Vomiting, sialorrhea, and at times glottic edema and dyspnea. White corrosive

crusts and burned areas are to be found in the mouth and the surrounding area.

Shock becomes progressive with falling blood pressure and rising pulse, cyanosis

and pallor, cold sweats, and circulatory collapse. Later, perhaps in 24 to 48 h,

there are increasing signs of intoxication such as renal damage, hematuria,

evidence of liver damage, hemolysis, disturbance of electrolyte and water

metabolism, and occasionally involvement of the central nervous system (CNS).

There is increasing risk of perforation or mediastinitis, pleuritis,

peritonitis, and tracheoesophageal fistula. Rapid wasting occurs. If the patient

survives, dysphagia gradually sets in due to stricture formation.

Pathogenesis. The coagulation necrosis due to acids and colliquative necrosis

due to lyes penetrates to varying depths. The corrosive scars in the mouth and

pharynx may he minimal because of rapid passage, with severe degrees extending

into the esophagus and possibly the stomach and intestine. The esophagus is more

severely afflicted than the stomach in lye burns because of reflex cardiospasm.

In acid burns the stomach is more severely affected.

The time course is as follows: (1) primary local necrosis in the mouth, pharynx,

esophagus, stomach, and intestine; (2) generalized intoxication; (3) acute,

subacute, and chronic corrosive esophagitis; (4) healing of the esophagitis with

scarring or stricture; (5) late complications such as late or restenosis and

possibly malignant degeneration. The scar tissue stenosis begins about the 3rd

week.

Diagnosis. It is made from the typical history of an accident or suicide and the

typical local findings. The corrosive substance must be identified. Radiographs

are taken of the thorax and abdomen. If the corrosive burns appear to be mild,

contrast views of the esophagus are taken and a careful esophagoscopy may be

done to allow the esophagus and stomach to be examined and a feeding tube to be

Introduced. Contraindications include shock and suspected perforation. Immediate

esophagoscopy is only carried out if the degree and extent of the corrosive burn

are not clear.

Treatment. If possible, large quantities of fluids such as milk, oil, etc.

should be drunk. The juice of citrus fruits or dilute 2% vinegar are given for

lye burns; magnesium oxide and antacids are given for acid burns but must be

given within 2 h. Analgesics and sedatives are given, and the patient is

admitted to an intensive care unit for intravenous management of shock,

administration of fluids, parenteral feeding, broad-spectrum antibiotics, and if

necessary gastrostomy and tracheotomy. High-dose steroids are given

intravenously.

The first careful esophagoscopy is carried out after 6 to 8 days. Dilatation can

begin at the end of the 2nd week if the radiographs and endoscopy show the

formation of a stricture. Follow-up esophagoscopies are carried out at intervals

of 10 days until mucosal defects are epithelialized. The patient is then checked

by radiography and esophagoscopy after 1, 3, 6, and 12 months.

Technique of bouginage. Two methods are available:

Early bouginage about 8 to 12 days after the burn using a thick bougie of about

14 mm in adults, 6,5 mm in children, and 10 mm in adolescents, increasing daily

in caliber until the patient can swallow without difficulty. The intervals are

then prolonged until the stenoses can no longer be demonstrated by radiography.

Late bouginage. This may only occur several weeks later.

Bouginage may take several weeks. The goal of treatment by bouginage in adults

is to achieve an esophageal lumen of about 15 mm diameter, about 10 to 12 mm in

children up to 10 years, and 10 to 14 mm in adolescents.

Dangers of bouginage include perforation of the esophageal wall. This does not

occur using the bouginage over a thread. Perforations tend to occur particularly

in the area of the necrotic stricture, in blind pouches, etc. and cause

mediastinitis, pleuritis, or peritonitis which must be drained externally.

If treatment by bouginage is unsatisfactory, operative treatment of the

stricture, partial esophageal resection and replacement by a segment of stomach

or bowel, must be considered. Because of the tendency to restenosis and to

malignant degeneration in old age, patients with esophageal strictures must be

kept under medical supervision by radiography and endosoopy at increasing

intervals.

FOREIGN BODIES IN THE EARS

Foreign bodies, both animate and inanimate, may be found in the ear. The latter

are much more frequently found, and especially so in children, and are often

introduced by the patients themselves. Inanimate objects may be divided into

those which swell with moisture, such as peas and beans, and those which do not

swell, such as beads, buttons or shells. Foreign bodies rarely cause any trouble

unless the tympanic membrane has been injured, and they may remain undetected

for years. Most complications result from ill-directed attempts at removal.

Gentle inspection will reveal the object in most cases. If it is not seen the

ear may be gently syringed, because a very small foreign body may lie out of

sight in the meatal floor, beyond the isthmus and close to the drum. When the

foreign body is seen and determined not to be of vegetable composition, removal

may be effected by syringing. The stream should be directed along that part of

the meatal wall where there is the widest space between it and the foreign body.

While the removal of a foreign body may be easily accomplished when it has not

been driven in by ill-directed interference, great difficulties may be presented

in cases of impaction, or when the object has become swollen from absorption of

fluid, or if the meatal walls have become inflamed. Such cases are best treated

in hospital. In cases of impaction it is sometimes possible to withdraw the

object by means of a fine hook. The use of forceps is inadvisable except in the

case of small or thin objects, because the jaws of the forceps often cause the

foreign body to slide further into the meatus. Some objects may be removed by

suction, a suitable catheter being used.

Attempts at removal of foreign bodies in children should not be prolonged,

because of the pain produced and the fright engendered. In such cases, and in

all cases when the object lies beyond the isthmus, it is wiser to remove it

under a general anaesthetic, often with the use of the operating microscope.

If the walls of the meatus are swollen and bleeding, it is advisable, before

operating, to insert a strip of 12 mm ribbon gauze soaked in a adrenaline

hydrochloride. Should a diffuse inflammation of the meatus have been set up by

attempts at removal, it may be best to treat the inflammation before attempting

removal. In rare instances repeated attempts at removal may have driven the

object into the middle ear, and an external operation will be required for its

extraction.

Animate foreign bodies in the external meatus are not rarely. Maggots cause

intense pain, and their presence is most likely in an ear where discharge is

already present, and which has become very offensive and bloodstained. It is

useless to attempt to syringe them out as they are firmly attached to the meatal

walls. Chloroform water or vapour must be applied to the external meatus in

order to anaesthetize or kill the maggots and so release their grip on the skin.

Thereafter they may be removed by syringing.

FOREIGN BODIES IN THE NOSE

Children, especially young children aged 2 or 3 years, frequently push foreign

bodies into the nose. Such objects may be classified as organic and inorganic.

Inorganic foreign bodies include metal objects, buttons, beads, plastic objects,

etc. These may lie undetected for many weeks, giving rise to no symptoms and

occasionally are found accidentally during routine examination. Organic foreign

bodies, such as wood, paper, cotton wool or foam rubber, produce a local

inflammatory reaction which may proceed to the formation of granulation tissue.

There is a nasal discharge from the affected side, and this quickly becomes

purulent and foul-smelling, and may be bloodstained. The object may swell with

the absorption of moisture from the mucus, but pain is seldom complained of.

In the early stage the object is situated just within the nostril and is easily

seen. In time it moves further into the nasal cavity - possibly due to the

child's habit of sniffing or possibly because it is pushed further in - and it

becomes encased with mucus, or mucopus if the object is organic in origin. In

this event it may not be seen because of the mucopus or the inflammatory

swelling of the mucous membrane.

Removal of the foreign body may be easy if it lies in the nostril. It may be

flicked out with a probe, or by getting the child to smell pepper and on closing

the opposite nostril it may be sneezed out. When the object reaches the nasal

cavity and becomes covered with secretions it becomes slippery and not easy to

grasp. A child may sit through one attempt at removal but if this fails, and

especially if the attempt produces bleeding, he is not likely to endure a

second. Accordingly it is wiser to give the child an anaesthetic for the removal

if one attempt has been made or if the object is situated far back at the

initial inspection. The anaesthetic need only be a short one for removal is

usually easily accomplished either with cupped forceps or with a metal probe,

the distal 5 mm of which have been bent to a right angle. The probe is passed,

point downwards, above the object which is pressed to the floor of the nose and

then raked out. The probe may fail with such a narrow object as a shirt button

because it slips, or with foam rubber which has become adherent to the mucosa.

In these cases the use of cup-shaped forceps is preferable. Very occasionally

the foreign body may be of such an irregular shape that it cannot be brought out

through the anterior naris, and it may have to be pushed gently into the

nasopharynx and recovered from there. The surgeon must be alive to the

possibility that there is a second foreign body present, either in the same side

or in the opposite one, and after removal of the object the nose must be

examined for this.

RHINOLITHS

Rhinoliths are calcareous masses which are occasionally found in the nose. They

may be found in one side only or they may be bilateral. The deposit of salts,

chiefly calcium and magnesium carbonates and phosphates, takes place around a

nucleus which may be organic or inorganic, and the nucleus may be a foreign body

or merely dried secretions of blood and mucus. Their presence must be considered