INJURIES, FOREIGN BODIES of ENT-ORGANS.

BLEEDING from
ENT-ORGANS

Any injury or disease of the larynx is manifested, first of all, by disruption of the
functions in the form of some or other signs and symptoms. As far as traumatic injuries of
the larynx, trachea and oesophagus are concerned, they may be internal and external.
The internal injuries of the larynx and oesophagus include scalds with hot steam and
chemical fluids (alkalis and acids) owing to their careless use or taking with a suicidal
purpose. Alkalis are more dangerous in such cases as they cause deep lesions in tissues.
An affection by alkalis and acids results in a peculiar bum of the mucous membrane,
destruction of its cells and a subsequent development of granulations and cicatrization,
with resultant cicatricial stenoses (most frequently in the oesophagus) requiring a
prolonged conservative bougienage and even surgical treatment.
The larynx may be injured in the process of eating with fish-bones; it causes a
haematoma in the area of the arytenoid cartilages and aryepiglottic folds passing into an
acute inflammation (phlegmonous laryngitis). Similar internal injuries more frequently
involve the oesophagus (foreign bodies) and may lead to perforation of its wall,
development of perioesophagitis and mediastinitis. Such pathological cases are clinically
characterized by inability to swallow food, dysphagia, pains radiating to the back, an
elevated body temperature and other symptoms of mediastinitis (roentgenologically, there is
some air or contents in the mediastinum).
Prevention consists in a careful removal of foreign bodies with help of
oesophagoscopy.
Treatment is performed by an intensive therapy, mediastinitis requires collar
mediastinotomy. These injuries are dealt with by a specialist in otorhinolaryngology.
For a general practitioner, very important are external injuries, that are divided into
open and closed (whether the skin on the neck is injured or not), as well as isolated (when
only one organ is involved) and combined (with involvement of other organs: the
hypopharynx and the larynx, the trachea and the oesophagus, etc.).
According to their origin, injuries of the cervical region are divided into battle, traffic,
industrial, sports and life ones.
At war-time, isolated injuries were less frequent than combined ones. External
traumas of the air tube and oesophagus may be caused by wounds (with fire- and side-
arms) or blunt injuries (contusion of the larynx, fractures of its cartilages, abruption of the
larynx from the trachea or the hyoid, rupture of the trachea), through wounds,
particularly gunshot ones, there is a danger of injuring neurovascular bundles and the
spinal cord, while blunt injuries are fraught with asphyxia.
The signs and symptoms of cervical injuries depend upon their character, an extent of
involvement of adjacent organs and the general state (a faint, a shock, a collapse).
External closed injuries of the larynx and trachea are caused by suicidal and violent
actions (strangulation with a loop, squeezing of the neck with hands, a blow with the edge of
the palm against the larynx, collision with a wire stretched across a road, etc.). As a result,
there may be fractures of the cartilages of the larynx, its abruption from the trachea,
haemorrhages and haematomata into the mucous membrane. A blow against the larynx
causes a laryngeal shock (a loss of consciousness, laryngospasm, a change of the voice), that
was often used at war-time when capturing identification prisoners. Later, the external
injuries also reveal other signs, they are: a haematoma on the neck, cough, a pain on
swallowing (dysphagja), a change of the voice (dysphonia) and phenomena of stenosis.
Laryngoscopy may reveal a haemorrhage into the laryngeal mucosa, hyperemia and a
change in the mobility of the vocal folds. In case of an abruption of the larynx from the
trachea, the most pronounced are phenomena of acute stenosis (inspiratory dyspnoea,
aphonia, a haemorrhage from the mouth and a sharply inflated neck, percussion above it
revealing tympanitis). In this case, it is indicated to perform tracheotomy with haemostasis
and introduction of a tube into the abrupted lower end of the trachea for restoration of the
breathing.
The clinical picture of injuries of the larynx and the trachea is manifested by typical
signs and presence of some wound on the neck (the wounds may differ by their size and
type, e.g. it may be small as in case of a stab with a knife, an awl, etc.). If the injury is
isolated and perforated, there is expectoration of blood from the mouth, a haemorrhage
from the wound, an emphysema of the cervical tissues on the neck, a cough, a hoarse
voice, dysphagia and signs of laryngeal stenosis. In a simultaneous involvement of the
hypopharynx and the oesophagus the above signs are accompanied with a discharge of
some saliva from the neck wound. In this case, injuries of the large vessels are dangerous.
Direct complications of the neck injuries are as follows: a massive blood loss and
asphyxia, with possible subsequent development of aspiration pneumonia, phlegmons of
the neck, mediastinitis and laryngeal chondroperichondritis. Therefore, when giving first
aid to such casualties, the doctor must fix the following aspects in his field of vision:
a) preservation of the life of the patient or casualty (an arrest of the blood loss and
elimination of the asphyxia);
b) measures to combat the shock, restoration of the natural breathing and the vocal
function (a stable elimination of the stenosis);
c) prevention of contamination of the wounds with infections and flowing of the
contents of the larynx and the oesophagus into the respiratory passages;
d) eating at stages of evacuation (in persons with combined injuries of the pharynx and
the larynx, the trachea and the oesophagus).
Qualified aid to such persons is rendered by specialists at relevant hospital formations or
ENT departments of clinical hospitals (tracheostomy, laryngofissure, laryngostomy,
plastic operations, etc.).
Foreign bodies in the larynx, trachea and bronchi are more common in children:
parts of toys, fruit stones (cherries, plums), seeds of berries, sunflower, pumpkin,
water-melon, haricot beans, peas, metal objects (nails, buttons, clips, cartridge-cases
of small-bore rifles, etc). The mechanism of entering is as follows: a deep
aspiration in fright, a habit of keeping these objects in the mouth during games,
pranks, etc. Foreign bodies may stick in the larynx, be wedged between two folds,
but more frequently they enter the trachea and then the bronchi (oftener the right
one as it is the continuation of the trachea). A foreign body may obstruct the
bronchi and cause atelectasis.
Aspiration of a foreign body has the following signs: a sudden hoarseness, a pronounced
cough with cyanosis of the face and vomiting (in young children); sometimes there may be
absolute aphonia, difficult breathing up to asphyxia (a foreign body may absolutely obstruct
the true glottis) which requires an urgent tracheotomy. If a foreign body has entered the
trachea and freely ballot there, the child becomes quiet, but will periodically have fits of
coughing. In this case, absence of any catarhal phenomena on the mucous membranes
(rhinitis, pharyngitis) and the proper anamnesis suggest a presence of a foreign body.
Applying his hand to the patient's neck in the projection of the trachea during a fit of
coughing, the doctor may reveal some flapping of the foreign body against the vocal folds.
Some time later the tracheal mucosa does not respond to the foreign body any more
(exhaustion of the cough reflex) and the cough becomes rare. Presence of the foreign body in
the trachea and later in the bronchus causes an inflammatory process with development of
bronchitis and bronchopneumonia leading to bronchiectases and even pulmonary abscesses.
The diagnosis is made on the basis of the anamnesis, clinical picture, X-ray examination and
auscultation of the lungs. If roentgenoscopy of the lungs reveals Goldknecht-Jackobson sign
(displacement of the mediastinum towards atelectasis), it is an indirect indication of radio-
opaque foreign bodies in the bronchus. The leguminous plants are particularly dangerous, as
being in the trachea and bronchus they (haricot, peas) swell from absorbed moisture and may
absolutely obstruct the trachea and the main bronchus with resultant asphyxia.
Prevention of foreign bodies is as follows: small parts of toys must be fastened, the
children should be weaned from such habits as taking of inedible objects into the mouth,
talking and laughing during meals, particularly when eating seeds (water-melon,
sunflower) and stone-fruits.
Treatment. Foreign bodies are removed with help of direct laryngoscopy (using a
laryngoscope), a Tikhomirov's spatula and proper forceps; from the trachea and bronchi
foreign bodies are removed by the superior bronchoscopy (with a Jackson's, Brunings',
Mezrin's or Fridel's bronchoesophagoscope) performed under the local anaesthesia (2 %
tetracaine hydrochloride, 5 % cocaine, lidocaine) with premedication (diphenylhydramine
hydrochloride, promedol, atropine) or under the general anaesthesia (in children).
Sometimes removal of haricot beans from the trachea and bronchi has to be done with
help of the inferior tracheobronchoscopy (through a tracheostoma).
Foreign bodies in the oesophagus are observed, as a rule, in older persons, because they
have a significantly reduced sensitivity of the oral cavity and particularly the pharynx, also
owing to a lack of teedi and available removable dentures. These pet-sons lose an ability to
determine the size of a food lump, as well as presence of any bones in it for this reason, some
meat obstructions are formed and the oesophagus receives meat bones which stay too long in
its lumen and injure the oesophagus. Fish bones usually stop on their way to the oesophagus
in the palatine or lingual tonsils and the pirifonn sinuses. In children, coins sometimes get to
the oesophagus because of a habit to keep them in the mouth. Usually, foreign bodies stick in
physiological narrowings of the oesophagus (near the entrance to the oesophagus, at the
place of its crossing with the tracheal tree and in the region of the passing of the diaphragm).
The clinical picture is manifested by painful and difficult swallowing, sometimes
vomiting, a sensation of a foreign body (in the pharynx) and, finally, inability to swallow
food and saliva, dull pains in the back and behind the breastbone. The corresponding
anamnesis, X-ray examination and oesophagoscopy make it possible to diagnose the case.
The treatment consists in removal of a foreign body with help of oesophagoscopy under
the local or general anaesthesia. Premedication is as follows: 0.1 % atropine (1.0 ml), 2 %
promedol (2.0 ml), 2 % diphenylhydramine hydrochloride (1.0 ml) 35-40minutes
before the manipulation. Then the mucous membranes of the pharynx and
oesophagus are oiled with 2 % solution of tetracaine hydroehloride, oesophagoscopy is
performed, presence of a bone is determined and the latter is removed with forceps. The
meat obstruction is removed in the same way, and its remainders go down to the
stomach. Any blind removal or pushing of foreign bodies is strictly forbidden, as it may
injure the oesophageal wall with resultant development of oesophagitis and
mediastinitis. Such cases are characterized by more severe pains in the back region,
an elevated body temperature up to 39-40°C, painful swallowing and
hypersalivation. Presence of a perforation sometimes necessitates collar
mediastinotomy, intensive care (antibiotics,
Nasal haemorrhages are not a nosological unit, but only a sign depending upon many
causes which may be divided into general and local ones. The local factors facilitating
development of nasal haemorrhages are represented, first of all, by various injuries (including
surgical ones), tumours (particularly malignant), as well as foreign bodies in the nasal cavity
(among them there may be leeches during bathing in water basins more typical for people
living in hot countries); ulcerous processes of specific character and various genesis,
telangiectasis, atrophic rhinitis. The general causes include: a) all infectious diseases with a
high temperature (influenza, typhus, malaria, hepatitis, leishmaniasis, and many others); b)
vascular pathology (atherosclerosis, hypertensive disease, when elasticity of the vessels is lost
and under an increase of blood pressure they are ruptured); c) haemorrhagic diataesis
(Weilhof’s disease, or thrombopenic puipura, and capillary toxicosis); d) avitaminosis,
particularly lack of vitamin C (scurvy), bioflavonoids (P and PP), vitamin K; e) hepatic
diseases resulting in disturbances of production of proteins participating in the blood
coagulation system (hepatitis, hepatic cinhosis); f) renal diseases, since their insufficient
activity triggers the renin-angiotensin system with renal hypertony, as well as development of
the preuremic and uremic status; g) changes in the atmospheric pressure, physical and mental
overstrain, sun and heat strokes are also important.
The clinical picture is characterized by a sudden appearance of blood with various
intensity from one or both halves of the nose. Sometimes the blood may flow both
forward and backward, to the nasopharynx, thereby causing cough and discharge of
blood clots from the mouth. In such a case this picture may be confused with pulmonary or
gastric haemorrhages, but they have their own peculiarities: in the pulmonary one the
blood is scarlet, foamy and does not form any clots, while blood from the stomach is
brownish (due to formation of hydrochloric hematin) and with a slight sour smell. If a
person has lost much blood, the above picture is accompanied with signs of acute
anaemia: paleness of the skin integuments, sonitus and ringing in the ears, an unsteady
gait, rapid pulse and reduction of the blood pressure down to a faint and collapse.
The first aid consists in an obligatory arrest of the haemorrhage. Outside a medical
establishment (when there are no necessary means at hand), it can be achieved by undoing
the collar and taking off the tie (in order not to compress the cervical veins), an
insignificant unbending of the head backward, an introduction and pressing of a cotton
tampon to the nasal septum. It is necessary to apply some cold to the area of the nose and
the back of the head (occiput), and give the patient 1/2 glass of 10 % solution of sodium
chloride. If the haemorrhage does not stop, medical measures should be taken; they
include local and general methds of arresting.
Since up to 90 % of haemorrhages occur from the anterior portions of the nasal
septum (Kiesselbach's area), sometimes it is enough just to cauterize the bleeding
vessel with 30 % silver nitrate, trichloracetic acid, a galvanocauter, or to employ
cryotherapy. Absence of any effect or a haemorrhage from other portions of the nose
necessitates use of the anterior or even posterior tamponade. Simultaneously, general
methods of arresting haemorrhages are to be used: intravenous administration of 10
% solution of calcium chloride,
transfusion of epsilon-aminocaproic acid, subcutaneous
injection of dicynon (3-4 ml), vicasol, 33 % solution of
sodium citrate (intravenously), blood transfusion and combat
with anaemia (in case of a large loss of blood). If despite all
the measures the haemorrhage is not arrested, surgical
methods should be engaged: if the haemorrhage is from the
external carotid arteries (posteroinferior portions of the
nose), they are ligated on the neck; if the source of the
haemorrhage is located in the anterosuperior portions of the
nasal cavity (supplied by the internal carotid artery), it is
necessary to ligate the ophthalmic carotid artery or destroy
the ethmoidal labyrinth approaching it via the maxillary sinus,
as well as to use embolization of the vessels at vascular
surgery hospital.