Work-up for a Patient with a Bone Stuck in the Throat
Any patient claiming to have a bone stuck in their throat should be believed and requires prompt evaluation and management to prevent potentially life-threatening complications. 1
Initial Assessment
History: Focus on:
- Duration and location of symptoms
- Type of bone ingested (fish, chicken, etc.)
- Associated symptoms (pain, dysphagia, drooling, respiratory distress)
- Ability to swallow saliva
- Hemoptysis or hematemesis
Physical examination:
- Assess for respiratory distress, stridor, or voice changes
- Examine oropharynx for visible foreign body
- Check for cervical tenderness, crepitus, or subcutaneous emphysema
- Assess vital signs including oxygen saturation
Diagnostic Workup
Laboratory Tests
- Complete blood count (CBC)
- C-reactive protein (CRP)
- Blood gas analysis for base excess and lactate 2
Imaging Studies (in sequence)
Plain Radiographs:
- Biplanar neck, chest, and abdominal X-rays should be the initial imaging
- Note: Plain radiography has a high false-negative rate (up to 47% generally, and up to 85% for fish/chicken bones) 2
Computed Tomography (CT):
- CT scan should be performed in all patients with suspected bone impaction and negative X-rays
- CT has superior sensitivity (90-100%) and specificity (93.7-100%) for detecting bone foreign bodies 2
- Essential if perforation or other complications are suspected
Avoid Contrast Studies:
- Barium or gastrografin swallow is not recommended
- May coat the foreign body and esophageal mucosa, impairing subsequent endoscopic visualization
- Risk of aspiration in patients with complete esophageal obstruction 2
Management
Endoscopic Intervention
- Endoscopy is the first-line treatment for esophageal foreign bodies 3
- Rigid esophagoscopy has a high success rate (99% in some studies) for foreign body removal 4
- Emergent endoscopy (<6 hours) is recommended for sharp-pointed objects 2
Surgical Management
- Indications for surgery include:
- Perforation
- Foreign bodies that are irretrievable endoscopically
- Foreign bodies close to vital structures
- Esophagotomy with foreign body extraction and primary closure is the preferred approach 2
Monitoring for Complications
- Monitor for signs of:
- Mediastinitis (severe sore throat, deep cervical pain, chest pain, dysphagia, painful swallowing, fever, crepitus)
- Esophageal perforation (pneumothorax, pneumomediastinum, subcutaneous emphysema)
- Paraesophageal abscess
- Tracheoesophageal fistula
- Aortoesophageal fistula (rare but life-threatening) 3
Post-Procedure Care
- Close observation for respiratory distress or stridor
- Administer appropriate analgesia
- Consider antibiotics if perforation is suspected or confirmed
- Patients should be informed about delayed symptoms of airway trauma and advised to seek medical help if they develop 2
Important Caveats
- Delays in intervention should be avoided to prevent complications 3
- A bone may not be visible on lateral radiographs of the neck, but the patient's complaint should still be taken seriously 1
- Even if objective signs are absent, a patient who is agitated or complains of difficulty breathing should never be ignored 2
Remember that prompt diagnosis and treatment are essential, as complications from esophageal foreign bodies can be severe and potentially fatal.