The Localisation of Foreign Bodies in the Chest

Abstract

A practical review is given of the means of localising missiles in the chest as used in an army chest centre. It represents 200 cases where the results have been observed at operation. Stress is laid on the importance of close co-operation between radiologist and surgeon and the frequent necessity of carrying out fluoroscopy during the actual operation. The surgical approaches used are described and the importance of the localisation being made in terms of anatomy indicated. If possible hæmothoraces should be aspirated before localisation and the optimum time for it is as shortly before operation as possible. A brief description of the routine is given. Localisation is then described in more detail dealing with each group of missiles separately. Peripheral foreign bodies. The ineffectiveness of skinmarking is indicated, and the great difficulty encountered in finding small foreign bodies lying in the rib plane is stressed. Needle localisation is usually the method of choice. Screening at the time of operation has often been needed. Mediastinal foreign bodies. Here the need for anatomical localisation is paramount. This can sometimes be done best from films (postero-anterior and lateral) but screening is usually necessary. Anterior mediastinal foreign bodies may be removed through a trephine hole in the sternum. Superior mediastinal ones usually need both films and fluoroscopy, while barium swallow and bronchography may be of use. The great help to be obtained from a study of transmitted impulse is stressed. These foreign bodies usually lie in the connective tissue between and around the main structures and may be very difficult to palpate at operation. Posterior mediastinal foreign bodies are marked by vertebral level and their relation to aortic arch, tracheal bifurcation, etc. A barium swallow may be of great use. Para-diaphragmatic foreign bodies call for aspiration of effusions and if possible the expansion of lower lobes before localisation. The difficulty of decision of relationship to diaphragm in many cases is noted. A study of their movement can be of great assistance. Induced pneumoperitoneum has proved of little value. Para- and intracardiac foreign bodies. The ease with which the small intracardiac foreign body can be missed is stressed. Deep penetration films may diminish this risk, but fluoroscopy is the safest method of obviating it. The need to divide the missiles into para- and intracardiac foreign bodies is suggested and the importance of tangential screening, the position of the foreign body, and its movement in relation to the heart, as factors in its localisation, is mentioned. Some indications of cardiac involvement are given and the “epicardial pad of fat” is described. For intrapulmonary missiles films may be enough, but foreign bodies near the periphery should be screened. The importance of indicating in which lobe the missile lies and to which surface of the lobe it is nearest is mentioned. The similarity between calcified nodes and glands, lung tracks, and bronchi, and the foreign body to palpation, is stressed. These lesions should therefore be indicated if possible. Centrally-situated pulmonary foreign bodies may need screening “on the table”. Finally the more difficult missile “sites” are indicated.