What imaging is recommended for a patient with a pill stuck in their throat?

Imaging for a Pill Stuck in a Patient's Throat

For a patient with a pill stuck in their throat, plain radiography (neck, chest, and abdominal) should be performed as the initial imaging modality, followed by CT scan if there is suspicion of complications or if plain radiographs are negative but clinical suspicion remains high. 1

Initial Imaging Approach

Plain Radiography

• First-line imaging: Plain neck, chest, and abdominal radiographs
• Views needed: Biplanar radiography (frontal and lateral projections)
• Purpose: To assess presence, location, shape, and size of the pill
• Limitations:
  • False-negative rate up to 47% for general foreign bodies
  • False-negative rate up to 85% for certain types of pills 1
  • Radiopacity of pills varies significantly based on composition

Pill Radiopacity Considerations:

Pills that are typically radiopaque and visible on X-ray:

• Chloral hydrate
• Iron-containing preparations
• Calcium carbonate
• Iodinated compounds
• Acetazolamide
• Busulfan
• Potassium preparations 2

Pills that may have variable radiopacity:

• Antihistamines
• Phenothiazines
• Tricyclic antidepressants 2
• Enteric-coated medications (variable visibility)

CT Scan

• Second-line imaging: When plain radiographs are negative but clinical suspicion remains
• Indications for immediate CT:
  • Suspected perforation
  • Signs of complications (abscess, mediastinitis)
  • Need for interventional endoscopy or surgery 1
• Benefits:
  • Higher sensitivity (90-100%) compared to plain radiography
  • Better visualization of surrounding soft tissue complications
  • Can detect radiolucent pills that may be missed on X-ray

Important Considerations

Avoid Contrast Swallow Studies

• Oral contrast studies (barium or gastrografin) should be avoided as they:
  • Increase risk of aspiration in patients with complete esophageal obstruction
  • May coat the pill and esophageal mucosa, impairing subsequent endoscopic visualization
  • Should not delay other investigations or interventions 1

Clinical Evaluation

• Assess for signs of complications:
  • Inability to swallow saliva
  • Respiratory distress
  • Pain beyond simple discomfort
  • Signs of perforation (subcutaneous emphysema)

Special Situations

For Pills in the Esophagus

• If the pill is suspected to be in the esophagus, a biphasic esophagram may be considered after ruling out complete obstruction
• This allows assessment of both structural and functional abnormalities of the esophagus 1

For Pills in the Oropharynx

• Direct visualization via laryngoscopy may be more appropriate than imaging
• If imaging is needed, a modified barium swallow with videofluoroscopy may be helpful to assess swallowing function 1

Common Pitfalls to Avoid

1. Relying solely on plain radiography when clinical suspicion is high but initial X-rays are negative
2. Using contrast studies as initial imaging
3. Failing to consider CT when complications are suspected
4. Not recognizing that many pills are radiolucent and will not appear on X-ray
5. Assuming enteric coating always makes pills radiopaque (this is not reliable) 2

By following this approach, you can effectively identify the location of a pill stuck in a patient's throat and determine the appropriate management strategy while minimizing risks of complications.