Management of Chicken Bone Ingestion in a 7-Year-Old
Obtain immediate biplanar radiographs (AP and lateral views) to confirm the presence and location of the chicken bone, then proceed with urgent endoscopic removal within 24 hours if lodged in the esophagus, or emergent removal within 2-6 hours if the child shows signs of complete obstruction. 1, 2
Initial Assessment and Risk Stratification
Assess for signs of complete obstruction immediately:
- Drooling or inability to handle secretions 2
- Respiratory distress 2
- Inability to swallow saliva 1
- Chest pain or dysphagia 3
A 7-year-old is at moderate risk for complications from bone ingestion, though the highest risk group is children under 4 years who lack fully developed molars and chewing ability 4. However, bones pose unique risks at any age due to their sharp edges and potential for perforation 3, 5, 6.
Diagnostic Approach
Obtain biplanar radiography immediately (anteroposterior and lateral views) to:
- Confirm presence of the bone (chicken bones are typically radiopaque) 2
- Distinguish between esophageal versus tracheal location 2
- Identify the exact anatomical level of impaction 1
Common impaction sites include the upper esophageal sphincter at the cricopharyngeus muscle and the thoracic esophagus at the aortic arch level 1, 7. The C4-C7 vertebral level is particularly vulnerable 1.
Management Algorithm
If Complete Obstruction Present:
Perform emergent endoscopic removal within 2-6 hours 1, 2
- Use rigid endoscopy for bones in the upper esophagus 1, 2
- Use flexible endoscopy for mid to lower esophageal foreign bodies 1, 2
If No Complete Obstruction:
Perform urgent endoscopy within 24 hours 1, 2
- Do not adopt a "wait and see" approach with bones, unlike coins 1
- Sharp bones can cause pressure necrosis and perforation even without complete obstruction 1, 3, 6
If Bone Has Passed to Stomach:
- Consider endoscopic removal even if in the stomach, given sharp edges 3
- Serial radiographs and close observation are insufficient for sharp objects 3
- Monitor for signs of perforation: abdominal pain, fever, peritoneal signs 3
Critical Complications to Monitor
Chicken bones pose life-threatening risks that distinguish them from blunt foreign bodies:
- Esophageal perforation leading to mediastinitis 1, 3, 6
- Aortoesophageal fistula (can occur days to months after initial ingestion, causing fatal hemorrhage) 3, 6
- Delayed hemorrhage from vascular injury (may present 6-9 months later) 6
- Aspiration risk if bone dislodges into airway 1, 8
- Pressure necrosis from prolonged contact with esophageal wall 1, 6
The case reports demonstrate that chicken bones can cause fatal complications even after initial symptoms resolve, with one patient dying 9 days post-ingestion from aortoesophageal fistula and another 6 months later from cervical esophageal hemorrhage 3, 6.
Common Pitfalls to Avoid
Do not discharge the patient if radiographs show a bone in the esophagus, even if asymptomatic 3, 6. One fatal case involved a patient who was discharged after symptoms resolved, only to return 9 days later with massive hemorrhage 3.
Do not rely on symptom resolution as evidence of safe passage 3, 6. Bones can embed in the esophageal wall and cause delayed catastrophic bleeding 6.
Do not perform blind removal attempts or encourage swallowing bread/water to push the bone down, as this can worsen impaction or cause perforation 5.
Post-Removal Care
After successful endoscopic removal:
- Observe for signs of esophageal injury (chest pain, fever, subcutaneous emphysema) 2
- Consider brief observation period given perforation risk 3, 5
- Provide anticipatory guidance to parents about cutting meat into small pieces and supervising meals 4, 2
Prevention Counseling
Educate parents that bones are high-risk choking hazards for all children, not just toddlers 4. Children should be supervised during meals, avoid talking or running while eating, and bones should be completely removed from chicken before serving to children 4.