BRITISH MEDICAL JOURNAL 8 MARCH 1975 561

sensorineural loss a few hours after the explosion and whenthere are no contraindications related to the other injuries. Inless severe cases it is our practice to prescribe vasodilator drugsand steroids, which appear to improve the recovery, thoughthere is no controlled statistical evidence for this.

Conclusions

Our experience with blast injuries shows that the ear hasexcellent properties of recovery after exposure to blast, witha high rate of spontaneous repair of the tympanic membrane andimprovement of sensorineural deafness. Unfortunately this doesnot happen in every case, and some patients are left with

residual perforations and permanent sensorineural deafness,often accompanied by tinnitus.

All of the E.N.T. surgeons in Belfast have been involved in thenrnagement of blast injuries of the ear, and we wish to express ourgratitude for the generous and co-operative way in which theyhave agreed to our reviewing both their notes and their patients.

ReferencesI Kerr, A. G., and Byrne, J. E. T., Journal of Laryngology, in press.2 Zalewski, T., Zeitschrift fur Ohrenheilkunde, 1906, 52, 109.3 Coles, R. R. A., Proceedings of the Royal Society of Medicine, 1970, 63, 56.4 Kellerhals, B., Hippert, F., and Pfaltz, C. R., Practica Oto-rhino-

laryngologica, 1971, 33, 260.

Clinical Problems

Oesophageal Foreign BodiesA. BARAKA, G. BIKHAZI

British Medical Journal, 1975, 1. 561-563

Summary

Impaction of foreign bodies in the oesophagus wasanalysed in 54 patients, 45 ofwhom were children. Of the45 children 28 were aged 2-4 years. Coins were the mostcommon foreign body in children (27 cases) while inadults a bolus of meat was most common (nine cases).

In 41 children there was no predisposing factor, butan underlying mechanism was detected in 88% of theadults. The mechanisms were of three types: oesophageal(stricture), neuromuscular (myasthenia gravis), andextrinsic and mechanical (ankylosing spondylitis). Inchildren most of the foreign bodies were impacted in theupper oesophagus at the cricopharyngeal junction, whichis the narrowest part of the oesophagus, while in adultsthe foreign body was usually impacted at the site of thepredisposing lesion or in the lower oesophagus.In all patients oesophagoscopy was performed under

general anaesthesia to remove the impacted foreign body.Complications were more frequent in adults, mainlyowing to the underlying condition.

Introduction

Oesophageal foreign body impaction and tracheobronchialinhalation are common in children. Inhalation of foreign bodiescan result in serious complications including death.' Thoughoesophageal foreign body impaction seems less dangerousinadequate management can also result in serious complications.We report here on impaction of oesophageal foreign bodies

in children and adults and analyse the management andcomplications of oesophagoscopy performed in both groups forthe removal of the foreign body.

Department of Anaesthesiology, American University of Beirut,Beirut, Lebanon

A. BARAKA, M.B., M.D., Associate ProfessorG. BIKHAZI, M.D., Resident in Anaesthesiology, (present address:Department of Anaesthesiology, Jackson Memorial Hospital, Miami,Florida)

Patients

Fifty-four patients, 45 children and 9 adults, with impactedoesophageal foreign bodies -were analysed. In 32 patients thediagnosis was confirmed by chest x-ray examination (antero-posterior and lateral) and in 13 by barium meal examina-tion. Twenty-eight of the children were aged 2-4 years (seetable). The type of foreign body varied according to age. Themost common foreign bodies in children were coins, beingpresent in 27 cases (fig. 1). In seven children the impactedobject was seeds, in one it was meat, and miscellaneous objectswere present in the remaining 10. In adults a bolus of meatwas impacted in seven cases (fig. 2) and a chicken rib in two.

Age Distribution of 45 Children and Nine Adults with Oesophageal ForeignBodies

Age (years) <2 2-4 -8 -12 .50 >50No. of patients 7 28 6 4 5 4

1.ffi.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ........

*~~~~~~~~~~~~~~~~~~~..

FIG. 1-Anteroposterior chest x-ray picture of child showing coinimpacted at upper oesophagus opposite 6th cervical vertebra.

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In 41 children no predisposing factor was detected, but eight(88%) adults had an underlying lesion. Of the remainingchildren two had a history of lye ingestion and two a congenitallesion such as hiatus hernia and oesophageal stricture. Three ofthe adults less than 50 years old had oesophageal stricture andhistories of lye ingestion (fig. 3) and one had myasthenia gravis,and of the four over 50 three were edentulous and -one hadkyphoscoliosis (fig. 4).

In children most of the foreign bodies were impacted at theupper oesophagus (35 patients), while in adults the foreignbody was usually impacted at the mid-oesophagus (3) or loweroesophagus (4).

......A...................... ...... ._

FIG. 2-Barium meal film in 45-year-old woman showing foreign body(meat) in lower end of oesophagus. No history of oesophageal obstruction.FIG. 3-Barium meal film in 31-year-old man who ingested caustic sodawhen 11 years showing complete obstruction of mid-oesophagus by foreignbody (meat). Next to obstruction oesophagus is moderately dilated. FIG. 4-X-ray picture of 56-year-old patient with ankylosing spondylitis and historyof repeated episodes of food impaction showing severe deformity in upperthoracic spine due to disease.

Management

As soon as the impaction of an oesophageal foreign body wasdiagnosed oesophagoscopy was performed under generalanaesthesia in all patients.

In children premedication was limited to pentobarbitonesodium (4 mg/kg) and atropine (0 1 mg/year of age). Anaesthesiawas induced via a face mask by oxygen-halothane using amodified T-piece system. In 17 children with foreign bodies atthe upper oesophagus, the face mask was removed and oeso-phagoscopy was performed directly to remove the foreign body.In the rest of the children an orotracheal tube was insertedbefore oesophagoscopy.The adult patients were premedicated with pethidine 75 mg

and atropine 0-6 mg injected intramuscularly 30 minutes beforeoesophagoscopy. Anaesthesia was induced with an intravenousinjection of thiopentone 350 mg and suxamethonium 100 mg.A cuffed non-kinkable orotracheal tube was inserted andanaesthesia maintained by nitrous oxide-oxygen and halothane.The tube was kept on the left side while the oesophagoscopewas introduced from the right. Enough anaesthesia was providedto ensure relaxation and prevent straining during oesophago-scopy.

ComplicationsIn children all foreign bodies were removed by forceps via theoesophagoscope except a marble and two open safety pins whichwere pushed to the stomach. Gastrostomy was done to remove

BinTISH MzDICAL JOURNAL 8 MARcH 1975

one safety pin, while the marble and the other safety pin passedspontaneously through the gastrointestinal tract and wereexcreted via the anal canal (fig. 5).

In adults complications were more common than in children.In one patient with ankylosing spondylitis, tracheal intubationwas difficult. In another with myasthenia gravis generalanaesthesia precipitated a "myasthenic crisis" and the dose ofanticholinesterase medication had to be adjusted and inter-mittent positive pressure ventilation applied for 24 hours. In athird adult oesophagoscopy resulted in perforation of theoesophagus, which was followed by mediastinitis and surgicalemphysema (fig. 6).

FIG. 5-Plain films of chest (a) and abdomen (b) of a 7-year-old child whoswallowed open safety pin showing migration of pin to stomach and in-testines. Pin passed spontaneously from anal canal.

IFIG. 6-Chest x-ray picture of 45-year-old woman. In-gestion of lipiodol after oesophagoscopy showed leakage oflipiodol from the lower end of the oesophagus into the leftpleural space.

Discussion

In this series of patients with oesophageal foreign bodies about83% of the patients were children, which differs from theexperience of other centres where about half the patients wereadults and half children.2

In most of the children there was no predisposing factor. Inadults, however, a predisposing factor usually contributed tothe impaction of foreign bodies in the oesophagus. Such factors

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interfere with normal swallowing, and can be classified accordingto the underlying mechanism into three categories: oesophageallesions (stricture), neuromuscular disturbances (myastheniagravis), and extrinsic mechanical hindrance (ankylosing spondy-litis). In elderly edentulous patients inadequate mastication maybe a sufficient explanation for impaction of an abnormally largebolus of food. Also, wearing artificial dentures, especially thefull upper denture, can obliterate tactile sensation in the roofof the mouth so that bones and other sharp objects are notdetected until they have entered the oropharynx.'

It is not surprising that impacted food is the commonest foreignbody in adults and elderly patients while coins rank first on thelist in children. Children of all ages have the habit of puttingcoins into their mouths and can inadvertently swallow them.

In most children the foreign body is impacted in the upperoesophagus at the level of cricoid cartilage, which is thenarrowest part of the oesophagus. This is followed by the mid-oesophagus where it is crossed by the aortic arch and leftbronchus and the lower oesophagus where it pierces thediaphragm.' In adults the bolus of food is usually impacted inthe lower oesophagus or at the site of the underlying lesion. Alarge solid bolus, such as poorly chewed meat, is usually impactedin the lower oesophagus.4The diagnosis of a radio-opaque foreign body in the oeso-

phagus can be confirmed by a chest x-ray examination (antero-posterior and lateral), while a barium meal examination can beused to localize impaction by other objects. Whenever anoesophageal foreign body is diagnosed it should be removed byoesophagoscopy. Blind methods, such as probing the pharynxwith a finger or passing catheters, hooks, etc., are not advisable.Turning the patient upside down or pounding him between theshoulder blades can have little if any effect on an oesophagealforeign body.5

In all patients attempts to remove the foreign body were byoesophagoscopy under general anaesthesia. Local anaesthesiacan be used for adults and is particularly advisable when theunderlying factor is expected to predispose to complicatedgeneral anaesthesia.

In adequately prepared children recently impacted coins atthe upper oesophagus may be removed by oesophagoscopywithout tracheal intubation. In other patients, however, anendotracheal tube must be inserted to provide an adequateairway during oesophagoscopy, and to minimize the incidenceof aspiration of saliva, food, and other material accumulatingin the oesophagus above the impacted foreign body and thepredisposing lesion.The tracheal tube comes out at the left side of the mouth,

leaving the pyriform sinus and the laryngopharynx availableto the endoscopist. Overinflation of the tracheal tube cuff cancreate extrinsic pressure on the oesophagus and interfere withoesophagoscopy and manipulation of the foreign body. Excessivepositive pressure ventilation can also cause the oesophagus tocompress the foreign body, increasing the degree of impactionor even leading to perforation of the oesophagus.5 Perforationcan also result from oesophageal manipulation, particularly whena foreign body is firmly impacted in a diseased oesophagus.Mediastinitis and mediastinal emphysema can follow and resultin serious complications. Complications are more common inadults than in children, which can be attributed to the presenceof underlying disease in most patients of the adult age group.

We thank our colleagues in the anaesthesia, ear, nose, and throat,and x-ray departments of the American University of Beirut fortheir co-operation and advice.

References1 Barake, A., British Journal of Anaesthesia, 1974, 6, 124.2 Jackson, C. L., American Journal of Surgery, 1957, 93, 308.3Gray, H., Gray's Anatomy, 32nd edn., p. 1393. London, Longmans

Green, 1958.4Paul, L. W., and Juhl, J. H., Essentials of Roentgen Interpretation, 2nd

edn., p. 393. New York, Harper and Row, 1965.5 Gabriel, F., and Tucker, J. R., in Management of Esophageal Disease.

Modern Treatment Volume 7, No. 6, ed. T. M. Bayless, p. 1301. NewYork, Harper and Row, 1970.

General Practice Observed

A Health Centre E.C.G. Service: Its Use and AbuseT. FYFE, N. M. MACLEAN

British Medical Journal, 1975, 1, 563-566

Summary

An average of 10-5 E.C.G.s were recorded weekly in ahealth centre used by 32 general practitioners serving apopulation of almost 65,000. The main indication for anE.C.G. was chest pain (73%). 47% of the E.C.G.s wereabnormal. A change in clinical diagnosis occurred in28% of cases and in patient management in 16%. A

Vale of Leven District General Hospital, Alexandria, Dun-bartonshire, G83 OAU

T. FYFE, M.D., M.R.C.P., Consultant PhysicianClydebank Health CentreN. M. MACLEAN, M.B., M.R.C.G.P., General Practioner

significant number of these changes were unwarranted,however.

It is recommended that the E.C.G.s should be recordedby suitably trained nurses and reported by a speciallytrained general practitioner. Further education ofgeneralpractitioners in the clinical use of the E.C.G. is required.

Introduction

There are several surveys analysing the indications for andabnormalities found in electrocardiograms (E.C.G.) carried outby general practitioners themselvesl13 and by hospital servicesfor general practitioners.4-9 There does not appear to be anyinformation published on how they use an E.C.G. service in themanagement of their patients apart from those of Morganset al.10 and Peniket and MacQuaide,'1 both of which werecarried out retrospectively. This topic has become important as

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