How to manage a suspected throat foreign body not visible on X-ray?

Management of Suspected Throat Foreign Body Not Visible on X-ray

A negative X-ray does not rule out a foreign body, and you should proceed directly to CT scan in symptomatic patients or those with high clinical suspicion, followed by laryngoscopy/endoscopy based on findings. 1

Diagnostic Limitations of X-ray

• Plain radiography has a false-negative rate up to 47% for esophageal foreign bodies and up to 85% for food bolus, fish bones, chicken bones, and other non-radiopaque objects 1
• Routine use of radiographs in assessing throat foreign bodies is inappropriate and should not guide clinical decision-making 2
• Many foreign bodies have very low radiopacity and will not be visualized on plain films 3

Immediate Next Steps

For symptomatic patients with negative X-ray, obtain CT scan immediately - it has 90-100% sensitivity and 93.7-100% specificity for detecting foreign bodies 1

Clinical Examination Priority

• Perform thorough visual inspection of the oropharynx looking for visible foreign bodies that can be manually extracted 3
• Never perform blind finger sweeps - this can impact the foreign body deeper or cause injury to the nasopharynx 3
• Only manually extract objects that are clearly visible in the mouth 3

Laryngoscopy Indications

• Indirect laryngoscopy has high diagnostic yield and should be performed in patients with persistent foreign body sensation 2
• In one study, 84.7% of patients referred to ENT underwent indirect laryngoscopy, which identified foreign bodies in 17.3% and other pathology in 4.8% 2

CT Scan Protocol

• CT is essential for locating non-radiopaque objects, evaluating for perforation, and assessing complications 3, 1
• Obtain contrast-enhanced CT of the neck and chest in hemodynamically stable patients with suspected perforation 3
• CT should evaluate for pneumomediastinum, subcutaneous emphysema, and soft tissue inflammation suggesting perforation 1

Laboratory Workup

For symptomatic patients requiring intervention:

• Complete blood count (CBC) 1
• C-reactive protein (CRP) and inflammatory markers if perforation suspected 3, 1
• Serum creatinine 3, 1
• Blood gas analysis in severe cases 1

Endoscopy Timing Based on Location and Symptoms

Emergent Endoscopy (within 2-6 hours):

• Complete esophageal obstruction 1
• Sharp-pointed objects 1
• Button/disk batteries 1
• Magnets 1

Urgent Endoscopy (within 24 hours):

• Partial esophageal obstruction 1
• Food bolus impaction without complete obstruction 1
• Persistent symptoms despite negative imaging 1

Airway Management Considerations

• If the patient has ineffective cough and suspected airway obstruction, encourage coughing first as this is physiologic and unlikely to cause harm 3
• Use back blows initially if coughing is ineffective 3
• Follow with abdominal thrusts if back blows fail (in patients >1 year old) 3
• Appropriately skilled healthcare providers should use Magill forceps for visible foreign body airway obstruction 3

Common Pitfalls to Avoid

• Do not dismiss symptoms based on negative X-ray alone - this is the most critical error, as up to 85% of certain foreign bodies are not visible radiographically 1
• Do not delay CT imaging in symptomatic patients waiting for "observation" 1
• Avoid blind instrumentation of the pharynx, which can cause injury or worsen obstruction 3
• Consider alternative diagnoses such as acute epiglottitis, which can present similarly to foreign body sensation 4
• Remember that thyroid cartilage displacement can mimic foreign body sensation and requires different management 5

Special Considerations

• In patients with suspected perforation and hemodynamic instability, proceed directly to surgical intervention without delaying for imaging 3
• Esophageal foreign bodies require intervention due to aspiration and perforation risk - attempt gentle pushing into stomach during endoscopy first, then retrieval if pushing fails 1
• Repeat imaging after extraction is generally not necessary unless new symptoms develop, as plain films have low sensitivity for pneumoperitoneum 3