l>yngeal or tra*eal c>tilages may foll[1 & result 9 l>yngeal /5osis requir+ tra*eotomy4 ,! damage produc$ by ! =eign body is (t5 mu* less ?an t caus$ by bl9d & ill-advis$ attempts at removal4 ,if ! =eign body becomes dislodg$ & moves d[nw>d1 ! dang] ( inte/9al p]=ation is enc\nt]$4 ,! prognosis1 !re=e1 mu/ be gu>d$ s long z ! intrud] rema9s 9 ! body4 ,treatm5t4--,x is a mi/ake to try to =ce a =eign body into ! /oma* ) ! /oma* tube or b\gie4 ,s\nd+ ! esophagus ) b\gies to det]m9e ! level ( ! ob/ruction1 or to palpate ! nature ( ! =eign body1 is unnecess>y & dang]\s4 ,esophagoscopy %\ld n be done )\t a previ\s ro5tg5ographic & fluoroscopic exam9ation ( ! *e/ & esophagus1 except = urg5t reasons4 ,! level ( ! /5osis1 & usually ! nature ( ! =eign body1 c ?us be decid$4 ,bl9d in/rum5tation is dang]\s1 & 9 view ( ! safety & success ( esophagoscopy1 repreh5sible4 ,if = any reason removal %\ld be delay$1 bismu? sub-nitrate1 gramme #j4f1 %\ld be giv5 dry on ! tongue e f\r h\rs4 ,x w adh]e to ! d5ud$ surfaces4 ,! addition ( calomel1 gramme #j4jjc1 = a few doses w increase ! antiseptic action4 ,%\ld swall[+ be pa9ful1 gramme #j4b ( or?(orm or ane/hes9 w be helpful4 ,emetics are ineffici5t & dang]\s4 ,hold+ ! pati5t up by ! heels is r>ely1 if ev]1 successful if ! =eign body is 9 ! esophagus4 ,9 ! report$ cases ! intrud] 0 probably 9 ! ph>ynx4 ,ext]nal esophagotomy = ! removal ( =eign bodies is unju/ifiable until esophagoscopy has fail$ 9 ! h&s ( at lea/ two skillful esophagoscopi/s4 ,x has be5 ! obs]vation 9 ! ,bron*oscopic ,cl9ic t e =eign body t has gone d[n ?r\gh ! m\? into ! esophagus c be br\ght back ! same way1 unless x has already p]=at$ ! esophageal wall1 9 :i* ev5t x is no long] a case ( =eign body 9 ! esophagus4 ,! mortality ( ext]nal esophagotomy = =eign bodies is f tw5ty to =ty-two p] c5t1 :ile t ( esophagoscopy is less ?an two p] c5t1 if ! =eign body has n already set up a s]i\s complication be=e ! esophagoscopy4 ,fur!rmore1 ext]nal esophagotomy c be successful only ) objects lodg$ 9 ! c]vical esophagus &1 moreov]1 x has happ5$ t aft] ! esophagus has be5 op5$1 ! =eign body c\ld n be f\nd because ( dislodgem5t & passage d[nw>d dur+ ! relaxation ( ! g5]al ane/hesia4 ,%\ld ?is occur dur+ esophagoscopy1 ! =eign body c be foll[$ ) ! esophagoscope1 & ev5 if x is n ov]tak5 & remov$1 no risk has be5 incurr$4 ,esophagoscopy is ! "o me?od ( removal wor?y ( s]i\s consid]ation4 ,%\ld x repeat$ly fail 9 ! h&s ( two skillful endoscopi/s1 :i* w be v r>ely1 if ev]1 !n ext]nal op]ation is to be consid]$ 9 c]vically lodg$ =eign bodies4 #ahg ,,*apt] ,,xix--,,esophagoscopy ,,= ,,=eign ,,body ,indications4--,esophagoscopy is dem&$ 9 e case 9 :i* a =eign body is kn[n to be1 or suspect$ ( be+1 9 ! esophagus4 ,contra9dications4--,!re is no absolute contra9dication to c>eful esophagoscopy = ! removal ( =eign bodies1 ev5 9 ! pres5ce ( aneurism1 s]i\s c>diovascul> disease1 hyp]t5sion or ! l1 al?\gh ^! conditions w\ld r5d] ! proc$ure inadvisable4 ,%\ld ! pati5t be 9 bad condition f previ\s ill-advis$ or bl9d attempts at extraction1 endoscopy %\ld be delay$ until ! traumatic esophagitis has subsid$ & ! g5]al /ate improv$4 ,x is r>ely ! =eign body itself :i* is produc+ ^! symptoms1 & ! removal ( ! object w n cause _! imm$iate subsid5ce2 :ile ! passage ( ! tube ?r\gh ! lac]at$1 infect$1 & inflam$ esophagus might fur!r h>m ! pati5t4 ,moreov]1 ! =eign body w be difficult to f9d & to remove f ! edemat\s & ble$+ folds1 & ! risk ( foll[+ a false passage into ! m$ia/9um or ov]rid+ ! =eign body is great4 ,wat] />vation %\ld be reliev$ by means ( proctoclysis & hypod]moclysis be=e endoscopy is done4 ,! esophagitis is be/ treat$ by plac+ dry on ! tongue at f\r-h\r int]vals ! foll[+ p[d]3 ,rx4 ,ane/hes9444gramme #j4ab ,bismu? subnitrate444gramme #j4f ,calomel1 gramme #j4jjf to #j4jjc may be add$ to ea* p[d] = a few doses to increase ! antiseptic effect4 ,if ! pati5t c swall[ liquids x is be/ to wait "o week f ! "t ( ! la/ attempt at removal be=e any endoscopy = extraction be done4 ,?is w give "t = nature to repair ! damage & r5d] ! removal ( ! object m c]ta9 & less haz>d\s4 ,p]=ation ( ! esophagus by ! =eign body1 or by bl9d in/rum5tation1 is a contra9dication to esophagoscopy4 ,x is manife/$ by su* signs z subcutane\s emphysema1 swell+ ( ! neck1 fev]1 irritability1 increase 9 pulsatory & respiratory rates1 & pa9 9 ! neck or *e/4 ,gase\s emphysema is pres5t 9 "s cases1 & d5otes a dang]\s infection4 ,esophagoscopy %\ld be po/pon$ & ! treatm5t m5tion$ at ! end ( ?is *apt] in/itut$4 ,aft] ! subsid5ce ( all symptoms o!r ?an esophageal1 esophagoscopy may be done safely4 ,pleural p]=ation is manife/$ by ! usual signs ( pneumo?orax1 & w be demon/rat$ 9 ! ro5tg5ogram4 ,,esophagoscopic ,,extraction ,,( ,,=eign ,,bodies ,x is unwise to d an endoscopy 9 a =eign-body case = ! sole purpose ( tak+ a prelim9>y look4 ,ev]y?+ likely to be ne$$ = extraction ( ! intrud] %\ld be /]ile & ready at h&4 ,fur!rmore1 all requir$ in/rum5ts = l>yngoscopy1 bron*oscopy or tra*eotomy %\ld be prep>$ z a matt] ( r\t9e1 h[ev] r>ely !y may be ne$$4 ,spong+ %\ld be done cauti\sly le/ ! =eign body be hidd5 9 secretions or food accumulation1 & dislodg$4 ,small food masses (t5 lodge above ! =eign body & are be/ remov$ ) =ceps4 ,! folds ( ! esophagus are to be c>efully se>*$ ) ! aid ( ! lip ( ! esophagoscope4 ,if ! mucosa ( ! esophagus is lac]at$ ) ! =ceps all fur!r "w is greatly hamp]$ by ! ooz+2 if ! lac]ation involve ! esophageal wall ! accid5t may be fatal3 & at be/ ! t5d5cy ( ! tube-m\? to ent] ! lac]ation & create a false passage is v great4 ,ov]rid+ or failure to f9d a =eign body kn[n to be pres5t is expla9$ by ! collaps$ walls & folds cov]+ ! object1 s9ce ! esophagoscope _c be ( suffici5t size to smoo? out ^! folds1 & /ill be ( small en\gh diamet] to pass ! con/rict$ po9ts ( ! esophagus not$ 9 ! *apt] on anatomy4 ,objects are (t5 hidd5 j di/al to ! cricoph>yngeal fold1 :i* fur!rmore makes a v]itable *ute 9 ?r[+ ! end ( ! tube =w>d to ov]ride ! =eign body & to int]pose a lay] ( tissue betwe5 ! tube & ! object1 s t ! contact at ! side ( ! tube is n felt z ! tube passes ov] ! =eign body 7,fig4 #ia74 ,! *ief factors 9 ov]rid+ an esophageal =eign body are3 #a4 ,! *ute-l effect ( ! plica cricoph>yngeus4 #b4 ,! *ute-l effect ( o!r folds4 #c4 ,! lurk+ ( ! =eign body 9 ! unexplor$ pyri=m s9us4 #d4 ,! use ( an esophagoscope ( small diamet]4 #e4 ,! obscuration ( ! intrud] by secretion or food debris4 #f4 ,! obscuration ( ! intrud] by its p5etration ( ! esophageal wall4 #g4 ,! obscuration ( ! intrud] by inflammatory sequelae4 ,,fig4 #ia4--;,illu/rat+ ! hid+ ( a co9 by ! fold+ d[nw>d ( ! plica cricoph>yngeus4 ,! muscul> contraction ?r[s ! beak ( ! esophagoscope upw>d :ile ! int]pos$ tissue prev5ts ! tactile appreciation ( contact ( ! =eign body ) ! side ( ! tube aft] ! tip has pass$ ov] ! =eign body4 ,o!r folds may 9 r>e in/ances act simil>ly 9 hid+ a =eign body f view4 ,?is ov]rid+ ( a =eign body is apt to cause dang]\s dyspnea by compression ( ! p>ty wall4 ,! esophageal speculum = ! removal ( =eign bodies is useful :5 ! object is n m ?an #b cm4 bel[ ! cricoid 9 a *ild1 & #c cm4 9 ! adult4 ,! fold ( ! cricoph>yngeus c be repress$ po/]iorw>d by ! =ceps :i* are !n 9 position to grasp ! object :5 x is f\nd4 ,! au?or's d[n-jaw =ceps 7,fig4 #bb7 are v useful to rea* d[n back ( ! cricoph>yngeal fold1 because ( ! (t5 small po/]ior =ceps space4 ,! speculum has ! disadvantage ( n all[+ deep] se>* %\ld ! =eign body move d[nw>d4 ,9 infants1 ! *ild's size l>yngoscope may be us$ z an esophageal speculum4 ,g5]al ane/hesia is n only unnecess>y b dang]\s1 because ( ! dyspnea creat$ by ! endoscopic tube4 ,local ane/hesia is unnecess>y z well z dang]\s 9 *ildr52 & its application is likely to dislodge ! =eign body unless us$ z a tro*e4 ,=bes esophageal speculum is excell5t4 ,,me*anical ,,problems ,,( ,,esophagoscopic ,,removal ,,( ,,=eign ,,bodies ,! bron*oscopic problems consid]$ 9 ! previ\s *apt] %\ld be /udi$4 ,! extraction ( transfix$ =eign bodies pres5ts mu* ! same problem z ^? 9 ! bron*i1 ?\gh !re is no limit "h to ! di/ance an object may be pu%$ d[n to free ! po9t4 ,?91 %>p =eign bodies su* z bones1 d5tures1 p9s1 safety-p9s1 etcet]a1 are (t5 f\nd to lie crosswise 9 ! esophagus1 & x is imp]ative t "o end be dis5gag$ & ! long axis ( ! object be made to correspond to t ( ! esophagus be=e traction = removal is made 7,fig4 #ib74 ,%\ld ! intrud] be grasp$ 9 ! c5t] & traction ex]t$1 s]i\s & p]haps fatal trauma might ensue4 #aia ,,fig4 #ib4--,! problem ( ! horizontally transfix$ =eign body 9 ! esophagus4 ,! po9t1 ,d1 _h caught z ! bone1 ,a1 0 be+ swall[$4 ,! end1 ,e1 0 =c$ d[n to ,c1 by food or by bl9d attempts at pu%+ ! bone d[nw>d4 ,! wall1 ,f1 %\ld be lat]ally displac$ to ,j1 ) ! esophagoscope1 p]mitt+ ! =ceps to grasp ! end1 ,m1 ( ! bone4 ,traction 9 ! direction ( ! d>t w disimpact ! bone & p]mit x to rotate4 ,! rotation =ceps are us$ z at ,k4 ,,fig4 #ic4--,solution ( ! me*anical problem ( ! broad =eign body hav+ a %>p po9t by v]sion4 ,if )drawn ) pla9 =ceps z appli$ at ,a1 ! po9t ,b1 w rip op5 ! esophageal wall4 ,if grasp$ at ,c1 ! po9t1 ,d1 w rotate 9 ! direction ( ,f & w trail h>mlessly4 ,to p]mit ?is v]sion ! rotation =ceps are us$ z at ,h4 ,on ?is pr9ciple flat =eign bodies ) jagg$ or r\gh p>ts are s turn$ t ! pot5tially traumatiz+ p>ts trail dur+ )drawal4 ,! extraction ( broad1 flat =eign bodies hav+ a %>p po9t or a r\gh place on "p ( _! p]iph]y is be/ accompli%$ by ! me?od ( rotation z %[n 9 ,fig4 #ic4 ,extraction ( ,op5 ,safety-p9s f ! ,esophagus4--,an op5 safety p9 ) ! po9t d[n (f]s no p>ticul> me*anical difficulty 9 removal4 ,great c>e mu/ be ex]cis$1 h[ev]1 t x be n ov]ridd5 or pu%$ ^u1 z ei!r accid5t might result 9 p]=ation ( ! esophagus by ! p9 po9t4 ,! coil$ spr+ is to be s\ght1 & :5 f\nd1 seiz$ ) ! rotation =ceps & ! p9 ?us drawn into ! esophagoscope to effect closure4 ,an op5 safety-p9 lodg$ po9t upw>d 9 ! esophagus is "o ( ! mo/ difficult & dang]\s problems4 ,a ro5tg5ogram %\ld always be made 9 ! plane %[+ ! wide/ spread ( ! p94 ,x is to be rememb]$ t ! endoscopi/ c see b "o portion ( ! p9 at a "t 7except 9 cases ( v small safety-p9s7 & t if he grasps ! "p fir/ %[+1 :i* is almo/ inv>iably ! keep]1 fatal trauma w surely be inflict$ :5 traction is made4 ,x may be be/ to close ! safety p9 ) ! safety-p9 clos]1 z illu/rat$ 9 ,fig4 #cg4 ,= ?is purpose ,arr[smi?'s clos] is excell5t4 ,9 o!r cases x may prove be/ to dis5gage ! po9t ( ! p9 & to br+ ! po9t$ %aft into ! esophagoscope ) ! ,tuck] =ceps & )draw ! p91 =ceps1 & esophagoscope1 ) ! keep] & its %aft slid+ alongside ! tube4 ,! r\nd$ end ( ! keep] ly+ outside ! tube all[s x to slip along ! esophageal walls dur+ )drawal )\t inflict+ trauma2 h[ev]1 %\ld resi/ance be felt1 )drawal mu/ imm$iately cease & ! p9 mu/ be rotat$ into a diff]5t plane to release ! keep] f ! fold 9 :i* x has probably caught4 ,! s5se ( t\* w aid ! s5se ( sight 9 ! execution ( ?is maneuv] 7,fig4 #hg74 ,:5 ! p9 rea*es ! cricoph>yngeal level ! esophagoscope1 =ceps1 & p9 %\ld be turn$ s t ! keep] w be to ! "r1 n s mu* because ( ! cricoph>yngeal muscle z to escape ! po/]iorly protub]ant cricoid c>tilage4 ,9 c]ta9 cases 9 :i* x is f\nd t ! po9t$ %aft ( a small safety p9 has p5etrat$ ! esophageal wall1 ! p9 has be5 successfully remov$ by work+ ! keep] into ! tube m\?1 grasp+ ! keep] ) ! rotation =ceps or side-curv$ =ceps1 & pull+ ! :ole p9 into ! tube by /raight5+ x4 ,?is1 h[ev]1 is a dang]\s me?od & applicable 9 b few cases4 ,x is bett] to dis5gage ! po9t by d[nw>d & inw>d rotation ) ! ,tuck] =ceps4 ,v]sion ( a ,safety ,p94--,a safety p9 ( v small size may be turn$ ov] 9 a direction t w cause ! po9t to trail4 ,an advanc+ po9t w puncture4 ,?is is a dang]\s proc$ure ) a l>ge safety p94 ,endoga/ric ,v]sion4--,a v useful & comp>atively safe me?od is illu/rat$ 9 ,figs4 #id & #ie4 ,9 ! execution ( ?is maneuv] ! p9 is seiz$ by ! spr+ ) a rotation =ceps1 & ?us pass$ along ) ! esophagoscope into ! /oma* :]e x is rotat$ s t ! spr+ is upp]mo/4 ,x c !n be drawn into ! tube m\? s z to protect ! tissues dur+ )drawal ( ! p91 =ceps1 & esophagoscope z "o piece4 ,only v small safety-p9s c be )drawn ?r\gh ! esophagoscope4 ,spatula-protect$ ,me?od4--,safety-p9s 9 *ildr51 po9t upw>d1 :5 lodg$ high 9 ! c]vical esophagus may be readily remov$ ) ! aid ( ! l>yngoscope1 or esophageal speculum4 ,! keep] end is grasp$ ) ! alligator =ceps1 :ile ! spatul> tip ( ! l>yngoscope is work$ "u ! po9t4 ,in/rum5ts & =eign body are !n remov$ toge!r4 ,(t5 ! p9 po9t w cat* 9 ! light-*amb] :]e x is v safely lodg$4 ,if ! p9 be !n pull$ ^u x w /raight5 out & may be )drawn ?r\gh ! tube4 ,,fig4 #id4--;,endoga/ric v]sion4 ,"o ( ! au?or's me?ods ( removal ( upw>d po9t$ esophageally lodg$ op5 safety-p9s by pass+ !m into /oma*1 :]e !y are turn$ & remov$4 ,! fir/ illu/ration 7,a7 %[s ! rotation =ceps be=e seiz+ p9 by ! r+ ( ! spr+ end4 7,=ceps jaws are %[n op5+ 9 ! wrong diamet]47 ,at ,b is %[n ! p9 seiz$ 9 ! r+ by ! po9ts ( ! =ceps4 ,at ,c is %[n ! p9 c>ri$ into ! /oma* & ab\t to be rotat$ by )drawal4 ,d1 ! )drawal ( ! p9 into ! esophagoscope :i* w !reby close x4 ,if )drawn by flat-jaw$ =ceps z at ,f1 ! esophageal wall w\ld be fatally lac]at$4 ,d\ble po9t$ tacks & /aples1 :5 lodg$ po9t upw>d1 mu/ be turn$ s t ! po9ts trail on removal4 ,?is may be done by c>ry+ !m into ! /oma* & turn+ !m1 z describ$ "u safety-p9s4 ,! extraction ( =eign bodies ( v l>ge size f ! esophagus is greatly facilitat$ by ! use ( g5]al ane/hesia1 :i* relaxes ! spasmodic contractions ( ! esophagus (t5 occurr+ :5 attempt is made to )draw ! =eign body4 ,g5]al ane/hesia1 ?\gh entirely unnecess>y = introduction ( ! esophagoscope1 9 any case may be us$ if ! body is l>ge1 %>p1 & r\gh1 9 ord] to prev5t lac]ation ?r\gh ! muscul> contractions o!rwise incid5t to )drawal499 ,9 exceptional cases x may be necess>y to comm9ute a l>ge =eign body su* z a too? plate4 ,a l>ge smoo? =eign body may be difficult to seize ) =ceps4 ,9 ?is case ! me*anical spoon or ! au?or's safety-p9 clos] may be us$4 99 ,x mu/ always be rememb]$ t l>ge =eign bodies are v prone to cause dyspnea t r5d]s g5]al ane/hesia exce$+ly dang]\s especially 9 *ildr54 ,,fig4 #ie4--,lat]al ro5tg5ogram ( a safety-p9 9 a *ild ag$ #aa mon?s1 demon/rat+ ! esophageal location ( ! p9 9 ?is case & ! great value ( ! lat]al ro5tg5ogram 9 ! localization ( =eign bodies4 ,! p9 0 remov$ by ! au?or's me?od ( endoga/ric v]sion4 7,plate made by ,george ,c4 ,john/on 7 ,! extraction ( meat & o!r foods f ! esophagus at ! level ( ! upp] ?oracic ap]ture is usually readily accompli%$ ) ! esophageal speculum & =ceps4 ,9 c]ta9 cases ! me*anical spoon w be f\nd useful4 ,%\ld ! bolus ( food be lodg$ at ! l[] level ! esophagoscope w be requir$4 ,extraction ( ,=eign ,bodies f ! ,/rictur$ ,esophagus4--,=eign bodies ( relatively small size w lodge 9 a /rictur$ esophagus4 ,removal may be r5d]$ difficult :5 ! pati5t has an upp] /ricture relatively l>g] ?an ! l[] "o1 & ! =eign body pass+ ! fir/ "o lodges at ! second4 ,/ill m difficult is ! case :5 ! second /ricture is consid]ably bel[ ! fir/1 & n conc5tric4 ,"u ^! circum/ances x is be/ to divulse ! upp] /ricture me*anically1 :5 a small tube c be ins]t$ pa/ ! fir/ /ricture to ! site ( lodgem5t ( ! =eign body4 ,prolong$ soj\rn ( =eign bodies 9 ! esophagus1 :ile n s common z 9 ! bron*i is by no means ( r>e occurr5ce4 ,foll[+ _! removal1 /ricture ( great] or less ext5t is almo/ c]ta9 to foll[ f contraction ( ! fibr\s-tissue produc$ by ! =eign body4 ,fluoroscopic esophagoscopy is a que/ionable proc$ure1 = ! esophagus c be explor$ ?r\gh\t by sight4 ,9 cases 9 :i* x is suspect$ t a =eign body1 su* z p91 has p>tially escap$ f ! esophagus1 ! fluoroscope may aid 9 a detail$ se>* to det]m9e its location1 b "u no circum/ances %\ld x be ! guide = ! application ( =ceps1 because ! transp>5t b vital tissues are almo/ c]ta9 to be includ$ 9 ! grasp4 #aig ,complications & ,dang]s ( ,esophagoscopy = ,=eign ,bodies4 ,asphyxia f ! pressure ( ! =eign body1 or ! =eign body plus ! esophagoscope1 is a possibility 7,fig4 #ia74 ,faulty position ( ! pati5t1 especially a l[ position ( ! head1 ) faulty direction ( ! esophagoscope may cause ! tube m\? to press ! membran\s tra*eo-esophageal wall into ! tra*ea1 s z tempor>ily to occlude ! tra*eal lum51 creat+ a v dang]\s situation 9 a pati5t "u g5]al ane/hesia4 ,prompt introduction ( a bron*oscope1 ) oxyg5 & amyl nitrite insufflation & artificial respiration1 may be necess>y to save life4 ,! dang] is great]1 ( c\rse1 ) *lor(orm ?an ) e!r ane/hesia4 ,coca9 poison+ may occur 9 ^? hav+ an idiosyncrasy to ! drug4 ,coca9 %\ld nev] be us$ ) *ildr51 & is ( little use 9 esophagoscopy 9 adults4 ,its application is m annoy+ & requires m "t ?an ! esophagoscopic removal ( ! =eign bodies )\t local ane/hesia4 ,traumatic esophagitis1 septic m$ia/9itis1 c]vical cellulitis1 &1 mo/ dang]\s1 gangr5\s esophagitis may be pres5t1 caus$ by ! =eign body itself or ill-advis$ ef=ts at removal4 ,p]=ation ( ! esophagus ) ! esophagoscope is r>e1 9 skillful h&s1 if ! esophageal wall is s\nd4 ,! esophageal wall1 h[ev]1 may be weak5$ by ulc]ation1 malignant disease1 or trauma1 s t ! possibility ( mak+ a false passage %\ld always det] ! endoscopi/ f advanc+ ! tube beyond a visible po9t ( weak5+4 ,to avoid ent]+ a false passage previ\sly creat$1 is (t5 exce$+ly difficult1 & usually x is bett] to wait = oblit]ative adhesive inflammation to seal ! tissue lay]s toge!r4 ,treatm5t4--,acute esophagitis calls = re/ 9 b$1 /]ile liquid food1 & ! adm9i/ration ( bismu? p[d] m5tion$ 9 ! p>agraph on contra9dications4 ,an ice bag appli$ to ! neck may af=d "s relief4 ,! m\? %\ld be h\rly cleans$ ) ! foll[+ solution3 ,dak9's solution #a "p ,c9namon wat] #e p>ts4 ,emphysema unaccompani$ by pyog5ic processes usually requires no treatm5t1 ?\gh an occasional case may require punctures ( ! sk9 to lib]ate ! air4 ,gase\s emphysema & pus =mation urg5tly dem& e>ly ext]nal dra9age1 pref]ably beh9d ! /]noma/oid4 ,%\ld ! pleura be p]=at$ by sudd5 puncture pyo-pneumo?orax is inevitable4 ,prompt ?oracotomy = dra9age may save ! pati5t's life if ! m$ia/9um has n also be5 infect$4 ,=eign bodies ulc]at+ ?r\gh may rea* ! lung )\t pleural leakage because ( ! seal+ toge!r ( ! visc]al & p>ietal pleurae4 ,9 ! s]i\s degrees ( esophageal trauma1 p>ticul>ly if ! pleura be p]=at$1 ga/ro/omy is indicat$ to af=d re/ ( ! esophagus1 & = alim5tation4 ,a duod5al fe$+ tube may be plac$ ?r\gh an esophagoscope pass$ into ! /oma* 9 ! usual way ?r\gh ! m\?1 avoid+ by ocul> guidance ! p]=ation into :i* a bl9dly pass$ /oma* tube w\ld be v likely to ent]1 ) probably dang]\s results4 #aii ,,*apt] ,,xx--,,pleuroscopy ,=eign bodies 9 ! pleural cavity %\ld be imm$iately remov$4 ,! esophageal speculum ins]t$ ?r\gh a small int]co/al incision makes an excell5t pleuroscope1 its spatul> tip be+ ( p>ticul> value 9 mov+ ! lung out ( ! way4 ,?is o!rwise d>k cavity is ?us brilliantly illum9at$ )\t ! necessity ( mak+ a l>ge flap resection1 an important factor 9 ^? cases 9 :i* !re is no infection pres5t4 ,! pleura & w\nd may be imm$iately clos$ )\t dra9age1 if ! pleura is n infect$4 ,excessive plus pressure or pus may require reop5+4 ,9 "o case 9 :i* ! au?or remov$ a =eign body by pleuroscopy1 heal+ 0 by fir/ int5tion & ! lung fill$ 9 a few days4 ,dra9age tubes t h slipp$ up into ! empyemic cavity are =eign bodies4 ,!y are readily remov$ ) ! retrograde esophagoscope ev5 ?r\gh ! smalle/ fi/ula4 ,! aspirat+ canal keeps a cle> field :ile se>*+ = ! dra94 ,pleuroscopy = ,disease4--,mo/ pleural diseases require a l>ge ext]nal op5+ = dra9age1 & ev5 "h ! pleuroscope may be ( "s use 9 explor+ ! cavities4 ,usually !re are _m adhesions & c>eful ray /udy may reveal "o or m ! break+ up ( :i* w improve dra9age to su* an ext5t z to cure an empyema ( long /&+4 ,repeat$ sev]+ ( adhesions1 aspiration & sometimes incision ( ! ?ick5$ visc]al pleura may be necess>y4 ,! au?or is s /rongly imbu$ ) ! idea t local exam9ation "u full illum9ation has s revolutioniz$ ! surg]y ( e region ( ! body to :i* x has be5 appli$1 t e accessible region %\ld be ?us /udi$4 ,! pleural cavity is q accessible ) or )\t rib-resection1 & !re is practically no risk 9 c>eful pleuroscopy4 #bja ,,*apt] ,,xxi--,,b5ign ,,gr[?s ,,9 ,,! ,,l>ynx ,b5ign gr[?s 9 ! l>ynx are easily & accurately removable by direct l>yngoscopy2 b p]haps no me?od has be5 m (t5 misus$ & foll[$ by mo/ un=tunate results4 ,x %\ld always be rememb]$ t b5ign gr[?s are b5ign1 & t h5ce !y d n ju/ify ! radical "w dem&$ 9 deal+ ) malignancy4 ,! l>ynx %\ld be work$ ^u ) ! same delicacy & respect = ! normal tissues t are cu/om>y 9 deal+ ) ! eye4 ,granulomata 9 ! l>ynx1 :ile n true neoplasms1 require extirpation 9 "s in/ances4 ,vocal nodules1 :5 o!r me?ods ( cure su* z vocal re/1 v>i\s vocal ex]cises1 etcet]a h fail$ may require surgical excision4 ,?is may be done ) ! l>yngeal tissue =ceps or ) ! au?or's vocal nodule =ceps4 ,sessile vocal nodules may be cur$ by t\*+ !m ) a f9e galvanocaut]y po9t1 b all "w on ! vocal cords mu/ be done ) extreme caution & nicety4 ,x is exce$+ly easy to ru9 a f9e voice4 ,fibromata1 (t5 ( inflammatory g5esis1 are be/ remov$ ) ! l>yngeal grasp+ =ceps1 ?\gh ! small l>yngeal pun* or tissue =ceps may be us$4 ,if v l>ge1 !y may be amputat$ ) ! sn>e1 ! base be+ treat$ ) galvanocaut]y ?\gh ?is is seldom advisable4 ,/rong traction %\ld be avoid$ z likely to d irrep>able injury to ! l>yngeal motility4 ,cy/omata may get well aft] simple excision or galvanopuncture ( a "p ( ! wall ( ! sac1 b complete extirpation ( ! sac is (t5 requir$ = cure4 ,! same is true ( ad5omata4 #bjb ,angiomata1 if ext5sive & deeply seat$1 may require deep excision1 b usually cure results f sup]ficial removal4 ,usually no caut]ization ( ! vessels at ! base is necess>y1 ei!r to arre/ hemorrhage or to less5 ! t5d5cy to recurr5ce4 ,a diffuse telangiectasis1 %\ld x require treatm5t1 may be g5tly t\*$ ) a ne$le-po9t$ galvanocau/ic electrode at a numb] ( sitt+s4 ,! galvanonocaut]y is a dang]\s me?od to use 9 ! l>ynx4 ,radium (f]s ! be/ results 9 ?is latt] =m ( angioma1 appli$ ei!r int]nally or to ! neck4 ,lymphoma1 en*ondroma & o/eoma1 if n too ext5sively involv+ ! l>yngeal walls1 may be excis$ ) basket pun* =ceps1 b lymphoma is probably bett] treat$ by radium499 ,true myxomata & lipomata are v r>e4 ,amyloid tumors are occasionally met )1 & are v resi/ant to treatm5t4 ,ab]rant ?yroid tumors d n require v radical excision ( normal base1 b %\ld be remov$ z completely z possible4 ,9 a g5]al way1 x may be /at$ t ) b5ign gr[?s 9 ! l>ynx ! be/ functional results are obta9$ by sup]ficial r ?an radical1 deep extirpation1 rememb]+ t x is easi] to remove tissue ?an to replace x1 & t cicatrices impair or ru9 ! voice & may cause /5osis4 99 ,9 a case report$ by ,delavan a complete cure ) p]fect re/oration ( voice result$ f radium aft] ,i _h fail$ to cure by op]ative me?ods4 7,proce$+s ,am]ican ,l>yngological ,association1 #aiba47 #bjc ,,*apt] ,,xxii--,,b5ign ,,gr[?s ,,9 ,,! ,,l>ynx 7,cont9u$7 ,,papillomata ,,( ,,! ,,l>ynx ,,9 ,,*ildr5 ,( all b5ign gr[?s 9 ! l>ynx papilloma is ! mo/ frequ5t4 ,x may occur at any age ( *ildhood & may ev5 be cong5ital4 ,! out/&+ fact :i* necess>ily influ5ces our treatm5t is ! t5d5cy to recurr5ces1 foll[$ ev5tually 9 practically all cases by a t5d5cy to disappe>ance4 ,9 ! au?or's op9ion multiple papillomata con/itute a b5ign1 self-limit$ disease4 ,!re are two classes ( cases4 #a4 ,^? 9 :i* ! gr[? gets well spontane\sly1 or ) slight treatm5t1 surgically or o!rwise2 &1 #b1 ^? n readily am5able to any =m ( treatm5t1 recurr5ces appe>+ p]si/5tly at ! old sites1 & 9 entirely new locations4 ,9 ! au?or's op9ion ^! two classes ( case repres5t n two diff]5t k9ds ( gr[?s1 b /ages 9 ! disease4 ,^? t get well aft] a s+le removal are ne> ! end ( ! disease4 ,papillomata are ( inflammatory orig9 & are n true neoplasms 9 ! /ricte/ s5se4 ,me?ods ( ,treatm5t4--,irritat+ applications probably provoke recurr5ces1 because ! gr[?s are ( inflammatory orig94 ,=m]ly l>yngo/omy 0 recomm5d$ z a la/ resort :5 all o!r means _h fail$4 ,! excell5t results f ! me?od describ$ 9 ! =ego+ p>agraph has relegat$ l>yngo/omy to ^? cases t come 9 ) a sev]e cicatricial /5osis f an injudici\s l>yng(issure2 & ev5 9 ^! cases cure ( ! /5osis z well z ! papillomata c usually be obta9$ by endoscopic me?ods alone1 us+ sup]ficial scalp+ (f ( ! papillomata ) subsequ5t l>yngoscopic b\g9age = ! /5osis4 ,?yrotomy = papillomata is m5tion$ only to be condemn$4 ,fulguration has be5 satisfactory 9 ! h&s ( "s1 disappo9t+ to o!rs4 ,x is easily & accurately appli$ ?r\gh ! direct l>yngoscope1 b damage to normal tissues mu/ be avoid$4 ,radium1 meso?orium1 & ! ro5tg5ray are report$ to h _h 9 c]ta9 isolat$ cases a seem+ly b5eficial action4 ,9 my exp]i5ce1 h[ev]1 ,i h nev] se5 a cure ( papillomata :i* c\ld be attribut$ to ! radiation4 ,i h se5 cases 9 :i* no effect on ! gr[?s or recurr5ce 0 app>5t1 & 9 "s cases ! gr[?s seem$ to h be5 /imulat$ to m rapid repullulations4 ,9 o!r mo/ un=tunate cases ,i h se5 p]i*ondritis ( ! l>yngeal c>tilages ) subsequ5t /5osis occurr+ aft] ! ro5tg5o!rapy4 ,possibly ! disa/r\s results 7 due to ov]dosage2 b ,i feel x a duty to /ate ! unfavorable exp]i5ce1 & to call att5tion to ! diff]5ce betwe5 canc] & papillomata4 ,multiple papillomata involve no dang] to life o!r ?an t ( easily obviat$ asphyxia1 & x is moreov] a b5ign self-limit$ disease t repullulates on ! surface4 ,9 canc] we h an infiltrat+ process t has no limits %ort ( life itself4 ,endol>yngeal extirpation ( papillomata 9 *ildr5 requires no ane/hetic1 g5]al or local2 ! gr[?s are devoid ( s5sibility4 ,if1 = any reason1 a g5]al ane/hetic is us$ x %\ld be only 9 tra*eotomiz$ cases1 because ! gr[?s ob/ruct ! airway4 ,ob/ruct$ respiration introduces into g5]al ane/hesia an enorm\s elem5t ( dang]4 ,conc]n+ ! treatm5t ( multiple papillomata x has be5 my exp]i5ce 9 hundr$s ( cases t h come to ! ,bron*oscopic ,cl9ic1 t repeat$ sup]ficial removals ) blunt non-cutt+ =ceps 7see ,*apt] ,i7 w s modify ! soil z to make x unfavorable = repullulation4 ,! removals are sup]ficial & d n include ! subjac5t normal tissue4 ,radical removal ( a papilloma situat$1 = in/ance1 on ! left v5tricul> b& or cord1 c 9 no way prev5t ! subsequ5t occurr5ce ( a simil> gr[? at a diff]5t site1 z ^u ! epiglottis1 or ev5 9 ! fauces4 ,fur!rmore1 radical removal ( ! basal tissues is c]ta9 to impair ! phonatory function4 ,excell5t results z to voice & fre$om f recurr5ce h always foll[$ repeat$ sup]ficial removal4 ,! "t requir$ has be5 mon?s or a ye> or two4 ,only r>ely has a cure foll[$ a s+le extirpation4 ,if ! *ild is b slightly dyspneic1 ! ob/ruct+ "p ( ! gr[? is fir/ remov$ )\t ane/hesia1 g5]al or local2 ! rema9+ fungations are extirpat$ subsequ5tly at a numb] ( brief seances4 ,! *ild is ?us n t]rifi$1 soon loses dread ( ! removals1 & appreciates ! relief4 ,%\ld ! *ild be v dyspneic :5 fir/ se51 a l[ tra*eotomy is imm$iately done1 & aft] an int]im ( t5 days1 l>yngoscopic removal ( ! gr[? is begun4 ,tra*eotomy probably has a b5eficial effect on ! disease4 ,tra*eal gr[?s require ! ins]tion ( ! bron*oscope = _! removal4 ,papillomata 9 ! l>ynx ( adults are1 on ! :ole1 mu* m am5able to treatm5t ?an simil> gr[?s 9 *ildr54 ,tra*eotomy is v r>ely requir$1 & ! t5d5cy to recurr5ce is less m>k$4 ,_m are cur$ by a s+le extirpation4 ,! be/ results are obta9$ by removal ( ! gr[?s ) ! l>yngeal grasp+-=ceps1 tak+ ! utmo/ c>e to avoid includ+ 9 ! bite ( ! =ceps any ( ! subjac5t normal tissue4 ,radical resection or caut]ization ( ! base is unwise because ( ! probable impairm5t ( ! voice1 or cicatricial /5osis1 )\t 9 anyway insur+ aga9/ repullulation4 ,! papillomata are s s(t t !y give no s5sation ( traction to ! =ceps4 ,!y c readily be scalp$ (f )\t any impairm5t ( ! s\nd tissues1 by ! use ( ! au?or's papilloma =ceps 7,fig4 #bi74 ,cutt+ =ceps ( all k9ds are objectionable because !y may w\nd ! normal tissues be=e ! s5se ( t\* c give w>n+4 ,a g5tle h& might be tru/$ ) ! cup =ceps 7,fig4 #cb1 l>ge size47 ,sir ,felix ,semon prov$ conclusively by 8 collective inve/igations t canc] _c be caus$ by ! repeat$ removals ( b5ign gr[?s4 ,!re=e1 no fe> ( caus+ canc] ne$ give rise to hesitation 9 repeat$ly remov+ ! repullulations ( papillomata or o!r b5ign gr[?s4 ,inde$ !re is mu* cl9ical evid5ce else:]e 9 ! body1 & m ?an a little su* evid5ce z to ! l>ynx1 to w>rant ! removal ( b5ign gr[?s1 repeat$ if necess>y1 z a prophylactic ( canc] 7,bibliography1 #ai74 #bjg ,,*apt] ,,xxiii--,,b5ign ,,gr[?s ,,prim>y ,,9 ,,! ,,tra*eobron*ial ,,tree ,ext5sion ( papillomata f ! l>ynx into ! c]vical tra*ea1 especially ab\t ! tra*eotomy w\nd1 is ( relatively common occurr5ce4 ,true prim>y gr[?s ( ! tra*eobron*ial tree1 ?\gh n frequ5t1 are by no means r>e4 ,^! prim>y gr[?s include prim>y papillomata & fibromata z ! mo/ frequ5t1 ab]rant ?yroid1 lipomata1 ad5omata1 granulomata & amyloid tumors4 ,*ondromata & o/eo*ondromata may be b5ign b are prone to develop malignancy1 & by s>comat\s or o!r *anges1 ev5 metaplasia4 ,edemat\s polypi & o!r m or less tumor-l inflammatory sequelae are occasionally enc\nt]$4 ,symptoms ( ,b5ign ,tumors ( ! ,tra*eobron*ial ,tree4--,c\gh1 :eez+ respiration1 & dyspnea1 v>y+ 9 degree ) ! size ( ! tumor1 indicate ob/ruction ( ! airway4 ,associat$ ) defective a]ation w be ! signs ( defici5t dra9age ( secretions4 ,ro5tg5ray exam9ation may %[ ! %ad[ ( en*ondromata or o/eomata1 & w also %[ v>iations 9 a]ation %\ld ! tumor be 9 a bron*us4 ,bron*oscopic removal ( b5ign gr[?s is readily accompli%$ ) ! endoscopic pun* =ceps %[n 9 ,figs4 #bh & #cc4 ,quick action may be necess>y %\ld a l>ge tumor produc+ great dyspnea be enc\nt]$1 = ! dyspnea is apt to be increas$ by ! conge/ion1 c\gh1 & increas$ respiration & spasm incid5tal to ! pres5ce ( ! bron*oscope 9 ! tra*ea4 ,g5]al ane/hesia1 z 9 all cases %[+ dyspnea1 is contra9dicat$4 ,! risks ( hemorrhage foll[+ removal are v slight1 provid$ fungations on an aneurismal erosion be n mi/ak5 = a tumor4 ,multiple papillomata :5 v num]\s are be/ remov$ by ! au?or's cor+ me?od4 ,?is consi/s 9 ! ins]tion ( an aspirat+ bron*oscope ) ! me*anical aspirator work+ at full negative pressure4 ,! papillomata are remov$ l cor+ an apple2 ?\gh ! r\nd$ edge ( ! bron*oscope does n ev5 scrat* ! tra*eal mucosa4 ,_m ( ! papillomata are tak5 (f by ! holes 9 ! bron*oscope4 ,aspiration ( ! deta*$ papillomata into ! lungs is prev5t$ by ! cork+ ( ! tube-m\? ) ! mass ( papillomata held by ! negative pressure at ! canal inlet orifice4 ,,*apt] ,,xxiv--,,b5ign ,,neoplasms ,,( ,,! ,,esophagus ,z a result ( prolong$ inflammation edemat\s polypi & granulomata are n infrequ5tly se51 b true b5ign tumors ( ! esophagus are r>e affections4 ,keloidal *anges 9 sc> tissue may occur4 ,cases ( ret5tion1 epi!lial & d]moid cy/s h be5 obs]v$2 & !re are isolat$ reports ( ! f9d+ ( papillomata1 fibromata1 lipomata1 myomata & ad5omata4 ,! removal ( ^! is readily accompli%$ ) ! tissue =ceps 7,fig4 #bh71 if ! gr[?s are small & project+ into ! esophageal lum54 ,! det]m9ation ( ! advisability ( ! removal ( keloidal sc>s w\ld require c>eful consid]ation ( ! p>ticul> case1 & ! same may be said ( v l>ge gr[?s ( any k9d4 ,! extreme ?9ness ( ! esophageal walls mu/ be always 9 ! m9d ( ! esophagoscopi/ if he w\ld avoid disa/]4 #baj ,,*apt] ,,xxv--,,endoscopy ,,9 ,,malignant ,,disease ,,( ,,! ,,l>ynx ,! g5]al surgical rule apply+ to individuals pa/ middle life1 t b5ign gr[?s expos$ to irritation %\ld be remov$1 probably applies to ! l>ynx z well z to any o!r epi!lializ$ /ructure4 ,! facility1 accuracy & ?or\ghness af=d$ by skill$1 direct1 l>yngeal op]ation (f]s a means ( less5+ ! incid5ce ( canc]4 ,to a mu* great] ext5t ! facility1 accuracy1 & ?or\ghness contribute to ! cure ( canc] by e/abli%+ ! necess>y e>ly diagnosis4 ,well-plann$1 c>eful1 ext]nal op]ation 7l>yng(issure7 foll[$ by pa9/ak+ aft]-c>e is ! only absolute cure s f> kn[n = malignant neoplasms ( ! l>ynx2 & x is a cure only 9 ^? intr9sic cases 9 :i* ! gr[? is small1 & is locat$ 9 ! ant]ior two-?irds ( ! intr9sic area4 ,by limit+ op]ations /rictly to ?is class ( case1 eighty-five p] c5t ( cures may be obta9$499 ,9 det]m9+ ! nature ( ! gr[? & its op]ability ! limits ( ! usefulness ( direct endoscopy are rea*$4 ,x is v unwise to attempt ! extirpation ( intr9sic l>yngeal malignancy by ! endoscopic me?od1 = ! reason t ! full ext5t ( ! gr[? _c be appreciat$ :5 view$ only f above1 & ! necess>y radical removal _c be accurately or completely accompli%$4 99 ,! au?or's results 9 l>yng(issure h rec5tly fall5 to #gi p] c5t ( relative cures by ?yro*ondrotomy4 ,malignant disease ( ! epiglottis1 9 ^? r>e cases :]e ! lesion is /rictly limit$ to ! tip is1 h[ev]1 an exception4 ,if amputation ( ! epiglottis w give a suffici5tly wide removal1 ?is may be done en masse ) a heavy sn>e1 & has result$ 9 complete cure4 ,v small gr[?s may be remov$ suffici5tly widely ) ! pun* =ceps 7,fig4 #cc72 b piece meal removal ( malignancy is to be avoid$4 ,diff]5tial ,diagnosis ( ,l>yngeal ,gr[?s 9 ! ,l>ynx ( ,adults4--,det]m9ation ( ! nature ( ! lesion 9 ^! cases usually consi/s 9 ! diagnosis by exclusion ( ! possibilities1 namely1 #a4 ,lues4 #b4 ,tub]culosis1 includ+ lupus4 #c4 ,scl]oma4 #d4 ,malignant neoplasm4 ,9 ! ,bron*oscopic ,cl9ic ! foll[+ is ! r\t9e proc$ure3 #a4 ,a ,wass]mann te/ is made4 ,if negative1 & !re rema9s a suspicion ( lues1 a !rapeutic te/ ) m]cury protoiodid is c>ri$ out by keep+ ! pati5t j "u ! salivation po9t = eight weeks2 dur+ :i* "t no potassium iodid is giv51 le/ its reaction ^u ! l>ynx cause an edema necessitat+ tra*eotomy4 ,if no improvem5t is notic$ lues is exclud$4 ,if ! ,wass]mann is positive1 malignancy & ! o!r possibilities are n consid]$ z exclud$ until ! pati5t has be5 completely cur$ by m]cury1 because1 = in/ance1 a leutic or tub]cul\s pati5t may h canc]2 a tub]cul\s pati5t may h lues2 or a leutic pati5t1 tub]culosis4 #b4 ,pulmon>y tub]culosis is exclud$ by ! usual means4 ,if pres5t ! l>yngeal lesion may or may n be tub]cul\s2 if ! l>yngoscopic appe>ances are d\btful a specim5 is tak54 ,lupoid l>yngeal tub]culosis s mu* resembles lues t bo? ! !rapeutic te/ & biopsy may be requir$ = c]ta9ty4 #c4 ,9 all cases 9 :i* ! diagnosis is n cle> a specim5 is tak54 ,?is is readily accompli%$ by direct l>yngoscopy "u local ane/hesia1 us+ ! regul> l>yngoscope or ! ant]ior commissure l>yngoscope4 ,! be/ =ceps 9 case ( l>ge gr[?s are ! alligator pun* =ceps 7,fig4 #cc74 ,small] gr[?s require tissue =ceps 7,fig4 #bh74 ,9 case ( small gr[?s1 x is be/ to remove ! entire gr[?2 b )\t any attempt at radical extirpation ( ! base2 because1 if ! gr[? prove b5ign x is unnecess>y2 if malignant1 x is insuffici5t4 ,inspection ( ! ,p>ty ,wall 9 ,cases ( ,suspect$ ,l>yngeal ,malignancy4--,:5 tak+ a specim5 ! p>ty wall %\ld be inspect$ by pass+ a l>yngoscope or1 if necess>y1 an esophageal speculum d[n ?r\gh ! l>yngoph>ynx & beyond ! cricoph>yngeus4 ,if ?is region %[s infiltration1 all hope ( cure by op]ation1 h[ev] radical1 %\ld be ab&on$4 ,radium & ! !rapeutic ro5tg5ray h giv5 good results1 b n su* z w\ld w>rant _! exclusive use 9 any case ( malignancy 9 ! l>ynx op]able by l>yng(issure4 ,) inop]able cases1 excell5t palliative results are obta9$4 ,9 "s cases an almo/ complete disappe>ance ( ! gr[? has occurr$1 b ultimately !re has be5 recurr5ce4 ,! me?od ( application ( ! radium1 dosage1 & its scre5+1 are be/ det]m9$ by ! radiologi/ 9 consultation ) ! l>yngologi/4 ,radium may be appli$ ext]nally to ! neck1 or susp5d$ 9 ! l>ynx2 radium-conta9+ ne$les may be buri$ 9 ! gr[?1 or ! emanations1 imprison$ 9 glass pe>ls or capill>y tubes1 may be ins]t$ deeply into ! gr[? by means ( a small troc> & cannula4 ,= all ( ^! proc$ures direct l>yngoscopy af=ds a ready means ( accurate application4 ,tra*eotomy is necess>y h[ev]1 because ( ! reaction>y swell+1 :i* may be s great z to close completely ! n>r[$ glottic *9k4 ,:]e ?is is ! case1 ! endol>yngeal application ( ! radium may be made by ins]t+ ! conta9] ?r\gh ! tra*eotomic w\nd1 & an*or+ x to ! cannula4 ,! au?or is mu* impress$ ) ,fre]'s me?od ( radiation f ! pyri=m s9us 9 su* cases z ^? 9 :i* ext]nal radiation alone is deem$ insuffici5t4 ,! "w ( ,drs4 ,d4 ,bryson ,delavan & ,d\glass ,m4 ,quick =ms "o ( ! mo/ important contributions to ! subject ( ! treatm5t ( radium by canc]4 7,see ,proce$+s ( ! ,am]ican ,l>yngological ,association1 #aibb2 also ,proce$+s ( ! ,t5? ,int]national ,otological ,congress1 ,p>is1 #aibb47 #bad ,,*apt] ,,xxvi--,,bron*oscopy ,,9 ,,malignant ,,gr[?s ,,( ,,! ,,tra*ea ,! tra*ea is (t5 second>ily invad$ by malignancy ( ! esophagus1 ?yroid gl&1 p]itra*eal or p]ibron*ial gl&s4 ,prim>y malignant neoplasms ( ! tra*ea or bron*us h n infrequ5tly be5 diagno/icat$ by bron*oscopy4 ,p]itra*eal or p]ibron*ial malignancy may produce a compressive /5osis cov]$ ) normal mucosa4 ,endoscopically1 ! wall is se5 to bulge 9 f "o side caus+ a cresc5tic picture1 or compression ( opposite walls may cause a scabb>d or pe> %ap$ lum54 ,endotra*eal & endobron*ial malignancy ulc]ate e>ly1 & are *>act]iz$ by ! bron*oscopic view ( a ble$+ mass ( fungat+ tissue ba!d 9 pus & secretion1 usually f\l4 ,! diagnosis 9 ^! cases re/s ^u ! exclusion ( lues1 & is r5d]$ c]ta9 by ! removal ( a specim5 = biopsy4 ,s>coma & c>c9oma ( ! ?yroid :5 p]=at+ ! tra*ea may become p$unculat$4 ,9 su* cases ab]rant non-pa?ologic ?yroid mu/ be exclud$ by biopsy4 ,endo!lioma ( ! tra*ea or bron*us may also assume a p$unculat$ =m1 b is m (t5 sessile4 ,treatm5t4--,p$unculat$ malignant gr[?s are readily remov$ ) sn>e or pun* =ceps4 ,cure has result$ 9 "o case ( ! au?or foll[+ bron*oscopic removal ( an endo!lioma f ! bron*us2 & a limit$ c>c9oma ( ! bron*us has be5 report$ cur$ by bron*oscopic removal1 ) caut]ization ( ! base4 ,mo/ ( ! cases1 h[ev]1 w be subjects = palliative tra*eotomy & radium !rapy4 ,x w be f\nd necess>y 9 _m ( ! cases to employ ! au?or's long1 cane-%ap$ tra*eal cannula 7,fig4 #ajd1 ,a71 9 ord] to pipe ! air d[n to "o or bo? bron*i pa/ ! project+ neoplasm4 ,x has rec5tly be5 demon/rat$ t foll[+ ! intrav5\s injection ( a susp5sion ( ! insoluble salt1 radium sulphate1 t ! susp5d$ p>ticles are held 9 ! capill>ies ( ! lung = a p]iod ( "o ye>4 ,intrav5\s injections ( a wat]y susp5sion1 & endobron*ial injections ( a susp5sion ( radium sulphate 9 oil1 h _h def9ite b5eficial action4 ,:ile z yet1 no relatively p]man5t cures ( pulmon>y malignancy h be5 obta9$1 ! amelioration & /eady improvem5t not$ 9 ! te*nic ( radium !rapy are s enc\rag+ t e inop]able case %\ld be ?us treat$1 if ! disease is n 9 a hopelessly advanc$ /age4 ,9 a case "u ! c>e ( ,dr4 ,rob]t ,m4 ,luk5s at ! ,bron*oscopic ,cl9ic1 a prim>y epi!lioma ( ! tra*ea 0 ret>d$ = #b ye>s by ! use ( radium appli$ by ,dr4 ,william ,s4 ,newcomet1 radium-!rapi/1 & ,miss ,ka!r9e ,e4 ,s*aeff]1 te*nician4 #baf ,,*apt] ,,xxvii--,,malignant ,,disease ,,( ,,! ,,esophagus ,canc] ( ! esophagus is a m preval5t disease ?an is commonly ?\ght4 ,9 ! male x usually develops dur+ ! f\r? & fif? decades ( life4 ,!re is 9 "s cases ! hi/ory ( ye>s ( m or less habitual consumption ( /rong alcoholic liquors4 ,9 ! female ! condition (t5 occurs at an e>li] age ?an 9 ! male1 & t5ds to run a m protract$ c\rse1 prece$$ 9 "s cases by ye>s ( precanc]\s dysphagia4 ,squam\s-cell$ epi!lioma is ! mo/ frequ5t type ( neoplasm4 ,9 ! l[] ?ird ( ! esophagus1 cyl9dric cell c>c9oma may be f\nd associat$ ) a l lesion 9 ! /oma*4 ,s>coma ( ! esophagus is relatively r>e 7,bibliography #a1 p4 #ddi74 ,! sites ( ! lesion are ^? ( physiologic n>r[+ ( ! esophagus4 ,! middle ?ird is mo/ frequ5tly involv$2 & ! l[] ?ird1 ne> ! c>dia1 comes next 9 frequ5cy4 ,canc] ( ! l[] ?ird ( ! esophagus prepond]ates 9 m51 :ile canc] ( ! upp] orifice is1 curi\sly1 m preval5t 9 wom54 ,! lesion is usually s+le1 b multiple lesions1 result+ f implantation meta/ases h be5 obs]v$ 7,bibliography #a1 p4 #cia74 ,bron*oesophageal fi/ula f ext5sion is n uncommon4 ,symptoms4--,malignant disease ( ! esophagus is r>ely se5 e>ly1 because ( ! abs5ce1 or mildness1 ( ! symptoms4 ,dysphagia1 ! "o common symptom ( all esophageal disease1 is (t5 ignor$ by ! pati5t until x becomes s m>k$ z to prev5t ! tak+ ( solid food2 !re=e1 ! onset may h ! similitude ( abruptness4 ,any well ma/icat$ solid food c be swall[$ ?r\gh a lum5 #e millimet]s 9 diamet]4 ,! inability to ma9ta9 ! nutrition is evid5c$ by loss ( weight & ! rapid developm5t ( ca*exia4 ,:5 ! /5osis becomes s sev]e t ! fluid intake is limit$1 rapid decl9e occurs f wat] />vation4 ,pa9 is usually a late symptom ( ! disease4 ,x may be ( an a*+ "* & ref]r$ to ! v]tebral region or to ! neck2 or x may only accompany ! act ( swall[+4 ,blood-/reak$1 regurgitat$ mat]ial1 & ! pres5ce ( odor1 are late manife/ations ( ulc]ation & second>y infection4 ,9 "s cases1 con/ant ooz+ ( blood f ! ulc]at$ area adds greatly to ! ca*exia4 ,if ! recurr5t l>yngeal n]ves are involv$1 unilat]al or bilat]al p>alysis ( ! l>ynx may complicate ! symptoms by c\gh1 dyspnea1 aphonia1 & possibly septic pneumonia4 ,diagnosis4--,x has be5 e/imat$ t #gj p] c5t ( /5oses ( ! esophagus 9 adults are malignant 9 nature4 ,?is %\ld /imulate ! e>ly & c>eful inve/igation ( e case ( dysphagia4 ,:5 all cases ( p]si/5t dysphagia1 h[ev] slight1 are endoscopically /udi$1 precanc]\s lesions may be discov]$ & treat$1 & ! limit$ malignancy ( ! e>ly /ages may be af=d$ surgical treatm5t :ile yet !re is hope ( complete removal4 ,luetic & tub]cul\s ulc]ation ( ! esophagus are to be elim9at$ by suitable te/s1 supplem5t$ 9 r>e in/ances by biopsy4 ,aneurysm ( ! aorta mu/ 9 all cases ( dysphagia be exclud$1 = ! dilat$ aorta may be ! sole cause ( ! condition1 & its pres5ce contra9dicates esophagoscopy because ( ! liability ( rupture4 ,=eign body is to be exclud$ by hi/ory & ro5tg5ographic /udy4 ,spasmodic /5osis ( ! esophagus may or may n h a malignant orig94 ,esophagoscopy & removal ( a specim5 = biopsy r5d]s ! diagnosis c]ta94 ,x is to be especially rememb]$1 h[ev]1 t x is v unwise to bite ?r\gh normal mucosa = ! purpose ( tak+ a specim5 f a p]iesophageal gr[?4 ,fungations & polypoid protub]ances af=d safe opportunities = ! removal ( specim5s ( tissue4 ,! esophagoscopic appe>ances ( malignant disease1 v>y+ ) ! /age & site ( orig9 ( ! gr[?1 may pres5t z foll[s3-- #a4 ,submucosal infiltration cov]$ by p]fectly normal membrane1 usually associat$ ) m or less bulg+ ( ! esophageal wall1 & v (t5 ) h>dness & infiltration4 #b4 ,leucoplakia4 #c4 ,ulc]ation project+ b little above ! surface at ! edges4 #d4 ,r\nd$ nodul> masses gr\p$ 9 mulb]ry-l =m1 ei!r d>k or light r$ 9 color4 #e4 ,polypoid masses4 #f4 ,caulifl[] fungations4 ,9 consid]+ ! esophagoscopic appe>ances ( canc]1 x is necess>y to rememb] t aft] ulc]ation has set 91 ! canc]\s process may h engraft$ ^u x1 & ^u its neighborhood1 ! results ( inflammation due to ! mix$ infections4 ,canc] invad+ ! wall f )\t may = a long "t be cov]$ ) p]fectly normal muc\s membrane4 ,! significant signs at ?is e>ly /age are3 #a4 ,abs5ce ( "o or m ( ! normal radial creases betwe5 ! folds4 #b4 ,asymmetry ( ! inspiratory enl>gem5t ( lum54 #c4 ,s5sation ( h>dness ( ! wall on palpation ) ! tube4 #d4 ,! involv$ wall w n readily be made to wr9kle :5 pu%$ ^u ) ! tube m\?4 ,9 all ! lat] =ms ( lesions ! two *>act]i/ics are 7a7 ! read9ess ) :i* ooz+ ( blood occurs2 & 7b7 ! s5se ( rigidity1 or fixation1 ( ! involv$ area z palpat$ ) ! esophagoscope1 9 contra/ to ! normally supple esophageal wall4 ,esophageal dilatation above a malignant lesion is r>ely great1 because ! /5osis is seldom sev]ely ob/ructive until late 9 ! c\rse ( ! disease4 ,treatm5t4--,! pres5t #ajj p] c5t mortality 9 canc] ( ! esophagus w be l[]$ & a c]ta9 p]c5tage ( surgical cures w be obta9$ :5 pati5ts ) esophageal symptoms are giv5 ! b5efit ( e>ly esophagoscopic /udy4 ,! relief or circumv5tion ( ! dysphagia requires e>ly measures to prev5t food & wat] />vation4 ,b\g9age ( a malignant esophagus to increase tempor>ily ! size ( ! /5os$ lum5 is ( que/ionable advisability1 & is att5d$ ) ! great risk ( p]=at+ ! weak5$ esophageal wall4 ,esophageal intubation may s]ve = a "t to delay ga/ro/omy b x _c supplant x1 nor obviate ! necessity = its ultimate p]=mance4 ,! ,*>t]s-,symonds or ,guisez esophageal intubation tube is readily ins]t$ aft] draw+ ! l>ynx =w>d ) ! l>yngoscope4 ,! tube mu/ be *ang$ e week or two = clean+1 & duplicate tubes mu/ be ready = imm$iate re9s]tion4 ,ev5tually1 a small]1 & !n a /ill small] tube are ne$$1 until f9ally none c be introduc$2 ?\gh 9 "s cases ! tube c be kept 9 ! s(t mass ( fungations until ! pati5t has di$ ( hemorrhage1 exhau/ion1 complications or int]curr5t disease4 ,ga/ro/omy is always indicat$ z ! disease progresses1 & x %\ld be done be=e nutrition is greatly impair$4 ,surgeons (t5 hesitate ?us to op]ate on an inop]able case2 b x mu/ be rememb]$ t no "o %\ld be all[$ to die ( hung] & ?ir/4 ,! op]ation %\ld be done be=e inanition has made s]i\s inroads4 ,z 9 ! case ( tra*eotomy1 we always prea* do+ x e>ly1 & always d x late4 ,if po/pon$ too long1 wat] />vation may proce$ s f> t ! pati5t w n recov]1 because ! wat]-/>v$ tissues w n take up wat] put 9 ! /oma*4 ,radio!rapy4--,radium & ! !rapeutic ro5tg5ray are today our only effective means ( ret>d+ ! progress ( esophageal malignant neoplasms4 ,no p]man5t cures h be5 report$1 b m>k$ tempor>y improvem5t 9 ! swall[+ function & prolongation ( life h be5 repeat$ly obs]v$4 ,! comb9ation ( radium treatm5t appli$ )9 ! esophageal lum5 & ! !rapeutic ro5tg5ray ?r\gh ! *e/ wall1 has ret>d$ ! progress ( "s cases4 ,! dosage ( radium or ! !rapeutic ray mu/ be det]m9$ by ! radiologi/ = ! p>ticul> individual case2 its me?od ( application %\ld be decid$ by consultation ( ! radiologi/ & ! endoscopi/4 ,two fundam5tal po9ts are to be consid]$1 h[ev]4 ,! radium capsule1 if appli$ )9 ! esophagus1 %\ld be s scre5$ t ! s(t1 irritat+1 beta rays1 & ! second>y rays1 are bo? filt]$ out to prev5t sl\gh+ ( ! esophageal mucosa4 ,! dose %\ld be l>ge en\gh to h a le?al effect ^u ! canc] cells at ! p]iph]y ( ! gr[? z well z 9 ! c5t]4 ,if ! dose be insuffici5t1 developm5t ( ! cells at ! outside ( ! gr[? is /imulat$ r ?an inhibit$4 ,x is ess5tial t ! radium capsule be accurately plac$ 9 ! c5t] ( ! malignant /rictur$ area & ?is c be done only by visual control ?r\gh ! esophagoscope 7,fig4 #ie7 ,drs4 ,h5ry ,k4 ,pancoa/1 ,george ,e4 ,pfahl] & ,william ,s4 ,newcomet h obta9$ v satisfactory palliative effects f ! use ( radium 9 esophageal canc]4 #bba ,,*apt] ,,xxviii--,,direct ,,l>yngoscopy ,,9 ,,diseases ,,( ,,! ,,l>ynx ,! diagnosis ( l>yngeal disease 9 "y *ildr51 impossible ) ! mirror1 has be5 made easy & precise by ! developm5t ( direct l>yngoscopy4 ,no ane/hetic1 local or g5]al1 %\ld be us$1 = ! practis$ endoscopi/ c complete ! exam9ation )9 a m9ute ( "t & )\t pa9 to ! pati5t4 ,! te*nic = do+ ?is %\ld be acquir$ by e l>yngologi/4 ,ane/hesia is absolutely contra9dicat$ because ( ! possibility ( ! pres5ce ( diph!ria1 & especially because ( ! dyspnea s frequ5tly pres5t 9 l>yngeal disease4 ,to attempt g5]al ane/hesia 9 a dyspneic case is to invite disa/] 7see ,tra*eotomy74 ,x is to be rememb]$ t c\gh+ & /ra9+ produce an engorgem5t ( ! l>yngeal mucosa1 s t ! fir/ glance %\ld include an e/imation ( ! color ( ! mucosa1 :i*1 z a result ( ! engorgem5t1 deep5s ) ! prolongation ( ! direct l>yngoscopy4 ,*ronic subglottic edema1 (t5 ! result ( p]i*ondritis1 may require l9e> caut]ization at v>i\s times1 to r$uce its bulk1 aft] ! und]ly+ cause has be5 remov$4 ,p]i*ondritis & abscess1 & _! sequelae are to be treat$ on ! accept$ surgical precepts4 ,!y may be due to trauma1 lues1 tub]culosis1 ent]ic fev]1 pneumonia1 influ5za1 etc4 ,tub]culosis ( ! l>ynx calls = cons]vatism 9 ! application ( surg]y4 ,ulc]ation limit$ to ! epiglottis may ju/ify amputation ( ! project+ portion or excision ( only ! ulc]at$ area4 ,9 ei!r case1 rapid heal+ may be expect$1 & relief f ! odynphagia is sometimes prompt4 ,amputation ( ! epiglottis is1 h[ev]1 n to be done if ulc]ation 9 o!r portions ( ! l>ynx coexi/4 ,! removal ( tub]culomata is sometimes indicat$1 & ! excision ( limit$ ulc]ative lesions situat$ else:]e ?an on ! epiglottis may be curative4 ,^! measures z well z ! galvanocaut]y are easily execut$ by ! facile op]ator2 b _! advisability %\ld always be consid]$ f a cons]vative viewpo9t4 ,!y are r>ely ju/ifiable until aft] mon?s ( absolute sil5ce & a g5]al antitub]cul\s regime h fail$ ( b5efit4 ,galvanopuncture = l>yngeal tub]culosis has yield$ excell5t results 9 r$uc+ ! l>ge pyri=m edemat\s swell+s ( ! aryepiglottic folds :5 ulc]ation has n yet develop$4 ,deep punctures at ne>ly a :ite heat1 made p]p5dicul> to ! surface1 are be/4 ,c>e mu/ be ex]cis$ n to injure ! crico>yt5oid jo9t4 ,fungat+ ulc]ations may 9 "s cases be made to cicatrize by sup]ficial caut]ization4 ,excessive reactions sometimes foll[1 s t a light application %\ld be made at ! fir/ treatm5t4 ,cong5ital l>yngeal /ridor is produc$ by an exagg]ation ( ! infantile type ( l>ynx4 ,! epiglottis w be f\nd long & tap]+1 its lat]al m>g9s roll$ backw>d s z to meet & =m a cyl9d] above4 ,! upp] edges ( ! aryepiglottic folds are approximat$1 leav+ a n>r[ *9k4 ,! lack ( firmness 9 ^! folds & ! loose tissue 9 ! po/]ior portion ( ! l>ynx1 favors ! draw+ inw>d ( ! l>yngeal ap]ture by ! inspiratory bla/4 ,! vibration ( ! m>g9s ( ?is ap]ture produces ! inspiratory /ridor4 ,diagnosis is quickly made by ! inspection ( ! l>ynx ) ! infant diagno/ic l>yngoscope4 ,no ane/hetic1 g5]al or local1 is ne$$4 ,/ridor\s respiration may also be due to ! pres5ce ( l>yngeal papillomata1 l>yngeal spasm1 ?ymic compression1 cong5ital web1 or an abnormal inspiratory bulg+ into ! tra*ea ( ! po/]ior membran\s tra*eo-esophageal wall4 ,! t]m cong5ital l>yngeal /ridor %\ld be limit$ to ! fir/ describ$ condition ( exagg]at$ infantile l>ynx4 ,treatm5t ( cong5ital l>yngeal /ridor %\ld be direct$ to ! relief ( dyspnea1 & to increas+ ! nutrition & developm5t ( ! infant4 ,! ins]tion ( a bron*oscope w tempor>ily relieve an urg5t dyspneic attack precipitat$ by exam9ation2 b ?is r>ely happ5s if ! exam9ation is n unduly prolong$4 ,tra*eotomy may be ne$$ to prev5t asphyxia or exhau/ion f loss ( sleep2 b v few cases require any?+ b att5tion to nutrition & hygi5e4 ,recov]y c be expect$ ) developm5t ( ! l>yngeal /ructures4 ,cong5ital webs ( ! l>ynx require incision or excision1 or p]haps simply b\g9age4 ,cong5ital goit] & cong5ital l>yngeal p>alysis1 bo? ( :i* may cause /]tor\s brea?+1 are consid]$ 9 connection ) o!r =ms ( /5osis ( ! air passages4 ,aphonia due to cicatricial webs ( ! l>ynx may be cur$ by pla/ic op]ations t re=m ! cords1 ) a clean1 %>p ant]ior commissure1 :i* is a necessity = cle> phonation4 ,! l>yngeal scissors & ! long sl5d] pun* are (t5 m useful = ^! op]ations ?an ! knife4 #bbd ,,*apt] ,,xxix--,,bron*oscopy ,,9 ,,diseases ,,( ,,! ,,tra*ea ,,& ,,bron*i ,! indications = bron*oscopy 9 disease are becom+ increas+ly num]\s4 ,among ! m important may be m5tion$3 #a4 ,bron*iectasis4 #b4 ,*ronic pulmon>y abscess4 #c4 ,unexpla9$ dyspnea4 #d4 ,dyspnea unreliev$ by tra*eotomy calls = bron*oscopic se>* = deep] ob/ruction4 #e4 ,p>alysis ( ! recurr5t l>yngeal n]ve1 ! cause ( :i* is n positively kn[n4 #f4 ,obscure ?oracic disease4 #g4 ,unexpla9$ hemoptysis4 #h4 ,unexpla9$ c\gh4 #i4 ,unexpla9$ expectoration4 ,contra9dications to bron*oscopy 9 disease d n exi/ if ! bron*oscopy is really ne$$4 ,s]i\s organic disease su* z aneurysm1 hyp]t5sion1 advanc$ c>diac disease1 might r5d] bron*oscopy inadvisable except = ! removal ( =eign bodies4 ,bron*oscopic ,appe>ances 9 ,disease4--,! fir/ look %\ld note ! color ( ! bron*ial mucosa1 due all[ance be+ made = ! pressure ( tubal contact1 secretions1 & ! engorgem5t incid5t to cont9u$ c\gh4 ,! c>9a tra*ealis normally moves sl[ly =w>d z well z d[nw>d dur+ deep inspiration1 return+ quickly dur+ expiration4 ,impair$ movem5t ( ! c>9a indicates p]itra*eal & p]ibron*ial pa?ology1 ! fixation be+ greate/ 9 advanc$ canc]4 ,9 *ildr5 & 9 ! small] tubes ( ! adult1 ! l5g!n+ & dilatation ( ! bron*i dur+ inspiration1 & _! %ort5+ & contraction dur+ expiration are readily se54 ,anomalies ( ! ,tra*eobron*ial ,tree4--,tra*eobron*ial anomalies are relatively r>e4 ,cong5ital esophagotra*eal & esophagobron*ial fi/ulae are occasionally se51 & cases ( c]vicotra*eal fi/ulae h be5 report$4 ,cong5ital webs & div]ticula ( ! tra*ea are cit$ infrequ5tly4 ,l>yngoptosis & deviation ( ! tra*ea may be cong5ital4 ,sub/]nal goitre1 aneurysm1 malignant gr[?s1 & v>i\s m$ia/9al ad5opa?ies may displace ! tra*ea f its normal c\rse4 ,! emphysemat\s *e/ fix$ 9 ! deep volunt>y inspiratory position produces 9 "s cases an elevation ( ! sup]ior ?oracic ap]ture simulat+ l>yngoptosis 7,bibliography r1 pp4 #dfh1 #eid74 ,compression ,/5osis ( ! ,tra*ea & ,bron*i4--,compression ( ! tra*ea is mo/ commonly caus$ by goit]1 sub/]nal or c]vical1 aneurysm1 malignancy1 or1 9 *ildr51 by enl>g$ ?ymus4 ,less frequ5tly1 enl>g$ m$ia/9al tub]cul\s1 leukemic1 leutic or ,hodgk9's gl&s compress ! airway4 ,! left bron*us may be /5os$ by pressure f a hyp]trophi$ c>diac auricle4 ,compression /5osis ( ! tra*ea associat$ ) pulmon>y emphysema acc\nts = ! dyspnea dur+ attacks ( c\gh+4 ,! endoscopic picture ( compression /5osis is t ( an elliptical or scabb>d-%ap$ lum5 :5 ! bron*us is at re/ or dur+ inspiration4 ,conc5tric funnel-l compression /5osis1 :ile r>e1 may be produc$ by annul> gr[?s4 ,treatm5t ( ,compression ,/5oses ( ! ,tra*ea4--,if ! ?ymus be at fault1 rapid amelioration ( symptoms foll[s ro5tg5ray or radium !rapy4 ,tra*eotomy & ! ins]tion ( ! long cane-%ap$ cannula 7,fig4 #ajd7 pa/ ! compress$ area is requir$ 9 ! cases caus$ by conditions less am5able to treatm5t ?an ?ymic enl>gem5t4 ,p]man5t cure dep5ds ^u ! removability ( ! compressive mass4 ,%\ld ! bron*i be s compress$ by a b5ign condition z to prev5t escape ( secretions f ! subjac5t air passages1 bron*ial intubation tubes may be ins]t$1 &1 if necess>y1 worn con/antly4 ,!y %\ld be remov$ weekly = cleans+ & (t5] if ob/ruct$4 ,influ5zal ,l>yngotra*eobron*itis4--,influ5zal infection1 n always by ! same organism1 sweeps ov] ! population1 attack+ ! air passages 9 a viol5t & q *>act]i/ic way4 ,bron*oscopy %[s ! influ5zal infection to be *>act]iz$ by int5se r$d5+ & swell+ ( ! mucosa4 ,9 "s cases ! swell+ is s great z to necessitate tra*eotomy1 or intubation ( ! l>ynx2 & if ! edema involve ! bron*i1 occlusion may be fatal4 ,hemorrhagic spots & sup]ficial erosions are commonly se51 & a ?ick1 t5aci\s exudate1 difficult ( expectoration1 lies 9 pat*es 9 ! tra*ea4 ,infants may asphyxiate f accumulation ( ?is secretion :i* !y are unable to expel4 ,! diff]5tial diagnosis f diph!ria is sometimes difficult4 ,! abs5ce ( true membrane & ! failure to f9d diph!ria bacilli 9 sme>s tak5 f ! tra*ea are ( aid b are n infallible4 ,9 d\btful cases1 ! adm9i/ration ( diph!ria antitox9 is a wise precaution p5d+ ! e/abli%m5t ( a def9ite diagnosis4 ,! pseudomembrane sometimes pres5t 9 influ5zal tra*eobron*itis is ?9n] & less pulpy ?an t ( ! e>li] /ages ( diph!ria4 ,! ca/s ( ! lat] /ages d n occur 9 influ5zal tra*eobron*itis 7,bibliography ,i1 p4 #dhj74 ,edemat\s ,tra*eobron*itis4--,?is is *iefly obs]v$ 9 *ildr54 ,! mo/ frequ5tly enc\nt]$ =m is ! epidemic disease to :i* ! "n ,influ5za has be5 giv5 7q4v4 supra74 ,! only noticeable diff]5ce betwe5 ! epidemic & ! sporadic cases is 9 ! m g5]al susceptibility to ! infective ag5t1 :i* gives ! influ5zal =m an appe>ance ( be+ m virul5tly infective4 ,possibly ! sporadic =m is simply ! attack ( *ildr5 n immuniz$ by a previ\s attack dur+ an epidemic4 ,!re is ano!r =m ( edemat\s tra*eobron*itis (t5 ( great sev]ity & grave prognosis1 t results f ! aspiration ( irritat+ liquids or vapors1 or ( c]ta9 organic sub/ances su* z peanut k]nels1 wat]melon se$s1 etcet]a4 ,tra*eotomy %\ld be done if m>k$ dyspnea be pres5t4 ,secretions c !n be easily remov$ & m$ication 9 ! =m ( oily solutions be in/ill$ at w into ! tra*ea4 ,9 ! ,bron*oscopic ,cl9ic _m *ildr5 h be5 kept alive = days1 & _! lives f9ally sav$ by aspiration ( ?ick1 t\gh1 sometimes clott$ & cru/$ secretions1 ) ! aspirat+ tube 7,fig4 #aj74 ,x is bett] 9 ^! cases n to pass ! bron*oscope repeat$ly4 ,if1 h[ev]1 evid5ces ( ob/ruction rema91 aft] aspiration1 x is necess>y to see ! nature ( ! ob/ruction & relieve x by removal1 dilatation1 or bron*ial intubation z ! case may require4 ,x is all a matt] ( plumb+ i4e41 cle>+ out ! pipes1 & ma9ta9+ a patul\s airway4 ,tra*eobron*ial ,diph!ria4--,urg5t dyspnea 9 diph!ria :5 no membrane & b slight less5+ ( ! l>yngeal airway is se51 calls = bron*oscopy4 ,_m lives h be5 sav$ by ! bron*oscopic removal ( membrane ob/ruct+ ! tra*ea or bron*i4 ,9 ! e>ly /ages1 pulpy masses look+ l "m ( v9eg> are v ob/ructive4 ,lat] ca/s ( membrane may simulate =eign bodies4 ,! local application ( diph!ria antitox9 to ! tra*ea & bron*i has also be5 recomm5d$4 ,a prep>ation free f a *emical irritant %\ld be select$4 ,abscess ( ! ,lung4--,if ( =eign-body orig91 pulmon>y abscess almo/ inv>iably heals aft] ! removal ( ! object & a regime ( fre% air & re/1 )\t local measures ( any k9d4 ,acute pulmon>y abscess f o!r causes may require bron*oscopic dra9age & g5tle dilatation ( ! swoll5 & n>r[$ bron*i lead+ to x4 ,"s ( ^! bron*i are practically fi/ulae4 ,ob/ructive granulations %\ld be remov$ ) cru%+1 n bit+ =ceps4 ,! regul> =eign-body =ceps are be/ = ?is purpose4 ,caution %\ld be us$ z to removal ( ! granulations ) :i* ! abscess cavity is fill$ 9 *ronic cases4 ,! t]m abscess is usually loosely appli$ to ! condition ( dr[n$ lung 9 :i* ! pus has accumulat$ 9 natural passages1 & 9 :i* !re is nei!r a new wall nor a break+ d[n ( normal walls4 ,*ronic lung-abscess is (t5 successfully treat$ by weekly bron*oscopic lavage ) #bj cc4 or m ( a w>m1 normal salt solution1 a #a3ajjj wat]y potassium p]manganate solution1 or a weak iod9e solution z 9 ! foll[+ =mula3 ,rx4 ,mono*lorph5ol 7,m]ck7 4#ab ,lugol's solution #h4jj ,normal salt solution #ejj4 ,p]haps ! be/ proc$ure is to prec$e m$ic9al applications by ! cle>+ out ( ! purul5t secretions by aspiration ) ! aspirat+ bron*oscope & ! indep5d5t aspirat+ tube1 ! latt] be+ ins]t$ into passages too small to ent] ) ! bron*oscope1 & ! endobron*ial in/illation ( f #aj to #cj cc4 ( ! m$icam5t4 ,! foll[+ h be5 us$3 ,argyrol1 #a p] c5t wat]y solution2 ,silvol1 #a p] c5t wat]y solution2 ,iod(orm1 oil emulsion #aj p] c5t2 ,guaiacol1 #aj p] c5t solution 9 p>aff9e oil2 ,gom5ol1 #bj p] c5t solution 9 oil2 or a bismu? subnitrate susp5sion 9 oil4 ,rob]t ,m4 ,luk5s & ,william ,f4 ,moore ( ! ,bron*oscopic ,cl9ic report excell5t results 9 po/-tonsillectomy abscesses f "o t5? ( "o p] c5t ph5ol 9 normal salt solution ) ! addition ( #b p] c5t ,lugol's solution4 ,*lor9at$ solutions are irritat+1 & if us$1 require copi\s dilution4 ,liquid petrolatum ) a little oil ( eucalyptus has be5 mo/ (t5 ! m$ium4 ,gangr5e ( ! ,lung4--,pulmon>y gangr5e has be5 foll[$ by recov]y aft] ! endobron*ial injection ( oily solutions ( gom5ol & guaiacol 7,guisez74 ,! injections are readily made ?r\gh ! l>yngoscope )\t ! ins]tion ( a bron*oscope4 ,a silk wov5 ca!t] may be us$ ) an ord9>y glass syr+e or a long-nozzl$ l>yngeal syr+e1 or a bron*oscopic syr+e may be us$4 ,lung-mapp+ by a ro5tg5ogram tak5 promptly aft] ! bron*oscopic insufflation ( bismu? subnitrate p[d] or ! injection ( a susp5sion ( bismu? 9 liquid petrolatum is advisable 9 mo/ cases ( pulmon>y abscess be=e beg9n+ any k9d ( treatm5t4 ,bron*ial ,/5osis4--,/5osis ( "o or m bron*i results at times f cicatricial contraction foll[+ second>y infection ( leutic1 tub]cul\s or traumatic lesions4 ,! n>r[+ result+ f =eign body traumatism r>ely requires second>y dilatation aft] ! =eign body has be5 remov$4 ,tub]cul\s bron*ial /5oses r>ely require local treatm5t1 b are easily dilat$ :5 necess>y4 ,luetic cicatricial /5osis may require repeat$ dilatation1 or ev5 bron*ial intubation4 ,endobron*ial neoplasms may cause a subjac5t bron*iectasis1 & sup]jac5t /5osis2 ! latt] may require dilatation4 ,cicatricial /5oses ( ! bron*i are readily recognizable by ! sc>r$ wall & ! abs5ce ( r+s at or ne> ! n>r[+4 ,bron*iectasis4--,9 mo/ cases ( bron*iectasis !re are /rong indications = a bron*oscopic diagnosis1 to elim9ate su* conditions z =eign body1 cicatricial bron*ial /5osis1 or endobron*ial neoplasm z etiologic factors4 ,9 ! idiopa?ic types consid]able b5efit has result$ f ! endobron*ial lavage & endobron*ial oily injections m5tion$ "u lung abscess4 ,x is probable t if bron*oscopic /udy 7 c>ri$ out 9 e case1 def9ite causes = _m s-call$ idiopa?ic cases w\ld be discov]$4 ,lung-mapp+ z else:]e h]e9 expla9$ is invaluable 9 ! /udy ( bron*iectasis4 ,bron*ial a/hma af=ds a l>ge field = bron*oscopic /udy4 ,z yet1 suffici5t data to af=d any def9ite conclusions ev5 z to ! endoscopic picture ( ?is disease h n be5 accumulat$4 ,( ! cases se5 9 ! ,bron*oscopic ,cl9ic "s %[$ no abnormality ( ! bron*i 9 ! int]vals betwe5 attacks1 o!rs a *ronic bron*itis4 ,9 cases /udi$ bron*oscopically dur+ an attack1 ! bron*i 7 f\nd fill$ ) bubbl+ secretions & ! mucosa 0 some:at cyanotic 9 color4 ,! bron*ial lum5 0 n>r[$ only z mu* z x w\ld be1 ) ! same degree ( c\gh1 9 any pati5t n subject to a/hma4 ,! secretions 7 remov$ & ! attack quickly subsid$2 b no influ5ce on ! recurr5ce ( attacks 0 obs]v$4 ,x is ess5tial t ! bron*oscopic /udies be made1 z 7 ^!1 )\t ane/hesia1 local or g5]al1 = x is kn[n t ! application ( coca9 or adr5al9 to ! l>ynx1 or ev5 9 ! nose1 w1 ) "s pati5ts1 /op ! attack4 ,:5 done )\t local ane/hesia1 all[ance mu/ be made = ! reaction to ! pres5ce ( ! tube4 ,9 ^? cases 9 :i* o!r means h fail$ to give relief1 ! endobron*ial application ( novoca9 & adr5al91 or?(orm1 propaes9 or ane/hes9 emulsion may be tri$4 ,cures h be5 report$ by ?is treatm5t4 ,arg5tic nitrate appli$ at weekly int]vals has prov5 v effici5t 9 "s cases4 ,associat$ infective disease ( ! bron*ial mucosa br+s ) x ! que/ions ( immunity1 all]gy1 anaphylaxis1 & vacc9e !rapy2 & ! (t5 pres5t defective metabolism has to be consid]$4 ,autodr[nage4--,autodr[nage is ! "n giv5 by ! au?or to ! dr[n+ ( ! pati5t 9 8 own secretions4 ,tra*eobron*ial secretions 9 excess ( ! am\nt requir$ to moi/5 ! inspir$ air1 become1 9 c]ta9 cases1 a me*anical m5ace to life1 unless remov$4 ,! c\gh reflex1 =c$ expiration1 & cili>y action1 normally remove ! excess4 ,:5 ^! me*anisms are impair$1 z 9 pr(\nd a/h5ia1 l>yngeal p>alysis1 l>yngeal or tra*eal /5osis1 etc42 & especially :5 9 addition to a mild degree ( glottic /5osis or impair$ l>yngeal mobility1 ! secretions become excessive1 ! accumulation may lit]ally dr[n ! pati5t 9 8 own secretions4 ,?is is illu/rat$ frequ5tly 9 influ5za & ara*idic bron*itis4 ,infants _c expectorate1 & _! c\gh reflex is exce$+ly ineffective 9 rais+ secretion to ! ph>ynx2 fur!rmore !y are easily exhau/$ by be*ic ef=ts2 s t age may be cit$ z "o ( ! mo/ frequ5t etiologic factors 9 ! condition ( autodr[nage4 ,bron*oscopic sponge-pump+ 7q4v47 & bron*oscopic aspiration are q effici5t & c save any pati5t n afflict$ ) conditions t are fatal by o!r pa?ologic processes4 ,lues ( ! ,tra*eobron*ial ,tree4--,comp>$ to l>yngeal involvem5t1 syphilis ( ! tra*eobron*ial tree is relatively r>e4 ,! lesions may be gummat\s1 ulc]ative1 or inflammatory1 or !re may be compressive granulomat\s masses4 ,hemoptysis may h its orig9 f a luetic ulc]ation4 ,excision ( fungations or ( a portion ( ! m>g9 ( ! ulc]ation = biopsy is advisable4 ,! ,wass]mann & !rapeutic te/s1 & ! elim9ation ( tub]culosis w be requir$ = confirmation4 ,luetic /5oses are ref]r$ to above4 ,tub]culosis ( ! ,tra*eobron*ial ,tree4--,! bron*oscopic /udy ( tub]culosis is v int]e/+1 b only a few cases ju/ify bron*oscopy4 ,! subglottic infiltrations f ext5sions ( l>yngeal disease are usually ( edemat\s appe>ance1 ?\gh !y are mu* m firm ?an 9 ord9>y inflammatory edema4 ,ulc]ations 9 ?is region are r>e1 except z direct ext5sions ( ulc]ation above ! cord4 ,! tra*ea is relatively r>ely involv$ 9 tub]culosis1 b we may h 9 ! tra*ea ! pale swell+ ( ! e>ly /age ( a p]i*ondritis1 or ! lat] ulc]ation & all ! ph5om5a foll[+ ! mix$ pyog5ic infections4 ,^! same conditions may exi/ 9 ! bron*i4 ,9 a numb] ( in/ances1 ! entire lum5 ( ! bron*us 0 occlud$ by *eesy pus & debris ( a p]ibron*ial gl& :i* _h erod$ ?r\gh4 ,z a rule1 ! mucosa ( tub]culosis is pale1 & ! pallor is acc5tuat$ by ! r blui% /reak ( vessels1 :]e ^! are visible4 ,erosion ?r\gh ( p]i-bron*ial or p]i-tra*eal lymph masses may be associat$ ) granulation tissue1 usually ( pale color1 b occasionally r$di%2 & sometimes ooz+ ( blood is notic$4 ,a mo/ common picture 9 tub]culosis is a broad5+ ( ! c>9a1 :i* may be s m>k$ z to oblit]ate ! c>9a & to bulge inw>d1 produc+ de=m$ lum9a 9 bo? bron*i4 ,sometimes ! lum9a are cresc5tic1 ! concavity ( ! cresc5t be+ int]nal1 t is1 t[>d ! m$ian l9e4 ,abs5ce ( ! normal ant]ior & d[nw>d movem5t ( ! c>9a on deep inspiration is almo/ pa?ognomonic ( a mass at ! bifurcation1 & su* a mass is usually tub]cul\s1 ?\gh x may be malignant1 &1 v r>ely1 luetic4 ,! only lesion visible 9 a tub]cul\s case may be cicatrices f heal$ processes4 ,9 a numb] ( cases !re has be5 a dis*>ge ( pus com+ f ! upp]-lobe bron*us4 ,fig4 #if4--,! au?or's tampons = pulmon>y hemo/asis by bron*oscopic tamponade4 ,! fold$ gauze is #aj cm4 long2 ! braid$ silk cord #fj cm4 long4 ,hemoptysis4--,9 cases n demon/rably tub]cul\s1 hemoptysis may require bron*oscopic exam9ation to det]m9e ! orig94 ,v>ices or unsuspect$ luetic1 malignant1 or tub]cul\s lesions may be f\nd to be ! cause4 ,x is me*anically easy to pack (f "o bron*us ) ! au?or's packs 7,fig4 #if7 introduc$ ?r\gh ! bron*oscope1 b ! advisability ( do+ s requires fur!r cl9ical te/s4 ,angioneurotic ,edema4--,angioneurotic edema manife/s itself by a pale or r$ swoll5 mucosa produc+ /5osis ( ! lum54 ,! tempor>y "* ( ! lesion & its appe>ance 9 o!r regions confirm ! diagnosis4 ,scl]oma ( ! tra*ea is *>act]iz$ by infiltration ( ! tra*eal mucosa1 :i* greatly n>r[s ! lum54 ,! infiltration may be limit$ 9 area & produce a s+le /ricture1 or x may involve ! entire tra*ea & ev5 close a bron*ial orifice4 ,dry+ & cru/+ ( secretions r5d]s ! /5osis /ill m di/ress+4 ,?is disease is b r>ely enc\nt]$ 9 ,am]ica b is n infrequ5t 9 "s p>ts ( ,europe4 ,treatm5t consi/s 9 ! prev5tion ( cru/s & _! removal4 ,limit$ /5otic areas may yield to bron*oscopic b\g9age4 ,urg5t dyspnea calls = tra*eotomy4 ,radium & ro5tg5ray !rapy h be5 advis$1 & cure has be5 report$ by intrav5\s salv>san treatm5t 7see article by ,s4 ,%elton ,watk9s1 on ,scl]oma 9 ,surg4 ,gynecol4 & ,ob/41 ,july1 #aiba1 p4 #dg74 ,atrophic tra*eitis1 ) symptoms q simil> to atrophic rh9itis is a n unusual accompanim5t ( ! nasal condition4 ,x may also exi/ )\t nasal involvem5t4 ,on tra*eoscopy ! mucosa is ?9n$1 pale & dry1 & is cov]$ ) pat*es ( ?ick mucilag9\s secretion & cru/s4 ,decomposition ( secretion produces tra*eal oz5a1 :ile ! accumulat$ cru/s give rise to ! s5sation ( a =eign body & may s]i\sly int]f]e ) respiration1 mak+ bron*oscopic removal imp]ative4 ,! associat$ developm5t ( tra*eal nodul> en*ondromata has be5 describ$4 ,! int]nal adm9i/ration ( iod9e & ! intratra*eal injection ( bl& oily solutions ( m5?ol1 guaiacol1 or gom5ol are helpful4 #bce ,,*apt] ,,xxx--,,diseases ,,( ,,! ,,esophagus ,! m frequ5t causes ( ! "o common symptom ( esophageal disease1 dysphagia1 are includ$ 9 ! li/ giv5 bel[4 ,to avoid elaboration & to obta9 maximum usefulness z a rem9d]1 ov]lapp+ has n be5 elim9at$4 #a4 ,anomalies4 #b4 ,esophagitis1 acute4 #c4 ,esophagitis1 *ronic4 #d4 ,erosion4 #e4 ,ulc]ation4 #f4 ,trauma4 #g4 ,/ricture1 cong5ital4 #h4 ,/ricture1 spasmodic1 includ+ cramp ( ! diaphragmatic p9*cock4 #i4 ,/ricture1 inflammatory4 #aj4 ,/ricture1 cicatricial4 #aa4 ,dilatation1 local4 #ab4 ,dilatation1 diffuse4 #ac4 ,div]ticulum4 #ad4 ,compression /5osis4 #ae4 ,m$ia/9al tumor4 #af4 ,m$ia/9al abscess4 #ag4 ,m$ia/9al gl&ul> mass4 #ah4 ,aneurysm4 #ai4 ,malignant neoplasm4 #bj4 ,b5ign neoplasm4 #ba4 ,tub]culosis4 #bb4 ,lues4 #bc4 ,act9omycosis4 #bd4 ,v>ix4 #be4 ,angioneurotic edema4 #bf4 ,hy/]ia4 #bg4 ,functional antip]i/alsis4 #bh4 ,p>alysis4 #bi4 ,=eign body 9 7a7 ph>ynx1 7b7 l>ynx1 7c7 tra*ea1 7d7 esophagus4 #bcf ,diagnosis4--,! swall[+ function c be /udi$ only ) ! fluoroscope2 esophagoscopy = diagnosis1 %\ld !re=e always be prec$$ by a fluoroscopic /udy ( deglutition ) a b>ium or o!r opaque mixture & exam9ation ( ! ?oracic organs to elim9ate ext]nal pressure on ! esophagus z ! cause ( /5osis4 ,complete physical exam9ation & ,wass]mann reaction are fur!r r\t9e prelim9>ies to any esophagoscopy4 ,special laboratory te/s are done z may be indicat$4 ,! physical exam9ation is meant to include a c>eful exam9ation ( ! lips1 tongue1 palate1 ph>ynx1 & a mirror exam9ation ( ! l>ynx :5 age p]mits4 ,indications = ,esophagoscopy 9 ,disease4--,any p]si/5t abnormal s5sation or di/urbance ( function ( ! esophagus calls = esophagoscopy4 ,vague /oma* symptoms may prove to be esophageal 9 orig91 = vomit+ is (t5 a compla9t :5 ! pati5t really regurgitates4 ,contra9dications to ,esophagoscopy4--,9 ! pres5ce ( aneurysm1 advanc$ organic disease1 ext5sive esophageal v>icosities1 acute necrotic or corrosive esophagitis1 esophagoscopy %\ld n be done except = urg5t reasons1 su* z ! lodgm5t ( a =eign body2 & 9 ?is case ! esophagoscopy may be po/pon$1 if necess>y1 unless ! pati5t is unable to swall[ fluids4 ,esophagoscopy %\ld be def]r$1 9 cases ( acute esophagitis f swall[+ ( cau/ics1 until sl\gh+ has ceas$ & heal+ has /r5g!n$ ! weak places4 ,! extremes ( age are n contra9dications to esophagoscopy4 ,a numb] ( newborn infants h be5 esophagoscop$ by ! au?or2 & he has remov$ =eign bodies f pati5ts ov] #hj ye>s ( age4 ,wat] />vation makes ! pati5t a v bad surgical subject1 & is a di/9ct contra9dication to esophagoscopy4 ,wat] mu/ be suppli$ by means ( proctoclysis & hypod]moclysis be=e any endoscopic or surgical proc$ure is attempt$4 ,if ! esophageal /5osis is n readily & quickly rem$iable1 ga/ro/omy %\ld be done imm$iately4 ,rectal fe$+ w supply wat] = a limit$ "t1 b = nutri5t purposes rectal alim5tation is dang]\sly ineffici5t4 ,prelim9>y exam9ation ( ! ph>ynx & l>ynx ) tongue depressor %\ld always prec$e esophagoscopy1 = any purpose1 because ! symptoms may be due to l>yngeal or ph>yngeal disease t might be ov]look$ 9 pass+ ! esophagoscope4 ,a high degree ( esophageal /5osis results 9 ret5tion 9 ! suprajac5t esophagus ( ! fluids :i* normally are cont9ually fl[+ d[nw>d4 ,! pyri=m s9uses 9 ^! cases are se5 ) ! l>yngeal mirror to be fill$ ) fro?y secretion 7,jackson's sign ( esophageal /5osis7 & ?is secretion may sometimes be se5 trickl+ into ! l>ynx4 ,?is ov]fl[ into ! l>ynx & l[] air passages is (t5 ! cause ( pulmon>y symptoms1 :i* are ?us /rictly second>y to ! esophageal disease4 ,,anomalies ,,( ,,! ,,esophagus ,cong5ital esophagotra*eal fi/ulae are ! mo/ frequ5t ( ! embryonic developm5tal errors ( ?is organ4 ,septic pneumonia f ! entrance ( fluids into ! lungs usually causes dea? )9 a few weeks4 ,imp]=ate esophagus usually %[s an upp] esophageal segm5t end+ 9 a bl9d p\*4 ,a l[] segm5t is usually pres5t & may be connect$ ) ! upp] segm5t by a fi/ula4 ,cong5ital /ricture ( ! esophagus may be s+le or multiple1 & may be ?9 & weblike1 or x may ext5d ov] a ?ird or m ( ! l5g? ( ! esophagus4 ,x may n become manife/ until solids are add$ to ! *ild's diet2 (t5 n = _m mon?s4 ,! lodgm5t ( an unusually l>ge bolus ( unma/icat$ food may set up an esophagitis ! swell+ ( :i* may completely close ! lum5 ( ! cong5itally n>r[ esophagus4 ,x is n uncommon to meet ) cases ( adults :o h nev] swall[$ z well z o!r p1 & 9 :om cicatricial & spasmodic /5osis c be exclud$ by esophagoscopy1 :i* demon/rates an obvi\s n>r[+ ( ! esophageal lum54 ,^! cases are d\btless cong5ital4 ,webs 9 ! upp] ?ird ( ! esophagus are be/ det]m9$ by ! passage ( a l>ge esophagoscope :i* puts ! esophagus on ! /ret*4 ,! webs may be brok5 by ! ins]tion ( a clos$ alligator =ceps1 :i* is !n )drawn ) op5$ blades4 ,bett] /ill is ! dilator %[n 9 ,fig4 #bf4 ,?is retrograde dilatation is relatively safe4 ,a silk-wov5 esophagoscopic b\gie or ! metallic tra*eal b\gie may be us$1 ) prop] caution4 ,subsequ5t dilatation = a few times w be requir$ to prev5t a reproduction ( ! /5osis4 ,treatm5t ( ,esophageal ,anomalies4--,ga/ro/omy is requir$ 9 ! imp]=ate cases4 ,esophagoscopic b\g9age is v successful 9 ! cure ( all cases ( cong5ital /5osis4 ,any sort ( lum5 c be enl>g$ s any well ma/icat$ food c be swall[$4 ,c>eful esophagoscopic "w ) ! b\gies 7,fig4 #dj7 w ultimately cure ) little or no risk ( mortality4 ,any =m ( rapid dilatation is dang]\s4 ,cong5ital /5osis1 if n an absolute atresia1 yields m readily to esophagoscopic b\g9age ?an cicatricial /5osis4 ,,rupture ,,& ,,trauma ,,( ,,! ,,esophagus ,^! may be spontane\s or may ensue f ! passage ( an in/rum5t1 or =eign body1 or ( bo? comb9$1 z exemplifi$ 9 ! bl9d attempts to remove a =eign body or to pu% x d[nw>ds4 ,dige/ion ( ! esophagus & p]=ation may result f ! /agnation ( regurgitat$ ga/ric juice !re94 ,?is condition sometimes occurs 9 pr(\nd toxic & debilitat$ /ates4 ,rupture ( ! ?oracic esophagus produces pr(\nd %ock1 fev]1 m$ia/9al emphysema1 & rapid s9k+4 ,pneumo?orax & empyema foll[ p]=ation into ! pleural cavity4 ,rupture ( ! c]vical esophagus is usually foll[$ by c]vical emphysema & c]vical abscess1 bo? ( :i* (t5 burr[ into ! m$ia/9um along ! fascial lay]s ( ! neck4 ,less] degrees ( trauma produce esophagitis usually accompani$ by fev] & pa9ful & difficult swall[+4 ,! treatm5t ( traumatic esophagitis consi/s 9 re/ 9 b$1 /]ile liquid food1 & ! adm9i/ration ( bismu? subnitrate 7ab\t "o gramme 9 an adult71 dry on ! tongue e #d h\rs4 ,rupture ( ! esophagus requires imm$iate ga/ro/omy to put ! esophagus at re/ & supply necess>y alim5tation4 ,?oracotomy = dra9age is requir$ :5 ! pleural cavity has be5 involv$1 n only = pleural secretions1 b = ! con/ant & copi\s esophageal leakage4 ,x is n ord9>ily realiz$ h[ mu* normal saliv>y dra9age passes d[n ! esophagus4 ,! cu/om>y treatm5t ( %ock is to be appli$4 ,no attempt %\ld be made to remove a =eign body until ! traumatic lesions h heal$4 ,?is may require a numb] ( weeks4 ,decision z to :5 to remove ! intrud] is det]m9$ by esophagoscopic inspection4 ,subcutane\s emphysema does n require puncture unless gase\s1 or unless pus =ms4 ,9 ! latt] ev5t free ext]nal dra9age becomes imp]ative4 ,,acute ,,esophagitis ,?is is usually ( traumatic or caut]ant orig94 ,if sev]e or ext5sive1 all ! symptoms describ$ "u ,rupture ( ! ,esophagus may be pres5t4 ,! endoscopic appe>ances are unmi/akable to anyone famili> ) ! appe>ance ( mucosal inflammations4 ,! pale1 blui% p9k color ( ! normal mucosa is replac$ by a deep-r$ velvety swoll5 appe>ance 9 :i* individual vessels are invisible4 ,aft] exudation ( s]um into ! tissues1 ! color may be pal] & 9 "s in/ances a typical edema may be se54 ,?is may dim9i% ! lum5 tempor>ily4 ,folds ( swoll5 mucosa cr[d into ! lum5 if ! inflammation is int5se4 ,^! folds are sometimes demon/rable 9 ! ro5tg5ogram by ! bismu? or b>ium 9 ! creases betwe5 :i* ! prom95ce ( ! folds %[ z isl&s z beautifully demon/rat$ by ,david ,r4 ,b[5 9 "o ( ! au?or's cases4 ,if ! inflammation is due to corrosives1 a grayi% exudate may be visible e>ly1 sl\ghs lat]4 ,,ulc]ation ,,( ,,! ,,esophagus ,sup]ficial erosions ( ! esophagus are by no means an uncommon accompanim5t ( ! /agnation ( food & secretions4 ,f ! irritation !y produce1 spa/ic /5osis may occur1 ?us con/itut+ a vici\s circle2 ! spasm ( ! esophagus increases ! /agnation :i* 9 turn results 9 fur!r inflammation & ultimate ulc]ation4 ,heal+ ( su* ulc]s may result 9 cicatricial contraction & organic /5osis4 ,ulc]ation may foll[ trauma by in/rum5t1 =eign body1 or corrosive4 ,,diff]5tial ,,diagnosis ,,( ,,ulc] ,,( ,,! ,,esophagus ,simple ulc] requires ! exclusion ( lues1 tub]culosis1 epi!lioma1 endo!lioma1 s>coma1 & act9omycosis4 ,simple ulc] ( ! esophagus is usually associat$ ) /5osis1 spa/ic or organic4 ,luetic ulc]s commonly %[ a surr\nd+ inflammatory areola1 & !y usually h ?ick5$ elevat$ edges1 g5]ally free f granulation tissue1 ) a pa/y c5t] n ble$+ readily :5 spong$4 ,! ,wass]mann reaction may contribute to ! diagnosis2 b if negative1 a ?or\gh & prolong$ te/ ) m]cury is imp]ative4 ,x mu/ be rememb]$ t a p]son ) lues may h a simple1 mix$1 or malignant ulc]ation ( ! esophagus1 or ! ?ree lesions may ev5 be comb9$4 ,x may be 9 "s cases possible to demon/rate ! treponema pallidum 9 scrap+s tak5 f ! ulc]4 ,! s+le tub]cul\s ulc] is usually pale1 sup]ficial1 & granul> 9 base4 ,if x is a cont9uation f m ext5sive extra-esophageal tub]cul\s ulc]ation1 pale caulifl[] granulations may be pres5t4 ,slight cicatrices may be se54 ,tub]culosis 9 o!r organs c almo/ always be demon/rat$ by ro5tg5ographic1 physical1 or laboratory /udies4 ,tub]cul9 te/s & animal injection ) an emulsion ( a specim5 ( tissue may be requir$4 ,! specim5 mu/ be tak5 v sup]ficially to avoid risk ( p]=ation4 ,s>comat\s ulc]s d n diff] mat]ially 9 appe>ance f ^? ( c>c9oma1 b !y are mu* m r>e4 ,c>c9omat\s ulc] is usually *>act]iz$ by ! v vascul> bright r$ zone1 rais$ edges1 fungations1 granulation tissue t ble$s freely on ! lighte/ t\*1 & above all1 x is almo/ inv>iably situat$ on an infiltrat$ base :i* communicates a feel+ ( h>dness to ! pressure ( sponges or ! esophagoscope itself4 ,a sc> may be f ! heal+ ( an ulc] f /asis1 or "o ( specific or precanc]\s "*4 ,x may be a canc]\s process develop+ on ! site ( a sc>1 s t ! pres5ce ( sc> tissue does n absolutely negative malignancy4 ,z a rule1 h[ev]1 sc>s are abs5t 9 canc] ( ! esophagus4 ,! firm & sometimes prom95t ridge ( ! cross+ ( ! left bron*us mu/ n be mi/ak5 = infiltration1 & ! esophagoscopi/ mu/ be famili> ) ! normal rigidity ( ! cricoph>yngeus4 #bdb ,mix$ infection gives to all esophageal ulc]ation a c]ta9 uni=mity ( appe>ance1 s t laboratory /udies ( sme>s or hi/ologic & bact]iologic /udy ( tissue specim5s tak5 f fungations or ?ick5$ edges are (t5 requir$ to confirm ! endoscopic diagnosis4 ,if ! edges are ?9 & flat1 ! tak+ ( a specim5 involves "s risk2 fungations c be remov$ )\t risk2 s c nodules1 b c>e mu/ be tak5 t project+ folds are n mi/ak5 = nodules4 ,x is always wise to pu% ! !rapeutic te/ ) potassium iodid & especially m]cury 9 any case ( esophageal ulc]ation unassociat$ ) /asis4 ,treatm5t ( ,acute & ,subacute ,inflammation & ,ulc]ation ( ! ,esophagus4--,bismu? subnitrate 9 doses ( ab\t "o gramme1 giv5 dry on ! tongue & swall[$ )\t wat]1 has a local antiseptic & protective action4 ,its antiseptic p[] may be enhanc$ by ! addition ( calomel to ! p[d]1 9 su* am\nt z may be tol]at$ by ! b[els4 ,if pa9 be pres5t ! comb9ation ( a gra9 or two ( ane/hes9 or or?(orm ) ! bismu? w be grateful4 ,! local application ( argyrol 9 #be p] c5t wat]y solution is also ( great value4 ,! m\? & tee? are to be kept clean ) a m\? wa% ( ,dak9's solution1 #a "p1 to pepp]m9t wat]1 #f p>ts4 ,! esophagus mu/ be plac$ at re/ z f> z possible by liquid diet or1 if ne$ be1 by ga/ro/omy4 ,,*ronic ,,esophagitis ,?is is usually a result ( /agnation ( food or secretion1 & w be consid]$ "u spasmodic /5osis & diffuse dilatation ( ! esophagus4 ,a v m>k$ case ) local di/ress & pa9 ext5d+ ?r\gh to ! back 0 se5 by ! au?or 9 consultation ) ,dr4 ,john ,b4 ,wright :o _h made ! diagnosis4 ,! pati5t 0 a suff]] f ankylo/omiasis4 #bdc ,,compression ,,/5osis ,,( ,,! ,,esophagus ,! esophagus may be n>r[$ by ! pressure ( any p]iesophageal disease or anomaly4 ,! lesions mo/ frequ5tly f\nd are3 #a4 ,goit]1 c]vical or ?oracic4 #b4 ,malignancy ( any ( ! intra?oracic visc]a4 #c4 ,aneurysm4 #d4 ,c>diac & aortic enl>gem5t4 #e4 ,lymphad5opa?ies4 ,hodgk9s' disease4 ,leukemia4 ,lues4 ,tub]culosis4 ,simple infective ad5itis4 #f4 ,lordosis4 #g4 ,enl>gem5t ( ! left hepatic lobe4 ,endoscopically1 compression /5osis ( ! esophagus is manife/$ by a slit-l crevice :i* occupies ! place ( ! lum5 & :i* does n op5 up readily be=e ! advanc+ tube4 ,! long axis ( ! slit is almo/ always at "r angles to ! compressive mass1 if ! esophageal wall be un9volv$4 ,! cov]+ mucosa may be normal or x may %[ signs ( *ronic inflammation4 ,malignant compressions are *>act]iz$ by _! h>dness :5 palpat$ ) ! tube4 ,associat$ pressure on ! recurr5t l>yngeal n]ve (t5 makes l>yngeal p>alysis coexi/5t4 ,! nature ( ! compressive mass w require = its det]m9ation ! aid ( ! ro5tg5ologi/1 int]ni/1 & cl9ical laboratory4 ,compression by ! enl>g$ left auricle has be5 obs]v$ a numb] ( times4 ,! pres5ce ( aneurysm is a di/9ct contra9dication to esophagoscopy = diagnosis except 9 case ( suspect$ =eign body4 ,treatm5t ( compressive /5osis ( ! esophagus dep5ds ^u ! nature ( ! compressive lesion & is )\t ! realm ( endoscopy4 ,9 unc]ta9 cases potassium iodid1 & especially m]cury1 %\ld always be giv5 a ?or\gh & prolong$ trial2 an occasional cure w result4 ,esophageal intubation is indicat$ 9 all conditions except aneurysm4 ,ga/ro/omy %\ld be done e>ly :5 necess>y4 ,,diffuse ,,dilatation ,,( ,,! ,,esophagus ,?is is practically always due to /agnation ectasia1 :i* is inv>iably associat$ ) ei!r organic or spasmodic /ricture1 exi/+ at ! "t ( obs]vation or at "s "t prior !reto4 ,! dilat+ effect ( ! repeat$ly accumulat$ food results 9 a p]man5t enl>gem5t1 s t ! esophagus acts z ! res]voir ( a l>ge funnel ) a v small op5+4 ,:5 food is swall[$ ! esophagus fills1 & ! cont5ts trickle sl[ly ?r\gh ! op5+4 ,gases due to f]m5tation increase ! di/5sion & cause sub/]nal pressure1 discom=t1 & bel*+4 ,a v l>ge dilatation ( ! ?oracic esophagus indicates spa/ic /5osis4 ,cicatricial /5oses d n result 9 su* l>ge dilatations & ! dilatation above a malignant /5osis is usually slight1 probably because ( its relatively %ort] duration4 ,! treatm5t ( diffuse esophageal dilatation consi/s 9 dilat+ ! diaphragmatic p9*cock t is1 ! hiatal esophagus4 ,*ronic esophagitis is to be controll$ by esophageal lavage1 ! regulation ( ! diet to liquefiable foods & ! adm9i/ration ( bismu? subnitrate4 ,! pati5t c be taught to d ! lavage4 ,! local esophagoscopic application ( a small quantity ( a #be p] c5t wat]y solution ( argyrol may be requir$ = ! /atic esophagitis4 ,! r$undancy probably nev] disappe>s2 b functional & subjective cures are usually obta9able4 #bde ,,*apt] ,,xxxi--,,diseases ,,( ,,! ,,esophagus 7,cont9u$7 ,,spasmodic ,,/5osis ,,( ,,! ,,esophagus ,etiology4--,! functional activity ( ! esophagus is dep5d5t ^u reflex action4 ,! food is propuls$ 9 a p]i/altic wave by ! same me*anism z1 & ?r\gh an inn]vation 7,au]ba* & ,meissn] plexus7 simil> to t :i* controls inte/9al movem5ts4 ,! vagus also is directly conc]n$ ) ! deglutitory act1 = swall[+ is impossible if bo? vagi are cut4 ,any?+ :i* unduly di/urbs ?is reflex arc may s]ve z an excit+ cause ( spasmodic /5osis4 ,bolt+ ( food1 sup]ficial erosions1 local esophageal disease1 or a small =eign body1 may produce spasmodic /5osis4 ,spasm second>y to disease ( ! /oma*1 liv]1 gall bladd]1 app5dix1 or o!r abdom9al organ is cl9ically well recogniz$4 ,a p]petuat+ cause 9 e/abli%$ cases is und\bt$ly n]ve cell habit1 & 9 _m cases !re is an und]ly+ neurotic factor4 ,%ock z an excit+ cause has be5 well exemplifi$ by ! numb] ( cases ( phr5ospasm develop+ 9 soldi]s dur+ ! ,_w ,w>4 ,cricoph>yngeal spasmodic /5osis usually pres5ts ! subjective symptom ( difficulty 9 />t+ ! bolus ( food d[nw>d4 ,once />t$1 ! food passes into ! /oma* unimp$$4 ,regurgitation1 if x occurs1 is imm$iate4 ,! condition consi/s 9 a tonic contraction1 ahead ( ! bolus1 ( ! circul> fib]s ( ! inf]ior con/rictor kn[n z ! cricoph>yngeus muscle1 or 9 a failure ( ?is muscle to relax s z to all[ ! bolus to pass4 ,9 ei!r case ! disord] may be second>y to an organic lesion4 ,local malignant disease or =eign bodies may be ! cause4 ,globus hy/]icus1 lump 9 ! ?roat1 & ! s5se ( con/riction & *ok+ dur+ emotion are due to ! same spasmodic condition4 ,diagnosis4--,at esophagoscopy !re w be f\nd m>k$ exagg]ation ( ! usual spasm :i* occurs at ! cricoph>yngeus dur+ ! introduction ( ! tube4 ,! lum5 may assume v>i\s %apes1 or be s tightly clos$ t ! folds =m a mammilli=m projection 9 ! c5t]4 ,if ! spasm gradually yields1 & a full-siz$ esophagoscope passes )\t fur!r resi/ance1 x may be /at$ t ! esophagus is ( normal calibre1 & a diagnosis ( spasmodic /5osis c be made4 ,consid]able exp]i5ce is requir$ to di/+ui% betwe5 normal & pa?ologic spasm 9 an unane/hetiz$ individual4 ,to ! less exp]i5c$ esophagoscopi/1 exam9ation "u e!r ane/hesia is recomm5d$4 ,deep ane/hesia w relax ! normal cricoph>yngeal reflex closure z well z any abnormal spasm1 ?us assi/+ 9 ! diff]5tiation betwe5 an organic /ricture & "o ( functional "*4 ,"u deep g5]al ane/hesia1 h[ev]1 x is impossible to diff]5tiate betwe5 ! normal reflex & a spasmodic condition1 s9ce bo? are aboli%$4 ,_m cases ( int]mitt5t esophageal /5osis suppos$ to be spasmodic are due to organic n>r[ness ( lum5 plus lodgem5t ( food1 ob/ructive 9 itself & 9 ! esophagitis result+ f its pres5ce4 ,! organic n>r[+1 cong5ital or pa?ologic1 is readily recognizable esophagoscopically4 ,treatm5t4--,! fundam5tal cause ( ! di/urbance ( ! reflex %\ld be se>*$ =1 & treat$ accord+ to its nature4 ,purely functional cases are (t5 cur$ by ! passage ( a l>ge esophagoscope4 ,recurr5ces may require simil> treatm5t4 #bdg ,,functional ,,hiatal ,,/5osis4 ,,hiatal ,,esophagismus4 ,,phr5ospasm1 ,,diaphragmatic ,,p9*cock ,,/5osis4 7,,s-,,call$ ,,c>diospasm7 ,!re is no sph9ct]ic muscul> arrangem5t at ! c>diac orifice ( ! esophagus1 s t spasmodic /5osis at ?is level is n possible & ! t]m c>diospasm is1 !re=e1 a misnom]4 ,x 0 fir/ demon/rat$ by ! au?or t 9 s-call$ c>diospasm ! functional closure ( ! esophagus occurr$ at ! diaphragmatic level1 & t x 0 due to ! diaphragmatic p9*cock4 ,anatomical /udies h corroborat$ ?is f9d+ by demon/rat+ a def9ite sph9ct]ic me*anism consi/+ ( muscle b&s spr++ f ! crura ( ! diaphragm & surr\nd+ ! esophagus at ! "u surface ( ! hiatus4 ,an inspection ( ! cadav]ic diaphragm f bel[ w demon/rate an arrangem5t l d\ble %e>s admirably adapt$ to ?is p9*cock action4 ,fur!r confirmation is ! fact t all dilatation ( ! esophagus incid5t to spasm at its l[] extremity is situat$ above ! diaphragm4 ,9 pass+ x may be /at$ t ! p9*cock action1 plus ! k9k+ ( ! esophagus normally prev5ts regurgitation :5 a man ) a full /oma* /&s on 8 head or inv]ts 8 body4 ,= ! upw>d escape ( food f ! /oma* an involunt>y co-ord9at$ antip]i/altic cycle is necess>y4 ,! dilatation result+ f phr5ospasm may rea* great size 7,fig4 #if;a71 & ! capacity ( ! sac may be z mu* z two lit]s4 ,:ile ! esophagus is usually dilat$1 ! /oma* on ! o!r h& is (t5 contract$1 l>gely f lack ( di/5tion by food1 b possibly also because ( a spa/ic /ate due to ! same causes z ! phr5ospasm4 ,rec5tly ,mo%] has demon/rat$ t hepatic abnormality may furni% an organic cause 9 _m cases =m]ly consid]$ spasmodic4 ,! symptoms ( hiatal esophagismus are v>iable 9 degree4 ,sub/]nal di/ress1 ) a feel+ ( fullness & pressure foll[$ by eructations ( gas & regurgitation ( food )9 a p]iod ( a qu>t] ( an h\r to sev]al h\rs aft] eat+1 are pres5t4 ,if ! esophageal dilatation be great1 regurgitation may occur only aft] an accumulation ( sev]al days1 :5 l>ge quantities ( /ale food w be expell$4 ,! g5]al nutrition is impair$1 & !re is usually ! hi/ory ( weight loss to a c]ta9 level at :i* x is ma9ta9$ ) b slight v>iation4 ,?is is expla9$ by ! trickl+ ( liquifi$ food f ! esophageal res]voir into ! /oma* z ! spasm int]mitt5tly relaxes1 ?is occurr+ usually be=e a s]i\s /ate ( inanition sup]v5es4 ,at times ! hiatal spasms are extremely viol5t & pa9ful1 ! pa9 be+ ref]r$ f ! xiphoid region to ! back1 or upw>d into ! neck4 ,pati5ts are (t5 consci\s ( ! times ( patul5cy ( ! esophagus2 !y w "k ! esophagus to be op5 & w eat )\t hesitation1 or w refuse food ) ! c]ta9 k t x w n pass into ! /oma*4 ,p]iods ( remission ( symptoms = mon?s & ye>s are not$4 ,! neurotic "* ( ! lesion 9 "s cases is evid5c$ by ! occasionally sudd5 & />tl+ cures foll[+ a s+le dilatation1 z well z by ! t5d5cy to relapse :5 ! individual is subject to :at is = him undue n]v\s t5sion4 ,9 a v few cases1 ) pati5ts ( r a /olid type1 all neurotic t5d5cies seem to be abs5t4 ,! diagnosis ( hiatal esophagismus requires ! exclusion ( local organic esophageal lesions4 ,9 ! typical case ) m>k$ dilatation1 ! esophagoscopic f9d+s are diagno/ic4 ,a :ite1 pa/y1 mac]at$ mucosa1 & normally contract$ hiatus esophageus :i* :5 f\nd p]mits ! l>ge esophagoscope to pass into ! /oma*1 w be recogniz$ z *>act]i/ic by anyone :o has se5 ! condition4 ,9 ! cases ) b little esophageal di/5sion ! diagnosis is confirm$ by ! con/ancy ( ! ob/ruction to a b>ium mixture at ! phr5ic level1 :ile at esophagoscopy ! usual resi/ance at ! hiatus esophageus is f\nd n to be increas$1 & no o!r local lesion is f\nd z ! esophagoscope ent]s ! /oma*4 ,x is ! failure ( ! diaphragmatic p9*cock to op51 z 9 ! normal deglutitory cycle1 r ?an a spasmodic tightness1 t ob/ructs ! food4 ,! pres5ce ( organic /5osis at ! hiatus may remove ! case altoge!r f ! spasmodic class1 or a cicatricial or infiltrat$ n>r[+ may be ! result ( /atic esophagitis4 ,a compressive /5osis due to hepatic abnormality may simulate spasmodic /5osis z %[n by ,mo%]1 :o believes t #ge p] c5t ( s-call$ c>diospasms are organic4 ,treatm5t ( hiatal esophagismus 7s-call$ c>diospasm7 consi/s 9 ! ov]-dilatation ( ! diaphragmatic p9*cock or hiatus esophageus1 & 9 prop] rem$ial measures = ! removal ( ! und]ly+ neurosis4 ,! simple passage ( ! esophagoscope suffices to cure "s cases4 ,fur!r dilatation by endoscopic guidance may be obta9$ by ! introduction ( ,mo%]'s divulsor ?r\gh ! esophagoscope1 by :i* accurate placem5t is obta9$4 ,! di/5sion %\ld n usually exce$ #be mm4 ,num]\s wat] & air bags h be5 devis$ = /ret*+ ! hiatus1 & excell5t results h be5 obta9$ by _! use4 ,possibly "s ( ! cures h be5 due to ! dilatation ( organic lesions1 or to ! cr[d+ back ( an enl>g$ malpos$1 or o!rwise abnormal left lobe ( ! liv]1 :i* ,mo%] has %[n to be an etiologic factor4 ,c]ta9 cases prove v ob/9ate ( cure1 & require esophageal lavage = ! esophagitis1 & fe$+s ?r\gh ! /oma* tube to increase nutrition & to dilate ! contract$ /oma*4 ,ga/ro/omy = fe$+ r>ely becomes necess>y1 = a /oma* tube c always be plac$ ) ! esophagoscope if x w n pass o!rwise4 ,retrograde dilatation ) ! f+]s ?r\gh a ga/ro/omy op5+ has be5 done1 b seems h>dly w>rant$ 9 view ( ! excell5t results obta9able f above4 ,in/ructions %\ld be giv5 conc]n+ ! prop] ma/ication ( food1 & dur+ treatm5t ! frequ5t p>tak+ ( small quantities ( liquid foods is recomm5d$4 ,liquids & foods %\ld be nei!r hot nor cold4 ,! neurologi/ %\ld be consult$ 9 cases deem$ neurotic4 #if;a4-,functional hiatal /5osis4 ,cramp ( ! diaphragmatic p9*cock 7s-call$ c>diospasm74 ,endocr9e imbalance %\ld be inve/igat$ & treat$1 z urg$ by ,mac,nab4 ,esophageal antip]i/alsis is ! "n giv5 by ! au?or to a h]et(ore undescrib$ disease associat$ ) regurgitation ( food f ! esophagus1 ! food n hav+ rea*$ ! /oma*4 ,x may be cont9u\s or p>oxysmal & may be ( s s]i\s a degree z to ?reat5 />vation4 ,! be/ treatm5t 9 sev]e cases is ga/ro/omy to put ! esophagus at re/4 ,mild] cases get well "u liquid diet1 re/ 9 b$1 endocr9e !rapy1 cure ( associat$ abdom9al disease1 etcet]a4 #bea ,,*apt] ,,xxxii--,,diseases ,,( ,,! ,,esophagus 7,cont9u$7 ,,cicatricial ,,/5osis ,,( ,,! ,,esophagus ,etiology4--,! accid5tal swall[+ ( cau/ic alkali 9 solutions ( lye or propriet>y wa%+ & cleans+ p[d]s1 is ! mo/ frequ5t cause ( cicatricial /5osis4 ,comm]cial lye prep>ations are ab\t #ie p] c5t sodium hydroxide4 ,! cleans+ & wa%+ p[d]s conta9 f eight to fifty p] c5t ( cau/ic alkali1 usually soda a%1 & are sold by groc]s ev]y:]e4 ,! labels on _! conta9]s n only give no w>n+ ( ! dang]\s nature ( ! cont5ts nor antidotal advice1 b h su* directly mislead+ /atem5ts z 3 ,w n injure ! mo/ delicate fabric1 ,w n injure ! h&s1 etc4 ,ut5sils us$ to measure or dissolve ! p[d]s are aft]w>d us$ = dr9k+1 )\t r9s+1 & ?us ! residue ( ! p[d] rema9+ is swall[$ 9 /rong solution4 ,at o!r times solutions ( lye are drunk 9 mi/ake = wat]1 c(fee1 or w9e4 ,^! entirely prev5table accid5ts w\ld be r>e if !y 7 z conspicu\sly labell$ ,poison z is requir$ by law 9 ! case ( ^! & any o!r poisons1 :5 sold by druggi/s4 ,! necessity = su* labell+ is ev5 great] ) ! lye prep>ations because !y g into ! kit*51 :]eas ! drugs g to ! m$ic9e %elf1 out ( ! rea* ( *ildr54 ,h\sehold ammonia1 salts ( t>t> 7potassium c>bonate71 wa%+ soda 7sodium c>bonate71 m]curic *loride1 & /rong acids are also1 ?\gh less frequ5tly1 ! cause ( cicatricial esophageal /ricture4 ,tub]culosis1 lues1 sc>let fev]1 diph!ria1 ent]ic fev] & pyog5ic conditions may produce ulc]ation foll[$ by cicatrices ( ! esophagus4 ,spasmodic /5osis ) its consequ5t esophagitis & erosions1 &1 lat]1 second>y pyog5ic infection1 may result 9 s]i\s cicatrices4 ,peptic ulc] ( ! l[] esophagus may be a cause4 ,! prolong$ soj\rn ( a =eign body is likely to result 9 cicatricial n>r[+4 ,,fig4 #ig4--,s*ematic illu/ration ( a s]ies ( ecc5tric /rictures ) int]/rictural sacculations1 9 ! esophagus ( a boy ag$ f\r ye>s4 ,! /rictures 7 divuls$ s]iatim f above d[nw>d ) ! divulsor1 ! esophageal wall1 ,d1 be+ mov$ sidewise to ! position ( ! dott$ l9e by means ( a small esophagoscope ins]t$ ?r\gh ! upp] /ricture1 ,a1 aft] divulsion ( ! latt]4 ,location ( ,cicatricial ,esophageal ,/rictures4--,! /rictures are (t5 multiple & _! lum9a are r>ely ei!r c5tral or conc5tric 7,fig4 #ig74 ,9 ord] ( frequ5cy ! sites ( cicatricial /5osis are3 #a4 ,at ! cross+ ( ! left bron*us2 #b4 ,9 ! region ( ! cricoph>yngeus2 #c4 ,at ! hiatal level4 ,/ricture at ! c>dia has r>ely be5 enc\nt]$ 9 ! ,bron*oscopic ,cl9ic4 ,/5osis ( ! pylorus has be5 not$1 b is r>e4 ,prognosis4--,spontane\s recov]y f cicatricial /5osis probably nev] occurs1 & ! mortality ( untreat$ small lum5 /rictures is v high4 ,bl9d me?ods ( dilatation are almo/ c]ta9 to result 9 dea? f p]=ation ( ! esophageal wall1 because "s pressure is necess>y to dilate a /ricture1 & ! po9t ( ! b\gie1 n be+ "u guidance ( ! eye1 is c]ta9 at sometime or o!r to be engag$ 9 a pocket in/ead ( 9 ! /ricture4 ,pressure !n results 9 p]=ation ( ! bottom ( ! pocket 7,fig4 #ih74 ,?is accid5t is contribut$ to by dilatation ) ! wr9kl$1 sc>r$ floor :i* usually develops above ! /ricture4 ,rapid divulsion & int]nal esophagotomy are me*anically v easily & accurately done ?r\gh ! esophagoscope1 & w\ld yield a few prompt cures2 b ! mortality w\ld be v high4 ,"u c]ta9 circum/ances1 to be expla9$ bel[1 g5tle divulsion ( ! proximal "o ( a s]ies ( /rictures has to be done4 ,) prop] precautions & a g5tle h&1 ! risk is slight4 ,"u esophagoscopic b\g9age ! prognosis is favorable z to ultimate cure1 ! duration ( ! treatm5t v>y+ ) ! numb] ( /rictures1 ! tightness1 & ! ext5t ( ! fibr\s tissue-*anges 9 ! esophageal wall4 ,mortality f ! endoscopic proc$ure is almo/ nil1 & if ga/ro/omy is done e>ly 9 ! tightly /5os$ cases1 ultimate cure may be confid5tly expect$ ) c>eful ?\gh prolong$ treatm5t4 ,,fig4 #ih4--,s*ema illu/rat+ ! me*anism ( p]=ation by bl9d b\g9age4 ,on enc\nt]+ resili5t resi/ance ! op]ator1 hav+ a false conception1 pu%es on ! b\gie4 ,p]=ation results because 9 reality ! b\gie is 9 a pocket ( ! supra/rictural ecc5tric dilatation4 ,symptoms4--,dysphagia1 regurgitation1 di/ress aft] eat+1 & loss ( weight1 v>y ) ! degree ( ! /5osis4 ,! int]mitt5cy ( ! symptoms is sometimes confus+1 = ! lodgm5t ( relatively l>ge p>ticles ( food (t5 simulates a spasmodic /5osis1 & 9 fact !re is (t5 an elem5t ( spasm :i* holds ! =eign body 9 ! /rictur$ area until x relaxes4 ,/atic esophagitis results 9 a swell+ ( ! esophageal walls & a n>r[+ ( ! lum51 s t swall[+ is m or less tr\blesome until ! esophagitis subsides4 ,esophagoscopic ,appe>ances ( ,cicatricial ,/5osis4--,! color ( ! cicatricial area is usually pal] ?an ! normal mucosa4 ,! sc>s may be v :ite & elevat$1 or !y may be flu% ) ! normal mucosa1 or ev5 depress$4 ,occasionally ! cicatrix is annul>1 b m (t5 x is ecc5tric & involves only a "p ( ! circumf]5ce ( ! wall4 ,if ! am\nt ( sc> tissue is small1 ! lum5 ma9ta9s its mobility2 op5s & closes dur+ respiration1 c\gh1 & vomiturition4 ,betwe5 two /rictures !re is (t5 a p\* conta9+ food remnants4 ,x is r>ely possible to see ! lum5 ( ! second /ricture1 because x is usually ecc5tric to ! fir/4 ,/agnation ( food results 9 sup]jac5t dilatation & esophagitis4 ,erosions & ulc]ations :i* foll[ ! /agnation esophagitis increase ! cicatricial /5osis 9 _! heal+4 ,diff]5tial ,diagnosis4--,:5 ! und]ly+ condition is mask$ by inflammation & ulc]ation1 ^! lesions mu/ be remov$ by frequ5t lavage1 ! adm9i/ration ( bismu? subnitrate ) ! occasional addition ( calomel p[d]1 & ! limitation ( ! diet to /ra9$ liquids4 ,! cicatricial nature ( ! /5osis c !n be /udi$ to bett] advantage4 ,9 mo/ cases ! cicatrices are unmi/akably conspicu\s4 ,spasmodic /5oses are diff]5tiat$ by ! abs5ce ( cicatrices & ! yield+ ( ! /5osis to g5tle b cont9u\s pressure ( ! esophagoscope4 ,:ile x is possible t spasmodic /5osis may supplem5t cicatricial /5osis1 x is c]ta9ly exce$+ly r>e4 ,ne>ly all ( ! occasions 9 :i* a tempor>y increase ( ! /5osis 9 a cicatricial case is attribut$ to an elem5t ( spasm1 ! real cause ( ! int]mitt5cy is n spasm b ob/ruction caus$ by food4 ,?is occurs 9 ?ree ways3 #a4 ,actual cork+ ( ! /rictur$ lum5 by a fragm5t ( food1 9 :i* case int]mitt5cy may be due to p>tial regurgitation ( ! cork+ mass ) subsequ5t s9k+ tightly into ! /ricture4 #b4 ,! cork may dissolve & pass on ?r\gh to be lat] replac$ by ano!r4 #c4 ,reaction>y swell+ ( ! esophageal mucosa due to /agnation4 ,"h aga9 ! ob/ruction may be prolong$1 or x may be q int]mitt5t1 due to a valve-l action ( ! swoll5 mucosal surfaces or folds int]mitt5tly com+ 9 contact4 ,canc]\s /5osis is accompani$ by infiltration ( ! p]iesophageal tissue1 & usually by project+ ble$+ fungations4 ,canc] may1 h[ev]1 develop on a cicatrix1 favor$ no d\bt by *ronic inflammation 9 tissue ( l[ resi/ance4 ,compression /5osis ( ! esophagus is *>act]iz$ by ! sudd5 transition ( ! lum5 to a l9e> or cresc5tic outl9e1 :ile ! cov]+ mucosa is normal unless esophagitis be pres5t4 ,! compressive mass c be detect$ by ! s5sation transmitt$ to ! t\* by ! esophagoscope4 ,treatm5t4--,bl9d b\g9age %\ld be disc>d$ z an obsolete & v dang]\s proc$ure4 ,if ! /5osis be s great z to int]f]e ) ! +e/ion ( ! requir$ am\nt ( liquids1 ga/ro/omy %\ld be done at once & esophagoscopic treatm5t po/pon$ until wat] hung] has be5 reliev$4 ,ga/ro/omy aids 9 ! treatm5t by putt+ ! esophagus at re/1 & by af=d+ ! means ( ma9ta9+ a high degree ( nutrition unhamp]$ by ! v>iability or effici5cy ( ! swall[+ function4 ,c>eful diet & g5tle treatm5t w1 h[ev]1 usually avoid ga/ro/omy4 ,! diet 9 ! ga/ro/omy-f$ pati5ts %\ld be z v>i$ z 9 oral alim5tation2 ev5 solids ( ! consi/5cy ( ma%$ potatoes1 if previ\sly =c$ ?r\gh a wire gauze /ra9]1 may be =c$ ?r\gh ! tube ) a glass injector4 ,liquids & readily liquefiable foods are to be giv5 ! non-ga/ro/omiz$ pati5t1 solids be+ add$ :5 demon/rat$ t no /agnation above ! /ricture occurs4 ,?or\gh ma/ication & ! sl[ p>tak+ ( small quantities at a "t are imp]ative4 ,%\ld food accumulation occur1 ! esophagus %\ld be empti$ by regurgitation1 foll[+ :i* a glassful ( w>m sodium bic>bonate solution is to be tak51 & ?is also regurgitat$ if x does n g ?r\gh promptly4 ,! esophagus is ?us lavag$ & empti$4 ,9 all ^! cases1 :e!r be+ f$ ?r\gh ! m\? or ! ga/ro/omic tube1 x is v important to rememb] t milk & eggs are n a complete diet>y4 ,a p$iatri/ %\ld be consult$4 ,pr(4 ,graham has sav$ ! lives ( _m *ildr5 by solv+ ! nutritive problems 9 ! cases at ! ,bron*oscopic ,cl9ic4 ,fruit & vegetable juices are necess>y4 ,vegetable s\ps & ma%$ fruits %\ld be /ra9$ ?r\gh a wire gauze c(fee /ra9]4 ,if ! saliva is spat out by ! *ild because x w n g ?r\gh ! /ricture ! *ild %\ld be taught to spit ! saliva into ! funnel ( ! abdom9al tube4 ,?is me?od ( improv+ nutrition 0 discov]$ by ,miss ,groves at ! ,bron*oscopic ,cl9ic4 ,esophagoscopic b\g9age ) ! au?or's silk-wov5 /eel-%ank endoscopic b\gies 7,fig4 #dj7 has prov5 ! safe/ & mo/ successful me?od ( treatm5t4 ,! /rictur$ lum5 is to be c5t]$ 9 ! esophagoscopic field1 & ?ree successively increas+ sizes ( b\gies are us$ "u direct vision4 ,l>g] & l>g] b\gies are us$ at ! successive treatm5ts :i* are giv5 at int]vals ( f f\r to sev5 days4 ,no ane/hesia1 g5]al or local1 is us$ = esophagoscopic b\g9age4 ,! tightness ( ! grasp+ ( ! b\gie by ! /ricture on )drawal1 det]m9es ! limitation ( sizes to be us$4 ,:5 ! upp] /ricture is dilat$1 l[] ones 9 ! s]ies are tak5 s]iatim4 ,if conc5tric1 two or m closely situat$ /rictures may be simultane\sly dilat$4 ,= ! use ( b\gies ( ! l>g] sizes1 ! special esophagoscopes ) bo? ! light-c>ri] canal & ! dra9age canal outside ! lum5 ( ! tube are ne$$4 ,functional cure is obta9$ ) a relatively small lum5 at ! po9t ( /5osis4 ,a lum5 ( #g mm4 w all[ ! passage ( any well ma/icat$ food4 ,x is unwise & unsafe to attempt to re/ore ! lum5 to its normal anatomic size4 ,9 cicatricial /ricture cases x is advisable to exam9e ! esophagus at mon?ly p]iods = a "t aft] a functional cure has be5 obta9$1 9 ord] t t5d5cy to recurr5ce may be e>ly detect$4 ,divulsion ( an upp] /ricture may be deem$ advisable 9 ord] to rea* o!rs l[] d[n1 especially 9 cases ( multiple ecc5tric /rictures 7,fig4 #ig74 ,?is proc$ure is be/ done ) ! au?or's esophagoscopic divuls]1 accurately plac$ by means ( ! esophagoscope2 b divulsion requires ! utmo/ c>e1 & a g5tle h&4 ,ev5 !n x is n s safe z esophagoscopic b\g9age4 ,int]nal esophagotomy by ! /r+-cutt+ in/rum5ts & esophagotome are relatively dang]\s me?ods1 & p]haps yield 9 ! end no quick] results ?an ! sl[] & safe b\g9age p] tubam4 ,electrolysis has be5 us$ ) v>y+ results 9 ! treatm5t ( cicatricial /5osis4 ,!rmic b\g9age ) electrically heat$ b\gies has be5 f\nd useful 9 "s cases by ,dean & ,imp]atori4 #beh ,/r+-swall[+1 ) ! passage ( olives ?read$ ov] ! /r+ has yield$ good results 9 ! h&s ( "s op]ators4 ,! /r+ may be us$ to pull up dilators 9 increas+ sizes1 introduc$ ?r\gh a ga/ro/omic fi/ula4 ,! /r+ /ret*$ across ! /oma* f ! c>dia to ! pylorus1 is fi%$ out ) ! au?or's pill> retractor1 or is f\nd ) ! retrograde esophagoscope 7,fig4 #dc74 ,! /r+ is atta*$ to a dilator 7,fig4 #ce71 & a fre% /r+ is pull$ 9 to replace ! "o pull$ out4 ,?is is ! safe/ ( ! bl9d me?ods4 ,x is r>ely possible to get a *ild "u two ye>s ( age to swall[ & tol]ate a /r+4 ,x is bett] aft] ea* treatm5t to draw ! upp] end ( ! /r+ ?r\gh ! nose1 z x is n s likely to be *ew$ (f & is less annoy+4 ,) ! esophagoscope1 ! /r+ is n necess>y1 because ! lum5 ( ! /ricture c be expos$ to view by ! esophagoscope4 ,retrograde esophagoscopy ?r\gh a ga/ro/omy w\nd (f]s "s advantages ov] p]oral treatm5t2 b unless ! ga/ro/omy is high1 ! proc$ure is und\bt$ly m difficult4 ,! approa* to ! l[e/ /ricture f bel[ is usually funnel %ap$ & free f dilatation & r$undancy4 ,x mu/ be rememb]$ ! /ricture se5 f bel[ may n be ! same "o se5 f above4 ,ro5tg5ray exam9ation ) b>ium mixture or esophagoscopes simultane\sly 9 situ above & bel[ are useful 9 ! /udy ( su* cases4 ,imp]meable /rictures ( ! c]vical esophagus are am5able to ext]nal esophagotomy1 ) pla/ic re=mation ( ! esophagus4 ,^? 9 ! middle ?ird h n be5 successfully treat$ by surgical me?ods1 ?\gh v>i\s +5i\s op]ations = ! =mation ( an extra?oracic esophagus h be5 sugge/$ z means ( secur+ relief4 ,imp]meable /rictures ( ! l[] ?ird c ) reasonable safety be treat$ by ! ,br5neman me?od1 :i* consi/s 9 pass+ ! esophagoscope d[n to ! /ricture :ile ! surgeon1 ins]t+ 8 f+] up into ! esophagus f ! /oma*1 c feel ! end ( ! esophagoscope4 ,an incision ?r\gh ! tissue b>ri] is !n made f bel[1 pass+ ! knife along ! f+] z a guide4 ,a s(t rubb] /oma*-tube is pull$ up f bel[ & left 9 situ1 be+ replac$ at int]vals by a fre% "o1 pull$ up f ! /oma*1 until epi!lialization ( ! new lum5 is complete4 ,ca!t]s are us$ 9 *ildr54 ,9 replac+ ! ca!t] or /oma* tube ! fre% "o is atta*$ to ! old "o by /it*+ 9 a loop ( braid$ silk4 ,frequ5t esophagoscopic b\g9age w be requir$ to ma9ta9 ! m or less fi/ul\s lum5 until x is epi!lializ$1 & 9 occasional cases1 = a long "t !reaft]4 ,9 cases ( absolute atresia ! saliva does n rea* ! /oma*4 ,no "o realizes ! quantity ( normal saliv>y dra9age1 nor its importance 9 nutritive processes4 ,oral insalivation is ( little consequ5ce comp>$ to esophagoga/ric dra9age4 ,ga/ro/omiz$ *ildr5 ) absolute atresia ( ! esophagus d n ?rive unless !y regurgitate ! saliv>y accumulations into ! funnel ( ! ga/ro/omic fe$+ tube4 ,?is has be5 abundantly prov5 by obs]vations at ! ,bron*oscopic ,cl9ic4 ,my att5tion 0 fir/ call$ to ?is cl9ical fact by ,miss ,frances ,groves :o has *>ge ( ^! cases4 ,intubation ( ! esophagus ) s(t rubb] tubes has occasionally prov5 useful4 #bfj ,,*apt] ,,xxxiii--,,diseases ,,( ,,! ,,esophagus 7,cont9u$7 ,,div]ticulum ,,( ,,! ,,esophagus ,div]ticula may1 & usually d1 consi/ 9 a p\*+ by h]niation1 ( ! :ole ?ickness ( ! esophageal wall2 or !y may be h]niations ( ! mucosa betwe5 ! muscul> lay]s4 ,!y are classifi$ accord+ to _! etiology1 z traction & pulsion div]ticula4 ,,fig4 #ii4--,traction div]ticulum ( ! esophagus r5d]$ visible 9 ! ro5tg5ogram by a swall[$ opaque mixture4 ,case ( ,h4 ,w4 ,da*tl]1 ,am4 ,j\rn4 ,ro5tg5ology4 ,traction div]ticulum ( ! esophagus 7,fig4 #ii7 is a r>e condition1 usually occurr+ 9 ! ?orax1 & z a rule con/itut+ a "o-sid$ enl>gem5t ( ! gullet r ?an a true p\* =mation4 ,x is suppos$ to be =m$ by ! pull+ dur+ c\gh1 respiration1 & swall[+1 on localiz$ adhesions ( ! esophagus to p]iesophageal /ructures1 su* z inflammatory p]ibron*ial gl&s4 ,diagnosis is (t5 incid5tal to exam9ation ( ! ga/ro9te/9al tract = o!r conditions1 because traction div]ticula usually cause no symptoms4 ,unless a v l>ge esophagoscope be us$1 a traction div]ticulum may easily be ov]look$ 9 ! mucosal folds4 ,c>eful lat]al se>*1 h[ev]1 w reveal ! dilatation1 & ! localiz$ p]iesophageal fixation may be demon/rat$4 ,! subdiv]ticul> esophagus is readily foll[$1 its lum5 op5+ dur+ inspiration unless v close to ! diaphragm1 :i* is v r>e4 ,p]haps mo/ cases w be discov]$ by ! ro5tg5ologi/4 ,x has be5 said t traction div]ticula are m readily demon/rat$ 9 ! ro5tg5ologic exam9ation1 if ! pati5t be plac$ ) pelvis elevat$4 ,pulsion div]ticulum ( ! esophagus is an acquir$ h]nia ( ! mucosa betwe5 ! circul> & oblique fib]s ( ! inf]ior con/rictor muscle ( ! ph>ynx4 ,a cong5ital anatomic basic factor 9 etiology probably exi/s4 ,! p\*+ develops 9 ! middle "p ( ! po/]ior wall1 betwe5 ! orbicul> & oblique fib]s ( ! cricoph>yngeus muscle1 at :i* po9t !re is a gap1 leav+ ! mucosa support$ only by a n v resi/ant fascia 7,fig4 #ajj74 ,:5 small1 ! sac is 9 ! midl9e1 b ) increase 9 size1 x pres5ts ei!r to ! "r or ! left side1 commonly ! latt]4 ,! sac may be v small1 or x may be suffici5tly l>ge to hold a p9t or m1 & to cause ! neck to bulge :5 fill$4 ,:5 l>ge1 ! p\* ext5ds into ! m$ia/9um4 ,x w be se5 t anatomically ! pulsion div]ticulum has its orig9 9 ! ph>ynx2 ! symptoms1 h[ev]1 are ref]able to ! esophagus & ! subdiv]ticul> esophagus is /5os$ by compression ( ! p\*2 !re=e1 x is prop]ly classifi$ z an esophageal disease4 ,,fig4 #ajj4--,s*ema illu/rative ( ! etiology ( pressure div]ticula4 ,o1 oblique fib]s ( ! cricoph>yngeus atta*$ to ! ?yroid c>tilage1 ,t4 ,! fundi=m fib]s1 ,f1 encircle ! m\? ( ! esophagus4 ,betwe5 ! two sets ( fib]s is a gap 9 ! support ( ! esophageal wall1 ?r\gh :i* ! wall h]niates ow+ to ! pressure ( food propell$ by ! oblique fib]s1 ,o1 advance ( ! bolus be+ resi/$ by spasmodic contraction ( ! orbicul> fib]s1 ,f4 ,etiology4--,pressure div]ticula occur aft] middle life1 & m (t5 9 m5 ?an 9 wom54 ,! ha/y swall[+ ( unma/icat$ food1 too l>ge a bolus1 defective or artificial tee?1 flaccidity ( tissues1 & spasm ( ! cricoph>yngeus muscle1 are etiologic factors4 ,cicatricial /5osis bel[ ! level ( ! inf]ior con/rictor is a contributory cause 9 "s cases4 ,prognosis4--,aft] ! p\* is =m$1 x /eadily increases 9 size1 s9ce ! swall[$ food fir/ fills & di/5ds ! sac be=e ! ov]fl[ passes d[n ! esophagus4 ,:5 a p5dul\s sac becomes fill$ ) food1 x presses on ! subdiv]ticul> esophagus1 & produces compression /5osis2 s t !re exi/s a vici\s circle4 ,! enl>gem5t ( ! sac produces increas+ /5osis ) consequ5t fur!r di/5sion ( ! p\*4 ,?is expla9s ! cl9ically obs]v$ fact1 t unless treat$1 pulsion div]ticula increase progressively 9 size1 & consequ5tly 9 di/ress+ symptoms4 ,! sac becomes s l>ge 9 "s cases z to contribute to ! occurr5ce ( c]ebral apoplexy by int]f]5ce ) v5\s return4 ,practically all cases c be cur$ by radical op]ation4 ,! op]ative mortality v>ies ) ! age1 /ate ( nutrition1 & g5]al heal? ( ! pati5t4 ,9 g5]al x may be said to h a mortality ( at lea/ #aj p] c5t1 l>gely due to ! fact t mo/ cases are poor surgical subjects4 ,recurr5ces aft] radical op]ation are due to a p]si/5ce ( ! orig9al causes1 i4e41 bolt+ ( food2 /5osis1 spasmodic or organic1 ( ! esophageal lum52 & weakness 9 ! support ( ! esophageal wall1 :i*1 unsupport$1 has little /r5g? ( its own4 ,symptoms4--,dysphagia1 regurgitation1 a gurgl+ s\nd & subjective bubbl+ s5sation on swall[+1 s\r odor to ! brea?1 & c\gh1 are ! *ief symptoms4 ,) l>g] p\*es1 emaciation1 pressure s5sation 9 ! neck & upp] m$ia/9um1 & ! pres5ce ( a mass 9 ! neck :5 ! sac is fill$1 are pres5t4 ,tra*eal compression by ! fill$ p\* may produce dyspnea4 ,! sac may be empti$ by pressure on ! neck1 ?is means ( relief be+ (t5 discov]$ by ! pati5t4 ,! sac sometimes spontane\sly empties itself by contraction ( its envelop+ muscul> lay]1 & "o ( ! mo/ annoy+ symptoms is ! p>oxysm ( c\gh+1 wak+ ! pati5t1 :5 dur+ ! relaxation ( sleep ! sac empties itself into ! ph>ynx & "s ( its cont5ts are aspirat$ into ! l>ynx4 ,!re are no pa?ognomonic symptoms4 ,^? recit$ are common to o!r =ms ( esophageal /5osis1 & are urg5t indications = diagno/ic esophagoscopy4 ,diagnosis4--,ro5tg5ray /udy ) b>ium mixtures1 is ! fir/ /ep 9 ! diagnosis 7,fig4 #aja74 ,?is is to be foll[$ by diagno/ic esophagoscopy4 ,malignant1 spasmodic1 cicatricial1 & compression /5osis are to be exclud$ by esophagoscopic appe>ances4 ,aneurysm is to be elim9at$ by ! usual means4 ,! ,boyce sign is almo/ inv>iably pres5t1 & is diagno/ic4 ,x is elicit$ by tell+ ! pati5t to swall[1 :i* action imprisons air 9 ! sac4 ,! imprison$ air is =c$ out by f+]-pressure on ! neck1 ov] ! sac4 ,! exit ( ! air bubble produces a gurgl+ s\nd audible at ! op5 m\? ( ! pati5t4 ,esophagoscopic ,appe>ances 9 ,pulsion ,div]ticulum4--,! esophagoscope w )\t difficulty ent] ! m\? ( ! sac :i* is really ! :ole bottom ( ! ph>ynx1 & w be arre/$ by ! bl9d end ( ! p\*1 ! dep? ( :i* may be f #d to #aj cm4 ,9 "s cases ! bottom ( ! p\* is 9 ! m$ia/9um4 ,! walls are (t5 pa/y1 & may be erod$1 or ulc]at$1 & !y may %[ vessels or cicatrices4 ,on )draw+ ! tube & se>*+ ! ant]ior wall1 ! subdiv]ticul> slit-l op5+ ( ! esophagus w be f\nd1 ?\gh p]haps n always easily4 ,! esophageal speculum w be f\nd p>ticul>ly useful 9 expos+ ! subdiv]ticul> orifice1 & ?r\gh ?is a small esophagoscope may be pass$ into ! esophagus1 ?us complet+ ! diagnosis4 ,c>e mu/ be ex]cis$ n to p]=ate ! bottom ( ! div]ticul> p\* by pressure ) ! esophagoscope or esophageal speculum4 ,! walls ( ! sac are surpris+ly ?94 ,,fig4 #aja4--,pulsion div]ticulum fill$ ) bismu? mixture 9 a man ( fifty ye>s4 ,treatm5t ( ,pulsion ,div]ticulum4--,if ! p\* is small1 ! subdiv]ticul> esophageal orifice may be dilat$ ) esophagoscopic b\gies1 ?us ov]com+ ! etiologic factor ( spa/ic or organic /5osis4 ,! r$undancy rema9s1 h[ev]1 ?\gh ! symptoms may be reliev$4 ,cutt+ ! common wall betwe5 ! esophagus & ! sac by means ( scissors pass$ ?r\gh ! endoscopic tube1 has be5 successfully done by ,mo%]4 ,v>i\s me?ods ( ext]nal op]ation h be5 devis$1 among :i* are3 7#a7 ,free+ ! sac ?r\gh an ext]nal c]vical incision & sutur+ its fundus upw>d aga9/ ! ph>ynx1 :i* has prov$ successful 9 "s cases4 7#b7 ,inv]sion ( ! sac into ! ph>ynx & suture ( ! m\? ( ! p\*4 ,9 a case s treat$ ! p\* 0 bl[n out aga9 dur+ a fit ( sneez+ eight mon?s aft] op]ation4 7#c7 ,plication ( ! walls ( ! sac by catgut sutures1 z 9 ! ,matas oblit]ative op]ation = aneurysm4 7#d7 ,free+ & remov+ ! sac1 ) suture ( ! esophageal w\nd4 7#e7 ,removal ( ! sac by a two-/age op]ation1 9 :i* me?od ! initial /ep is ! deliv]ance ( ! sac into ! c]vical w\nd1 :]e x rema9s surr\nd$ by gauze pack+ until adhesions h wall$ (f ! m$ia/9um4 ,! "w is complet$ by cutt+ (f ! sac & ei!r sutur+ ! esophageal w\nd or t\*+ x ) ! caut]y1 & all[+ x to heal by granulation4 ,ext]nal exposure & amputation ( ! sac has be5 m frequ5tly done ?an any o!r op]ation4 ,unless ! p\* is l>ge1 x is extremely difficult to f9d aft] ! surgeon has expos$ ! esophagus1 = ! reasons t at op]ation x is empty & t :5 ! adhesions ab\t x are remov$ ! walls ( ! sac contract4 ,aft] removal1 ! sac is disappo9t+ly small z comp>$ ) its previ\s size 9 ! ro5tg5ogram1 :i* %[s x di/5d$ ) opaque mat]ial4 ,x has be5 ! *agr9 ( skill$ surgeons to f9d ! div]ticulum pres5t functionally & ro5tg5ographically precisely ! same z be=e ! p]=mance ( ! v try+ & difficult op]ation4 ,! "t ( op]ation may be %ort5$ at lea/ by "o-half by ! aid ( ! esophagoscopi/ 9 ! ,gaub-,jackson op]ation4 ,intratra*eally insufflat$ e!r is ! ane/hesia ( *oice4 ,aft] ! surgeon has expos$ ! esophagus by dissection1 ! endoscopi/ introduces ! esophagoscope into ! sac1 & deliv]s x into ! w\nd1 :ile ! surgeon frees x f adhesions4 ,! esophagoscope is n[ )drawn f ! p\* & ent]$ into ! esophagus prop]1 bel[ ! div]ticulum1 :ile ! surgeon cuts (f ! h]nial sac & sutures ! esophagoph>yngeal w\nd ov] ! esophagoscope4 ,! pres5ce ( ! esophagoscope prev5ts too tight suture & possible n>r[+ ( ! lum5 7,fig4 #ajb74 ,,fig4 #ajb4--,s*ematic repres5tation ( esophagoscopic aid 9 ! excision ( a div]ticulum 9 ! ,gaub-,jackson op]ation4 ,at ,a ! esophagoscope is repres5t$ 9 ! bottom ( ! p\* aft] ! surgeon has cut d[n to :]e he c feel ! esophagoscope4 ,!n ! esophagoscopi/ causes ! p\* to protrude z %[n by ! dott$ l9e at ,b4 ,aft] ! surgeon has dissect$ ! sac entirely loose f its surr\nd+s1 traction is made ^u ! sac z %[n at ,h & ! esophagoscope is ins]t$ d[n ! lum5 ( ! esophagus z %[n at ,c4 ,! esophagoscope n[ occupies ! lum5 :i* ! pati5t w ne$ = swall[+4 ,x only rema9s = ! surgeon to remove ! r$undancy1 )\t risk ( remov+ any ( ! normal wall4 ,! esophagoscope "h %[n is ( ! =m squ>ely cut (f at ! end4 ,! /&>d =m ( in/rum5t ) slant$ end w s]ve z well4 ,aft]-c>e4--,fe$+ may be c>ri$ on by ! plac+ ( a small nasal fe$+ tube into ! /oma* at ! "t ( op]ation4 ,ga/ro/omy = fe$+ z a prelim9>y to ! esophageal op]ation has be5 sugge/$1 & is c]ta9ly ideal f ! viewpo9t ( nutrition & esophageal re/4 ,! decision ( its p]=mance may p]haps be be/ made by ! pati5t himself4 ,%\ld leakage ?r\gh ! neck occur1 ! fi/ula %\ld be flu%$ by ! intake ( /]ile wat] by m\?4 ,oral sepsis %\ld1 ( c\rse1 be treat$ be=e op]ation & combat$ aft] op]ation by frequ5t bru%+ ( ! tee? & r9s+ ( ! m\? ) ,dak9's solution1 "o "p1 to t5 p>ts ( pepp]m9t wat]4 ,a po/op]ative b>ium ro5tg5ogram %\ld be made 9 e case z a matt] ( record & to make c]ta9 ! prop] function+ ( ! esophagus4 #bfh ,,*apt] ,,xxxiv--,,diseases ,,( ,,! ,,esophagus 7,cont9u$7 ,,p>alysis ,,( ,,! ,,esophagus ,! passage ( liquids & solids ?r\gh ! esophagus is a purely muscul> act1 controll$1 aft] ! propulsive usually volunt>y />t giv5 to ! bolus by ! inf]ior con/rictor1 by a reflex arc hav+ connection ) ! c5tral n]v\s sy/em ?r\gh ! vagus n]ve4 ,gravity plays little or no "p 9 ! act ( deglutition1 & alone w n c>ry food or dr9k to ! /oma*4 ,p>alysis ( ! esophagus may be said to be motor or s5sory4 ,x is r>ely if ev] unassociat$ ) l lesions ( contigu\s organs4 ,motor p>alysis ( ! esophagus is fir/ manife/$ by inability to swall[4 ,?is is associat$ ) ! accumulation ( secretion 9 ! pyri=m s9uses 7! au?or's sign ( esophageal /5osis7 :i* ov]fl[s into ! l>ynx & incites viol5t c\gh+4 ,motor p>alysis may affect ! con/rictors or ! esophageal muscul> fib]s or bo?4 ,s5sory p>alysis ( ! esophagus by break+ ! cont9uity ( ! reflex arc1 may s impair ! p]i/altic movem5ts z to produce aphagia4 ,! same fill+ ( ! pyri=m s9uses w be not$1 b z ! l>ynx is usually ane/hetic also1 x may be t no c\gh is produc$ :5 secretions ov]fl[ into x4 ,etiology4--#a4 ,toxic p>alysis z 9 diph!ria4 #b4 ,functional p>alysis z 9 hy/]ia4 #c4 ,p]iph]al p>alysis f neuritis4 #d4 ,c5tral p>alysis1 usually ( bulb> orig94 ,embolism or ?rombosis ( ! po/]ior c]ebral art]y is a report$ cause 9 two cases4 ,lues is always to be exclud$ z ! fundam5tal factor 9 ! gr\ps #c & #d4 ,esophageal p>alysis is n uncommon 9 mya/h5ia gravis4 ,esophagoscopic f9d+s are ^? ( abs5ce ( ! normal resi/ance at ! cricoph>yngeus1 flaccidity & lack ( s5sation ( ! esophageal walls1 & p]haps adh]5ce ( p>ticles ( food to ! folds4 ,! hiatal contraction is usually t normally enc\nt]$1 = ?is is accompli%$ by ! diaphragmatic musculature4 ,9 p>alysis ( s5sation1 ! reflexes ( c\gh+1 vomiturition & vomit+ are obtund$4 ,diagnosis4--,hy/]ia mu/ n be decid$ ^u z ! cause ( dysphagia1 until aft] esophagoscopy has elim9at$ p>alysis4 ,dysphagia aft] rec5t diph!ria %\ld sugge/ p>alysis ( ! esophagus4 ,! l>ynx1 lips1 tongue1 & ph>ynx also1 are usually p>alyz$ 9 esophageal p>alysis ( bulb> orig94 ,! abs5ce ( ! cricoph>yngeal resi/ance to ! esophagoscope pass$ )\t ane/hesia1 g5]al or local1 is diagno/ic4 ,treatm5t4--,! int]ni/ & neurologi/ %\ld gov]n ! basic treatm5t4 ,nutrition c be ma9ta9$ by fe$+ ) ! /oma*-tube1 :i* meets no resi/ance to its passage4 ,%\ld ?is be contra9dicat$ by ulc]ation ( ! esophagus1 ga/ro/omy %\ld be done4 ,,lues ,,( ,,! ,,esophagus ,esophageal syphilis is a r r>e affection1 & may %[ itself z a muc\s plaque1 a gumma1 an ulc]ation1 or a cicatrix4 ,cicatricial /5osis develop+ late 9 life )\t hi/ory ( ! swall[+ ( es*>otics or ulc]ative lesions is /rongly sugge/ive ( syphilis1 ?\gh ! late manife/ation ( a cong5ital /5osis is a possibility4 ,esophagoscopic appe>ances ( lues are n always *>act]i/ic4 ,z 9 any ulc]ative lesion1 ! inflammatory *anges ( mix$ infections mask ! basic nature4 ,! muc\s plaque has ! same appe>ance z "o situat$ on ! velum1 & gummata resemble ^? se5 9 ! mucosa else:]e4 ,!re is no?+ *>act]i/ic 9 luetic cicatrices4 ,! diagnosis ( luetic lesions ( ! esophagus1 !re=e1 dep5ds ^u ! hi/ory1 pres5ce ( luetic lesions else:]e1 ! s]ologic reaction1 !rapeutic te/1 exam9ation ( tissue1 & ! demon/ration ( ! treponema pallidum4 ,! !rapeutic te/ by prolong$ saturation ( ! sy/em ) m]cury is imp]ative 9 all suspect$ cases & no o!r negative result %\ld be deem$ suffici5t4 ,! treatm5t ( luetic esophagitis is sy/emic1 n local4 ,luetic cicatrices contract /rongly1 & are v resi/ant to treatm5t1 s t esophagoscopic b\g9age %\ld be begun z e>ly z possible aft] ! heal+ ( a luetic ulc]ation1 9 ord] to prev5t /5osis4 ,a silk-wov5 endoscopic b\gie plac$ 9 position by ocul> guidance1 & left 9 situ = f half to "o h\r daily1 may prev5t sev]e contraction1 if us$ e>ly 9 ! /age ( cicatrization4 ,prolong$ treatm5t is requir$ = ! cure ( e/abli%$ luetic cicatricial /5osis4 ,if ga/ro/omy has be5 done retrograde b\g9age 7,fig4 #ce7 may be us$4 ,,tub]culosis ,,( ,,! ,,esophagus ,esophageal tub]culosis is n commonly met1 b is probably n infrequ5tly associat$ ) ! dysphagia ( tub]cul\s l>yngitis4 ,x may r>ely occur z a prim>y infection1 b usually ! esophagus is involv$ 9 an ext5sion f a tub]cul\s process 9 ! l>ynx1 m$ia/9al lymphatics1 pleura1 bron*i1 or lungs4 ,prim>y lesions appe> z sup]ficial erosions or ulc]ations1 ) a surr\nd+ yell[i% granul> zone1 or ! granules may alone be pres5t4 ,! mucosa 9 tub]cul\s lesions is usually pallid1 ! abs5ce ( vascul>ity be+ m>k$4 ,invasion f ! p]iesophageal organs produces m or less localiz$ compression & fixation ( ! esophagus4 ,! "* ( op5 ulc]ation is modifi$ by ! mix$ infections4 ,heal$ tub]cul\s lesions1 sometimes result+ f ! evacuation ( tub]cul\s m$ia/9al lymph nodes into ! esophagus may be enc\nt]$4 ,! local fixation & cicatricial contraction may be ! site ( a traction div]ticulum4 ,tub]cul\s esophago-bron*ial fi/ulae are occasionally se54 ,diagnosis1 to be c]ta91 requires ! demon/ration ( ! tub]cule bacilli & ! *>act]i/ic cell accumulation ( ! tub]cle 9 a specim5 ( tissue remov$ f ! lesion4 ,act9omycosis mu/ be exclud$1 & ! possibility ( mix$ luetic & tub]cul\s lesions is to be kept 9 m9d4 ,po/-tub]cul\s cicatrices h no recognizable *>act]i/ics4 ,treatm5t4--,! ma9t5ance ( nutrition to ! highe/ degree1 & ! in/itution ( a /rict antitub]cul\s regime are dem&$4 ,local applications are ( no avail4 ,ga/ro/omy = fe$+ %\ld be done if dysphagia be sev]e1 & has ! advantage ( putt+ ! esophagus at re/4 ,! passage ( a /oma*-tube = fe$+ purposes may be done1 b x is (t5 pa9ful1 & is dang]\s 9 ! pres5ce ( ulc]ation4 ,pa9 is n m>k$ if ! lesion be limit$ to ! esophagus1 ?\gh if x is pres5t or?(orm1 ane/hes91 or apo!s91 9 p[d] =m1 swall[$ dry1 may prove helpful4 ,,v>ix ,,& ,,angioma ,,( ,,! ,,esophagus ,^! lesions are sometimes ! cause ( esophageal hemorrhage1 ! regurgitat$ blood be+ bright r$1 & alkal9e 9 reaction1 9 contradi/9ction to ! acid c(fee gr\nd blood ( ga/ric orig94 ,esophageal v>ices may coexi/ ) ! common dilatation ( ! v5\s sy/em 9 :i* ! ve9s ( ! rectum1 scrotum1 & legs are mo/ conspicu\sly affect$4 ,cirrhosis & canc] ( ! liv] may1 by int]f]5ce ) ! portal circulation1 produce dilatation ( ! ve9s 9 ! l[] ?ird ( ! esophagus4 ,angioma ( ! esophagus is am5able to radium treatm5t4 ,,act9omycosis ,,( ,,! ,,esophagus ,esophageal act9omycosis has be5 autoptically discov]$4 ,its diagnosis1 & diff]5tiation f tub]culosis1 w\ld probably re/ ^u ! microscopic /udy ( tissue remov$ esophagoscopically1 ?\gh z yet no su* case has be5 report$4 ,,angioneurotic ,,edema ,angioneurotic edema involv+ ! esophagus1 may produce int]mitt5t & transi5t dysphagia4 ,! lesions are r>ely limit$ to ! esophagus alone2 !y may occur 9 any portion ( ! ga/ro9te/9al1 g5it\r9>y1 or respiratory tracts1 & concomitant cutane\s manife/ations usually r5d] ! diagnosis cle>4 ,! treatm5t is g5]al4 ,,deviation ,,( ,,! ,,esophagus ,deviation ( ! esophagus may be m>k$ 9 ! pres5ce ( a de=m$ v]tebral column1 ?\gh dysphagia is a v uncommon symptom4 ,! lack ( esophageal symptoms 9 deviation ( sp9al production is probably expla9$ by ! longitud9al %ort5+ ( ! sp9e :i* accompanies ! deflection4 ,compression /5osis ( ! esophagus is commonly associat$ ) deviations produc$ by a ?oracic mass4 ,,plate ,,iv ,a1 ,ga/roscopic view ( a ga/rojejuno/omy op5+ drawn patul\s by ! tube m\?4 7,ga/rojejuno/omy done by ,dr4 ,george ,l4 ,hays47 ,b1 ,c>c9oma ( ! less] curvature4 7,pati5t aft]w>d surgically explor$ & diagnosis v]ifi$ by ,dr4 ,john ,j4 ,bu*anan47 ,c1 ,heal$ p]=at$ ulc]4 7,pati5t ref]r$ by ,dr4 ,john ,w4 ,boyce47 ,drawn f a case ( po/diph!ric subglottic /5osis cur$ by ! au?or's me?od ( direct galvanocaut]ization ( ! hyp]trophies4 ,a1 ,imm$iately aft] removal ( ! intubation tube2 hyp]trophies l turb9als are se5 project+ into ! subglottic lum54 ,b1 ,five m9utes lat]2 ! masses h n[ clos$ ! lum5 almo/ completely4 ,! pati5t became s cyanotic t a bron*oscope 0 at once introduc$ to prev5t asphyxia4 ,c1 ,! left mass has be5 caut]iz$ by a v]tical application ( ! inc&esc5t knife4 ,d1 ,completely & p]man5tly cur$ aft] repeat$ caut]izations4 ,direct view2 recumb5t pati5t4 ,,photoprocess ,,reproductions ,,( ,,! ,,au?or',s ,,oil-,,color ,,draw+s ,,f ,,life #bgc ,,*apt] ,,xxxv--,,ga/roscopy ,! /oma* ( any individual hav+ a normal esophagus & normal sp9e c be explor$ ) an op5-tube ga/roscope4 ,! adult size esophagoscope be+ #ec cm4 long w rea* ! /oma* ( ! av]age individual4 ,long] ga/roscopes are us$1 :5 necess>y1 to explore a ptos$ /oma*4 ,v>i\s l5s-sy/em ga/roscopes h be5 devis$1 :i* af=d an excell5t view ( ! walls ( ! air-inflat$ /oma*4 ,! optical sy/em1 h[ev]1 int]f]es ) ! ins]tion ( in/rum5ts1 s t ! op5-tube ga/roscope is requir$ = ! removal ( ga/ric =eign bodies1 ! palpation (1 or spong+ secretions f1 ga/ric lesions4 ,! op5-tube ga/roscope may be clos$ ) a w9d[ plug 7,fig4 #f7 hav+ a rubb] diaphragm ) a c5tral p]=ation = =ceps1 :5 x is desir$ to inflate ! /oma*4 ,te*nic4--,relaxation by g5]al ane/hesia p]mits lat]al displacem5t ( ! dome ( ! diaphragm along ) ! esophagus1 & ?us makes possible a wid] range ( motion ( ! di/al end ( ! ga/roscope4 ,all ( ! rec5t ga/roscopies 9 ! ,bron*oscopic ,cl9ic1 h[ev]1 h be5 p]=m$ )\t ane/hesia4 ,! me?od ( introduction ( ! ga/roscope ?r\gh ! esophagus is precisely ! same z ! introduction ( ! esophagoscope 7q4v474 ,x %\ld be emphasiz$ t ) ! l5s-sy/em ga/roscopes1 ! tube %\ld be introduc$ into ! /oma* "u direct ocul> guidance1 )\t a m&r91 & ! optical app>atus %\ld be ins]t$ ?r\gh ! tube only aft] ! /oma* has be5 ent]$4 ,bl9d ins]tion ( a rigid metallic tube into ! esophagus is an extremely dang]\s proc$ure4 ,! descriptions & illu/rations ( ! /oma* 9 anatomical works mu/ be disreg>d$ z cadav]ic4 ,9 ! liv+ body1 ! empty /oma* is usually f\nd1 on endoscopic inspection1 to be a collaps$ tube ( su* %ape z to fit :atev] space is available at ! p>ticul> mom5t1 ) folds & rugae runn+ 9 all directions1 ! impression giv5 z to =m be+ /rik+ly l se>*+ among a mass ( e>? worms or boil$ spaghetti4 ,! color is p9k1 "u prop] illum9ation1 if no food is pres5t4 ,poor illum9ation may make ! color appe> deep crimson4 ,if food is pres5t1 or has j be5 regurgitat$1 ! color is bright r$4 ,to appreciate ! appe>ance ( ga/ritis1 ! eye mu/ h be5 educat$ to ! endoscopic appe>ances "u a degree ( illum9ation always ! same4 ,! left two-?irds ( ! /oma* is mo/ easily exam9$4 ,! /oma* wall c be pu%$ by ! tube into almo/ any position1 & ) ! aid ( g5tle ext]nal abdom9al manipulation to draw ov] ! pylorus x is possible to exam9e directly almo/ all ( ! ga/ric walls except ! pyloric antrum1 :i* is rea*able 9 relatively few cases4 ,a lat]al motion ( f #aj to #ag cm4 c be imp>t$ to ! ga/roscope1 provid$ ! diaphragmatic musculature is relax$ by deep ane/hesia4 ,! /oma* is explor$ by progressive trav]se4 ,t is1 aft] explor+ d[n to ! great] curvature1 ! tube-m\? is mov$ lat]ally ab\t #b c5timet]s1 & ! )draw+ travel explores a new field4 ,!n a lat]al movem5t af=ds a fre% field dur+ ! next ins]tion4 ,?is is repeat$ until ! entire explorable area has be5 cov]$4 ,balloon+ ! /oma* ) air or oxyg5 is sometimes helpful1 b ! di/5sion fixes ! /oma*1 less5s ! mobility ( ! ar* ( ! diaphragm1 & ?us less5s ! lat]al range ( ga/roscopic vision4 ,fur!rmore1 balloon+ pu%es ! ga/ric walls f> away f ! rea* ( ! tube-m\?4 ,a w9d[ plug 7,fig4 #f7 is ins]t$ into ! ocul> end ( ! ga/roscope = ! balloon+ proc$ure4 #bge ,l _m o!r valuable diagno/ic means1 ga/roscopy is v valuable 9 its positive f9d+s4 ,negative results are entitl$ to little weight except z to ! explorable area4 ,! ga/roscopi/ work+ 9 conjunction ) ! abdom9al surgeon %\ld be able to r5d] him invaluable assi/ance 9 8 "w on ! /oma*4 ,! surgeon ) 8 glov$ h& 9 ! abdom51 by manipulat+ suspect$ areas ( ! /oma* 9 front ( ! tube-m\? c receive imm$iately a report ( its int]ior appe>ance1 :e!r canc]\s1 ulc]at$1 hemorrhagic1 etc4 ,l5s-sy/em balloon+ ga/roscopy may possibly af=d additional in=mation aft] all possible data f op5-tube ga/roscopy has be5 obta9$4 ,c>e mu/ be ex]cis$ n to ex]t an injuri\s degree ( air-pressure4 ,! di/5d$ portion ( ! /oma* assumes a funnel-l =m end+ at ! apex 9 a depression ) radiat+ folds1 t leads ! obs]v] to ?9k he is look+ at ! pylorus4 ,! =e%ort5+ produc$ by ! l5s sy/em also contributes to ?is illusion4 ,! be/ l5s-sy/em ga/roscope is t ( ,h5ry ,janeway1 :i* comb9es ! op5-tube & ! l5s sy/em4 ,ga/roscopy = ,=eign ,bodies4--,! great majority ( =eign bodies t rea* ! /oma* unassi/$ are pass$ p] rectum1 provid$ ! natural protective means are n impair$ by ! adm9i/ration ( ca?>tics1 *anges 9 diet1 etcet]a4 ,?is1 h[ev]1 does n mean t esophageal =eign bodies %\ld be pu%$ into ! /oma* by bl9d me?ods1 or by esophagoscopy1 because a swall[$ object lodg$ 9 ! esophagus c always be return$ ?r\gh ! m\?4 ,=eign bodies 9 ! /oma* & inte/9es %\ld be fluoroscopically wat*$ ea* second day4 ,if an object is se5 to lodge five days 9 "o location 9 ! inte/9es1 x %\ld be remov$ by lap>otomy1 s9ce x w almo/ c]ta9ly p]=ate4 ,c]ta9 objects rea*+ ! /oma* may be judg$ too l>ge to pass ! pylorus & inte/9al angles4 ,^! %\ld be remov$ by ga/roscopy :5 su* decision is made4 ,x is to be rememb]$ t ga/ric =eign bodies may be regurgitat$ & may lodge 9 ! esophagus1 :5ce !y are easily remov$ by esophagoscopy4 ,! d\ble-plan$ fluoroscope ( ,manges is helpful 9 ! removal ( ga/ric =eign bodies1 b !re is great dang] ( injury to ! /oma* walls1 & ev5 ! p]itoneum1 unless =ceps are us$ ) ! utmo/ caution4 #bgg ,,*apt] ,,xxxvi--,,acute ,,/5osis ,,( ,,! ,,l>ynx ,etiology4--,causes ( a relatively sudd5 n>r[+ ( ! lum5 ( ! l>ynx & subjac5t tra*ea are includ$ 9 ! foll[+ li/4 ,two or m may be comb9$4 #a4 ,=eign body4 #b4 ,accumulation ( secretions or exudate 9 ! lum54 #c4 ,di/5sion ( ! tissues by air1 inflammatory products1 s]um1 pus1 etc4 #d4 ,displacem5t ( relatively normal tissues1 z 9 abductor p>alysis1 cong5ital l>yngeal /ridor1 etcet]a4 #e4 ,neoplasms4 #f4 ,granulomata4 ,edema ( ! l>ynx may be at ! glottic level1 or 9 ! supraglottic or subglottic regions4 ,! loose cellul> tissue is mo/ frequ5tly conc]n$ 9 ! process r ?an ! mucosal lay] alone4 ,9 *ildr5 ! subglottic area is v vascul>1 & swell+ quickly results f trauma or inflammation1 s t acute /5osis ( ! l>ynx 9 *ildr5 commonly has its po9t ( n>r[+ bel[ ! cords4 ,dyspnea1 & cr\py1 b>k+1 c\gh ) no *ange 9 ! tone or pit* ( ! speak+ voice are *>act]i/ic signs ( subglottic /5osis4 ,edema may accompany inflammation ( ei!r ! sup]ficial or deep /ructures ( ! l>ynx4 ,! l>yngeal lesion may be prim>y1 or may complicate g5]al diseases2 among ! latt]1 typhoid fev] des]ves especial m5tion4 ,acute l>yngeal /5osis complicat+ typhoid fev] is frequ5tly ov]look$ & (t5 fatal1 = ! a/h5ic pati5t makes no fight = air1 & ho>s5ess1 if pres5t1 is v slight4 ,! l>yngeal lesion may be due to cordal immobility f ei!r p>alysis or inflammatory aryt5oid fixation1 9 ! abs5ce ( edema4 ,p]i*ondritis & *ondritis ( ! l>yngeal c>tilages (t5 foll[ typhoid ulc]ation ( ! l>ynx1 *ronic /5osis result+4 ,l>yngeal /5osis 9 ! newborn may be due to v>i\s anomalies ( ! l>ynx or tra*ea1 or to traumatism ( ^! /ructures dur+ deliv]y4 ,! normal glottis 9 ! newborn is relatively n>r[1 s t ev5 slight encroa*m5t on its lum5 produces a s]i\s degree ( dyspnea4 ,! *>act]i/ic signs are inspiratory indraw+ ( ! supraclavicul> fossae1 ! supra/]nal not*1 ! epiga/rium1 & ! l[] /]num & ribs4 ,cyanosis is se5 at fir/1 lat] giv+ place to pallid asphyxia :5 c>diac failure occurs4 ,little air is he>d to ent] ! lungs1 dur+ respiratory ef=ts & ! infant1 becom+ exhau/$ by ! great muscul> ex]tion1 soon ceases to brea!4 ,p>alytic /5osis ( ! l>ynx sometimes foll[s difficult =ceps deliv]ies dur+ :i* /ret*+ or compression ( ! recurr5t n]ves occur4 ,acute l>yngeal /5osis 9 infants1 f l>yngeal p]i*ondritis1 may be a delay$ result ( traumatism to ! l>yngeal c>tilages dur+ deliv]y4 ,! symptoms usually develop )9 f\r weeks aft] bir?4 ,lues & tub]culosis are possible factors to be elim9at$ by ! usual me?ods4 ,surgical ,treatm5t ( ,acute ,l>yngeal ,/5osis4--,multiple puncture ( acute inflammatory edema1 :ile readily p]=m$ ) ! l>yngeal knife us$ ?r\gh ! direct l>yngoscope1 is an unc]ta9 measure ( relief4 ,tra*eotomy1 if done l[ 9 ! neck1 w completely relieve ! dyspnea4 ,by its !rapeutic effect ( re/1 x favors ! rapid subsid5ce ( ! inflammation 9 ! l>ynx & is ! treatm5t to be pref]r$4 ,intubation is trea*]\s & unreliable except 9 diph!ritic cases2 b 9 ! diph!ritic cases x is ideal1 if con/ant skill$ wat*+ c be _h4 #bgi ,,*apt] ,,xxxvii--,,tra*eotomy ,indications4--,tra*eotomy is indicat$ 9 dyspnea ( l>yngotra*eal orig94 ,! c>d9al signs ( ?is =m ( dyspnea are3 #a4 ,indraw+ at ! supra/]nal not*4 #b4 ,indraw+ ar\nd ! clavicles4 #c4 ,indraw+ ( ! int]co/al spaces4 #d4 ,re/lessness4 #e4 ,*ok+ & wak+ z soon z ! aid ( ! volunt>y respiratory muscles ceases 9 fall+ to sleep4 #f4 ,cyanosis is a dang]\sly late symptom4 ,z a !rapeutic measure 9 diseases ( ! l>ynx its place has be5 ?or\ghly e/abli%$4 ,m>k$ improvem5t ( ! l>yngeal lesions has be5 obs]v$ to foll[ tra*eotomy 9 advanc$ l>yngeal tub]culosis1 & 9 canc] ( ! l>ynx4 ,x has prov51 9 "s cases1 a useful adjunct 9 ! treatm5t ( luetic l>yngitis1 ?\gh x _c be reg>d$ z indicat$1 9 ! abs5ce ( dyspnea4 ,p]i*ondritis & o!r inflammations are b5efit$ by tra*eotomy4 ,a m>k$ !rapeutic effect on multiple l>yngotra*eal papillomata 9 *ildr5 has be5 not$ by ! au?or 9 hundr$s ( cases4 ,tra*eotomy = =eign body is no long] indicat$ ei!r = ! removal ( ! intrud]1 or = ! ins]tion ( ! bron*oscope4 ,tra*eotomy may be urg5tly indicat$ = =eign body dyspnea1 b n = =eign body removal4 ,subcutane\s rupture ( ! tra*ea f ext]nal trauma may produce dyspnea & g5]aliz$ emphysema1 bo? ( :i* w be reliev$ by tra*eotomy4 #bhj ,acromegalic /5osis ( ! l>ynx is a r>e b urg5t indication = tra*eotomy4 ,contra9dications4--,!re are no contra9dications to tra*eotomy = dyspnea4 ,! in/rum5ts requir$ = an ord]ly tra*eotomy are3 ,headlight ,scalpels #b ,retractors ,tr\sseau dilator #f ,hemo/ats ,scissors 7dissect+7 ,tra*eal cannulae 7six sizes7 ,curv$ ne$les ,ne$le hold] ,hypod]mic syr+e = local ane/hesia ,no4 #a pla9 catgut ligatures ,l95 tape ,gauze sponges ,^! are /]iliz$ & kept 9 a /]ile copp] box ready = in/ant use4 ,beside ! pati5t's b$ foll[+ ! tra*eotomy ! foll[+ /]ile mat]ials are plac$3 ,/]ile gloves #a ,hemo/at ,/]ile new gauze ,tr\sseau dilator ,scissors ,duplicate tra*eotomy tube ,silv] probe ,bas9 ( ,bi*loride ( m]cury solution1 #a 3 #aj1jjj ,tra*eotomy is "o ( ! olde/ op]ations kn[n to surg]y1 yet /range to say1 x is probably m (t5 improp]ly p]=m$ today1 & m (t5 foll[$ by ne$less mortality1 ?an any o!r op]ation4 ,! two *ief prev5table sequelae are dea? f improp] r\t9e surgical c>e & wrongly fitt$ tube1 & /5osis f too high an op]ation4 ,! classical descriptions ( crico-?yroidotomy & high & l[ tra*eotomy h be5 h&$ d[n to g5]ations ( m$ical /ud5ts )\t revision4 ,e m$ical graduate has be5 taught t !re are two k9ds ( tra*eotomy1 high & l[1 ! l[ op]ation be+ v difficult1 ! high op]ation v easy4 ,:5 he is sudd5ly call$ ^u to d an em]g5cy tra*eotomy1 ?is errone\s tea*+ is ab\t all t rema9s 9 ! dim recesses ( 8 memory2 consequ5tly he makes sure ( do+ ! op]ation high en\gh1 & goes 9 ?r\gh ! l>ynx1 usually divid+ ! cricoid c>tilage1 ! only complete r+ 9 ! tra*ea4 ,z orig9ally made ! di/9ction betwe5 high & l[ z appli$ to tra*eotomy ref]r$ to op]ations above & bel[ ! i/hmus ( ! ?yroid gl&1 9 a day :5 primitive surg]y atta*$ too mu* importance to op]ations ^u ! ?yroid gl&4 ,! i/hmus is entitl$ to absolutely no consid]ation :atev] 9 decid+ ! location at :i* to incise s vital a /ructure z ! tra*ea4 ,/ud5ts are taught diff]5t %ort sk9 incisions = ^! two op]ations1 & x is no wond] t !y1 z did _! pr$ecessors1 f9d tra*eotomy a difficult1 bloody1 & (t5 futile op]ation4 ,! tra*ea is se>*$ = at ! bottom ( a %ort1 deep w\nd fill$ ) blood1 ! s\rce ( :i* is difficult to f9d & impossible to control4 ,tra*eotomic cannulae %\ld be made ( /]l+ silv]4 ,g]man silv] plat$ ) pure silv] is good en\gh = tempor>y use1 b ! plat+ soon we>s (f "u ! galvanic action set up betwe5 ! two metals4 ,alum9um becomes r\gh5$ by boil+ & contact ) secretions1 & causes ! =mation ( granulations :i* 9 "t lead to /5osis4 ,h>d rubb] tubes _c be boil$1 ! walls are s ?ick z to leave too little lum51 & ! rubb] is irritat+ to ! tissues4 ,all tra*eotomy tubes %\ld be fitt$ ) pilots4 ,_m ( ! tubes furni%$ to pati5ts h no pilots to facilitate ! introduction1 & ! tubes are ins]t$ ) some:at ! effect ( a *eese te/]1 & ) great pa9 & suff]+ on ! "p ( ! pati5t4 ,mo/ ( ! ! tubes 9 ! %ops are too %ort to all[ = ! swell+ ( ! tissues ( ! neck foll[+ ! op]ation4 ,!y may rea* ! tra*ea at ! "t ( ! op]ation1 b z soon z ! reaction>y swell+ occurs1 ! end ( ! tube is pull$ out 7,fig4 #ajc7 ( ! tra*eal incision2 ! air hiss+ along ! tube is consid]$ by ! att5dant to indicate t ! tube is /ill 9 place1 & ! increas+ dyspnea & accel]at$ respiratory rate are attribut$ to suppos$ pneumonia or edema ( ! lungs1 "u :i* errone\s diagnosis ! pati5t is buri$4 ,9 all cases 9 :i* x is report$ t 9 spite ( tra*eotomy ! dyspnea 0 only tempor>ily reliev$1 ! fault is ! lack ( a plumb]4 ,t is1 an att5dant :o w make sure t !re is at all times a cle> airway all ! way d[n to ! lungs4 ,) a bron*oscope & aspirator he w see t ! airway is cle>4 ,to beg9 )1 a prop] siz$ cannula mu/ be select$4 ,! s]ies ( diff]5t siz$1 full curv$ tubes1 "o ( :i* is illu/rat$ 9 ,fig4 #ajd1 w "u all conditions rea* ! tra*ea4 ,if ! tube seems to be too long 9 any giv5 case1 x w usually be f\nd t ! tra*eotomy has be5 done too high1 & a l[] "o %\ld be done at once4 ,if ! op]ation has n be5 done too high1 & ! cannula is too long1 a pad ( gauze "u ! %ield w take up ! surplus l5g?4 ,9 cases ( tra*eal compression f new gr[?1 ?ymus or o!r su* cases1 9 :i* ! ord9>y tube w n pass ! ob/ruction1 ! au?or's long cane-%ap$ cannula 7see ,fig4 #ajd7 c be ins]t$ pa/ ! ob/ruction1 & if necess>y into ei!r bron*us4 ,! f5e/rum plac$ 9 ! cannula 9 _m ( ! old] tubes1 ) ! suppos$ function ( all[+ p>tial brea?+ ?r\gh ! l>ynx1 is a mo/ p]nici\s ?+4 ,a prop]ly fitt$ tube %\ld n take up m ?an half ( ! cross section ( ! tra*ea1 & %\ld all[ ! passage ( suffici5t air = free l>yngeal brea?+ :5 x is completely cork$4 ,! f5e/rum is1 moreov]1 r>ely s situat$ t air c pass ?r\gh x2 ! f5e/ral edges act z a con/ant irritant to ! w\nd1 produc+ ble$+ & granulation tissue4 ,,fig4 #ajc4--,s*ema %[+ ?ick pad ( gauze dress+1 fill+ ! space1 ,a1 & us$ to hold out ! au?or's full-curv$ cannula :5 too long1 prior to reaction>y swell+1 & aft] subsid5ce ( ! latt]4 ,at ! "r is %[n ! mann] 9 :i* ! ord9>y cannula ( ! %ops p]mits a pati5t to asphyxiate1 ?\gh "s air is he>d pass+ ?r\gh ! tra*eal op5+1 ,h1 aft] ! cannula has be5 p>tially )drawn by swell+ ( ! tissues1 ,t4 ,,fig4 #ajd4--,! au?or's tra*eotomic cannulae4 ,a1 %[s cane-%ap$ cannula = use 9 intra?oracic compressive or o!r /5oses4 ,b1 %[s full curv$ cannula = regul> use4 ,pilots are made to fit ! out] cannula2 ! inn] cannula n be+ ins]t$ until aft] )drawal ( ! pilot4 ,ane/hesia4--,no dyspneic pati5t %\ld be giv5 a g5]al ane/hetic2 because any pati5t dyspneic en\gh to ne$ a tra*eotomy = dyspnea is dep5d+ l>gely ^u ! action ( ! accessory respiratory muscles4 ,:5 ?is action is /opp$ by beg9n+ unconsci\sness1 respiration ceases4 ,if ! tra*ea is n imm$iately op5$1 artificial respiration in/itut$1 & oxyg5 insufflat$1 ! pati5t dies on ! table4 ,sk9 infiltration along ! l9e ( incision ) a v weak coca9e solution 7#a_/aj ( #a p] c5t71 apo!s9e 7#b p] c5t71 novoca9e1 ,s*lei*'s fluid or o!r local ane/hetic1 suffices to r5d] ! op]ation pa9less4 ,! deep] /ructures h little s5sation & d n require infiltration4 ,x has be5 advocat$ t an int]annul> injection ( coca9e solution ) a hypod]mic syr+e be done j prior to incision ( ! tra*ea = ! purpose ( prev5t+ c\gh aft] ! incision ( ! tra*ea & ! ins]tion ( ! cannula4 ,x w\ld seem1 h[ev]1 t ?is introduces ! risk ( aspiration pneumonia & pulmon>y abscess1 by p]mitt+ ! aspiration & clott+ ( blood 9 small bron*i1 foll[$ by subsequ5t break+ d[n ( ! clots4 ,z ! au?or has s (t5 said1 ,! c\gh reflex is ! wat* dog ( ! lungs1 & if n drugg$ asleep by local or g5]al ane/hesia c safely be reli$ ^u to prev5t all possibility ( ! blood or ! pus :i* ne>ly always is pres5t 9 acute or *ronic conditions call+ = tra*eotomy1 be+ aspirat$ into ! deep] air-passages4 ,coca9e 9 any =m1 by any me?od1 & 9 any dosage1 is dang]\s 9 v "y *ildr54 ,te*nic4--,! pati5t %\ld be plac$ 9 ! recumb5t position1 ) ! ext5d$ head held 9 ! midl9e by an assi/ant4 ,! %\ld]s1 n ! neck1 %\ld be slightly rais$ ) a s& bag4 ,! head %\ld be some:at l[] ?an ! feet1 to less5 ! dang] ( aspiration ( blood4 ,a midl9e incision divid+ ! sk9 & fascia is made f ! ?yroid not* to j above ! supra/]nal not*4 ,! cricoid is n[ locat$1 & ! deep] dissection is cont9u$ f bel[ ?is po9t4 ,! ribbon muscles are sep>at$ ) dissect+ scissors or knife1 & held ap>t ) retractors4 ,if ! i/hmus ( ! ?yroid gl& is 9 ! way1 x may be retract$ upw>d2 if l>ge1 h[ev]1 x %\ld be divid$ & ligat$1 = x is apt to slip ov] ! tra*eal incision aft]w>d1 & r5d] difficult ! quick f9d+ ( ! incision dur+ aft]-c>e4 ,?is cov]+ ( ! tra*eal incision by ! slipp+ back ( ! drawn-aside ?yroidal i/hmus is "o ( ! mo/ frequ5t avoidable causes ( mortality1 because x deflects ! cannula (f into ! tissues :5 x is replac$ aft] clean+ dur+ ! e>ly po/op]ative p]iod4 ,! corrugat$ surface ( ! tra*ea c be felt1 & its exact location c be det]m9$ by ! index f+]4 ,if ! tra*eotomy is proce$+ 9 an ord]ly mann]1 all ble$+ po9ts %\ld be caught & ti$ ) pla9 catgut 7,no4 #a7 be=e ! tra*ea is op5$4 ,because ( di/5sion ( vessels dur+ c\gh1 all b ! t9ie/ vessels %\ld be ligat$4 ,side-cut ve9s are p>ticul>ly trea*]\s4 ,!y %\ld be fre$ ( tissue1 cut across & ! divid$ ends ligat$4 ,! incision 9 ! tra*ea %\ld be z l[ z possible1 & %\ld nev] be made ?r\gh ! fir/ r+4 ,! incision %\ld be ?r\gh ! ?ird1 f\r? & fif? r+s4 ,only 9 cases ( l>yngoptosis w x be necess>y to incise ! tra*ea high] ?an ?is4 ,! incision mu/ be made 9 ! midl9e1 & 9 ! long axis ( ! tra*ea1 & c>e mu/ be ex]cis$ t ! po9t ( ! knife does n p]=ate ! po/]ior tra*eal wall4 ,/ab incisions are always to be avoid$4 ,if ! incision 9 ! tra*ea is f\nd to be ( insuffici5t l5g?1 ! orig9al incision mu/ be f\nd & elongat$4 ,a second incision mu/ n be made1 = ! portion ( c>tilage betwe5 ! two incisions w die & w almo/ c]ta9ly make a site ( future tra*eal /5osis4 ,! cricoid %\ld nev] be cut1 = /5osis is almo/ sure to foll[ ! we>+ ( a cannula 9 ?is position4 ,a ,tr\sseau dilator %\ld n[ be ins]t$ 9 ! tra*eal incision1 its blades g5tly sep>at$4 ,) ! tra*eal lum5 ?us op5$1 a cannula ( prop] size is introduc$ ) absolute c]ta9ty ( its hav+ ent]$ ! tra*ea4 ,a quadruple-fold$ squ>e ( gauze 9 ! =m ( a pad ab\t f\r in*es squ>e is moi/5$ ) m]curic *loride solution 7#a3aj1jjj7 & is slit f ! l[] bord] to its midpo9t4 ,?is pad is slipp$ f above d[nw>d "u ! tape hold] ( ! cannula1 ! slit p]mitt+ ! tubal "p ( ! cannula to rea* ! c5tral "p ( ! pad 7,fig4 #ajh71 & completely cov]s ! w\nd4 ,no attempt %\ld be made to suture ! sk9 w\nd1 = ?is t5ds to =m a pocket 9 :i* lodge ! bron*ial secretions t escape alongside ! tube1 result+ 9 infection ( ! w\nd4 ,fur!rmore x r5d]s ! daily *ang+ ( ! tube mu* m difficult4 ,9 fact x prev5ts ! att5dant f be+ c]ta9 t ! tube is actually plac$ 9 ! tra*ea4 ,sutur+ ( ! sk9 to ! tra*ea %\ld nev] be done1 = ! sutures soon te> out & (t5 set up a p]i*ondritis ( ! tra*eal c>tilages1 ) result+ difficult decannulation4 ,,fig4 #aje4--,s*ema ( practical gross anatomy to be memoriz$ = em]g5cy tra*eotomy4 ,! middle l9e is ! safety l9e1 ! high] ! wid]4 ,bel[1 ! safety l9e n>r[s to ! vani%+ po9t ,,vp4 ,! upp] limit ( ! safety l9e is ! ?yroid not* until ! tra*ea is b>$1 :5 ! limit falls bel[ ! fir/ tra*eal r+4 ,9 practice ! two-d>k dang] l9es are pu%$ back ) ! left ?umb & middle f+] z %[n 9 ,fig4 #ajf1 ?us ?r[+ ! safety l9e into prom95ce4 ,?is is g5]ally kn[n z ,jackson's tra*eotomic triangle4 ,,fig4 #ajf4--,s*ema %[+ ! au?or's me?od ( rapid tra*eotomy4 ,fir/ /age4 ,! h&s are drawn unglov$ = ! sake ( cle>ness4 ,! upp] h& is ! left1 ( :i* ! middle f+] 7,m7 & ! ?umb are us$ to repress ! /]no-cleido-ma/oid muscles1 ! f+] & ?umb be+ close to ! tra*ea 9 ord] to press backw>d out ( ! way ! c>otid art]ies & ! jugul> ve94 ,?is ?r[s ! tra*ea =w>d into prom95ce1 & "o deep sla%+ cut w incise all ( ! s(t tissues d[n to ! tra*ea4 ,em]g5cy ,tra*eotomy4--,/abb+ ( ! crico?yroid membrane1 or an attempt$ /abb+ ( ! tra*ea1 s long taught z an em]g5cy tra*eotomy1 is a mi/ake4 ,! au?or's two /age1 f+] guid$ me?od is saf]1 quick]1 m effici5t1 & n likely to be foll[$ by /5osis4 ,to execute ?is promptly1 ! op]ator is requir$ to =get 8 textbook anatomy & memorize ! s*ema 7,fig4 #aje74 ,! l>ynx & tra*ea are /eadi$ by ! ?umb & middle f+] ( ! left h&1 :i* at ! same "t pu% back ! important n]ves & vessels :i* p>allel ! tra*ea1 & r5d] ! c5tral safety l9e m prom95t 7,fig4 #ajf74 ,a long incision is n[ made f ! ?yroid not* almo/ to ! supra/]nal not*1 & deep en\gh to rea* ! tra*ea4 ,?is completes ! fir/ /age4 ,,fig4 #ajg4--;,illu/rat+ ! au?or's me?od ( quick tra*eotomy4 ,second /age4 ,! f+]s are drawn unglov$ = ! sake ( cle>ness4 ,9 op]at+ ! :ole w\nd is full ( blood1 & ! r+s ( ! tra*ea are felt ) ! left index :i* is !n mov$ slightly to ! pati5t's left1 :ile ! knife is slid d[n along ! left index to exactly ! middle l9e :5 ! tra*ea is incis$4 ,second /age4 ,! entire w\nd is full ( blood & ! tra*ea _c be se51 b its corrugations c be v readily felt by ! tip ( ! free left index f+]4 ,! left index f+] is n[ mov$ a little to ! pati5t's left 9 ord] t ! knife %all come precisely 9 ! midl9e ( ! tra*ea1 & ?ree r+s ( ! tra*ea are divid$ f above d[nw>d 7,fig4 #ajg74 ,! ,tr\sseau dilator %\ld n[ be ins]t$1 ! head ( ! table %\ld be l[]$1 & ! pati5t %\ld be turn$ on ! side to all[ ! blood to run away f ! w\nd4 ,if respiration has ceas$1 a cannula is slipp$ 91 & artificial respiration is begun4 ,oxyg5 insufflation w aid 9 ! re/oration ( respiration1 & a pe>l ( amyl nitrite %\ld be cru%$ 9 gauze & bl[n 9 ) ! oxyg54 ,9 all su* cases1 excessive pressure ( oxyg5 %\ld be avoid$ because ( ! dang] ( produc+ is*emia ( ! lungs4 ,hope ( re/or+ respiration %\ld n be ab&on$ = half an h\r at lea/4 ,"o ( ! au?or's assi/ants1 ,dr4 ,phillip ,/\t1 sav$ a pati5t's life by keep+ up artificial respiration = tw5ty m9utes be=e ! pati5t c\ld d 8 own brea?+4 ,! aft]-c>e ( ! tra*eotomic w\nd is ( ! utmo/ importance4 ,a special day & night nurse are requir$4 ,! inn] tube ( ! cannula mu/ be remov$ & clean$ z soon z x conta9s secretion4 ,secretion c\gh$ out mu/ be wip$ away quickly1 b g5tly1 be=e x is aga9 aspirat$4 ,! gauze dress+ cov]+ ! w\nd mu/ be *ang$ z soon z soil$ ) secretions f ! w\nd & ! air-passages4 ,ea* fre% pad %\ld be moi/5$ ) v weak bi*loride ( m]cury solution 7#a3aj1jjj74 ,! out] tube mu/ be *ang$ e tw5ty-f\r h\rs1 & (t5] if ! bron*ial secretion is abundant4 ,/ud5t-physicians :o h be5 taught my me?ods & :o h se5 ! cases 9 c>e ( our nurses h (t5 express$ amazem5t at ! neglect unkn[+ly inflict$ on su* cases else:]e1 9 ! c\rse ( ord9>y r\t9e surg]y4 ,x is n unusual = a pati5t to be s5t to ! ,bron*oscopic ,cl9ic :o has worn 8 cannula )\t a s+le *ang+ = "o or two ye>s4 ,9 "s cases ! tube _h brok5 & a portion _h be5 aspirat$ into ! tra*ea4 ,,fig4 #ajh4--,me?od ( dress+ a tra*eotomic w\nd4 ,a broad quadruple1 9-fold$ pad ( gauze is cut to its c5tre s t x c be slipp$ a/ride ( ! tube ( ! cannula back ( ! %ield4 ,no /r+s1 ravell+s or /rips ( gauze are p]missible because ( ! risk ( _! gett+ d[n into ! tra*ea4 ,if ! respiratory rate increases1 in/ead ( attribut+ x to pulmon>y complications1 ! entire cannula %\ld be remov$1 ! w\nd dilat$ ) ! ,tr\sseau =ceps1 ! int]ior ( ! tra*ea inspect$1 & all secretions clean$ away4 ,!n ! tra*eal mucosa bel[ ! w\nd %\ld be g5tly t\*$ ) a /]ile b5t probe1 to induce c\gh to rid ! l[] air passages ( accumulat$ secretions4 ,9 _m cases x is a life-sav+ proc$ure to ins]t a /]ile long malleable aspirat+ tube to remove secretions f ! l[] air-passages4 ,:5 all is cle>1 a fre% /]ile cannula :i* has be5 c>efully inspect$ to see t its lum5 has be5 ?or\ghly clean$1 is ins]t$1 & its tapes ti$4 ,good plumb+1 t is1 ! ma9t5ance at all times ( a cle>1 clean passage 9 all ! pipes1 natural & artificial1 is ! reason :y ! mortality 9 ! ,bron*oscopic ,cl9ic has be5 less ?an half ( "o p] c5t1 :ile 9 ord9>y r\t9e surgical c>e 9 all hospitals collectively x ranges f #aj to #bj p] c5t4 ,bron*ial ,aspiration4--,z m5tion$ above1 bron*ial aspiration is (t5 necess>y4 ,:5 ! pati5t is unable to get up secretions1 he w1 z demon/rat$ by ! au?or _m ye>s ago1 dr[n 9 8 own secretions4 ,9 "s cases bron*oscopic aspiration is requir$ 7,p]oral ,endoscopy1 p4 #dhc74 ,occasionally1 v ?ick secretions w require removal ) =ceps4 ,pus may become v ?ick & gummy f ! adm9i/ration ( morph94 ,opiates d n less5 pus =mation1 b !y d less5 ! normal secretions t ord9>ily increase ! quantity & fluidity ( ! pus4 ,:5 to ?is is add$ ! dessicat+ effect ( ! air inhal$ ?r\gh ! cannula1 unmoi/5$ by ! upp] air-passages1 ! secretions may be s ?ick z to =m cru/s & plugs t are equival5t to =eign bodies & require removal ) =ceps4 ,diph!ritic membrane 9 ! tra*ea may require removal ) bron*oscope & =ceps4 ,?9n] secretions may be remov$ by sponge-pump+4 ,9 mo/ cases1 h[ev]1 secretions c be br\ght up ?r\gh an aspirat+ tube1 connect$ to a bron*oscopic aspirat+ syr+e 7,fig4 #aa71 an ord9>y aspirat+ bottle1 or pref]ably1 a me*anical aspirator su* z t %[n 9 ,fig4 #ab4 ,9 ?is1 comb9$ ) bron*oscopic oxyg5 insuflation 7q4v471 we h a life-sav+ measure ( ! highe/ effici5cy 9 cases ( poison+ by *lor9e & o!r irritant & asphyxiat+ gases4 ,an aspirat+ tube = ins]tion into ! deep] air passages %\ld be ( copp]1 s t x c be b5t to ! prop] curve to rea* into ! v>i\s p>ts ( ! tra*eobron*ial tree1 & x %\ld h a removable copp]-wire core to prev5t k9k+1 & collapse ( ! lum54 ,! di/al end %\ld be ?ick5$1 & also p]=at$ at ! sides1 to prev5t draw+-9 ( ! mucosa & trauma !reto4 ,a rubb] tube may be us$1 b is n s satisfactory4 ,! "o %[n 9 ,fig4 #aj ,i _h made by ,mr4 ,pill+1 & x has prov$ v satisfactory4 ,decannulation4--,:5 ! tra*eal incision is plac$ bel[ ! fir/ r+1 no difficulty 9 decannulation %\ld result f ! op]ation p] se4 ,:5 by tempor>ily occlud+ ! cannula ) ! f+] x is evid5t t ! l>yngeal ap]ture has rega9$ suffici5t size to all[ free brea?+1 a small]-siz$ tra*eotomic tube %\ld be sub/itut$ to all[ free passage ( air ar\nd ! cannula 9 ! tra*ea4 ,9 do+ ?is1 ! am\nt ( secretion & ! h&icap ( impair$ glottic mobility 9 ! expulsion ( ?ick secretions mu/ be borne 9 m9d4 ,babies labor "u a special h&icap 9 _! ineffici5t be*ic expulsion & especially 9 _! small cannulae :i* are s readily occlud$4 ,if brea?+ is n free & quiet ) ! small] tube2 ! l>g] "o mu/ be replac$4 ,if1 h[ev]1 !re is no tr\ble ) secretions1 & ! brea?+ is free & quiet1 ! inn] cannula %\ld be remov$1 & ! ext]nal orifice ( ! out] cannula firmly clos$ ) a rubb] cork4 ,if ! l>yngeal condition has be5 acute1 decannulation c usually be safely done aft] ! pati5t has be5 able to sleep quietly = ?ree nights ) a cork$ cannula4 ,if free brea?+ _c be obta9$ :5 ! cannula is cork$1 ! l>ynx is /5os$1 & special "w w be requir$ to remove ! tube4 ,*ildr5 sometimes become panic /rick5 :5 ! cannula is completely cork$ at once & !y are =c$ to brea! ?r\gh ! l>ynx in/ead ( ! easi] %ortcut ?r\gh ! neck4 ,9 su* a case1 ! fir/ /ep is p>tially to cork ! cannula ) a half or two-?irds plug made f a pure rubb] cord fa%ion$ 9 ! desir$ %ape by gr9d+ ) an em]y :eel 7,fig4 #aab74 ,?us ! pati5t is gradually taught to use ! natural air-way1 /ill feel+ t he has an an*or to w9dw>d 9 ! op5+ 9 ! cannula4 ,:5 "s swell+ ( ! l>yngeal /ructures /ill exi/s1 ?is gradual cork+ has a !rapeutic effect 9 less5+ ! /5osis by ex]cis+ ! muscles ( abduction ( ! cords & mobiliz+ ! crico>yt5oid articulation dur+ ! inspiratory ef=t4 ,! =c$ respiration keeps ! l>ynx fre$ f secretions1 :i* are m or less purul5t & h5ce irritat+4 ,aft] remov+ ! cannula1 9 ord] t heal+ may proce$ f ! bottom upw>d1 ! w\nd %\ld be dress$ 9 ! foll[+ mann]3 ,a s+le ?ickness ( gauze %\ld be plac$ ov] ! w\nd & ! front ( ! neck1 & a gauze w$ge firmly ins]t$ ov] ?is to ! dep?s ( ! tra*eotomic w\nd1 all ( ?is dress+ be+ held 9 place by a b&age4 ,if ! sk9-w\nd heals be=e ! fibr\s union ( ! tra*eal c>tilages is complete1 exub]ant granulations are apt to =m & occlude ! tra*ea1 p]haps necessitat+ a new tra*eotomy = dyspnea4 ,x is s important to fix indelibly 9 ! m9d ! c>d9al po9ts conc]n+ tra*eotomy t ,i h app5d$ to ?is *apt] ! tea*+ notes t ,i h be5 = ye>s giv+ my classes ( /ud5ts & practition]s1 hundr$s ( :om h ?ank$ me = giv+ !m ! cle>-cut conception ( tra*eotomy t enabl$ !m1 :5 _! turn came to d an em]g5cy tra*eotomy1 to save human life4 ,,resume ,,( ,,tra*eotomy ,in/rum5ts4 ,headlight ,s&bag ,scalpel ,hemo/ats ,small retractors ,t5aculum ,tra*eotomic cannulae 7prop] k9d7 ,long4 ,half area cross-section tra*ea4 ,prop] curve3 ,radius too %ort w press ant4 tra*eal wall2 too long1 po/4 wall4 ,/]l+ ,silv] ,tra*eobron*ial aspirator4 ,probe4 ,tapes = cannulae ,tr\sseau dilator ,sponges ,infiltration syr+e & solution ,oxyg5 tank4 ,indications3 ,l>yngeal dyspnea4 7,indraw+ guttural & clavicul> fossae & at epiga/rium4 ,pallor4 ,re/lessness4 ,dr[n+ 9 8 own secretions47 ,d x e>ly4 ,don't wait = cyanosis4 #bid ,nev] use g5]al ane/hesia on dyspneic pati5t4 ,=get ab\t high & l[ di/9ctions until tra*ea is expos$4 ,memorize ,jackson's tra*eotomic triangle4 ,pati5t recumb5t1 s& bag "u %\ld]s or neck4 ,nose to z5i?4 ,infiltration1 ,intrad]matic4 ,incise f ,adam's apple to guttural fossa4 ,hemo/asis4 ,keep 9 middle l9e4 ,feel = tra*ea4 ,expose i/hmus ( ?yroid gl&4 ,draw x upw>d or d[nw>d or cut x4 ,ligature1 torsion1 etc4 be=e incis+ tra*ea4 ,hold tra*ea ) t5aculum4 ,incise tra*ea bel[ fir/ r+4 ,avoid cutt+ cricoid or fir/ r+4 ,cut #c r+s v]tically4 ,don't hack4 ,don't cut po/]ior wall :i* almo/ t\*es ! ant]ior wall dur+ c\gh4 ,spread c>efully1 ) ,tr\sseau dilator4 ,ins]t cannula2 see x ent] tra*eal lum52 remove pilot2 tie tapes4 ,don't suture w\nd4 ,dress ) l>ge squ>es4 ,don't give morph9e4 ,decannulation by cork+ p>tially1 aft] *ang+ to small] cannula4 ,d n remove cannula p]man5tly until pati5t sleeps )\t indraw+ ) cork$ cannula4 ,,resume ,,( ,,em]g5cy ,,tra*eotomy ,! foll[+ notes %\ld be memoriz$4 #a4 ,ess5tials3 ,knife & pair ( h&s 7b full equipm5t bett]74 #bie #b4 ,don't d a l>yngotomy1 or /abb+4 #c4 ,two /age1 f+] guid$ op]ation bett]4 #d4 ,s& bag or sub/itute4 #e4 ,press back dang] l9es ) left ?umb & middle f+]1 mak+ safety l9e & tra*ea prom95t4 #f4 ,memorize ,jackson's tra*eotomic triangle4 #g4 ,incise exactly 9 middle l9e f ,adam's apple to /]num4 #h4 ,feel = tra*eal corrugations ) left index 9 pool ( blood1 foll[+ tra*ea ) f+] d[nw>d f sup]ficial ,adam's apple4 #i4 ,pass knife along index & incise tra*ea 7n too deeply1 may cut po/]ior wall74 #aj4 ,don't m9d ble$+2 b keep middle l9e & keep head /raight2 keep head l[2 don't bo!r ab\t ?yroid gl&4 #aa4 ,don't expect hiss :5 tra*ea is cut if pati5t has /opp$ brea?+4 #ab4 ,/>t artificial respiration4 #ac4 ,amyl nitrite4 ,oxyg54 #ad4 ,practice palpation ( ! neck until ! tra*eal l&m>ks are famili>4 #ae4 ,practice above te*nic1 up to po9t ( incision1 at e opportunity4 #af4 ,jackson's tra*eotomic triangle3 ,a triangulation ( ! front ( ! neck int5d$ to facilitate a prop] em]g5cy tra*eotomy4 ,apex at supra/]nal not*4 ,sides ant]ior edge /]noma/oids4 ,base horizontal l9e l[] edge cricoid4 ,,resume ,,( ,,aft]-,,c>e ,,( ,a ,,tra*eotomic ,,case #a4 ,always be> 9 m9d t tra*eotomy is n an ultimate object4 ,! ultimate object is to pipe air d[n into ! lungs4 ,tra*eotomy is only a means to t end4 #b4 ,/]ile tray beside b$ %\ld conta9 duplicate 7exact7 tra*eotomy tube1 ,tr\sseau dilator1 hemo/at1 ?umb =ceps1 silv] probe1 scissors1 scalpel1 probe-po9t$ curv$ bi/\ry4 ,/]ile gloves ready4 #c4 ,special nurs+ necess>y = safety4 #d4 ,laxative4 #e4 ,sponge away secretions be=e !y are drawn 94 #f4 ,cov] w\nd ) wide l>ge gauze squ>e slit s x fits ar\nd cannula "u ! tape hold]4 ,pull (f ravel+s4 ,keep wet ) #a 3 #aj1jjj ,bi*loride solution4 #g4 ,*ange dress+ e h\r or (t5]4 #h4 ,abundance ( fre% air1 temp]ature pref]ably ab\t #gj degrees4 #i4 ,nurse %\ld remove inn] cannula z (t5 z ne$$ & clean x ) pipe clean] be=e boil+4 #aj4 ,out] cannula %\ld be *ang$ e day by ! surgeon or long-exp]i5c$ tra*eotomy nurse4 ,a pilot %\ld be us$ & c>e %\ld be tak5 n to injure ! cut ends ( ! tra*eal c>tilage4 #aa4 ,a /]ile1 b5t probe may be ins]t$ d[nw>d 9 ! tra*ea ) bo? cannulae out to excite c\gh if necess>y to expel secretions4 ,an aspirat+ tube %\ld be us$1 :5 necess>y4 #ab4 ,a pati5t ) a prop]ly fitt$ cannula free ( secretions brea!s noiselessly4 ,any s\nd dem&s imm$iate att5tion4 #ac4 ,if ! respiratory rate increase x is mu* m likely to be due to ob/ruction 91 malposition (1 or %ortness ( ! cannula ?an to lung complications4 #ad4 ,be sure t3 7a7 ,! cannula is cle> & clean4 7b7 ,! cannula is long en\gh to rea* well d[n into ! tra*ea4 ,a cannula t 0 long en\gh :5 ! op]ation 0 done may be too %ort aft] ! c]vical tissues swell4 7c7 ,! di/al end ( ! cannula actually is deeply 9 ! tra*ea4 ,! only way to be sure is1 :5 ins]t+ ! cannula1 to spread ! w\nd & ! tra*eal incision ) a ,tr\sseau dilator1 !n see ! int]ior ( ! tra*eal lum5 & see ! cannula ent] !re94 #ae4 ,if aft] att5d+ to ! above m5tion$ details !re are /ill signs ( ob/ructive dyspnea1 a bron*oscopy %\ld be done = f9d+ & removal ( ! ob/ruction 9 ! tra*ea or ma9 bron*i4 #af4 ,if all ! pipes1 natural & in/rum5tal1 are cle> !re c be no su* ?+ z ob/ructive dyspnea4 #ag4 ,pneumonia & pulmon>y edema may exi/ be=e tra*eotomy1 b !y are r>e sequelae4 #ah4 ,decannulation1 9 cases ( tra*eotomy done = tempor>y conditions %\ld n be attempt$ until ! pati5t has slept at lea/ #c nights ) 8 cannula tightly cork$4 ,a prop]ly fitt$ cannula 7i4e4 "o n l>g] ?an half ! area ( cross section ( ! tra*ea7 p]mits ! by-passage ( pl5ty ( air4 ,a p>tial cork %\ld be worn = a few days fir/ = te/+ & wean+ a *ild away f ! easi] brea?+ ?r\gh ! neck4 ,9 cases ( *ronic l>yngeal /5osis a prolong$ te/ is necess>y be=e attempt+ decannulation4 #ai4 ,a tra*eotomic case may be aphonic1 h5ce unable to call = help4 #bj4 ,! =ego+ rules apply to ! po/-op]ative p]iods4 ,aft] ! w\nd has heal$ & a fi/ula is e/abli%$1 ! pati5t1 if n a *ild1 may le>n to c>e = 8 own cannula4 #bih #ba4 ,d n give c\gh-s$atives or n>cotics4 ,! c\gh reflex is ! wat* dog ( ! lungs4 ,,notes ,,on ,,nurs+ ,,tra*eotomiz$ ,,pati5ts ,b$side tray %\ld conta93 ,duplicate cannula ,scalpel ,tr\sseau dilator ,hemo/at ,dress+ =ceps ,/]ile vasel9e ,scissors ,tape ,probe ,gauze sponges ,gauze squ>es ,probe-po9t$ curv$ bi/\ry4 #a4 ,room %\ld be abundantly v5tilat$1 z free f du/ & l9t z possible1 & ! air %\ld be moi/5$ by /eam 9 w9t]4 #b4 ,keep m\? clean4 ,too? bru%4 ,r9se alcohol #a3aj4 #c4 ,sponge away secretion aft] ! c\gh be=e drawn 94 #d4 ,remove inn] cannula 7n out]7 z (t5 z ne$$4 ,n less (t5 ?an e h\r4 ,replace imm$iately4 ,nev] boil a cannula until y h ?or\ghly clean$ x4 #e4 ,ob/ruction ( cannula call+ = clean+ indicat$ by3 ,blue or a%y color4 ,indraw+ at clavicles1 /]nal not*1 epiga/rium4 ,noisy brea?+4 7,le>n s\nd47 #f4 ,surgeon 79 our cases7 w *ange out] cannula once daily or (t5]4 #g4 ,duplicate cannulae4 #h4 ,be c>eful 9 clean+ cannulae n to damage4 #i4 ,wat* = loose p>ts on cannula4 #aj4 ,*ange dress+ 79 our cases7 z (t5 z soil$4 ,n less (t5 ?an e h\r4 ,l>ge squ>es4 ,nev] n>r[ /rips4 #aa4 ,wat* color ( lips & e>s & face4 #bii #ab4 ,report at once if food or wat] leaks ?r\gh w\nd4 7,c\gh+ & *ok+74 #ac4 ,nev] leave a tra*eotomiz$ pati5t unwat*$ dur+ ! fir/ days or weeks1 accord+ to case4 #ad4 ,rememb] ,tr\sseau dilator or hemo/at w spread ! tra*eal w\nd or fi/ula :5 cannula is out4 #ae4 ,rememb] life dep5ds on a cle> cannula if ! pati5t gets no air ?r\gh ! m\?4 #af4 ,rememb] x takes v little to clog ! small cannula ( a *ild4 #ag4 ,rememb] a tra*eotomiz$ pati5t _c call = help4 #ah4 ,decannulation4 ,te/+ by cork+ p>tially4 ,wat* corks n too small1 or brok54 ,atta* !m by braid$ silk ?read4 ,pure rubb] cord gr\nd d[n makes be/ cork4 #cjj ,,*apt] ,,xxxviii--,,*ronic ,,/5osis ,,( ,,! ,,l>ynx ,,& ,,tra*ea ,! v>i\s =ms ( l>yngeal /5osis = :i* tra*eotomy or intubation has be5 p]=m$1 & ! difficulties enc\nt]$ 9 re/or+ ! natural brea?+1 may be classifi$ into ! foll[+ types3 #a4 ,panic #b4 ,spasmodic #c4 ,p>alytic #d4 ,ankylotic 7aryt5oid7 #e4 ,neopla/ic #f4 ,hyp]pla/ic #g4 ,cicatricial 7a7 ,loss ( c>tilage 7b7 ,loss ( muscul> tissue 7c7 ,fibr\s ,panic4--,no?+ s t]rifies a *ild z sev]e dyspnea2 & ! memory ( previ\s /ruggles = air1 toge!r ) ! great] ease ( brea?+ ?r\gh ! tra*eotomic cannula ?an ?r\gh ev5 a normal l>ynx1 incites 9 "s cases s great a degree ( fe> t x may prop]ly be call$ panic1 :5 attempts at decannulation are made4 ,cry+ & possibly glottic spasm increase ! difficulties4 ,spasmodic /5osis may be associat$ ) panic1 or may be excit$ by subglottic inflammation4 ,prolong$ we>+ ( an intubation tube1 by di/urb+ ! normal reciprocal equilibrium ( ! abductors & adductors1 is "o ( ! *ief causes4 ,! treatm5t = spasmodic /5osis & panic is simil>4 ,! use ( a special intubation tube hav+ a long ant]o-po/]ior lum5 & a n>r[ neck1 :i* =m all[s great] action ( ! musculature1 has be5 successful 9 "s cases4 ,repeat$ removal & replacem5t ( ! intubation tube :5 dyspnea requires x may prove suffici5t 9 ! mild] cases4 ,v r>ely a tra*eotomy may be requir$2 if s1 x %\ld be done l[4 ,! we>+ ( a tra*eotomic cannula p]mits a re/oration ( ! muscle balance & a subsid5ce ( ! subglottic inflammation4 ,cork+ ! cannula ) a slott$ cork 7,fig4 #aaa7 w n[ re/ore l>yngeal brea?+1 aft] :i* ! tra*eotomic cannula may be remov$4 ,,plate ,v--,,photoprocess ,,reproductions ,,( ,,! ,,au?or',s ,,oil-,,color ,,draw+s ,,f ,,life--,,l>yngeal ,,& ,,tra*eal ,,/5oses3 #a1 ,indirect view1 sitt+ position2 po/diph!ric cicatricial /5osis p]man5tly cur$ by endoscopic evisc]ation4 7,see ,fig4 #e47 #b1 ,indirect view1 sitt+ position2 po/typhoid cicatricial /5osis4 ,mucosa 0 v cyanotic because cannula 0 re-mov$ = l>yngoscopy & bron*oscopy4 ,cur$ by l>yngo/omy4 7,see ,fig4 #f47 #c1 ,indirect view1 sitt+ position2 po/typhoid infiltrative /5osis1 left aryt5oid de/roy$ by necrosis4 ,cur$ by l>yngo/omy2 failure to =m adv5titi\s b& 7,fig4 #g7 because ( lack ( aryt5oid activity4 #d1 ,indirect view1 recumb5t position2 po/typhoid cicatricial /5osis4 ,cur$ ( /5osis by endoscopic evisc]ation ) slid+ pun* =ceps4 ,ant]ior commissure twice aft]w>d cle>$ ( cicatricial tissue z 9 ! o!r case %[n 9 ,fig4 #ae4 ,ultimate result %[n 9 ,fig4 #h4 #e1 ,same pati5t z ,fig4 #a2 sket* made two ye>s aft] decannulation & pla/ic4 #f1 ,same pati5t z ,fig4 #b2 sket* made f\r ye>s aft] decannulation & pla/ic4 #g1 ,same pati5t z ,fig4 #c2 sket* made ?ree ye>s aft] decannulation & pla/ic4 #h1 ,same pati5t z ,fig4 #d2 sket* made "o ye> aft] decannulation1 f\rte5 mon?s aft] cle>+ ( ! ant]ior commissure to =m adv5titi\s cords4 #i1 ,direct view1 recumb5t pati5t2 web po/diph!ric 787 or cong5ital 7874 ,r\gh voice s9ce bir?1 b l>ynx nev] exam9$ until /5os$ aft] diph!ria4 ,web remov$ & l>ynx evisc]at$ ) pun* =ceps2 recurr5ce ( /5osis 7n ( web74 ,cure by l>yngo/omy4 ,?is view also illu/rates ! true dep? ( ! l>ynx :i* is (t5 ov]look$ because ( ! mislead+ flatness ( l>yngeal illu/rations4 #aj1 ,direct l>yngoscopic view2 po/diph!ric hyp]trophic subglottic /5osis4 ,cur$ by galvanocaut]ization4 #aa1 ,direct l>yngoscopic view2 po/diph!ric hyp]trophic supraglottic /5osis4 ,=ceps excision2 extubation "o mon? lat]2 /ill well aft] f\r ye>s4 #ab1 ,bron*oscopic view ( po/tra*eotomic /5osis foll[+ a pla/ic flap tra*eotomy done = acute edema4 #ac1 ,direct l>yngoscopic view2 ant]olat]al ?ymic compression /5osis 9 a *ild ( eighte5 mon?s4 ,cur$ by ?ymopexy4 #ad1 ,indirect l>yngoscopic 7mirror7 view2 l>yngo/omy rubb] tube 9 position 9 treatm5t ( po/-typhoid /5osis4 #ae1 ,direct view2 po/typhoid /5osis aft] cure by l>yngo/omy4 ,dott$ l9e %[s place ( excision = cle>+ out ! ant]ior commissure to re/ore ! voice4 #af1 ,endoscopic view ( po/tra*eotomic tra*eal /5osis f badly plac$ incision & *ondrial necrosis4 ,tra*eotomy orig9ally done = influ5zal tra*eitis4 ,cur$ by tra*eo/omy4 ,p>alysis4--,bilat]al abductor l>yngeal p>alysis causes sev]e /5osis1 & usually tra*eotomy is urg5tly requir$4 ,9 cadav]ic p>alysis bo? cords are 9 a position midway betwe5 abduction & adduction1 & _! m>g9s are cresc5tic1 s t suffici5t airway rema9s4 ,ef=ts to produce ! cadav]ic position ( ! cords by division or excision ( a portion ( ! recurr5t l>yngeal n]ves1 h be5 failures4 ,! op]ation ( v5triculocordectomy consi/s 9 remov+ a vocal cord & ! portion or all ( ! v5tricul> floor by means ( a pun* =ceps introduc$ ?r\gh ! direct l>yngoscope4 ,usually x is bett] to remove only ! portion ( ! floor ant]ior to ! vocal process ( ! aryt5oid4 ,9 "s cases monolat]al v5triculocordectomy is suffici5t2 9 mo/ cases1 h[ev]1 op]ation on bo? sides is ne$$4 ,an int]val ( two mon?s betwe5 op]ations is advisable to avoid adhesions4 ,9 almo/ all cases1 v5triculocordectomy w result 9 a suffici5t increase 9 ! glottic *9k = normal respiration4 ,! ultimate vocal results are good4 ,evisc]ation ( ! l>ynx1 ei!r by ! endoscopic or ?yrotomic me?od1 usually yields excell5t results :5 no lesion o!r ?an p>alysis exi/s4 ,only too (t51 h[ev]1 ! condition is complicat$ by ! results ( a faultily high tra*eotomy4 ,a r\gh1 inflexible voice is ultimately obta9$ aft] ?is op]ation1 especially if ! aryt5oid c>tilage is unh>m$4 ,9 rec5t bilat]al recurr5t p>alysis1 x may be wor?y ( trial to suture ! recurr5t to ! pneumoga/ric4 ,op]ations on ! l>ynx = p>alytic /5osis %\ld n be und]tak5 e>li] ?an twelve mon?s f ! inception ( ! condition1 ?is "t be+ all[$ = possible n]ve reg5]ation1 ! pati5t be+ made safe & com=table1 mean:ile1 by a l[ tra*eotomy4 ,ankylosis4--,fixation ( ! crico-aryt5oid jo9ts ) an approximation ( ! cords may require evisc]ation ( ! l>ynx4 ,?is1 h[ev]1 %\ld n be attempt$ until aft] a ye>'s lapse1 & %\ld be prec$$ by attempts to improve ! condition by endoscopic b\g9age1 & by p>tial cork+ ( ! tra*eotomic cannula4 ,neoplasms4--,decannulation 9 neopla/ic cases dep5ds ^u ! nature ( ! gr[?1 & its curability4 ,cicatricial contraction foll[+ op]ative removal ( malignant gr[?s is be/ treat$ by intubational dilatation1 provid$ recurr5ce has be5 rul$ out4 ,! /5osis produc$ by b5ign tumors is usually reliev$ by _! removal4 ,papillomata4--,decannulation aft] tra*eotomy done = papillomata %\ld be def]r$ at lea/ #f mon?s aft] ! discont9uance ( recurr5ce4 ,n uncommonly ! op]ative treatm5t ( ! gr[?s has be5 s mi/ak5ly radical z to result 9 cicatricial or ankylotic /5oses :i* require _! appropriate treatm5ts4 ,x is ! au?or's op9ion t recurr5t papillomata con/itute a b5ign self-limit$ disease & are be/ treat$ by repeat$ sup]ficial removals1 leav+ ! und]ly+ normal /ructures un9jur$4 ,?is me?od w yield ultimately a p]fect voice & w avoid ! un=tunate complications ( cicatricial hyp]trophic & ankylotic /5osis4 ,compression ,/5osis ( ! ,tra*ea4--,decannulation 9 ^! cases c only foll[ ! removal ( ! compressive mass1 :i* may be ?ymic1 neopla/ic1 hyp]trophic or inflammatory4 ,gl&ul> disease may be ( ! ,hodgk9s' type4 ,?ymic compression yields readily to radium & ! ro5tg5ray1 & ! tub]cul\s & leukemic ad5itides are sometimes favorably influ5c$ by ! same ag5ts4 ,surg]y w relieve ! compression ( /ruma & b5ign neoplasms1 & may be indicat$ 9 c]ta9 neoplasms ( malignant orig94 ,! possible coexi/5ce ( l>yngeal p>alysis ) tra*eal compression is frequ5tly ov]look$ by ! surgeon4 ,monolat]al or bilat]al p>alysis ( ! l>ynx is by no means an uncommon po/op]ative sequel to ?yroidectomy1 ev5 ?\gh ! recurr5t n]ves h be5 9 no way injur$ at op]ation4 ,probably a localiz$ neuritis1 a cicatricial traction1 or inclusion ( a n]ve trunk acc\nts = mo/ ( ^! cases4 ,hyp]pla/ic & cicatricial *ronic /5oses prev5t+ decannulation may be classifi$ etiologically z foll[s3 #a4 ,tub]culosis #b4 ,lues #c4 ,scl]oma #d4 ,acute infecti\s diseases 7a7 ,diph!ria 7b7 ,typhoid fev] 7c7 ,sc>let fev] 7d7 ,measles 7e7 ,p]tussis #e4 ,decubitus 7a7 ,cannul> 7b7 ,tubal #f4 ,trauma 7a7 ,tra*eotomic 7b7 ,intubational 7c7 ,op]ative 7d7 ,suicidal & homicidal 7e7 ,accid5tal 7by =eign bodies1 ext]nal viol5ce1 bullets1 etc47 ,mo/ ( ! organic /5oses1 o!r ?an ! p>alytic & neopla/ic =ms1 are ! result ( inflammation1 (t5 ) ulc]ation & second>y *anges 9 ! c>tilages or ! s(t tissues4 #cjd ,tub]culosis4--,9 ! non-cicatricial =ms1 galvanocau/ic puncture appli$ ?r\gh ! direct l>yngoscope w usually r$uce ! infiltrations suffici5tly to provide a free airway4 ,%\ld ! pulmon>y & l>yngeal tub]culosis be =tunately cur$1 leav+1 h[ev]1 a cicatricial /5osis ( ! l>ynx1 decannulation may be accompli%$ by l>yngo/omy4 ,lues4--,active & p]si/5t antiluetic m$ication mu/ prec$e & accompany any local treatm5t ( luetic l>yngeal /5osis4 ,prolong$ /ret*+ ) ov]siz$ intubation tubes foll[+ excision or caut]ization may sometimes be successful1 b l>yngo/omy is usually requir$ to combat ! vici\s contraction ( luetic cicatrices4 ,scl]oma is r>ely enc\nt]$ 9 ,am]ica4 ,radio!rapy has be5 advocat$ & good results h be5 report$ f ! intrav5\s injection ( salv>san4 ,radium may be tri$1 & its application is readily made ?r\gh ! direct l>yngoscope4 ,diph!ria4--,*ronic po/diph!ritic /5osis may be ( ! panic1 spasmodic or1 r>ely1 ! p>alytic types2 b m (t5 x is ( ei!r ! hyp]trophic or cicatricial =ms4 ,only too frequ5tly ! /5osis %\ld be call$ po/tra*eotomic r ?an po/diph!ritic1 s9ce decannulation aft] ! subsid5ce ( ! acute /5osis w\ld h be5 easy _h x n be5 = ! sequelae ( ! faulty tra*eotomy4 ,prolong$ intubation may induce ei!r a supraglottic or subglottic tissue hyp]plasia4 ,! supraglottic type consi/s 9 an edemat\s ?ick5+ ar\nd ! base ( ! epiglottis1 sometimes involv+ also ! glossoepiglottic folds & ! v5tricul> b&s4 ,an improp]ly %ap$ or fitt$ tube is ! usual cause ( ?is condition1 & a *ange to a correct =m ( intubation tube may be all t is requir$4 ,excessive polypoid tissue hyp]trophy %\ld be excis$4 ,! less r$undant cases subside "u galvanocau/ic treatm5t1 :i* may be prec$$ by tra*eotomy & extubation1 or ! intubation tube may be replac$ aft] ! application ( ! caut]y4 ,! =m] me?od is pref]able s9ce ! pati5t is f> saf] ) a tra*eotomic cannula &1 fur!r1 ! con/ant irritation ( ! intubation tube is avoid$4 ,subglottic hyp]trophic /5osis consi/s 9 symmetrical turb9al-l swell+s encroa*+ on ! lum5 f ei!r side4 ,cauti\s galvanocaut]ant treatm5t accurately appli$ by ! direct me?od w practically always cure ?is condition4 ,prelim9>y tra*eotomy is requir$ 9 ^? cases 9 :i* x has n already be5 done1 & 9 ! cases 9 :i* a high tra*eotomy has be5 done1 a l[ tra*eotomy mu/ be ! fir/ /ep 9 ! cure4 ,cicatricial types ( po/diph!ritic /5osis may be se5 z webs1 annul> cicatrices ( funnel %ape1 or masses ( fibr\s tissue caus+ fixation ( ! aryt5oids z well z encroa*m5t on ! glottic lum54 7,see color plates47 ,z a rule1 :5 a convalesc5t diph!ritic pati5t _c be extubat$ two weeks aft] ?ree negative cultures h be5 obta9$ ! advisability ( a l[ tra*eotomy %\ld be consid]$4 ,if a convalesc5t intubat$ pati5t c\gh up a tube & become dyspneic a l[ tra*eotomy is usually pref]able to =c+ 9 an ov]siz$ intubation tube4 ,typhoid ,fev]4--,ulc]ative lesions 9 ! l>ynx dur+ typhoid fev] are almo/ always ! result ( mix$ infection1 ?\gh ?rombosis ( a small vessel1 ) subsequ5t necrosis is also se54 ,if ! ulc]ation rea*es ! c>tilage1 cicatricial /5osis is almo/ c]ta9 to foll[4 ,trauma4--,! *ief traumatic factors 9 *ronic l>yngeal /5osis are3 7a7 prolong$ pres5ce ( a =eign body 9 ! l>ynx 7b7 unskill$ attempts at intubation & ! we>+ ( poorly fitt+ intubation tubes2 7c7 a faulty tra*eotomy2 7d7 a badly fitt+ cannula2 7e7 w> injuries2 7f7 attempt$ suicide2 7g7 attempt$ homicide2 7h7 neglect ( cleanl9ess & c>e ( ei!r intubation tubes or tra*eotomic cannulae all[+ incru/ation & r\gh5+ :i* traumatize ! tissues at ea* movem5t ( ! ev]-mov+ l>ynx & tra*ea4 ,treatm5t ( ,cicatricial ,/5osis4--,a c>eful direct endoscopic exam9ation is ess5tial be=e decid+ on ! me?od ( treatm5t = ea* p>ticul> case4 ,granulations %\ld be remov$4 ,intubat$ cases are usually be/ treat$ by tra*eotomy & extubation be=e fur!r endoscopic treatm5t is und]tak54 ,a c]ta9 diagnosis z to ! cause ( ! condition mu/ be made by laboratory & !rapeutic te/s1 supplem5t$ by biopsy if necess>y4 ,vigor\s antiluetic treatm5t1 especially ) protiodide ( m]cury1 mu/ prec$e op]ation 9 all luetic cases4 ,necrotic c>tilage is be/ treat$ by l>yngo/omy4 ,intubational dilatation w succe$ 9 "s cases4 ,,fig4 #aji4--,s*ema %[+ ! au?or's me?od ( l>yngo/omy4 ,! holl[ upw>d metallic bran* 7,n7 ( ! cannula 7,c7 holds ! rubb] tube 7,r7 back firmly aga9/ ! spur usually f\nd on ! back wall ( ! tra*ea4 ,moreov]1 ! air pass+ up ?r\gh ! rubb] tube 7,r7 p]mits ! pati5t to talk 9 a l\d :isp]1 ! ext]nal orifice ( ! cannula be+ occlud$ mo/ ( ! "t ) ! cork 7,k74 ,! rubb] tub+1 :5 l>ge sizes are rea*$ may ext5d d[n to ! l[] end ( ! cannula1 ! "p ,c com+ out ?r\gh a l>ge hole cut 9 ! tub+ at ! prop] di/ance f ! l[] end4 ,l>yngoscopic b\g9age once weekly ) ! l>yngeal b\gies 7,fig4 #db7 w cure mo/ cases ( l>yngeal /5osis4 ,= ! tra*ea1 r\nd1 silk-wov51 or metallic b\gies 7,fig4 #dj7 are bett]4 #cjg ,l>yngo/omy consi/s 9 a midl9e division ( ! l>yngeal & tra*eal c>tilages z l[ z ! tra*eotomic fi/ula1 excision ( ?ick cicatricial tissue1 v cauti\s incision ( ! sc> tissue on ! po/]ior wall1 if necess>y1 & ! plac+ ( ! au?or's l>yngo/omy tube = dilatation 7,fig4 #aji74 ,ov] ! upw>d bran* ( ! l>yngo/omy tube is slipp$ a piece ( rubb] tub+ :i* is 9 turn an*or$ to ! tape c>ri] by braid$ silk ?read4 ,progressively l>g] sizes ( rubb] tub+ are us$ z ! l>yngeal lum5 increases 9 size "u ! absorptive influ5ce ( ! cont9u\s ela/ic pressure ( ! rubb]4 ,sev]al mon?s ( we>+ ! tube are requir$ until dilatation & epi!lialization ( ! op5 tr\gh ?us =m$ are complet$4 ,pa9/ak+ aft]-c>e is ess5tial to success4 ,:5 dilatation & heal+ h tak5 place1 ! l>yngo/omy w\nd 9 ! neck is clos$ by a pla/ic op]ation to conv]t ! tr\gh into a tra*ea by supply+ an ant]ior wall4 ,intubational treatm5t ( *ronic l>yngeal /5osis may be tri$ 9 c]ta9 =ms ( /5osis 9 :i* ! cicatrices d n seem v ?ick4 ,! tube is a silv]-plat$ brass "o ( l>ge size 7,fig4 #aaj74 ,a po/ :i* screws into ! ant]ior surface ( ! tube prev5ts its expulsion4 ,ov] ! po/ is slipp$ a block :i* s]ves to keep op5 ! tra*eal fi/ula4 ,detail$ discussion ( ^! op]ative treatm5ts is outside ! scope ( ?is "w1 b m5tion is made = ! sake ( complet5ess4 ,be=e und]tak+ any ( ! =ego+ proc$ures1 a c>eful /udy ( ! complete descriptions 9 ,p]oral ,endoscopy is necess>y1 & a practical c\rse ( tra9+ is advisable4 ,,fig4 #aaj4--,! au?or's reta9+ intubation tube = treatm5t ( *ronic l>yngeal /5osis4 ,! tube 7,a7 is introduc$ ?r\gh ! m\?1 !n ! po/ 7,b7 is screw$ 9 ?r\gh ! tra*eal w\nd4 ,!n ! block 7,c7 is slid into ! w\nd1 ! squ>e hole 9 ! block gu>d+ ! po/ aga9/ all possibility ( unscrew+4 ,if ! ?reads ( ! po/ are prop]ly fitt$ & tightly screw$ up ) a hemo/at1 h[ev]1 !re is no *ance ( unscrew+ & gauze pack+ is us$ in/ead ( ! block to ma9ta9 a l>ge fi/ula4 ,! %ape ( ! intubation tube has be5 arriv$ at aft] long cl9ical /udy & trials1 & _c be alt]$ )\t risk ( fall+ into errors t h be5 made & elim9at$ 9 ! developm5t ( ?is %ape4 #cji ,,*apt] ,,xxxix--,,decannulation ,,aft] ,,cure ,,( ,,l>yngeal ,,/5osis ,9 ord] to tra9 ! pati5t to brea! aga9 ?r\gh ! l>ynx x is necess>y to occlude ! cannula4 ,?is is be/ done by ins]t+ a rubb] cork 9 ! inn] cannula4 ,at fir/ x may be necess>y to make a slot 9 ! cork s z to p]mit "s air to ent] ?r\gh ! tube to supplem5t ! insuffici5t supply obta9able ?r\gh ! insuffici5tly patul\s glottis1 new corks ) small] grooves be+ sub/itut$ z l>yngeal brea?+ becomes easi]4 ,cork+ ! cannula is an excell5t or?op$ic treatm5t 9 c]ta9 cases :]e muscle atrophy & p>tial inflammatory fixation ( ! crico>yt5oid jo9ts are etiological factors 9 ! /5osis4 ,! add$ pull ( ! po/]ior crico>yt5oid muscles dur+ ! slight ef=t at inspiration re/ores _! tone & increases ! mobility ( all ! atta*$ /ructures4 ,by no o!r me?od c panic & spasmodic /5osis be s effici5tly cur$4 ,,fig4 #aaa4--;,illu/ration ( corks us$ to occlude ! cannula 9 tra9+ pati5ts to brea! ?r\gh ! m\? aga91 be=e decannulation4 ,! corks all[ air leakage1 ! am\nt ( :i* is regulat$ by ! use ( diff]5t %apes4 ,a small] & /ill small] air leak is p]mitt$ until f9ally an ungroov$ cork is tol]at$4 ,a c5tral hole is sometimes us$ in/ead ( a slot4 ,a1 "o-?ird cork2 ,b1 half cork2 ,c1 ?ree-qu>t] cork2 ,d1 :ole cork4 ,foll[+ ! subsid5ce ( an acute l>yngeal /5osis1 x is my rule to decannulate aft] ! pati5t has be5 able to brea! ?r\gh ! l>ynx ) ! cannula tightly cork$ = #c days & nights4 ,?is rule does n apply to *ronic l>yngeal /5osis1 = :ile ! lum5 "u ord9>y conditions might be ample1 a slight degree ( inflammation might r5d] x dang]\sly small4 ,9 ^! cases1 _m weeks are sometimes requir$ to det]m9e :5 decannulation is safe4 ,a te/ p]iod ( a few mon?s is advisable 9 mo/ cases ( *ronic l>yngeal /5osis4 ,recurr5t contractions aft] closure ( ! w\nd are be/ treat$ by endoscopic b\g9age4 ,! corks are be/ made ( pure rubb] cord1 cut & gr\nd to %ape1 & groov$1 if desir$1 on a small em]y :eel 7,fig4 #aab74 ,! ord9>y rubb] corks & ^? made ( cork-b>k %\ld n be us$ because ( _! friability1 & ! possible aspiration ( a fragm5t into ! bron*us1 :]e rubb] p>ticles =m v irritant =eign bodies4 ,,fig4 #aab4--,?is illu/ration %[s ! me?od ( mak+ safe corks = tra*eotomic cannulae by gr9d+ pure rubb] cord to %ape on an em]y :eel4 ,aft] gr9d+ ! tap]1 if a p>tial cork is desir$1 a groove is gr\nd on ! angle ( ! :eel4 ,if a half-cork is desir$ half ( ! cork is gr\nd away on ! side ( ! :eel4 ,reliable corks made 9 ?is way are n[ obta9able f ,mess]s ,*>les ,j4 ,pill+ & ,son4 ,,bibliography ,! foll[+ li/ ( publications ( ! au?or may be useful = ref]5ce3 #a4 ,p]oral ,endoscopy & ,l>yngeal ,surg]y1 ,textbook1 #aiad4 7,conta9s full bibliography to date ( publication47 #b4 ,acromegaly ( ! ,l>ynx4 ,j\rn4 ,am]4 ,m$4 ,asso41 ,nov4 #cj1 #aiah1 ,vol4 ,,lxxi1 pp4 #aghg-aghi4 #c4 ,a ,f5ce ,/aple 9 ! ,lung4 ,a ,new ,me?od ( ,bron*oscopic ,removal4 ,j\rn4 ,am]4 ,m$4 ,asso41 ,vol4 ,,lxiv1 ,june #e1 #aiag1 pp4 #aijf-g4 #d4 ,amalgam ,too?-fill+ ,aspirat$ into ,lung ,dur+ ,extraction4 ,d5tal ,cosmos1 ,vol4 ,,lix1 ,may1 #aiag1 pp4 #ejj-ejb4 #e4 ,amalgam ,fill+ ,remov$ f ,lung aft] a ,sev5 ,mon?s' ,soj\rn3 ,case ,report4 ,d5tal ,cosmos1 ,april1 #aibj4 #f4 ,a ,me*anical ,spoon = ,esophagoscopic ,use4 ,! ,l>yngoscope1 ,janu>y1 #aiah1 ,,pp4 #dg-dh4 #g4 ,an ,ant]ior ,commissure ,l>yngoscope4 ,! ,l>yngoscope1 ,vol4 ,,xxv1 ,aug41 #aiae1 ,p4 #ehi4 #h4 ,anci5t ,=eign ,body ,cases4 ,editorial4 ,! ,l>yngoscope1 ,vol4 ,,xxvii1 ,july1 #aiag1 ,,pp4 #ehc-ehd4 #i4 ,an ,esophagoscopic ,=ceps4 ,! ,l>yngoscope1 ,jan41 #aiah1 p4 #di4 #aj4 ,a ,new ,diagno/ic ,sign ( ,=eign ,body 9 ,tra*ea or ,bron*i1 ! ,a/hmatoid ,:eeze4 ,am]4 ,j\rn4 ,m$4 ,sci5ces1 ,vol4 ,,clvi1 ,no4 #e1 ,nov41 #aiah1 p4 #fbe4 #aa4 ,a ,new ,me?od ( ,work+ ,out ,difficult ,me*anical ,problems ( ,bron*oscopic ,=eign-body ,extraction4 ,! ,l>yngoscope1 ,vol4 ,,xxvii1 ,oct41 #aiag1 p4 #gbe4 #ab4 ,ara*idic ,bron*itis4 ,j\rn4 ,am]4 ,m$4 ,asso41 ,aug4 #cj1 #aiai1 ,vol4 ,,lxxiii1 pp4 #fgb-fgg4 #ac4 ,b& ( a ,gold ,cr[n 9 ! ,bron*us3 ,report ( a ,case4 ,d5tal ,cosmos4 ,vol4 ,,lx1 ,oct41 #aiah1 p4 #ije4 #ad4 ,bron*iectasis & ,bron*iectatic ,symptoms ,due to ,=eign ,bodies4 ,p5n4 ,m$4 ,j\rn41 ,vol4 ,,xix1 ,aug41 #aiaf1 pp4 #hjg-had4 #ae4 ,bron*oscopic & ,esophagoscopic ,po/ulates4 ,annals ( ,otology1 ,rh9ology & ,l>yngology1 ,june1 #aiaf1 pp4 #dad-daf4 #af4 ,bron*oscopic ,removal ( a ,coll> ,button aft] ,tw5ty-six ,ye>s ,soj\rn 9 ! ,lung4 ,annals ( ,otology1 ,rh9ology & ,l>yngology1 ,june1 #aiac4 #ag4 ,bron*oscopy4 ,ke5's ,surg]y1 #aiba1 ,vol4 ,,viii4 #ah4 ,caisson ,bron*oscopy 9 ,lung-abscess ,due to ,=eign ,body4 ,surg41 ,gyn4 & ,ob/et41 ,oct41 #aiag1 pp4 #dbd-dbh4 #ai4 ,canc] ( ! ,l>ynx4 ,is x ,prec$$ by a ,recognizable ,precanc]\s ,condition8 ,proce$+s ,am]4 ,l>yngol4 ,soc41 #aibb4 #bj4 ,d94 ,editorial4 ,! ,l>yngoscope1 ,vol4 ,,xxvi1 ,dec41 #aiaf1 pp4 #ache-achg4 #bc4 ,endoscopie ,p]orale et ,*irurgie ,l>yngi5ne4 ,ar*4 de ,l>yngol41 ,t4 ,,xxxvii1 ,no4 #c1 #aiad1 pp4 #fdi-fhj4 #bd4 ,endoscopy & ! ,w>4 ,editorial4 ,! ,l>yngoscope1 ,vol4 ,,xxvi1 ,june1 #aiaf1 p4 #iib4 #be4 ,endo!lioma ( ! ,"r ,bron*us ,remov$ by ,p]oral ,bron*oscopy4 ,am]4 ,j\rn4 ( ,m$4 ,sci41 ,no4 #c1 ,vol4 ,,clii1 ,m>*1 #aiag1 p4 #cga4 #bf4 ,esophageal ,/5osis ,foll[+ ! ,swall[+ ( ,cau/ic ,alkalies1 ,j\rn4 ,am]4 ,m$4 ,asso41 ,july #b1 #aiba1 ,vol4 ,,lxxvii1 pp4 #bb-bc4 #bg4 ,esophagoscopic ,radium ,scre5s4 ,! ,l>yngoscope1 ,feb41 #aiad4 #bh4 ,=eign ,bodies 9 ! ,insane4 ,editorial4 ,! ,l>yngoscope1 ,vol4 ,,xxvii1 ,june1 #aiag1 pp4 #eac-eae4 #bi4 ,=eign ,bodies 9 ! ,l>ynx1 ,tra*ea1 ,bron*i & ,esophagus ,etiologically ,consid]$4 ,trans4 ,sec4 ,l>yn41 ,otol4 & ,rh941 ,am]4 ,m$4 ,asso41 #aiag1 pp4 #cf-ef4 #cj4 ,gold ,?ree-too? ,mol> ,bridge ,removal f ! ,"r ,bron*us3 ,case ,report4 ,d5tal ,cosmos1 ,oct41 #aiai4 #ca4 ,high ,tra*eotomy & ,o!r ,errors ! ,*ief ,causes ( ,*ronic ,l>yngeal ,/5osis4 ,surg41 ,gyn4 & ,ob/et41 ,may1 #aiba1 pp4 #cib-cih4 #cb4 ,induc+ a ,*ild to ,op5 ,its ,m\?4 ,editorial4 ,! ,l>yngoscope1 ,vol4 ,,xxvi1 ,nov41 #aiag1 p4 #gie4 #cc4 ,inte/9al ,=eign ,bodies4 ,editorial4 ,! ,l>yngoscope1 ,vol4 ,,xxvi1 ,may1 #aiaf1 p4 #ibi4 #cd4 ,l>yngoscopic1 ,esophagoscopic & ,bron*oscopic ,cl9ic4 ,int]national ,cl9ics1 ,vol4 ,,iv1 #aiah4 ,j4 ,b4 ,lipp9cott ,co4 #ce4 ,local ,application ( ,radium ,supplem5t$ by ,ro5tg5 ,!rapy 7,discussion74 ,am]4 ,j\rn4 ( ,ro5tg5ology4 #cf4 ,localization ( ! ,lobes ( ! ,lungs by ,means ( ,transp>5t ,outl9e ,films4 ,am]4 ,j\rn4 ,ro5t41 ,vol4 ,v1 ,oct41 #aiah1 p4 #def4 ,also ,proc4 ,am]4 ,l>yn41 ,rh94 & ,otol4 ,soc41 #aiah4 #cg4 ,me*anical ,problems ( ,bron*oscopic & ,esophagoscopic ,=eign ,body ,extraction1 ,j\rn4 ,am4 ,m$4 ,assn41 ,jan4 #bg1 #aiag4 #ch4 ,obs]vation on ! ,pa?ology ( ,=eign ,bodies 9 ! ,air & ,food ,passages ,bas$ on ! ,analysis ( #fbh ,cases4 ,mutt] ,lecture1 #aiag1 ,surg4 ,gyn4 & ,ob/et41 ,m>41 #aiai1 pp4 #bja-bfa4 #ci4 ,or?op$ic ,treatm5t by ,cork+4 ,j\rn4 ( ,l>yn4 & ,otol41 ,london1 ,vol4 ,,xxxii1 ,feb41 #aiag4 #dj4 ,p]oral ,endoscopy4 ,j\rn4 ( ,l>yn4 & ,otol41 ,ed9burgh1 ,nov41 #aiba4 #da4 ,p]oral ,endoscopy & ,l>yngeal ,surg]y4 ,! ,l>yngoscope1 ,feb41 #aiai4 #db4 ,po/ulates on ! ,c\gh ,reflex 9 ,"s ( its ,m$ical & ,surgical ,phases4 ,!rapeutic ,gazette1 ,sept4 #ae1 #aibj4 #dc4 ,prognosis ( ,=eign ,body 9 ! ,lung4 ,j\rn41 ,am]4 ,m$4 ,asso41 ,oct4 #h1 #aiba1 ,vol4 ,,lxxvii1 pp4 #aagh-aaha4 #dd4 ,pulsion ,div]ticulum ( ! ,esophagus4 ,surg41 ,gyn4 & ,ob/et41 ,vol4 ,,xxi1 ,july1 #aiae1 ,,pp4 #eb-ee4 #de4 ,radium4 ,editorial4 ,! ,l>yngoscope1 ,vol4 ,,xxvi1 ,aug41 #aiaf1 pp4 #aaaa-aaac4 #df4 ,reaction aft] ,bron*oscopy4 ,p5n4 ,m$4 ,j\rn41 ,april1 #aiai4 ,vol4 ,,xxii ,p4 #dcd4 #dg4 ,root-canal ,broa* ,remov$ f ! ,lung by ,bron*oscopy4 ,! ,d5tal ,cosmos1 ,vol4 ,,lvii1 ,m>*1 #aiae1 p4 #bdg4 #dh4 ,safety ,p9s 9 ,/oma*1 ,p]oral ,ga/roscopic ,removal )\t ,ane/hesia4 ,j\rn4 ,am]4 ,m$4 ,asso41 ,feb4 #bf1 #aiba1 ,vol4 ,,lxxvi1 pp4 #egg-egi4 #di4 ,symptomatology & ,diagnosis ( ,=eign ,bodies 9 ! ,air & ,food ,passages4 ,am4 ,j\rn4 ,m$4 ,sci41 ,may1 #aiba1 ,vol4 ,,clxi1 ,no4 #e1 p4 #fbe4 #ej4 ,! ,bron*ial ,tree1 ,its ,/udy by ,insufllation ( ,opaque ,sub/ances 9 ! ,liv+4 ,am]4 ,j\rn4 ,ro5tg5ology1 ,vol4 #e1 ,oct41 #aiah1 p4 #ded4 ,also ,proc4 ,am]4 ,l>yn41 ,rh9ol4 & ,otol4 ,soc41 #aiah4 #ea4 ,?ymic ,dea?4 ,editorial4 ,! ,l>yngoscope1 ,vol4 ,,xxvi1 ,may1 #aiaf1 p4 #ibi4 #eb4 ,tra*eobron*itis ,due to ,nitric ,acid ,fumes4 ,new ,york ,m$4 ,j\rn41 ,nov4 #d1 #aiaf1 ,,pp4 #hih-hii4 #ec4 ,treatm5t ( ,l>yngeal ,/5osis by ,cork+ ! ,tra*eotomic ,cannula1 ,! ,l>yngoscope1 ,jan41 #aiai4 #ed4 ,v5triculocordectomy4 ,proce$+s ,am]4 ,l>yngol4 ,soc41 #aiba4 #ee4 ,new ,me*anical ,problems 9 ! ,bron*oscopic ,extraction ( ,=eign ,bodies f ! ,lungs & ,esophagus4 ,annals ( ,surg]y1 ,jan41 #aibb4 #ef4 ,! ,diaphragmatic ,p9*cock 9 ,s-call$ ,c>diospasm4 ,l>yngoscope1 ,jan41 #aibb4