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VOL. 47, No. 2 March, 1955 101 Bronchoscopy and Esophagoscopy in a Small Hospital* MARCUS W. MOORE, M.D. Baltimore, Maryland BRONCHOSCOPY and esophagoscopy are local irritation with routine studies, should be relatively new devolpments which render investigated by bronchoscopy. Pathology may be extensive aid in the diagnosis and therapy of pul- uncovered in the bronchial tree which has been monary and esophageal diseases.' The instruments unsuspected. Hemoptysis may occur in bronchiec- used have opened a new field in medical science tasis, tumor formation, lung abscess,15 bronchitis, for future exploration and development. asthmatics, and aspirations of foreign bodies. It The accurate localization of disease of seg- is important to perform bronchoscopy to rule out mental bronchial orifices and sections of the the more serious lesions. esophagus can be made via the bronchoscope2, 3, 4 Esophagoscopy5 is indicated in all cases of and the esophagoscope. esophageal obstruction. Difficulty in swallowing Schwartz5 states that bronchial and esophageal solid food, regurgitation of saliva, water and food endoscopy has become one of the most important are common symptoms of obstruction. Esophago- procedures used now for the examination and scopy is indicated in cases where x-ray examina- treatment of certain chest conditions. One may tion is inconclusive and in cases where a positive improve the drainage of the bronchial tree with microscopic diagnosis is desired. Esophagoscopy the use of a bronchoscope. With this instrument, is often indicated for diagnosis and treatment in a new understanding of the bronchial obstructive benign inflammatory strictures, lye strictures, webs, mechanism has been obtained. Treatment by direct and achalasia. In cases of suspected foreign body application of medicines can be made accurately in the esophagus, esophagoscopy is definitely in- with the bronchoscope and with the esophagoscope. dicated. Bleeding from the esophagus manifested Tucker6 states that the endobronchial approach by hematemesis or melena may be coming from to the study and treatment of bronchial diseases esophagitis, hiatus hernia, esophageal ulcer, by means of the bronchoscope is of the utmost im- varices,16 benign or malignant tumor or foreign portance in the understanding, prevention and body. Esophagoscopy is indicated in these types cure of these diseases. The use of the bronchoscope of cases where x-ray examination is negative, but is indicated in a number of conditions and many where symptoms referable to the esophagus per- combinations of symptoms.7 8 The presence of a sist. When x-ray examination shows only spasm tracheal or bronchial wheeze constitutes one of the of the esophagus, there may be some serious most important indications for bronchoscopy. underlying disease which can be demonstrated by Wheezing may be caused by incomplete obstruction esophagoscopy. to the bronchus, by benign tumor of the bronchus, Color motion pictures of a bronchoscopic pro- polypoid malignant bronchial tumors,9' 10, 11 or cedure were shown. The motion pictures were even by excessive secretions seen in bronchitis or made at Provident Hospital operating room bronchiectasis.12 under the direction of the author of this paper. Stenotic proliferative, or ulcerative tuberculous'3 The techniques of local anesthesia, positioning of lesions may also cause a wheeze. Bronchial ob- the patient, and the passing of the bronchoscope struction, which may be complete or incomplete, were demonstrated. is a very important indication for bronchoscopy.14 As stated by Pembleton and Vinson,17 the Bronchoscopy is necessary to determine the nature majority of peroral endoscopic examinations can and extent of the obstruction. Cough which is be made with local anesthesia or without anes- persistent and not determined to be caused by a thesia. The patient does not experience a great deal of discomfort and satisfactory operative re- Read before the Ear, Nose and Tlhroat Section at the Fifty- sults can be obtained. The technique of bron- Ninth Annual Convention of the National Medical Asso- ciation, Washington, D. C., August 12, 1954. choscopy used in this series was similar to that 102 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION MARCH, 1955 used in other clinics.18 1`1 The patient lies in the were 63 single bronchoscopies and 16 patients recumbent position with the head held in the had two or more examinations. One case of mul- hands of a trained assistant. The head must be tiple lung abscesses received a total of nine thera- held forward with extension at the occipito-atloid peutic bronchoscopies over a period of 14 months joint. With the aid of the larnygoscope, the epi- with excellent results. There were 17 single glottis is exposed, the tip of it is lifted, the larynx esophagoscopies, and one patient had two pro- brought into view, and the arytenoids and vocal cedures performed. Of the bronchoscopies, 58 cords are examined as to size, shape and mobility. were diagnostic and 56 were operative. There The bronchoscope is next introduced through the were 8 procedures performed with biopsy. Thir- laryngoscope, which is then removed, leaving the teen of the bronchoscopies were therapeutic for bronchoscope in place. The patient's head is atelectasis and 34 for toilet procedure. One bron- lowered, and the inspection of the tracheobron- choscopy was done for removal of foreign bodies. chial tree is inspected. In the usual examination, Fifteen of the esophagoscopies were diagnostic a 7mm-40cm bronchoscope is used, for this per- and four were operative. There were two pro- mits adequate visualization and instrumentation. cedures performed with biopsy. Two esophago- In performing esophagoscopy, the patient lies scopies were performed for removal of foreign recumbent with head extended. The distal half bodies. of the esophagoscope is well lubricated with min- In many of the patients analyzed, bronchoscopy eral oil. The scope is inserted in an almost ver- and esophagoscopy revealed no positive findings. tical direction posterior to the base of the tongue. The absence of lesions in many cases was of im- The instrument is introduced slightly forward portant significance in obtaining a final diagnosis.* under direct vision toward the right piriform * When this paper was read, color motion pictutres sinus, thence downward in the midline to the were shown of cases in which bronchoscopy or cso- cricopharyngeus. The scope should pass th-ie crico- phagoscopy had been performed. The cases were: pharyngeus readily and into the esophagus. CASE 1: MULTIPLE LUNG ABSCESSES We wish to present a preliminary analysis of A 47-year-old male admitted in critical condition. 133 procedures done in a small hospital over a Extensive clearing and healing was obtained with re- period of 30 months. The procedures were per- peated therapeutic bronchoscopy. formed at Provident Hospital, Baltimore, Mary- CASE II: POSTOPERATIVE ATELECTASIS land, during the period from January, 1952 to June, 1954. This is a small hospital of 130 bed A 30-year-old female who developed massive post- operative atelectasis following pelvic surgery. Immediate capacity, which had total admissions of 12,883 therapeutic bronchoscopy achieved excellent results, Figs. patients in the 30 month period. The sources of 1 and 2. the cases were from the surgical, medical and CASE III: ANEURYSM OF ASCENDING AORTA pediatric services, the out-patient department, pri- A 44-year-old male with a large superior mediastinal vate practitioners, and the Baltimore City Public mass. Diagnostic bronchoscopy and esophagoscopy were Health Service, Bureau of Tuberculosis. performed. There was a total of 133 procedures performed CASE IV: CARCINOMA OF THE LUNG on 97 patients. Of the 97 cases, 77 were male A 62-year-old male in which bronchoscopic washings patients and 20 were females. The age groups contained carcinoma cells and a definite diagnosis was ranged from eight months to 71 years of age. established. There were three patients between one month CASE V: CARCINOMA OF THE LUNG and ten years of age; two between 10 and 20 A 65-year-old male in which bronchoscopy with bi- years of age; two between 20 and 30 years of age; opsy of a tumor in the left main stem bronchus proved 12 between 30 and 40 years of age; 20 between to be carcinoma. 40 and 50 years of age; 28 between 50 and 60 CASE VI: FOREIGN BODY IN THE ESOPHAGUS years of age; 29 between 60 and 70 years of age and one patient over 70 years of age. A 5-year-old female with an embedded foreign body (coin) in the esophagus for over thre. months. The There were 80 single procedures performed coin was successfully removed by therapeutic esophago- and 17 cases had multiple examinations. There scopy, Fig. 3. VOL. 47, No. 2 Brol7choscopy and Esophagoscopy in a Smnall Hospital 103 *d~~~~~~~~~~~~~~~~~~~~~~~. . .... Fl I Po toperative atelectasis right lower lobe of Fig. 2 X-ray immediately following therapeutic bron- the lung. choscopy. CASE VII: FOREIGN BODY CAUSING ASPHYXIA CASE X: BRONCHIECTASIS O: LEFT LOWER LOBE An eight-month-old infant had swallowed a large iron A 25-year-old female with severe saccular bronchi- ball bearing, developed marked cyanotic. Immediate ectasis of the left lower lobe of the lung. Therapeutic tratclheotomy was performed, miraculously saving the bronchoscopies were performed, Fig. 4. infant's life. The ball bearing which fitted the hypo- pharynx as if in an encased socket, was removed with CASE XI: BRONCHIECTASIS WITH tremendous difficulty. BRONCHO-PLEURAL FISTULA A 47-year-old male admitted critically ill with bron- CASE VIII: ANEURYSM OF THE INNOMINATE ARTERY chiectasis and broncho-pleural fistula with severe pneu- A 48-year-old male with a tumor in the right upper monitis. Patient responded well with multiple therapeutic thorax and superior mediastiuLm. Diagnostic bronchoscopy bronchoscopies. and esophagoscopy were performed. CASE XII: INFECTED LUNG CYST A 42-year-old male complaining of repeated attacks CASE IX: THYROGLOSSAL DUCT CYST of pneumonitis, chronic coughing, hemoptysis and pains A 32-year-old male with anterior neck tumor. Diag- in the chest. Routine diagnostic studies revealed an nostic bronchoscopy and esophagoscopy were performed. infected lung cyst in the right lower lobe. Fig. 3-Foreign body (coin) embedded in the esophagus for over three months Fig. 4 Bronchogram demonstrating saccular bron- whilch was removed by esophagoscopy. chiectasis of the left lower lobe. 104 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION MARCH, 1955 SUMMARY 9. BETTS, R. H. Carcinoma of the Lungs-Broncho- scopic Aspects, New England Journal of Medicine, Bronchoscopy and esophagoscopy are important 225: 519 (October), 1941. procedures used for the examination and treat- 10. BROYLES, E. N. Bronchoscopic Experiences with ment of certain chest diseases. The indications Tumors of the Lower Respiratory Tract, Annals of for bronchoscopy and esophagoscopy are described. Otology, Rhinology, and Laryngology, 57: 129 A preliminary analysis is made of one hundred (March), 1948. 11. HOCHBERG, L. A. and A. MACKLES. The Early and thirty-three procedures in a small hospital. Diagnosis of Bronchogenic Carcinoma, Clinical Sym- posia, 2: 103-126, (April), 1950. LITERATURE CITED 12. CLERF, L. H. Bronchoscopy in Bronchiectasis, Dis- eases of the Chest, 9: 56-62, 1943. 1. JACKSON and JACKSON. Bronchoscopy, Esophago- 13. BELL, F. G. and B. SCHAFF. Bronchoscopy-Its scopy, and Gastroscopy; A Manual of Peroral En- Role in the Diagnosis and Treatment of Pulmonary doscopy and Laryngeal Surgery, Third Edition, W. Tuberculosis, Journal of The Missouri State Medi- B. Saunders, Philadelphia, 1934. cal Association, 42: 549 (September), 1945. 2. HOLLINGER, P. H. Recent Advances in Broncho- 14. LELL, W. A. Bronchoscopy in the Treatment of scopic Technic, Diseases of the Chest, 11: 427-430 Postoperative Pulmonary Atelectasis, Pennsylvania (September-October), 1945. Medical Journal, 44: 1551 (September), 1941. 3. SAMSON, P. C. Bronchoscopy in Relation to Tho- 15. MOERSCH, H. J. and A. M. OLSEN. The Role of racic Surgery, West. J. Surgery, 47: 687-91, 1939. Bronchoscopy in the Treatment of Pulmonary Ab- 4. WOODWARD, F. D. and W. W. WADDELL. Bron- scess, Surgery, 9: 905 (June), 1941. choscopy in the Newborn Infant, Journal of Pedi- 16. SAMSON, P. C. and L. FOREE. Direct Injection of atrics, 23: 79 (July), 1943. Esophageal Varices through the Esophagoscope, 5. SCHWARTZ, V. J. Phases of Bronchoscopy and Western Journal of Surgery, Obstetrics and Gyne- Esophagoscopy of Importance in General Practice, cology, 50: 73 (February), 1942. Minnesota Medicine, 21: 601 (September), 1938. 17. PEMBLETON, W. E. and P. P. VINSON. Anesthesia 6. TUCKER, G. Bronchoscopic Aspects of Bronchiec- in Peroral Endoscopy, Especially General Anesthesia tasis, Archives of Otolaryngology, 34: (November), in Esophagoscopy and Gastroscopy, Archives of 1941. Otololaryngology, 50: 561 (November), 1949. 7. HOLLINGER, P. H. Indications for Bronchoscopy in 18. WESISEL, W. and A. TELLA. Reaction of Tetra- Pulmonary Disease, Journal-Lancet, 65: 235 (July), caine (Pontocaine) Used as Topical Anesthetic in 1945. Bronchoscopy. Study of 1,000 cases, Journal of 8. BENEDICT, E. B. Endoscopy, First Edition, Williams American Medical Association, 147: 218 (Septem- and Wilkins Company, Baltimore, 33-137, 1951. ber 15), 1951. 1954 YEAR OF HIGHEST BIRTH AND LOWEST DEATH RATES The lowest death rate in the history of the country and the largest annual number of births were forecast for 1954 by Dr. Leonard A. Scheele, Surgeon General of the Public Service of the U. S. Department of Health, Education, and Welfare. Dr. Scheele made his statement on the basis of vital statistics reports for the first 10 months of the year. The death rate for the year is expected to close at 9.2 deaths per 1,000 population, a substantial drop from the rates of 9.6 or 9.7 which have prevailed over the past five years. The absence of any reported out- break of influenza in 1954, with consequent low death rates for the chronic cardiovascular diseases, was cited as a principal reason for the decline. Infant and maternal deaths were also expected to hit new lows. Births will top the 4-million mark for the first time, according to preliminary estimates. The expected birth rate of 25.2 per 1,000 population is the second highest in twenty-eight years, and only 5.3 per cent below the peak year of 1947. A continuing rise in the births of third, fourth, and fifth children is probably responsible for the birth increases in 1953 and 1954. No increase in births of first children was expected because of falling marriage rates since 1951. The marriage rate sank to 9.2 per 1,000 population in the first 10 months of 1954, compared with 9.7 for the same period the year before. Low birth rates during the 1930's, resulting in relative scarcity of young people of marriageable age in the present decade, were held chiefly responsible for the marriage decline. Divorces in the first nine months of 1954 were down 4 per cent from the comparable 1953 period, on the basis of reports from twenty-five areas. Since the 1946 peak, divorce rates have dropped over 40 per cent.
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