Why we do What we do: Esophageal Foreign Bodies (Fish Bones)

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The ER was presented with a patient reporting that she had swallowed a fish bone and had a foreign body sensation in her throat. The question arose, how does one manage these patients – is xray enough? Does every patient need to be scoped by ENT? How does CT scan factor into management? Check out this article and read the discussion below.

Is CT effective in cases of upper oesophageal fish bone ingestion – 2007
Emerg Med J. 2007 January; 24(1): 48–49.

When considering a patient with foreign body, based on the evidence, neck xray has not fallen out of favor. It is a very specific test. Or in other words, if it is identified on xray it has ruled in foreign body. However, if not present, based on the literature, it does not rule it out. Based on an old article in 1951 certain fish bones are less radiopaque including: fresh salmon, smoked salmon, yellow pike, bluefish, butterfish, mackerel, pompano and trout. Therefore our work is not done with a negative xray. However, when considering the amount of radiation a simple xray exposes a patient to in a sensitive area (thyroid)

So what is the next step? Some go down the ENT route and call for esophagoscopy and direct laryngoscopy – which can be effective if a foreign body is identified on exam. But if it is not, it has not ruled out foreign body (namely sharp foreign bodies like fish bones). The article above reviewed multiple studies looking at the effectiveness of CT scan for identification of bones. Although it does not get into the details of what type of fish, there should be disruption/abnormality of the surrounding soft tissues or a radiopaque foreign body in the soft tissues identified. Based on the review, CT proved to be 100% sensitive, thus ruling out foreign body. The review encompassed a total of 144 patients and argues that “a negative CT scan should confidently exclude fish and chicken bones”. It can then be concluded that ENT evaluation is unnecessary in the setting of a negative CT scan.

When would ENT evaluation be considered? Obviously if a foreign body is identified by xray ENT would have to prepare for retrieval of the foreign body. Other considerations include the pregnant patient who you don’t want to expose to radiation.

Reference:
1. Das, D et al. “Is CT effective in cases of upper oesophageal fish bone ingestion?”, Emerg Med J. 2007 January; 24(1): 48–49.
2. Kazam et al., “Computed tomography scan for the diagnosis of esophageal foreign body”, American Journal of EM (2005) 23: 897-898.
3. Goldman, J.L., Fish Bones in the Esophagus, Ann. Otol. Rhin. & Laryng. 6:957 (Dec) 1951.

One Comment

  • sann

    I had a patient the other day who continued to have sensation of something stuck in his throat despite a negative XR and a CT neck that showed only some air in the parapharyngeal soft tissue extending 1cm laterally but no foreign body. We had ENT come scope him and the fishbone was still there. The 100% CT sensitivity for FB goes out the window for me.

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